Physiotherapy Assessment and Treatment of the Equine Forelimb

Original Editor - Jess Bell Top Contributors -

Introduction[edit | edit source]

Physiotherapists do not often play a significant role in the management of forelimb injuries in horses. These injuries tend to require veterinarian management. However, equine therapists must still have a detailed understanding of the front limb, so that they are able to determine if referral to the veterinarian is necessary and to identify any compensatory dysfunction that may respond to physiotherapy input.

This page will discuss key considerations for the animal physiotherapist, including the importance of working closely with the multidisciplinary team (i.e. veterinarian, farrier, rider), the need to obtain a thorough history, as well as the basics of physiotherapy assessment and treatment of forelimb injuries.

Physiotherapy Assessment[edit | edit source]

Once the horse has been given a diagnosis by a veterinarian, the equine therapist needs to obtain a full history of the patient’s presenting condition. This will provide important information about the horse’s level of disability, the timeline and progression of the condition, and any past history that is relevant to the current presentation.[1]

Questions to include in the subjective interview are:[2]

  • When did the horse go lame?
  • How lame is the horse?
  • What interventions / medications have been tried so far?
  • What occurred in the lead up to the injury? (including training, shoes, boots, surfaces, supplements)
  • What type of work does the horse do? What is the horse’s expected level? What schooling, breeding, and training programmes does it have?
  • Have there been any changes in saddles, bridles etc?
  • Does pain / lameness improve when the horse has warmed up or does it get worse throughout the ride? Is it worse on small circles or with a change of direction?
  • Are changes more subtle? (e.g. loss of height in piaffe / passage, dropping its foot over bigger fences, changing lead at gallop)

It can be useful to also discuss the patient’s history with its grooms, and handlers - particularly when attempting to determine what other interventions the animal has received.[2]

While obtaining the subjective history from the owner, the therapist is also able to observe the horse’s demeanour, behaviour, condition, conformation, gait and posture.[1]

[3]

Observation[edit | edit source]

Static Observation[edit | edit source]

The therapist should observe and compare with other horses from the same breed, the patient’s:[1]

  • Conformation
  • Mentation
  • Muscular condition and coverage (compared to horses of its age, type, level of work)
  • Muscle symmetry and bony landmarks
  • Weight bearing ability (compared side to side)

Dynamic Observation[edit | edit source]

Observing the horse in motion enables the therapist to establish how willing the patient is to move. Movements must be provocative enough to highlight the impairment (walking / trotting in a straight line may not adequately challenge the horse).[1]

Movements that could be included in a dynamic assessment are:[2]

  • Horse walks away and back with the handler
    • Therapist looks at the way the horse goes, if there is any reluctance to move, can the handler settle the horse?
  • Repeat
    • Therapist looks for symmetry of movement, flat foot placement, even strides, head nod
  • Trot away and trot back
    • Therapist looks for any head nod (which indicates forelimb lameness) and at stride length
  • Small circles
    • Therapist looks for cross over in both directions, neck bend
  • Different surfaces
    • Therapist looks for any apprehension, snatch back
  • Lunging
    • Therapist looks for symmetry, enthusiasm without the riders weight
  • Under saddle
    • Looser rein, then collection

Functional Assessment[edit | edit source]

The functional assessment might include whole tasks (e.g. gait / functional activities) or components of movements. For example:[1]

  • Small circles
  • Gait on a hill
  • Walking on soft surfaces, over poles

Any functional test / movement can be used as both an assessment and as an intervention.[1]

[4]

Physical Assessment[edit | edit source]

The physical examination should include:[1]

  • Active physiological movements
  • Soft tissue palpation and testing
  • Passive physiological joint assessment
  • Passive accessory joint assessment
  • Neuromechanical tissue testing

Goniometers, tape measure, and photography / video are often used as outcome measures during the physical assessment in equine physiotherapy.[1]

Palpation[edit | edit source]

When palpating a horse, it is important to consider the following points:[2]

