This OTTB Went From Kissing Spines Diagnosis To Makeover With Physical Therapy Instead Of Surgery

When Kathryn Jenkins and First Commander stepped into the ring as finalists for the 2020 Thoroughbred Makeover Show Hunter division in October 2021, it wasn't just the culmination of many hours of hard work – it was a comeback story.

Jenkins had found First Commander, fondly known as Mattis, in early 2020 as she was on the hunt for a new OTTB project. She had lost her last Thoroughbred to a rare neurological disease which had resulted in some explosive behavior and was ready for a new challenge in a quieter package. Mattis seemed perfect, and as a bonus, he was eligible for the 2020 Makeover class.

The Makeover requires eligible horses to have made a start or entered a published workout within a certain timeframe in advance of the competition year, as its goal is to showcase off-track horses at the very beginning of their retraining. When Jenkins found him, Mattis hadn't yet begun his under-saddle retraining but he looked relaxed, sound, and happy jogging and cantering at liberty in the field and passed a pre-sale veterinary soundness examination. He seemed sweet, quiet, and like he'd be a gentle kick ride – the perfect antidote to the intense, highly sensitive horse she had just lost. She fell in love immediately and took him home to her South Carolina base.

“He just seemed like a big dopey gelding who was real cute,” she recalled. “He seemed like maybe not the best mover, but he was what I needed at the time.”

Most horse owners have had a run of bad luck with their horses, where one problem sidelines them, only to be followed by another. Jenkins' early months with Mattis were defined by such a run. He made the move to the warmer, damper winter in South Carolina and broke out with a painful bout of rain rot. When he recovered from that, he popped a splint. After the nagging splint calmed, he came up with a suspensory injury. As those periods of rest/recovery/return to work wore on, Jenkins would notice odd bursts of attitude changes in her formerly sweet gelding – an unwillingness to go forward, sometimes sprinkled with sudden and aggressive tantrums. A diagnosis of serious ulcers seemed initially to be the explanation, but the progress he'd made after treatment quickly plateaued. When he came back from his lay-up with the ligament injury, he was a different horse – and not in a good way.

“Then the wheels really fell off. All the mean personality changes really came back,” she said. “I figured something was wrong, so I asked my vet to x-ray his back. She was like, 'Let's just rescope for ulcers' and I said 'No. Something's wrong with this horse. He's five years old. This doesn't just happen.'

“I was at work and she texted me pictures of the x-rays and didn't say anything. We'd found the problem.”

The radiographs showed a serious case of kissing spines, the common name for impingement of the dorsal spinous processes in a horse's back. When seen on x-ray, horses' vertebrae have long fin-shaped projections at the top. These are covered with muscle and tissue to form the rounded shape we're used to seeing when we throw a saddle on. Normally, there should be a gap in between each fin in a radiographic image, the same way there are gaps on x-ray between human vertebrae because those spaces are filled with soft tissue which doesn't show up on a radiograph. In kissing spines, the fins of two or more spinous processes appear in the image to touch, creating painful pinching and friction.

With the advent of digital radiography strong enough to take imagery of a horse's back, kissing spines has become a more common diagnosis among riding horses in recent years. Thoroughbreds are thought to be at a slightly higher risk than other breeds, but the disorder does not seem to discriminate based solely on age or breed. Affected horses experience significant back pain and may demonstrate this in a variety of ways, including resistance to exercise, unnatural or asymmetrical movement as they try to minimize the need to move their back, or personality changes. Secondary limb injuries can also be seen in cases where the horse will move forward but does so awkwardly.

This radiograph shows an example of kissing spines in another horse

One of the go-to treatments for many practitioners facing kissing spines is a surgery called inter-spinous ligament desmotomy, in which the ligament between two problematic vertebrae is cut, allowing the bones to move apart and return to their correct position.

“He's not really a surgical candidate because he doesn't handle stall rest well. At all,” said Jenkins, who had struggled to keep Mattis from injuring himself or others during his ligament rehabilitation, even with heavy sedation. “They said, 'You can try turning him out for six months to a year and maybe he'll fuse and you can have a retired 5-year-old. Or, nobody's going to fault you for putting this horse down.'”

