The Real Problem: Lack of Structure and Individualisation
Many rehab journeys follow the same loose structure:

• Box rest
• ​Graduated walking and trotting program
• Scans look clear
• ​Owner told to gradually return to full work
• Re-injury ?

In theory this should work, so why does it so often fail? It's because it's missing structured progression, exercise specificity, measurable outcomes, and individualisation to the horse in front of you. What works on paper doesn’t always work in practice, especially when owner time or experience constraints, co-morbidities, and horse behaviour are involved.

There Is No “Recipe”
Rehab isn’t prescriptive by injury type. A superficial SDFT disruption in a 20 year old low-level pleasure horse requires a completely different approach than the same injury in a young high-level showjumper.

Each plan needs to consider:

• The horse’s job and functional demands
• ​Owner capacity (time, skill, environment)
• Response to previous training loads
• Comorbidities or past compensation patterns
• ​Baseline strength and symmetry
  
  

Think of Exercise like Medication
It helps to reframe exercise prescription in a similar way to medication dosing:

• Too little = no tissue adaptation, delayed healing 
• Too much = overload to tissues, risk of re-injury
• ​Just right = positive adaptation (i.e. things get better!)

If we can get more precise about exercise dosage — frequency, intensity, type, time, and progression, we can move away from “one-size-fits-most” protocols and start getting better results for our clients and their horses.

Practice What You Preach
As rehab professionals, we need to lead the process, this means actually showing our clients what to do, not just giving a handout and hoping for the best! That means:

• Completing the program with the horse and handler during consults
• ​Teaching correct execution of exercises
• Tracking meaningful, objective markers
• ​Adjusting programs based on the horse's response, not a calendar
  
  

Rehab isn’t linear. But with structure, strategy, and data-driven decisions, we can significantly reduce the re-injury cycle and give our clients a better shot at long-term soundness.

If you want to improve how you deliver your exercise programs, check out our software, EQ Active.

If you want to learn more about how to best structure and design rehab programs, we've created some resources to help. These include our popular book, and webinar series.

Comparing Tendon Rehabilitation: Humans vs. Horses

How Human Tendon Rehab Works Tendon rehab is built on the principle of progressive loading—gradually increasing stress on the tendon to stimulate healing and strengthen the tissue. Some of the key approaches include:

• Heavy Slow Resistance (HSR) Training: Lifting progressively heavier weights at a slow, controlled tempo to build tendon strength.
• Tendon Neuroplastic Training (TNT): Using external pacing (e.g., metronomes) to retrain neuromuscular control.
• Relative Rest Instead of Complete Rest: Tendons need load to heal. Athletes reduce intensity rather than eliminating movement altogether.
• Pain as a Guide: Mild discomfort is acceptable, as avoiding all pain often leads to underloading and poor recovery.
  
  

How We Rehab Horses (and Where It Falls Short) In contrast, equine tendon rehab has traditionally focused on:

• Prolonged Rest: Many protocols start with months of box rest, leading to de-conditioning.
• Strict, Gradual Walking Programs: Increasing exercise based on time, rather than placing progressively heavier loads to facilitate adaptation and prepare for a return to work.
• Minimal Strength Training: Unlike humans, where resistance exercises are used to strengthen tendons, horses rarely undergo targeted tendon-loading exercises.
• No individualised approach: The same program is typically prescribed to each horse, regardless of factors such as severity of injury, age, discipline or other co-morbidities. 

The result? Many horses suffer re-injury upon returning to work because their tendons haven’t been conditioned to adapt to the higher loads that come with a return to full work.

Why This Approach Needs to Change
Tendons require mechanical loading to remodel and strengthen. They are mechanosensitive tissues, meaning they require appropriate mechanical loading to stimulate collagen synthesis, maintain structural integrity, and enhance tensile strength. Load reduction is necessary to in cases where injury has occurred, but we should not eliminate all mechanical stimuli. When a horse is kept on strict rest, the tendon doesn’t get the necessary stimulus to adapt. 

