The Straw That Broke the Horse’s Back: Is Lower Back Pain Self-limiting in Equestrians?

When working with riders, practitioners must identify the discipline and level at which they compete. For example, there is a big difference between novice dressage and Grand Prix. In short, the more novice dressage rider will rise up and down from the saddle in the trot gait, which reduces forces through the back. More skilled riders look like they are doing less despite sustaining the same or higher forces, and this is a monumental neuromuscular coordination task⁽⁷⁾. Should the rider be experiencing lower back pain, they must remain seated in the saddle and use their pelvic girdle, trunk musculature, and spine to absorb the shock. Researchers from Hartpury College surveyed elite British dressage riders and found lower back pain may negatively impact performance. The pain affects the rider’s coordination dynamics, affecting the horse and their combined performance⁽⁸⁾.

Show jumping riders go through the canter gait over several fences that can reach 1.65 meters high and two meters wide. They absorb most of the shock through their hips, knees, and ankles. This is known as ‘light seat,’ and they are predominantly in this position when riding. However, when the rider lands from a fence, a considerable amount of force is also absorbed through the spine⁽³⁾.    

Advanced riders achieve more synchronicity and coordination with the horse’s movement when compared to novice riders⁽⁹⁾. Moreover, amateur riders have a higher incidence of lower back pain even though they spend significantly less time in the saddle than advanced riders⁽¹⁰⁾. Researchers from the University of Primorska in Slovenia aimed to describe the neuromuscular mechanisms that advanced and novice riders utilize to manage shock forces when riding. Using EMG and inertial measurements, they found that the more advanced riders attenuate shock better due to the timing of muscular contraction and not the level of contraction alone^(7,11). They initially hypothesized that the advanced riders would have better shock attenuation due to the timing of contraction and level of muscular contraction in relation to maximal volitional contraction (MVC). However, the MVC was lower in the advanced group than expected⁽¹¹⁾. Experienced riders control their body position better by correctly timing the contraction of the antagonistic erector spinae and rectus abdominus⁽⁵⁾.

Therefore, it appears that advanced riders are better at anticipating the impact of a horse’s stride at a neuromuscular level when compared to novice riders⁽⁷⁾.

Managing equestrians

Horse riders are passionate and strive to continue riding despite injuries⁽³⁾. Practitioners cannot overlook the power of the athlete’s relationship with their horse. Horse-riding differs from other sports due to the horse-rider relationship. Practitioners must understand the biopsychosocial factors that affect horse riders, particularly when providing pain and injury management guidelines. Anecdotally, they will likely find another therapist if one tries to stop them from riding. There is a dogma in the equestrian world that athletes are expected to ride with pain, whether it is recreational or professional⁽³⁾.

Patient Education

1. Educate the athlete about current pain science theories and how they are more empowering than limiting⁽¹⁾
2. Explain misconceptions in lower back pain therapy, the most notable⁽¹⁾:
   1. Flare-ups don’t have to indicate tissue damage
   2. Scans are not always needed to identify the cause of the pain
   3. Repeated spinal loading does not result in tissue wear-and-tear
   4. Pain during exercise therapy does not indicate that the treatment is not working or is causing more damage
3. Align therapy with patient expectations to increase success⁽¹²⁾

Temporary activity modification

Temporary activity modification provides the athlete with relief from symptoms while continuing to ride. Practitioners should identify which gait is the most uncomfortable on the rider’s back and then may advise that they reduce the time spent practicing that gait. For riders with current back pain, the ridden walk seems to positively influence pain intensity⁽³⁾.

Practitioners should also identify if there is a way to make the painful gait more comfortable. For example, if a higher-level dressage rider needs to do a predominantly sitting trot, switch up to a rising trot for a brief period, which transfers the shock absorption to legs and stirrups, not through the rider’s spine and pelvis. 

As horse riding is often an escape for many athletes, identifying cross-training rides may modify mechanical loads and irritations while providing psychosocial and skill benefits. For example, out-rides are a fantastic alternative to more intensive and competitive disciplines. Other modifications that practitioners can advise include temporarily reducing fence height during show jumping or spending more time doing less intense ‘flatwork’ while symptoms settle.

Interestingly, for some athletes, increasing activity on the horse may positively affect pain⁽³⁾. For example, 61.6 % of dressage riders report symptom improvement when riding. However, this was only true in 40.9 % of show jumpers⁽³⁾. This further reiterates the complex biopsychosocial factors at play in lower back pain. 

Out-of-the-saddle training

There is very little research on the type of training most effective for improving riding performance and pain management. Working on early reaction and pre-activation of the core muscles could increase riding performance and decrease the rider’s spinal loading. This may alleviate a current episode of lower back pain. Furthermore, practitioners should add plyometric and proprioceptive exercises to a rider’s training regime to improve general conditioning.

Participating in an eight-week core fitness program can significantly affect rider symmetry. This may be an essential method for reducing asymmetrical loading on the horse, thus improving performance⁽¹³⁾. In addition, exercise therapy continuously demonstrates benefits for low back pain management⁽¹⁴⁾. There is potential room for improving the rider’s self-efficacy and fear-avoidant behavior with out-of-the-saddle exercise therapy, and adding strength and conditioning will enhance performance and possibly prevent injury.

Riding into the sunset

Horse riders are a challenging population to work with. It is an extremely dangerous sport with high injury rates. Sixty percent of the injured riders did not seek medical attention after injury, and physiotherapy consultation was even lower at 10.3%⁽¹⁵⁾. Preparing athletes for the specific demands of horse riding is not a new concept. Strength training reduces the prevalence of injuries and builds biomechanical robustness⁽¹⁶⁾. For example, spinal discs may adapt positively to loads imposed on them^(17,18,19). Therefore, practitioners must seek proactive and preventive measures when managing athletes with low back pain. Practitioner-athlete relationships must improve to help more riders successfully treat injuries and manage pain.

References

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