  • Always approach the horse with care
  • Palpate for muscle type, bulk
    • Remember to consider the horse’s breed (i.e thin thoroughbreds vs heavier cobs)
  • Allow the horse to be comfortable with you
  • Check the horse’s temperature, response to touch, and look for swelling, symmetry and effusion
  • Compare left to right
  • Look for compensatory patterns – assess the opposite musculature, and diagonal musculature

A top down approach can be useful when palpating the forelimb of a horse:[2]

  • Scapular ridge
  • Spine of scapular
  • Supraspinatus, infraspinatus
  • Scapulohumeral joint
  • Biceps bursa and biceps tendon
  • Triceps and elbow, point of the olecranon
  • Forearm – flexor groups. Muscles and associated tendon sheaths
  • Extensors - muscles and associated tendon sheaths
  • Radius – medially palpate the radial bone
  • Carpus – extensors over the front of the carpus. Carpal effusion
  • Accessory carpal bone, effusion in carpal sheath
  • Metacarpus and splint bones
  • Flexor tendons
  • Suspensory ligament
  • MCP joint and palmar digital flexor tendon sheath
  • Pastern
  • Coronary band and hoof

General Management Principles[edit | edit source]

This section explores physiotherapy interventions that can be applied to the equine forelimb. Specific forelimb injuries and their management are discussed here.

Thermal Therapy[edit | edit source]

Cold Therapy[edit | edit source]

Cold therapy is used to reduce:[5]

  • Local circulation
  • Tissue swelling
  • Pain sensation

It is most beneficial in the acute phase (i.e. 24-48 hours) after an injury or surgery. Cold therapy works by constricting blood vessels and reducing tissue temperature. Reduced blood flow helps to decrease oedema, haemorrhage and the extravasation (i.e. leakage) of inflammatory cells.[5]

Heat Therapy[edit | edit source]

Heat therapy is used to:[5]

  • Increase local circulation
  • Promote muscle relaxation (and thus reduce muscle spasm / pain)
  • Increase tissue extensibility

Heat therapy is particularly useful for:[5]

  • Wound healing
  • Promoting resorption of oedema
  • Pain management
  • Encouraging more effective stretching of tissues

Heat therapy should be used after the acute phase of healing.[5]

Contrast Therapy[edit | edit source]

Contrast therapy (i.e. alternating hot / cold therapy) is often used to treat human patients, but it has not been widely researched in equine therapy. A recent study by Haussler and colleagues has looked at its potential for use in horses.[6] They found that it is possible to achieve therapeutic tissue temperatures (i.e. <15 and >40°C) in tissues as deep as the deep digital flexor tendon with contrast therapy.[6]

Therapeutic Ultrasound[edit | edit source]

Therapeutic ultrasound has been shown to have thermal and non-thermal benefits in both human and animal patients.[7]

Thermal benefits include:[7]

  • Improved extensibility of collagen
  • Decreased pain
  • Decreased muscle spasm
  • Increased blood flow

Non-thermal (i.e. biologic) effects cause changes in the cellular environment that lead to changes in cellular function. This may result in:[7]

  • Shortened inflammatory phase of healing
  • Increased vascularity
  • Enhanced proliferation of fibroblasts

Non-thermal ultrasound is often, therefore, used for for patients with fracture or tendinopathy.[7]

In general, ultrasound is indicated for:[8]

  • Tendons and ligaments - to minimise contraction
  • Fascial planes
  • Joint capsules - to improve range of motion
  • Scar tissue
  • Osteophytes / enthesiophytes - to decrease pain
  • Muscle spasms - to slow gamma fiber transmission
  • Wounds - to increase protein synthesis in fibroblasts (from 2 weeks post-injury)
  • Oedema
  • Nerve injuries - to encourage remyelination and regeneration of damaged axons

Extracorporeal Shock Wave Therapy[edit | edit source]

Extracorporeal shock wave therapy (ESWT) is often used to treat soft tissue and bone injuries in equine patients.[5][9] Pulses are transmitted from the shockwave unit into the tissues to help stimulate healing.[9]

It is indicated when a horse has:[5]

  • Tendinitis
  • Desmitis
  • Osteoarthritis
  • Deep muscle pain

It is believed that ESWT:[5]

