November 28, 2017

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Physiotherapy for the Performance Horse

Why I use equine physiotherapy

I looked into equine physiotherapy again this year, having used it very successfully in the past for performance enhancement. I was confident that my horse was physiologically in good shape, but that his competition performance could be improved with the right help. I have also used equine physiotherapy in the past for pain related issues with success and it has always been my personal preference to use physiotherapy over podiatric or balancing treatments. One of my favourite things about equine physiotherapy is the amount of information about your horse you can obtain from just one session. When a vet attends your horse, it’s often to assess an injury or ailment, so that is the focus. With a physio session, I’ve always felt you get to really look at the overall picture (and obviously it tends to be a much less intense situation).

 

I knew as soon as I met Sarah that I wanted her to work with Cicero. It had been a really difficult month, Cicero had suffered a traumatic facial injury caused by a tiny piece of Dengie Alfalfa getting stuck in his gum while chewing. This turned into an abscess which was treated with antibiotics. Unfortunately a large amount of puss from the infection solidified and ended

up having to be cut from Cicero’s cheek on the outside leaving a serious wound. He was very low throughout both the infection and the recovery and had become understandably head shy and wary of anyone he didn’t know. I spoke to Sarah about this and she was very patient and gentle with Cicero until he became more relaxed during his treatments.

 

Sarah confirmed what I had thought, that Cicero was in good shape, but was also sure we could make a huge difference. I had noticed he could get a little sore in his lumbar if we’d been out jumping frequently, I could tell when washing him down. I also knew he was quite ‘right-handed’, making him difficult to ride on the left rein with a tendency to occasional head tilting. I discussed these issues with Sarah who quickly ascertained where the issues were after a simple gait analysis (or trot-up, to normal people).

 

Treatment and Homework

At every session, Sarah performs a thorough gait analysis (basically, me running up and down the yard trying to drag an uninterested warmblood behind me). We also discuss what Cicero has been doing and anything I’ve noticed in training or at competitions. Sarah was very keen to get on top of the sore lumbar issue and found during first treatment it was quite hard to get him to release. However, resolving lumbar tenderness has become easier with every treatment.

 

Sarah also got me started with a TENS machine, if Cicero has been working really hard or appears sore at a treatment we use this every day. Otherwise I can just use it once a week or so, in between treatments. This is a really inexpensive and useful treatment that I can do myself and I really notice a huge difference. Cicero really enjoys having it on while he eats his dinner!

 

The other thing I was tasked with was more pole work. As an eventer, Cicero always does a huge variety of work including hills, schooling and long walks, but I’ve learnt there’s always more room for pole work! After every treatment Sarah recommends specific exercises to work on.

 

Importantly, Sarah also helped me understand that our one-sidedness was arising from unequal hind limb strength. Basically, the way I remember it is that his hind leg with the white sock is weaker than the one without a white sock! He therefore curls himself round to the right at all times to compensate and then head tilts when he’s tired. This was making him sore in all sorts of places, from his back to his poll. The solution has been a mixture of treatment and strengthening work combined with using the TENS machine.

 

We’ll never be perfectly straight but I can’t believe how far we’ve come in six months! I’ve also realised that when schooling on the flat I need to be acutely aware of both straightness and whether that white sock is properly pushing under behind! If it is, the straightness improves and any head tilt disappears…

 

Related Issues and Unforeseen Consequences

A performance issue crept up on us a couple of months ago. As I started jumping bigger classes, I suddenly found Cicero couldn’t land on the correct leg. He seemed to particularly

struggle to land on the left leg and I was really concerned we had a foot or limb issue. Luckily, that week Sarah came to watch us compete in an Intermediate Novice class at Tweseldown where she saw the issue first hand. Suddenly, jumping at 1.15m+ Cicero had lost the ability to land on the correct leg. We discussed the issue at length and Sarah suggested that it could be related to the hind limb weakness (that naughty white sock again!). We increased the pole work much to Cicero’s horror (he doesn’t really enjoy breaking a sweat). At first nothing really changed but we persevered and three months later Cicero started being able to land on the correct leg! Lucky, I thought, as we were about to attempt our first CIC 1* together... 