Meanwhile, in human athletes, studies show that progressively increasing load leads to better long-term outcomes. The key isn’t avoiding strain altogether but ensuring the appropriate type and amount of load.

Applying Human Rehab Principles to Horses
If we take what works in human medicine and apply it to equine rehabilitation, we may be able to create more effective rehab strategies. Here are some things to consider:
1. Replace Prolonged Stall Rest with Relative Rest

• Instead of complete rest, consider if load reduction is more appropriate, such as reducing frequency or intensity of sessions but not necessarily stopping work altogether. 

2. Incorporate Strength and Neuromuscular Training

• There is no reason to not give more specific exercises, as opposed to just "hand-walking". The use of groundwork exercises, poles, and proprioceptive tools can be applied in early stage rehab if prescribed appropriately.
• Use progressive load increases (increasing the intensity of exercises) rather than time-based progressions (just walking for longer periods of time).

3. Monitor and Adjust Based on Response, Not Just Time

• Instead of rigid timelines (e.g., “six weeks of walking”), use measurable criteria that determines when the horse is ready to progress to the next stage.
• Employ gait analysis tools or simple tracking methods to help guide this.

4. Tailor to the Individual Horse

• Don't employ a "one size fits all" approach, but design a program based on the individual horse, taking into consideration factors such as:
  • age of the horse
  • discipline
  • owner availability, resources and skill
  • severity of the injury
  • other injuries or issues

Where to Learn More
​If you’re ready to rethink equine rehab, explore our book, A Practical Guide to Exercise Prescription in Equine Rehabilitation and EQ Active—a platform designed to help equine professionals create structured, progressive rehab programs.

Early-Stage Rehabilitation: Settling Things Down

This stage focuses on gentle, controlled exercise to support tissue healing and manage pain. Research shows that even a single bout of exercise can reduce pain through multiple analgesic mechanisms (Lesnak & Sluka, 2020). However, careful attention must be paid to exercise dosage to avoid overloading fragile tissues. Activities might include:

• Walking on flat, straight surfaces.
• Ground exercises to improve weight shift and mobility.
• Incorporating flat poles for variety.

Mid-Stage Rehabilitation: Building Back Up
​​
As tissues heal, the focus shifts to gradually increasing the load on bones and soft tissues to promote adaptation. This phase often requires ongoing adjustments to maintain progress and client compliance. Exercises at this stage may include:

• Faster speeds, circles, and slopes.
• Raised poles or more complex pole configurations.
• Ground and ridden exercises targeting strength and stability.

Late-Stage Rehabilitation: Preparing for Return to High Performance
​
This often-overlooked stage ensures that the horse is ready to handle the demands of full work and competition. Without progressive, discipline-specific training, horses are at risk of re-injury. Advanced exercises might include:

• ​High-intensity training and sport-specific movements.
• Gymnastic jumping, lateral movements, and collected gaits.
• Longer, more intense training sessions with varied surfaces and gradients.

Why It Matters
​
Each stage requires careful planning and progression to avoid overloading tissues and to ensure the horse is physically and mentally prepared for the demands of its job. By gradually introducing variables like speed, surface changes, and obstacles, we can safely guide horses through the rehabilitation process.

Want to learn more about crafting effective rehab plans for your equine patients? Check out our book for detailed guidance and practical insights, or subscribe to EQ Active, our exercise prescription software to create customised programs that will allow you to effectively guide your clients through each rehab stage.

​Getting the right balance when it comes to rehabilitation is key, and it can be difficult for owners and practitioners to know how to get this right. Train too little, and their horse plateaus, often with signs such as no muscle growth, minimal mobility gains, and slow recovery. Train too hard, and this is often when we see the risk of serious setbacks. Signs the horse may show in this situation are behavioural changes, swelling, lameness, or even re-injury. The difference between success and failure in equine rehab often boils down to one simple but crucial question: is the workload “just right”?

What often happens in equine rehab is starting out in the “too cold” zone and then making a sudden leap into the “too hot” zone once the horse is considered sound. Owners and practitioners tend to be extremely cautious in the early stages. Typical hand-walking programs are often under-dosed, placing minimal and very low loads on injured tissues for prolonged periods.

