Rehabilitating A Horse With A Hindlimb Suspensory Injury

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Hugo's Story - The One Pound Pony:

For those of you who don't already know... we welcomed Hugo (aka The One Pound Pony) to our family in August 2024. He's a lovely 15.3hh Connemara x Thoroughbred who came to us with some physical challenges that needed addressing. Despite failing a vetting and showing signs of lameness, something about him convinced us to take a chance. What started as a lease agreement turned into purchasing him for just £1 - hence his nickname, The One Pound Pony!

Keep an eye out for Hugo's full story in my World article in the Spring-Summer 2025 magazine, where I'll share all the details of how this special boy came into our lives. Below you'll find videos documenting our rehabilitation journey together...

https://youtube.com/shorts/UXjjmLF6u0A

Our First Steps with Hugo

When Hugo first joined the IH family, we knew we needed a systematic approach to understand and address his challenges. For those of you who have completed the Online Horse Psychology Course, you'll recognize this systematic problem-solving approach from Week 6! Here's what we did in those crucial first weeks:

Initial physio assessment revealed key issues
Hind limb offloading and forward weight shift
Muscle wastage around withers
Significant back discomfort
Strong saddle aversion

Our in-house physiotherapist Abi Pass's full assessment revealed Hugo was typically standing in a 'downhill' position, offloading his hind limbs. He showed noticeable atrophy under the saddle area and reduced shoulder extension. The most concerning observation was his extreme reaction to the saddle - he would retreat to the back of his stable when it approached. There were significant muscle spasms around the saddle region and tension in his gluteal muscles, particularly on the right side.

Treating Poll Sensitivity

https://youtube.com/shorts/buxWYZrln5g

When Hugo arrived, his reactions to tack told us immediately we needed to address these issues. Here's how we approached both:

Saddle Challenges:

✓ Severe aversion to saddle
✓ Back muscle spasms
✓ Required careful reintroduction

The moment we approached Hugo with a saddle, his distress was clear - he would retreat to the back of his stable and his back muscles would actually spasm as the saddle came near. Instead of rushing to a full saddle fitting, we made a strategic decision. Daisy had a saddle of the appropriate size that could be adjusted with shims in the saddle cloth.

After consulting with our saddle fitter, we agreed it would be counterproductive to do a full fitting before Hugo was in better physical condition and ready for proper schooling. Through video consultations and careful adjustments, we found a comfortable temporary solution. We knew we'd succeeded when the spasms disappeared completely and Hugo stopped showing anxiety around saddling.

Key tip: Remember that saddle comfort is a two-way street - it needs to work for both horse AND rider. Our chosen saddle allows the riders to feel secure and comfortable too, which is crucial for building confidence together.

Saddle Assessment Webinar (Member-exclusive)

IH Trainer, Julia Fisher, lectures on Saddle Assessment on the Five Day Foundation course and has a wealth of knowledge...

✓ Completed in first week
✓ Results: All clear!

I got Hugo's feet X-rayed within the first week because if the feet aren't right, nothing is going to be right. The results were thankfully fine - a great foundation to build on.

Here's a tip: Check with your local veterinary practices about hoof X-ray costs. It's often more affordable than you might expect and is absolutely money well spent for peace of mind.

✓ Completed in first week
✓ Revealed allergy markers (Eosinophils at 7%)

Getting a baseline blood test was essential. The results showed elevated Eosinophils (marked as E or Eo) at 7% - normal is less than 3%. This matched his symptoms of coughing and thick nasal discharge. This finding actually catalyzed a big change in our yard management, leading us to create a more dust-free environment. Sometimes one horse's needs can improve life for everyone in the yard!

✓ Medium level (325epg strongyle)
✓ Presence of bot eggs

Hugo's worm count showed medium-level strongyles, but what really surprised us were the bot eggs on his legs and shoulders. I hadn't seen bot eggs since my Pony Club days! It was particularly curious as he'd only been living a mile down the road, yet we'd never had bots here. After appropriate treatment, we've implemented a regular worm count schedule. It will be interesting to see if the bot eggs return next year.

Bridle & Bitting Issues:

✓ Head-lifting evasion during bridling
✓ Facial expressions indicating discomfort
✓ Unusual growth near bit area
✓ Required expert consultation

Hugo's bridle issues were complex. He would raise his head as high as possible when approached with a bridle (quite a challenge for my shorter family members!), and once bitted, he developed an unnatural sneer, particularly pronounced on the left side.

Intriguingly, we discovered a marble-sized growth on the right side of his mouth, just above where the bit sits. (Update: this has gradually disappeared completely - quite curious!)

We took a systematic approach to solving these issues:

Expert Consultation:

Consulted Dr James Cooling (GP, IH Trainer and bit/bridle specialist)
Shared videos of:
- His mouth movement
- Ridden work in previous bit
- Dental procedures

Solution Implementation:

Switched to NS Demi Anki Loose 70mm bit
Removed noseband completely for observation
Monitored mouth relaxation and movement

Results:

Gradual improvement in acceptance
More relaxed mouth when in gentle contact
Reduced tension in facial expressions

We're still monitoring his response as we gradually return to schooling work, but the improvement in his general comfort and acceptance of the bridle has been remarkable.