 

We went into the show jumping in a very competitive position and I felt very positive we could put in a good round. However, after fence 3 Cicero landed on the left leg in front (yay), but not behind! That damn white sock! He got disunited and unbalanced, I panicked and he

stopped at fence 4! So definitely a case of one step forward and two steps backwards. We made it over fence 4 on representing but knocked it down and our accumulated show jumping penalties lost us our competitive position. In hindsight, perhaps it wasn’t the right time to upgrade to international level when we were only just getting on top of such a tricky issue. But I was very pleased with his overall performance, particularly the dressage where he scored a sub 50 FEI score and was in the judge’s top five, plus a very confident round across country - I don’t think I should complain too much.

 

Onwards and Upwards

Feeling slightly deflated I took myself off to see my jumping trainer, armed with the footage of my round. I was pleasantly surprised when my trainer told me that Cicero had improved significantly and that I needed to keep going! He watched the footage and said ‘just one of those things, a baby mistake, I doubt he’ll do it again’ – I was so relieved. I booked myself in for three BS competitions and decided to crack on. I was over the moon that Cicero did a perfect double clear at each of those three shows and more importantly landed on the correct leg over every single fence. I feel like we’ve overcome a huge hurdle and none of this would have been possible without Sarah’s hard work and support. I now understand so much more about Cicero’s body and weaknesses, which has really allowed me to tailor his training and overcome performance issues. 

 

All going so well

With our new found show jumping confidence, Cicero and I traveled a long way down the M4 to Dauntsey Horse Trials. Sadly, there had been a lot of rain and I was the last to go in my section so the ground conditions were not favourable. Having said that, Cicero has always been confident in the mud so I stayed positive. We sloshed around the dressage for a slightly disappointing 66% but I was pleased because Cicero really did try his best in the conditions.

 

In the show jumping warm-up Cicero was feeling incredible. This was slightly our undoing… he was really showing off, some horses were over-jumping because of the deep mud but Cicero was simply was showing off how fabulous he is, especially now he can use that white sock of his! He absolutely launched himself over fence 3 and I tried my best to stay with him. Somehow I caught my hand and I was suddenly in a lot of pain. I limped round the rest of the course trying my best to steer but generally being quite useless. We had one fence down where I really lost my steering, but again, considering the conditions, 4 faults was still very competitive.

 

As I was due to go cross country straight after show jumping I didn’t really give myself any time to think how injured I was and off I went! I soon discovered that although I could hold the right rein I couldn’t really steer. I had to keep slowing Cicero down but he miraculously jumped clear round what was a very tricky Novice course. I drove home from Dauntsey feeling quite sorry for myself but over the moon with my horse. He had pulled out all the stops in horrible conditions, landed on the correct leg and carried me round the XC. The next day I was convinced to take my sore hand off to hospital where they told me I have a rather nasty spiral fracture to my finger and ligament damage to my hand.

 

The future

So… just as things were really coming good we’ve had to end our British Eventing season. After a week off, I’ve started riding again, but I’m banned from leaving the ground until my finger is fully healed because of the risk of re-injury.

 

I can’t express how much I’ve enjoyed working with Sarah. We’ve really made a huge amount of progress which puts us in great shape to tackle international events next year and hopefully get a few more results at Novice before we move up to Intermediate.

 

I now know that I wouldn’t have been able to move up the grades without the support of an Equine Physiotherapist as we’d have always been in a muddle in the jumping and struggling with one-sidedness. I feel much more confident that we have a way of managing any soreness that might arise through strenuous exercise like jumping 1.20+ classes. I also feel very confident that with Sarah’s support we are much more likely to be able to tackle multi-day show jumping competitions and three day events – eek! I can see myself, standing in a temporary stable at a showground with Cicero happily munching on his dinner with that TENS on! 