Over time, the horse naturally appears more sound. At this point, owners are frequently advised to resume “normal” training but often receive little guidance on how to safely transition back to full work. As a result, many go too hard, too fast. The recovering tissues, which haven’t been exposed to progressive loading to adapt to increased demands, simply can’t handle the sudden change. Essentially, we go from hand-walking a horse for 30 minutes a day to putting a rider back on board and quickly introducing trot and canter. Imagine if you’d been limited to walking after an injury for months and then were suddenly asked to go for a 5km run! This is when re-injury is more likely to occur.
​
Why can getting this right be difficult?
Unlike people, horses can’t tell us when they’re sore or tired. Small signs—subtle changes in movement, resistance during work, or even a minor shift in behaviour—may be their only way to communicate that something’s wrong. And if we miss these signs, the consequences can be significant. 

Without a reliable way to gauge the training load, it’s easy to slide into the “too cold” zone, where little progress is made, or the “too hot” zone, where injuries flare up.

​So, how can you be sure you’re getting it right?
In order to take the guesswork out of determining if the load is “just right“, objective outcome measures should be used wherever possible. Examples can include objective gait analysis, palpation and atrophy scales, and posture measurements. Regular measurements are essential to determine that the horse is on, and stays on, the right path.

Rest matters too. While the training load may be “just right“, if the rest / recovery time is too short, negative changes may occur.
​
Rehab involves smartly pushing boundaries. Move too fast, and the horse may go from sound to sidelined. Progress too cautiously, and you may never see results.

In our book, A Practical Guide to Exercise Prescription in Equine Rehabilitation, we explore evidence-based strategies, real-world examples, and practical tools to help practitioners determine those "just right" loads. If this is an area you need some practical guidance in, we highly recommend you check it out!

In equine rehabilitation, much like baking, the foundation is essential. For a cake, the basics—flour, eggs, milk, and butter—form the core structure. Similarly, in equine physiotherapy and rehabilitation, the key ingredients are exercise, load management, nutrition, optimal biomechanics and rest/recovery. These elements lay the groundwork for any successful equine exercise program.

Just as a cake can be enhanced with flavouring, icing, or toppings, adjunct therapies in equine rehab—like manual therapy, electrotherapy, or supplements—can add value. These extras can help reduce pain and potentially speed up recovery, but they are not substitutes for the foundational components of a horse's rehabilitation program. Many horse owners may seek out these “quick fixes,” expecting rapid results, but it’s crucial to remind them that without the foundations, such as appropriate exercise and load management, these treatments will seldom be effective on their own.
​
Often, people say equine physiotherapy or rehabilitation has failed, attributing the lack of results to the “wrong” treatment. In reality, the issue is often that these treatments are applied without the essential foundation. The adjunct therapies are like frosting on a cake—they can enhance the outcome but cannot stand alone.

Furthermore, just as the brand of ingredients in baking rarely changes the outcome, the specific exercises used in an equine exercise program can vary as long as they are progressively loading the targeted areas. What matters most is the balance, order, and amount of each exercise, much like the precision required in measuring baking ingredients. Understanding the complexity of movement and the demands on a horse’s body is key to tailoring an effective rehabilitation program.
​
By reinforcing these fundamental principles of equine rehabilitation, you can help your clients understand that the best results come from a balanced approach, with a strong foundation of exercise and recovery strategies.

If you struggle with knowing how best to design an equine rehabilitation program, we have developed some educational resources to help you out.

These include:
1. Our book, A Practical Guide to Exercise Prescription in Equine Rehabilitation, available both as a digital download and a hard copy.

2. Our 3 part webinar series, Mastering Equine Exercise Prescription.

4. Our series of “cheat sheets”, the first of which is all about knowing the effect of different rehab exercises and tools, and is available to download now.

5. Two FREE eBooks all about the basic principles of exercise rehab and how to increase client compliance with their home exercise programs

6. Professional consults and mentoring - if you need more individualised and tailored advice, we can help you consult on cases or provide mentoring services. Contact us to learn more about how we can work together.

