Q: My 16-year-old Oldenburg gelding has been experiencing progressive left hock and back pain for about two years now. I took him to a well-qualified sports-medicine veterinarian, who x-rayed his back and hock and diagnosed kissing spine (impingement of the dorsal spinous processes) and hock arthritis. Initially, he received antibiotic and steroid injections in both locations; later he was injected with hyaluronic acid along with the antibiotic and steroid. The injections were repeated every four months. 

Last spring he developed worsening pain after the back injection, and since that time I have had only his hocks injected. He has definite improvement within two weeks of hock injection, but the back pain seems to have worsened over the past year. 

He grinds his teeth when he backs up to have his stall door opened, and he can no longer tolerate extension of his left leg backward for shoeing. He loses his balance unless we can get him to lean on the wall to his right side.

He does not, however, seem to have trouble with the weight of the rider and he is comfortable with his saddle. Walking forward relieves his pain; in fact, he loves to ride up the road and into the woods. We do not trot anymore unless he initiates it, and I have not asked him to canter under saddle for a year or jump in the past two years.

He spends his days in a large stall with a walk-out paddock and is out in a large paddock all night, with five hours in a large grassy field in the morning. Just last fall he was galloping in the field and cantering, flipping leads freely with his pasturemates. 

I am worried that his back problem is reaching a point where it can’t be treated. Veterinarians have suggested stem cell therapy for his hocks, but I feel his primary problem now is in his back. Is surgery ever advised for kissing spines, or is there some type of physical therapy I could do? 

My veterinarian told me his back is too “hypermobile” for chiropractic treatment. Is there a center or a specialist in the United States who is interested in this problem? This horse means a lot to me.—Denise F. Poulin, MD; Greenfield, New Hampshire

A: When I was in veterinary school more than 30 years ago we were taught that 85 percent of all back problems in horses are secondary to hind-limb lameness. I can comfortably tell you now that percentage is far less. Certainly almost all hind lamenesses will have a sore-back component, but there are many, many horses like yours with primary back pain issues.

Many lamenesses that I see have a multiple site involvement. Think of a horse as a card table: When one leg is off balance, the whole table wobbles. Once we put a matchbook under the appropriate leg, the table stabilizes.

Horses can balance a slightly asymmetrical leg for a while, but eventually we will see compensatory lameness issues somewhere other than the primary source. It may be manifested in soreness in the neck, back, suspensory ligament or anywhere else in their musculoskeletal system. To manage the condition, we need to try to identify all involved areas.

Your horse sounds like he is loading in different areas to make up for a sore hock and sore back, and you will be unable to fix either problem without addressing the “whole” horse. I am sure it won’t be a surprise that I don’t have great news for you, but there are some options for you to explore:

  • More accurately placed injections. The new portable digital radiograph machines may produce a higher resolution image of your horse’s kissing spines, and an ultrasound may also be helpful to see a desmitis (ligament damage or inflammation) in the dorsal ligaments of the back. These examinations may be useful if they can pin-point a better target for injections, which can produce dramatic, albeit temporary, improvement.
  • Surgery. Surgical procedures to relieve the spinal impingement in kissing spines are usually unrewarding. Often the source of the pain is not at the top, where the vertebrae actually touch, but down at the facet joints that articulate vertebra to vertebra, where there may be arthritis. Remember, an accurate diagnosis is the cornerstone to an effective treatment.
  • Chiropractic care. I have some concerns about chiropractic care: We don’t know in which direction to move those bones and we can risk making the problem worse. Even if we manipulate the surrounding tissues and create pain relief, the results will be temporary because the primary disease will not just go away. That said, chiropractors have been able to help manage chronic pain in many of my elite-athlete patients.
  • Acupuncture. I have the same concerns about acupuncture as I do about chiropractic care. However, I have never seen a worsening of symptoms after acupuncture, and it may help manage chronic pain. Either therapy might provide your horse some short-term relief. Just don’t expect a “fix.”
  • Stem-cell therapy. This treatment involves harvesting stem cells from a horse’s body and injecting them into the joint to encourage repair of the damaged cartilage. I use stem-cell therapy often in my practice and have had some remarkable results. The
    arthritis in your horse’s hock may be too far progressed for stem cells to be helpful, but that is also another avenue to explore.
  • Alternative pain treatments. Shock wave treatment (for both back and hock), massage, laser and electromagnetic treatment may be helpful as well for the management of pain in both sites.
  • Medications. Nonsteroidal anti-inflammatory drugs may be effective. These include old standbys like phenylbutazone and flunixin as well as the new Equioxx, which is especially beneficial if he has gastric ulcers. This may be important because chronic pain can cause the stress that leads to ulcers. Remember, there are thousands and thousands of Americans who take daily anti-inflammatory drugs to manage their arthritis symptoms and have a great, useful and oftentimes athletic life.
  • Exercise and weight control. Lastly, watch his weight and make sure he has regular exercise. I just lost 30 pounds, and all of my middle-age aches and pains feel so much better! Our horses are no different. Movement, stretching and exercise are an important aspect to his health.

At the end of the day, all treatments may be temporary. But it sounds like you’ve been “listening” carefully to what your horse is telling you and won’t push him beyond his abilities. Good luck with him. Your care and concern will serve him well for many years to come.

Richard B. Markell, DVM
Encinitas, California