In despair, Jenkins posted on her Facebook page about her options. That's when she heard from the trainer who sold her the horse, suggesting she reach out to Dr. Chris Newton, partner and ambulatory veterinarian at Rood and Riddle Equine Hospital.

Newton approached Mattis' case similarly to the way he approaches many other complex lameness cases – with the notion that the lameness problem a horse presents with is likely secondary to a longer-festering underlying cause, and with the idea that physical therapy can address that root cause long-term in concert with therapeutic drugs and (sometimes) farriery changes.

Prior to getting his veterinary degree, Newton grew up riding in Pony Club and eventing regularly. He still events alongside his veterinary practice, where he specializes in sport horse medicine, alternative medicine, physical therapy, and equine reproduction. His eventing experience has required him to understand dressage, and he has been able to combine some exercises from that discipline with his physical therapy approach to treating injuries in athletic horses.

Newton believes that veterinary understanding of kissing spines as a growing and recent problem may be influenced by our sudden ability to see it.

“Prior to the advent of digital radiography, we didn't even talk about it,” said Newton. “Luckily I'm with Rood and Riddle, which has access to pretty high levels of diagnostics. I began to shoot radiographs on all of my pre-purchases' backs, just as part of a study and would see a tremendous number of horses with impingement but who didn't have any pain.”

In fact, it's hard to know yet how many of those radiographic changes really are responsible for symptoms, and how many horses would x-ray the same way while appearing perfectly comfortable. Having a better system for imaging the soft tissues in a horse's back would help better define how active the problem is, but Newton said the types of machines that would be strong enough to make an examination of those tissues in an area as dense as a horse's back are probably a long way off for most equine veterinarians.

Newton's examination of Mattis did confirm significant back pain which coincided with the radiographic findings. In lieu of surgery, Newton injected Mattis' back muscles with a medication cocktail to reduce inflammation and cause mild numbing, and showed Jenkins how to use a set of long lines to encourage the gelding to stretch his head and neck down gradually, requiring him to lift slowly with his mid-back. A lifelong hunter, long lining was new to Jenkins, but she was willing to learn whatever she had to.

“It was amazing,” she said. “After his first injection, watching him move was incredible. He was a really nice mover, which I never would have known because he wouldn't go forward.

“Initially I was long lining him in the dark, in the rain. I would not miss a day.”

Mattis on the lunge, showing the stretching motion Newton was asking for. Photo courtesy Kathryn Jenkins

Unlike humans, horses can't be convinced to soldier on through physical therapy exercises that may initially cause pain or stiffness with a rational explanation about their long-term benefit, which is why Newton provides temporary pain relief while having owners work the muscles. The idea is the medication will wear off, but the horse's back and core muscles will get stronger in the interim, helping them hold proper posture. While repeated treatments may be needed, they should become less frequent as the horse's posture and gait improve, and eventually will no longer be necessary.

The physical work requires horses to stretch their head and necks down at the walk and trot, tightening their core and stretching their mid-back.

“In my opinion, [radiographic findings of kissing spines] is not the cause of pain, but it is the symptom of a hyperlordosis of the thoracic spine which primarily presents with neuromuscular pain and a progressive hyperlordosis due to inability to move the back,” said Newton. “So, accompanied with hyper-dorsoflexive physical therapy and pain removal, I have seen a significantly greater result than the surgical interventions that are currently being enacted.

“Just like treating carpal tunnel syndrome in humans, the surgical procedure, when not accompanied with occupational therapy, is fairly unsuccessful. The surgical procedure in horses not accompanied with physical therapy is fairly unsuccessful. I think that removing the pain and allowing the back to function in the anatomy that it has formed around since its fetal construction is a route we should go forward with in general.”

Jenkins is overwhelmed upon learning the pair came second in the 2020 Show Hunters division at the Thoroughbred Makeover

Now, a year after beginning the process, Jenkins said she has a different horse. Although Mattis never became a cuddly, in-your-pocket personality, his temperament is even and honest. She said he tells her the minute he encounters discomfort and trusts her to help them work through it together. He has discovered a love of the competition ring, adopting a focused and flashy effort there which he didn't have before.

Although dressage was completely new to Jenkins, she found herself entering both the show hunters and the dressage at the 2020 Makeover. The pair were the highest-placing amateur rider team in 2020 dressage, and were second in the show hunters in a five-horse final that was otherwise populated by professional riders.