1. Define your target market: Clearly define your target market by identifying the specific demographics, such as age, gender, income, and location of your ideal client.
 
2. Understand their needs and pain points: Understand the needs and pain points of your ideal client, this will help you to create services and solutions that meet their specific requirements.
  
3. Look at your current client base: Look at your current client base and identify patterns in their demographics, needs, and behaviours. This will help you to identify the characteristics of your ideal client.

4. Use data and research: Use data and research to identify your ideal client, this can be done through surveys, focus groups, and market research.
 
5. Ask for feedback: Ask your current clients for feedback on your services, this will help you to understand their needs and identify areas for improvement.
 
6. Consider the client's journey: Consider the client's journey, from their initial contact with your business to the end of their own or their horse's treatment, this will help you to understand their needs and preferences.
 
7. Test your assumptions: Test your assumptions about your ideal client by reaching out to potential clients and gathering feedback. This will help you to validate your findings and make any necessary adjustments.

8. Continuously evaluate: Continuously evaluate and update your understanding of your ideal client as your business and market evolves.

 
Goal Setting
 
As a practitioner we must consider not only what are we trying to achieve in our programming, but what are the goals of the owner. Points to consider include:

• Is a full recovery likely or will there need to be lifestyle or discipline changes?
• What are the owner’s expectations and goals? Are they realistic and how will you manage them if they are not?
• Consider the owners long term or ultimate goal and break it down into the smaller short-term goals that will help achieve this big goal. Ticking off these short-term goals can be motivating for the owner and help them see a path to recovery.

 
Program Design
 
Before we start to plan our programs, it’s important to consider the capacity of the owner. We want to ensure that we set our owners up for success and we need to consider the owner’s ability to commit to our rehab programs.
 
Once we start to plan the program, some of the areas to consider include:
 
Strengthening
 
Strengthening exercises are used to progressively improve neuromuscular control and load and strengthen musculoskeletal tissues, with the overall aim of strengthening to adapt the horse to the demands of performance.
 
A basic principle of training is that a single exercise session leads to fatigue and mild cellular damage which, in turn, results in short-term adaptive responses. When exercise is performed regularly and training stimulus is increased gradually, the adaptation that occurs during the recovery period of a single training session leads to an overall improvement in performance. Thus, the basis of any training program is to continually provide increased levels of stress to the physiological systems to improve performance.
 
However, it is important to appreciate that there is an upper limit for these adaptations and that individual horses will differ in relation to how well they can cope with this stress. When training is too vigorous and/or rest periods between training sessions too short, performance is reduced due to an imbalance between training stress and recovery.
 
The time before exposure to the next training stimuli should be of sufficient duration to allow time for the training effect (adaptation) from the previous session to occur. If not, then performance decrements can occur in the form of earlier onset of fatigue within each session. Recovery time / strategies are equally as important to schedule in a program as load!

​Cardiovascular Training
 
The aim of cardiovascular training is to increase heart rate without aggravating the injury.
Some examples include swimming / water walker or treadmill, ridden submerged water training (RSWT), lunging / long lining and restricted riding.
 
Preliminary results from a recent observational study have established for the first time that RSWT can be classed as a moderate submaximal intensity exercise in elite event horses whilst restricting an increase in temperature of the distal limb that is commonly associated with tendon rupture. It involves submerging a horse up to sternum height and trotting for set intervals.
 
Training loads can be measured using tools such as heart rate monitors, GPS and activity trackers.
 
Proprioceptive training
 
The aim of proprioceptive training is to increase the speed and efficiency of neuromuscular control to prevent reinjury. Ligament, tendon, and joint injuries are often accompanied by proprioceptive impairments, which often persist after the acute injury phase.
 
The closed loop feedback system implies that when a movement command is generated the intended motion is compared with feedback regarding the body’s status and the relationship with its environment. From a neuromotor control perspective it is an extremely valuable tool to utilise the closed loop to facilitate appropriate or change an existing trunk or limb motion in equine rehab and performance enhancement. It can be utilised very effectively in the horse by applying sensory facilitation aids directly to the horse’s skin or body, such as tape, resistance bands and tactile stimulation bracelets.  
 