Key Learning: Sometimes the solution isn't just about finding the right equipment - it's about giving the horse time to trust that the equipment won't cause discomfort."

What You Need To Know About Bridle Fitting

Kelly talks bridles with Dr James Cooling independent bitting and bridle fitting expert founding member of the Association of Professional Bit and Bridle Fitters (APBBF)...

✓ Examined by Dr Chris Pearce
✓ Multiple issues identified requiring attention

Our equine dental vet, Dr Chris Pearce, found several issues needing attention:

Unusual staining patterns suggesting uneven feeding habits Getting the mouth comfortable was crucial for Hugo's overall wellbeing and future training. The uneven wear patterns particularly explained some of his bitting issues and unusual hay-chewing patterns we'd noticed."

Perfectly even front bite (good news!)
Uneven wear on left side upper teeth, particularly outside Sharp points with corresponding pinpoint ulcers
Presence of peripheral caries
Overgrown lower tooth with slight rotations
Unusual staining patterns suggesting uneven feeding habits

Getting the mouth comfortable was crucial for Hugo's overall wellbeing and future training. The uneven wear patterns particularly explained some of his bitting issues and unusual hay-chewing patterns we'd noticed.

Common Misconceptions with Equine Dentistry

European Veterinary Equine Dental Specialist unpacks some common misconceptions around the Equine Dental industry....

Veterinary Assessment & Diagnosis

After noticing subtle irregularities in Hugo's movement—such as a slight hip hike and discomfort when transitioning to canter—it was clear a full veterinary workup was needed. We had already planned a thorough lameness evaluation with Dr. Jessica Kidd, a renowned equine orthopaedic surgeon with extensive experience in diagnosing and treating complex cases. Her expertise was crucial at this stage to pinpoint the issue.

One of the key signs that raised concern was Hugo’s inability to back up or shift his weight backwards—a serious red flag that didn’t improve with training. This suggested a physical issue, not just a behavioural one, highlighting the need for a professional diagnosis.

Veterinary Assessment

On a soft surface, Hugo displayed right hind limb lameness, especially on the right rein.
He consistently bucked during canter transitions and struggled with balance on the lunge, falling in on circles while keeping his head turned to the outside.
A nerve block on the deep branch of the lateral plantar nerve in the right hind limb was performed. Within minutes, the lameness switched to the left hind, confirming bilateral hind limb pain.
Radiographs of his dorsal spinous processes (DSPs) showed minimal changes, ruling out severe conditions like kissing spine.
An ultrasound scan of the proximal suspensory ligaments revealed a moderate lesion in the right hind and a milder issue in the left hind.

https://youtu.be/5V2g-ARaMps

The Diagnosis: Proximal Suspensory Desmitis (PSD)

Hugo was diagnosed with Proximal Suspensory Desmitis (PSD), a serious ligament injury affecting both hind limbs. If left untreated, this could lead to chronic lameness and limit Hugo’s ability to perform athletically in the future.

Understanding and Treating Proximal Hindlimb Suspensory Desmitis (PSD)

https://youtu.be/CCtYPIPqqb4

with Dr Jessica Kid

Veterinary expert Dr. Jessica Kidd, who we were fortunate to have overseeing Hugo’s case, takes a deep dive into proximal suspensory desmitis (PSD) in this informative video. She breaks down why hindlimb PSD is more challenging to treat than forelimb cases, highlighting the anatomical constraints that make conservative treatment less effective. Dr Kidd discusses surgical options like plantar neurectomy and fasciotomy, explaining how they help relieve pain and pressure on the suspensory ligament. She also covers non-surgical approaches, post-operative care, and key factors that affect a horse’s recovery. Additionally, she emphasises the importance of varied activities to reduce injury risk and offers insights into the best time to start a horse’s training.

Proximal Hindlimb Suspensory Desmitis (PSD) is a condition affecting the suspensory ligament at its origin on the back of the cannon bone in the hindlimbs. Due to the rigid anatomical compartment surrounding the ligament, swelling and inflammation lead to significant pain and functional impairment. This condition is a major cause of lameness in sport and performance horses and often requires specialized treatment due to its complex nature.

While forelimb PSD generally has a favourable prognosis with conservative management, hindlimb PSD is significantly more problematic due to anatomical constraints. The key difference lies in the structure of the hindlimb suspensory ligament, which is encased within a rigid compartment formed by the back of the cannon bone, splint bones, and a tough sheet of fascia. This anatomical setup increases the risk of compartment syndrome, making healing more difficult and pain more persistent.