In hindsight, Jenkins knows they climbed a mountain together – and that for many people, it would have been easier to move on to a different horse.

“I'm really stubborn,” she said. “That's probably a big part of it, and the other part is when we were having all these smaller problems, I didn't quite realize the bigger picture. Once I realized the bigger picture I thought, 'I can't have another horse die. If I can do anything to save him, I will.' My last horse, there was nothing I could do. With Mattis, I thought if I could give him a fighting chance, I'd do it. It's paid off tenfold because minus the terrible kissing spine, he's everything I wanted in a horse.”

Mattis and Jenkins plan to spend 2022 continuing in their home territory of show hunters, but also delve into jumpers and foxhunting, mixed in with their regular dressage work and occasional quiet trail rides. With the help of their physical therapy program, it seems the sky is the limit.

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Kissing Spines: What Is It, And Why Does It Seem Like It’s Everywhere?

The seemingly innocent term “kissing spines” actually refers to a potentially painful, performance limiting condition of the equine back. While kissing spines (impinging spinous processes) may seem like a diagnosis du jour, garnering only intermittent fad-like attention, Sue Dyson, an internationally renowned equine lameness expert, says this back problem occurs quite commonly in young, fit racehorses. In fact, Thoroughbreds have a higher frequency of occurrence of kissing spines than many other breeds.

In a normal spinal column, the individual vertebrae are lined up like a row of ducks. Long, thin bony projections called spinous processes extend upwards from these bony vertebrae (dorsally). Normally, these skyward reaching spinous processes should be physically separated from one another, even during locomotion. In some cases, however, the spinous processes end up crowding one another, gently touching or “kissing.” In severe cases, the spinous processes actually overlap one another.

As one can imagine, having these bony projections compressing on one another can severely limit performance.

“In the racehorse world, there seems to be a lack of awareness of the presence of musculoskeletal pain unless a horse shows overt lameness. In turn, there is a lack of recognition that back pain can compromise performance,” said Dyson.

According to Dyson, back pain may be mistaken for bilateral forelimb or hind limb lameness because it often results in shortened steps without overt lameness. In some cases, back pain is overlooked completely with the horse instead being described as a “scratchy mover.”

“Many racehorses have back pain that goes unrecognized, which may be compounded by a poorly-fitting saddle or a work rider who is not always in balance with the horse at all gaits,” Dyson said.

In fact, poor behavior or behavior changes may be the only obvious “abnormality” appreciated in horses with back pain, but this often goes unrecognized.

Horses with back pain, including those with kissing spines, may manifest their discomfort by:

  • Displaying abnormal behavior when tacked up
  • Stiffening the back when first mounted
  • Dipping (extending) the back when first moving forwards
  • Bucking
  • Exhibiting an unwillingness to bend or move forward as freely as normal
  • Bunny hopping in the canter
  • Failing to pick up or hold a specific lead on their canter

“Horses can even show behaviors that are sometimes attributable to the horse's untoward demeanor rather than as a result of pain,” Dyson explained.

Recognizing that behavior may be a valuable indicator of pain, Dyson developed a pain ethogram to help identify musculoskeletal pain in horses. This ethogram uses a set of 24 well-described and named behaviors that Dyson identified much more frequently in lame/painful horses compared with sound horses.

Those behaviors were subsequently categorized by Dyson based on the type of behavior, such as facial, body, or gait markers.

For example, facial markers suggestive of musculoskeletal pain included head tilting, rotating ears back behind vertical or lying flat for >5 seconds, closing eyelids for two to five seconds, and repeatedly exposing the sclera. Body markers included clamping the tail tightly and tail swishing, and gait markers were rushed gaits and spontaneous changes in gait.

To use this pain ethogram in real life, one or more evaluators observe the horse move during their typical work and specific exercises (i.e., straight lines, circles, and transitions in walk, trot, and canter under saddle). If the horse exhibits any of the 24 behaviors included in the ethogram, those behaviors are recorded.

“When this ethogram was validated in sport horses, the presence of eight or more of the 24 behaviors was highly likely to reflect the presence of musculoskeletal pain,” said Dyson.