You can also utilise progressive balance exercises such as weight shifting, stability pads, picking up opposite/diagonal limbs, poles and walking on different surfaces.

Measuring progress
 
Measuring progress is vital to help us to amend or progress the program. Ideally it should be objective where possible. Providing owners with simple tools to measure their own progress along the way can be extremely motivating and make them feel in control of their progress. Simple examples might include regular photos to monitor posture or muscle bulk or counting the number of times a horse trips or displays specific pain behaviours within a session.
 
Progression of rehabilitation programs includes type of activity, duration, intensity, frequency, and complexity. Consider changing just one variable at a time in order to avoid overloading too quickly.
 
Pain Management
 
In conjunction to the exercise component of a rehabilitation program, other interventions such as medication, manual therapy and electrotherapy may play a role in helping to manage pain and encourage healing.
 
It’s important to consider that exercise plays a role in pain management too and reassure our clients not to be fearful of encouraging movement and exercise in their injured horse.
 
Exercise Compliance
 
Compliance is one of the biggest challenges therapists face in regards to rehabilitation programs. There has been a recent increase in the use of apps to deliver home exercise programs, as opposed to more traditional paper handouts. Preliminary research suggests in some groups there may be increased compliance and improved outcomes in patients with the use of app-based delivery of programs, however communication with the therapist was a key part of the intervention. Further research is needed, however apps can be an effective way to motivate and check in on patients, along with being a time saving tool for the practitioner.
 
EQ Active is an equine and rider specific platform, that also allows you to access canine and human content from our partners.

To learn more and to try it free for 30 days, head over to www.eq-active.com

​References
 

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• Atalaia, T.; Prazeres, J.; Abrantes, J.; Clayton, H.M. Equine Rehabilitation: A Scoping Review of the Literature. Animals 2021, 11, 1508. https://doi.org/10.3390/ani11061508
• Chaabene, H., Behm, D. G., Negra, Y., & Granacher, U. (2019). Acute Effects of Static Stretching on Muscle Strength and Power: An Attempt to Clarify Previous Caveats. Frontiers in physiology, 10, 1468. https://doi.org/10.3389/fphys.2019.01468.
• Clayton, H.M., Kaiser, L.J., Stubbs, N.C., 2011a. Hind limb flexion response to different types of tactile devices. American Journal of Veterinary Research 72, 1489-1495
• Clayton, H.M., Lavagnino, M., Kaiser, L.J., Stubbs, N.C., 2011b. Swing phase kinematic and kinetic response to weighting the hind pasterns. Equine Veterinary Journal 43, 210-215
• Clayton, H.M., White, A.D., Kaiser, L.J., Nauwelaerts, S., Lavagnino, M., Stubbs, N.C., 2010. Hind limb response to tactile stimulation of the pastern and coronet. Equine Veterinary Journal 42, 227-233
• Crook, Tracy & Wilson, Alan & Hodson-Tole, Emma. (2010). The effect of treadmill speed and gradient on equine hindlimb muscle activity. Equine veterinary journal. Supplement. 42. 412-6. 10.1111/j.2042-3306.2010.00222.x.
• Dunphy, E., Hamilton, F.L., Spasić, I. et al. Acceptability of a digital health intervention alongside physiotherapy to support patients following anterior cruciate ligament reconstruction. BMC Musculoskelet Disord 18, 471 (2017). https://doi.org/10.1186/s12891-017-1846-0
• Herbert RD, de Noronha M. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004577. doi: 10.1002/14651858.CD004577.pub2. Update in: Cochrane Database Syst Rev. 2011;(7):CD004577. PMID: 17943822.
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• O' Brien C, Pegg J. A Preliminary Investigation into Ridden Water Submersion Training as an Adjunct to Current Condition Training Protocols in Performance Horses. Animals (Basel). 2021 Sep 7;11(9):2629. doi: 10.3390/ani11092629. PMID: 34573594; PMCID: PMC8470757.
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