 

At the moment, progress with that naughty white sock is looking very positive and I absolutely can’t wait for my hand to heal so we can get back to competing. We started the season with Cicero injured and we’ve ended the season with me injured… but what a great six months we’ve had. It’s all about the journey… or so people keep telling me!

The physio’s perspective

I first saw Cicero in the spring, and after a thorough assessment and discussion with Lottie it soon became clear that although he was out competing successfully, there were some physical weaknesses that were hindering Cicero’s performance and that, left unattended could cause more serious issues further down the line.  Cicero’s vet had carried out a full examination and had cleared him for physiotherapy.

 

Cicero’s main issue was a weak right hind, causing compensatory movement through the right side of his spine - the quarters ‘swing’ to the right to make up for the reduced limb movement (if you try this yourself by swinging your hip up, you will feel it in your lumbar area).  When this movement continues over time, it overstresses and causes shortening of the muscle fibres leading to muscle spasm and further restricted movement.  The restricted movement of Cicero's hindlimbs had also caused him to become tight through his hamstrings. 

 

Another consideration with a weak hindlimb is that of the opposing forelimb, as additional weight is transferred across the diagonal.  Because of this, Cicero had some tightness in his left shoulder, travelling up his neck and into his poll (hence the head tilt). 

 

Physiotherapy sessions

Cicero’s physio sessions consist predominately of manual therapy, using massage and soft tissue and joint mobilisations to reduce pain, stimulate healing of stressed tissue and increase mobility and flexibility. Especially tight spots, or trigger points, are targeted with phototherapy (aka LASER or redlight). 

 

Phototherapy has huge benefits in therapy by stimulating the release of endogenous opioids to relieve pain in tight muscles, and supporting cellular activity to help repair damaged tissues.  It’s a great tool for sensitive horses too as they cannot feel the light (beyond a gentle warming sensation), and it has the added benefit of relaxing them. After his facial surgery, Cicero was understandably sensitive to being ‘messed around with’ again, so this was a great treatment option for him. 

 

Kinesiotaping – supporting and activating the weak muscles

To address the weak right hind, alongside pole exercises (more on that later), I applied kinesiotape to Cicero’s quadriceps muscles (which flex the hip and extend the stifle – lifting and advancing the hindlimb). 

 

K-tape works by supporting the muscles and providing proprioceptive stimulus, essentially making the horse more ‘aware’ of the muscle and encouraging them to use it!  

 

By releasing the hamstrings with manual therapy and activating the quadriceps with k-tape, we started to influence Cicero’s ability to step up and through with that right hind.

 

Addressing the primary issue with homework

Walking and trotting over poles may seem ridiculous for a horse out jumping 1.20 courses, however, it is a hugely important and valuable therapeutic tool for all horses, improving core strength, proprioception (the body’s awareness of where it is in space) and, crucially for Cicero, it encourages equal use of ALL limbs; there can’t be a lazy limb as they all have to do the same amount of work! 

 

I saw huge improvement in the strength of Cicero’s right hind after just a few weeks of his polework regime.  We also incorporated some lateral polework to target Cicero’s one-sidedness, working towards equal flexion on each side supported by good old carrot stretches.

 

Of course as physios we will always be able to reduce pain and improve the function of the muscles through physio treatment.  However, in cases like these without appropriately targeted homework this is really only half the story.

 

Moving up the levels

We have made great progress with Cicero over the past few months, and following a fairly intense initial treatment plan he is now on a maintenance physio programme responsive to his level of work.  Lottie has been the perfect client, always following advice to the letter and completely onboard with Cicero’s programme. 

 

We have successfully managed his physio around his competition schedule without any interruptions, and most importantly, Cicero has ended a busy event season fit, well and without injury (it’s just a shame the same can’t be said of his rider!).

 

 

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