While originally described by Dyson as a ridden horse pain ethogram (RHpE), she that research shows this RHpE can be used to help detect any form of musculoskeletal pain, including primary back pain associated with impinging spinous processes.

“I have not specifically tested the RHpE in racing Thoroughbreds, but I would be surprised if, with some modifications, it was not helpful,” she added.

If a racehorse performs poorly or displays abnormal behavior during ridden exercise, then the back should be examined carefully. The presence of muscle tension and pain or limited range of motion of the back should prompt radiographic assessment.

“Low-grade impinging spinous processes may not be a cause of pain, so infiltration of local anesthetic solution around the close spinous processes is necessary to determine their clinical significance,” Dyson suggested.

In other words, some horses with radiographic evidence of kissing spines may not be experiencing pain at those sites.

In sum, back pain and kissing spines should be considered even in young, apparently healthy Thoroughbred racehorses, especially those with behavior issues, a short-stepping gait or a reluctance to work. Failure to recognize primary back pain may lead to an alteration in gait predisposing to other problems.

Training and racing performance may be improved substantially by successful treatment of impinging spinous processes. Local infiltration of corticosteroids close to the narrowed interspinous spaces, extracorporeal shockwave therapy (ESWT), acupuncture, and mesotherapy are possible treatment options, with surgery as a last resort.

“Any treatment program should be combined with physiotherapy to help to release tight muscles and reduce muscle pain,” she said. “Management changes such as feeding from the ground to encourage back flexion, use of heat lamps or other heating methods prior to exercise, warming-up by walking on a horse walker before ridden exercise, and improving saddle fit will also helpful to try to optimize performance.”

Another factor to consider is that kissing spines may not only affect a racehorses' training and performance, but also their future careers once they have moved on from the track.

“In my role as a veterinary advisor to a racehorse rehabilitation center, we assess all horses' backs clinically and radiographically,” said Dyson. “We have had many horses that we have not been able to rehome as riding horses because of chronic back problems relating to severe impinging spinous processes and other secondary problems.”

Dr. Stacey Oke is a seasoned freelance writer, veterinarian, and life-long horse lover. When not researching ways for horses to live longer, healthier lives as athletes and human companions, she practices small animal medicine in New York. A busy mom of three, Stacey also finds time for running, hiking, tap dancing, and dog agility training. 

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Kissing Spines: A Manageable Disease, With The Right Treatment Program

The horse's spine is very different from a human's. Each vertebra has a fin-like projection called a spinous process that extends upward from the spine. The spinous processes form the horse's withers and back, and to them are attached thick ligaments and muscles. When two or more of these spinous processes are too close together, they may touch, which results in severe back pain from arthritic changes, inflammation, and even microfractures. These impinging spinous processes are called kissing spines.

A horse with kissing spines will be reluctant to flex its back, so it will not use its body to its fullest extent. It will tend to alter its posture and way of going to compensate, which creates imbalances that put undue strain on certain muscles, joints, ligaments, and tendons. The horse may refuse to perform certain functions that cause acute pain. If the rider isn't astute, he or she may attribute the changes in the horse to a leg problem or a behavioral issue.

Genevieve Faith and Catherine Hazelroth have horses with kissing spines. Faith's horse is a three-day eventing mare, Maggie, an unraced Thoroughbred, and Hazelroth's horse Stretch is a cutting Quarter Horse. Both women are clients of Dr. Tracy Turner, a board-certified surgeon in the Minneapolis area who, in 2011, completed a large, eight-year study of horses with kissing spines.

Unusual Symptoms

Faith brought Maggie to Turner when she was concerned the then-5-year-old wasn't maximizing her stride, reaching with her shoulders, or pushing off her stifles. Any engagement of Maggie's back muscles elicited pain.

“She overstressed her back muscles a lot, and her hind gluteal muscles were overstrained by working to compensate to get the pressure off her back,” Faith recalled. “If it is sore somewhere, a horse is going to work other muscles harder essentially to make it less painful. Whereas, with a leg lameness, you usually can see it somewhere throughout the leg itself.”

Hazelroth, a veterinary technician, bought Stretch as a 6-year-old from a Texas ranch. The sellers advised her that he had a history of problems with his hock, stifle, and trochanteric bursa (“whorlbone”), which would need to be injected regularly.