Anatomical Constraints: The suspensory ligament in the hindlimbs has limited space to expand when injured, leading to compression and persistent pain.
Nerve Involvement: Compression can affect nearby nerves, leading to neurogenic pain, which can contribute to chronic lameness.
Lower Success Rate with Conservative Treatment: Unlike in forelimbs, where 90% of suspensory injuries heal with conservative treatment, hindlimb PSD only has a 10-14% success rate without surgical intervention.

For horses undergoing conservative treatment, the protocol includes:

Rest & Controlled Exercise: Initial rest followed by structured rehabilitation, starting with extended periods of in-hand walking.
Shockwave Therapy: Helps stimulate healing and alleviate pain.
Corticosteroid Injections: Can temporarily reduce inflammation but do not provide a long-term solution.
Stem Cell Therapy: Aims to repair damaged fibers in the suspensory ligament.
Corrective Shoeing & Hoof Balance: Addressing predisposing factors such as long toes and low heels can improve the prognosis.

However, due to the anatomical challenges of hindlimb PSD, many cases ultimately require surgical intervention for the best chance at recovery.

When conservative management fails, surgery is often the recommended course of action. The procedure consists of two key components:

Plantar Neurectomy: Cutting the nerves that supply the top of the suspensory ligament to reduce pain.
Fasciotomy: Cutting the rigid fascia to relieve pressure and improve circulation, similar to carpal tunnel surgery in humans.

Single vs. Multiple Orthopedic Issues: Horses with only PSD tend to have better outcomes post-surgery (~80% return to their intended use). Those with concurrent orthopedic problems may not recover as well.
Conformation: Horses with straight hocks, long sloping pasterns, or poor hoof angles are more predisposed to PSD and have a lower likelihood of full recovery.
Age & Training: Horses started later (around age five) may have better ligament strength, reducing the risk of PSD.

Immediate Post-Surgical Management: Box rest for a couple of weeks, followed by controlled in-hand walking.
Gradual Reintroduction of Load: Progressive increase in work to strengthen the ligament without causing reinjury.
Therapeutic Ultrasound & Physiotherapy: Help address secondary biomechanical issues arising from altered movement patterns.

Varied Training: Incorporating different types of movement can help prevent repetitive strain injuries.
Balanced Hoof Care: Proper trimming and shoeing to maintain good foot balance.
Monitoring & Early Intervention: Regular veterinary check-ups and prompt treatment of any early signs of lameness can improve long-term outcomes.

Hugo’s Rehabilitation Process

Following his surgery for Proximal Suspensory Desmitis (PSD), Hugo’s recovery was carefully structured to allow his ligaments to heal while gradually reintroducing movement.

For the first two weeks post-surgery, Hugo remained on strict box rest to allow initial healing. His daily routine included:

Hand-grazing twice a day for five minutes to provide mental stimulation while ensuring he didn’t overexert himself.
Daily monitoring of surgical wounds, using Leucillin spray to keep the area clean.
Regular physiotherapy with Abi Pass, focusing on gentle massage, lymphatic drainage, and weight shifts to aid circulation, reduce stiffness, and promote early healing.

At week 3, Hugo was introduced to small-pen turnout—a stable-sized enclosed area—allowing him some natural movement while keeping his activity restricted. This was essential in preventing stiffness without risking sudden movements.

At the same time, hand-walking was introduced, starting at 10 minutes twice daily and increasing by 5 minutes per week..

Led in a Dually halter with sidereins, ensuring balance without discomfort.

Walking routes were varied to prevent him anticipating grass time and pulling towards it.

As Hugo built more stability, we transitioned to long-lining to encourage engagement and self-carriage:

Straight-line work to minimize strain on healing ligaments.
Introduced gentle rein cues to improve posture and encourage correct weight distribution.

During this period, turnout was expanded to a tennis court-sized pen, allowing greater but controlled movement while preventing sudden exertion.

At this stage, Hugo was ready to increase engagement and mobility with raised pole work:

Helped strengthen his hindquarters and core muscles.
Encouraged proper weight distribution and coordination.

During this time, water treadmill therapy was introduced as an additional tool for controlled rehabilitation:

Used buoyancy to reduce impact, allowing him to exercise without excessive strain.
Encouraged hind limb flexion, core strength, and correct movement patterns.
Sessions were twice a week, with close monitoring to ensure he remained comfortable.

Hugo’s turnout was increased in carefully controlled stages:

Small-pen turnout (weeks 3-6): Stable-sized for early movement.
Larger enclosed turnout (week 12): Tennis court-sized, allowing more movement while keeping him contained.
Small paddock turnout (week 14): Introduced to restricted field access under supervision.
Full turnout (week 16): Allowed to roam freely, while still being monitored for signs of discomfort.

https://youtu.be/xlj22dg9Iqk

By three months post-surgery, Hugo was ready for ridden walking:

Short, controlled sessions focused on straightness, relaxation, and core engagement.
Light pole work under saddle to ensure correct posture.
Gradual rein contact as he built confidence and strength.