  • Reduces inflammatory mediators
  • Increases angiogenic cytokines (causing vessel proliferation)
  • Increases growth factors (causing tissue healing)
  • Increases the number of osteoblasts
  • Recruits mesenchymal stem cells
  • Helps to manage pain

One recent study found that ESWT increased mechanical nociceptive threshold in horses with back pain.[10] It can also improve the rate of healing and the prognosis of equine patients who have proximal suspensory desmitis.[9]

Joint Mobilisations / Manipulations[edit | edit source]

Much of the information about manual techniques in equine therapy comes from human research:[11]

  • Joint mobilisation and manipulation can be used as a diagnostic tool and to guide interventions for musculoskeletal dysfunction in horses
  • Soft tissue mobilisation aims to restore movement in tissues, and to enhance tissue repair, extensibility and function
  • Joint mobilisation is used to restore normal, symmetric joint range of motion, end feel and to stretch connective tissues
  • Manipulation is a high velocity technique that moves a joint beyond its physiologic range of motion

Manual techniques are often used to help manage musculoskeletal injuries in performance horses. It is particularly beneficial for:[11]

  • Chronic or recurring musculoskeletal conditions
  • Conditions that are not easily diagnosed or not responding to conventional veterinary care

They are also indicated to help prevent negative effects of joint immobilisation and to help retrain proprioception. They have been fou to have a positive effect on pain, flexibility, muscle hypertonicity and spinal motion symmetry.[12]

Laser Therapy[edit | edit source]

High intensity laser therapy (HILT) is used as a non-invasive treatment option for musculoskeletal disorders in horses. Indications for low-level laser therapy include:[5]

  • Wound therapy
  • Soft tissue injuries
  • Osteoarthritis
  • When local pain relief is required

Laser appears to:[5]

  • Have anti-inflammatory effects
  • Reduce pain sensation through reduced nerve depolarisation, the release of endorphins and enhanced ATP production

A recent study by Zielinska and colleagues found it can help to reduce pain, oedema, visual lameness and lesion percentage in horses who have tendinopathy and desmopathy. It may, therefore, help to improve the quality of life of equine patients who have chronic musculoskeletal pain.[13]

Exercise[edit | edit source]

Exercise forms a key component of many rehabilitation protocols for horses.[14] Exercise is slowly progressed depending on the horse’s level of conditioning, injury status and assessment findings.[5]

For many soft tissue injuries, hand walking is encouraged soon after injury to enhance fibre alignment and to prevent the formation of restrictive adhesions. [5]

Hydrotherapy and Water Treadmills[edit | edit source]

Hydrotherapy is commonly used to rehabilitate equine patients, but few studies have explored its efficacy for this group of patients.[15] Hydrotherapy has a significant effect on physiological responses in human patients and research suggest that horses may have similar responses.[16] The benefits of hydrotherapy in people include:[15]

  • Increased joint mobility
  • Promoting normal motor patterns
  • Enhanced muscle activation
  • Decreased incidence of secondary musculoskeletal injuries

Other Adjuncts[edit | edit source]

Massage[edit | edit source]

Massage is a popular intervention for equine athletes and horses in general. Proposed benefits include:[17]

  • Increased range of motion and stride length
  • Reduced activity of nociceptive receptors
  • Reduced stress response
  • Enhanced exercise recovery

Many massage techniques used on horses were first developed in humans and while further research is needed, massage currently has a significant role in equine therapy.[17]

Proprioceptive Rehabilitation[edit | edit source]

Proprioceptive retraining is an important part of equine rehabilitation.[18] In human patients, taping, in particular, is often used to help stimulate mechanoreceptive and proprioceptive activity in superficial structures. Recent studies have found that tactile stimulation caused by taping can have an impact on equine gait.[18]

Nutraceuticals (Joint Supplements)[edit | edit source]

It has been suggested that nutraceuticals (i.e. a food that is said to provide medical / health benefits) may be beneficial for horses, particularly those with osteoarthritis. However, evidence for their efficacy is poor.[19]

Summary[edit | edit source]