After taking Stretch back to Minnesota, Hazelroth tried to cope with his unusual quirks.

“He had really odd reactions during riding that I had not experienced before on other horses with healthy backs, like he was trying to run away from pain,” she said. “He had a weird flight response that didn't correspond with what I was asking him to do.

“The horse would hit a stop in front of a cow. Then, instead of turning with the cow like he was trained to do and his natural instinct is to do, he would just run forward out of his stop instead of rolling back through his turn.”

Hazelroth was puzzled when she pushed Stretch toward a cow and he would hollow his back and do a “dolphin” motion—pushing off with both hindlegs instead of using his hind end properly. Stretch wanted to keep his head up in the air and resisted when she took hold of him.

Trainers told Hazelroth her horse was hock sore because he didn't put weight on his hind end, or they said he was stubborn and advised her to get after him, ride him harder, put a bigger bit on him. But she wasn't buying it, so she turned to Turner, her boss for six years. Turner was amidst his large study of horses with kissing spines, so he quickly recognized Stretch was experiencing back pain. X-rays of the horse's spine confirmed his suspicion.

Menu of Treatments

Turner began each horse's treatment with shockwave therapy, one session a month for three months. Shockwave provides pain relief when applied to the location of the kissing spines and the muscles it affects. With less pain, the horses became willing to participate in a prescribed exercise program, designed for the individual horse's specific needs.

For Hazelroth's cutting horse, Turner added mesotherapy, a technique of multiple (720) injections of an anti-inflammatory solution into the skin, starting at the withers and proceeding over the back and croup. Some veterinarians use injections deep into the affected muscles. Because Stretch primarily was exhibiting nerve pain, Turner suggested that Hazelroth get him a magnetic blanket. She additionally bought a Back on Track blanket, which provides soothing, dry heat.

“The combination of everything we did really helped Stretch to loosen up that back and carry himself in a different way,” Hazelroth said. “He lost a lot of the tension in his back and learned how to carry himself for the first time in his life in a little bit more of a dressage frame, which kept his back and his stifles a lot happier.”

A radiograph from the start of Maggie's treatment shows where she had vertebrae touching

Kissing spines is characterized as Grades 1 through 5, with 5 being the worst. Faith's mare has Grade 4 kissing spines, or “severe overriding,” which makes it virtually impossible to insert a needle to inject the spinous processes. Turner instead administered Osphos, a bisphosphonate, with good results. Maggie gets Osphos every six months as pain management.

Faith enlists a chiropractor before eventing season begins to assure Maggie is in alignment for competition, and Maggie gets regular massage therapy throughout the season to assure she is comfortable while competing.

Owner-Friendly Maintenance 

Horses with kissing spines need lifetime maintenance and possibly management changes, depending on the individual horse.

“Maintenance is really an owner-friendly program, which, of course, makes it easier to follow,” Hazelroth said. “Mesotherapy and shockwave treatments only take maybe a total of 30 minutes combined. In terms of riding him differently, I'd say that came pretty easy for him once he started feeling better. The blankets and such were an easy at-home management program. Put the magnetic blanket on for two hours while he was eating dinner with a fan on him so he wouldn't overheat, then swap that out and put the Back on Track blanket on overnight.”

Faith has a custom-fit saddle for Maggie, and she has to ensure the mare maintains good weight. Faith doesn't allow Maggie to get long breaks because if she starts to lose muscle along her spine, she gets back sore, which sets her back to square one, needing 12 weeks to get her fit again.

“You don't want them to have an injury, so if you can make them strong, you can protect that back,” she said.

Stretch returned to competition and was successful in cutting horse shows until he retired at age 17. For the past two years, he's been an energetic trail horse who likes to cruise at a brisk trot, Hazelroth said.

Maggie also returned to the show ring, doing well while competing in FEI three-day events that consist of dressage, stadium jumping, and cross-country.

“She's fantastic. She loves competition,” Faith said. “Dressage is our weakest phase, and I attribute a lot of that to the kissing spines.”

Faith added that owners of horses with kissing spines should be encouraged.

“It is quite manageable as long as you go through the options, because each horse responds differently,” she said.

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