  • While physiotherapists do not play a significant role in the management of forelimb injuries in the equine athlete, they still need to have a good understanding of this area in order to accurately assess, refer, and, where appropriate, provide suitable interventions
  • There are numerous physiotherapy interventions available that can be beneficial for horses with forelimb lameness, but technique choice will vary based on the horse
  • Specific forelimb injuries are discussed in detail here

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Goff L. Physiotherapy Assessment for the Equine Athlete. Vet Clin North Am Equine Pract. 2016;32(1):31-47.
  2. 2.0 2.1 2.2 2.3 2.4 Legg K. Physiotherapy Assessment and Treatment of the Equine Forelimb Course. Physioplus, 2021.
  3. SmartPak. Equine Lameness Exams. Available from: https://www.youtube.com/watch?v=O2cmb8MDu78 [last accessed 15/3/21]
  4. Lameness Trainer. Lameness Trainer Module 1 Forelimb Lameness. Available from: https://www.youtube.com/watch?v=9hOI4fuTcaw [last accessed 15/3/21]
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Kaneps AJ. Practical Rehabilitation and Physical Therapy for the General Equine Practitioner. Vet Clin North Am Equine Pract. 2016;32(1):167-80.
  6. 6.0 6.1 Haussler KK, Wilde SR, Davis MS, Hess AM, McIlwraith CW. Contrast therapy: Tissue heating and cooling properties within the equine distal limb. Equine Vet J. 2021;53(1):149-56.
  7. 7.0 7.1 7.2 7.3 Montgomery L, Elliott SB, Adair HS. Muscle and tendon heating rates with therapeutic ultrasound in horses. Vet Surg. 2013;42(3):243-9.
  8. Schlachter C, Lewis C. Electrophysical Therapies for the Equine Athlete. Vet Clin North Am Equine Pract. 2016;32(1):127-47.
  9. 9.0 9.1 9.2 Seabaugh KA, Thoresen M, Giguère S. Extracorporeal shockwave therapy increases growth factor release from equine platelet-rich plasma in vitro. Frontiers in Veterinary Science. 2017;4:205.
  10. Trager LR, Funk RA, Clapp KS, Dahlgren LA, Werre SR, Hodgson DR et al. Extracorporeal shockwave therapy raises mechanical nociceptive threshold in horses with thoracolumbar pain. Equine Vet J. 2020;52(2):250-7.
  11. 11.0 11.1 Haussler KK. Joint Mobilization and Manipulation for the Equine Athlete. Vet Clin North Am Equine Pract. 2016;32(1):87-101.
  12. Haussler KK. Equine Manual Therapies in Sport Horse Practice. Vet Clin North Am Equine Pract. 2018;34(2):375-89.
  13. Zielińska P, Nicpoń J, Kiełbowicz Z, Soroko M, Dudek K, Zaborski D. Effects of High Intensity Laser Therapy in the Treatment of Tendon and Ligament Injuries in Performance Horses. Animals (Basel). 2020;10(8):1327.
  14. Davidson EJ. Controlled Exercise in Equine Rehabilitation. Vet Clin North Am Equine Pract. 2016;32(1):159-65.
  15. 15.0 15.1 King MR. Principles and Application of Hydrotherapy for Equine Athletes. Vet Clin North Am Equine Pract. 2016;32(1):115-26.
  16. Tranquille CA, Nankervis KJ, Walker VA, Tacey JB, Murray RC. Current knowledge of equine water treadmill exercise: what can we learn from human and canine studies? Journal of Equine Veterinary Science. 2017;50:76-83.
  17. 17.0 17.1 Scott M, Swenson LA. Evaluating the benefits of equine massage therapy: a review of the evidence and current practices. Journal of Equine Veterinary Science. 2009;29(9):687-97.
  18. 18.0 18.1 McGowan CM, Cottriall S. Introduction to Equine Physical Therapy and Rehabilitation. Vet Clin North Am Equine Pract. 2016;32(1):1-12.
  19. Vandeweerd JM, Coisnon C, Clegg P, Cambier C, Pierson A, Hontoir F et al. Systematic review of efficacy of nutraceuticals to alleviate clinical signs of osteoarthritis. J Vet Intern Med. 2012;26(3):448-56.