“Competing horses should not show clinical signs of pain,” said Lori Bidwell, DVM, Dipl. ACVAA, CVA, co-owner and founder of East West Equine Sports Medicine, based in Lexington, Kentucky.

“… And a horse needing daily pain medication shouldn’t be competing,” added Richard Markell, DVM, MRCVS, MBA, owner of IlluminX Consulting, in Encinitas, California.

Bidwell and Markell addressed the medical and ethical challenges of managing pain in sport horses during their presentation at the 2024 American Association of Equine Practitioners Convention, held Dec. 7-11 in Orlando, Florida.  

Balancing Equine Medicine with Ethics

Managing pain in performance horses responsibly can be complex. Veterinarians must balance animal welfare with the expectations of owners and trainers in competitive equine sports. “First of all, true pain must be differentiated from transient ‘day after the gym’ soreness,” Markell said.

“Persistent pain often signals underlying issues like musculoskeletal injuries or gastric ulcers, which should be investigated and ruled out rather than masked by pain medication,” Bidwell added, underscoring veterinarians’ responsibility to act as advocates for horses.

The Effects and Legalities of Different Medications

Veterinarians commonly use various pain medications in horses, including the nonsteroidal anti-inflammatory drugs (NSAIDs) phenylbutazone and flunixin meglumine (Banamine), as well as bisphosphonates to reduce pain and extend the careers of performance horses. Bidwell and Markell warned that overuse and misuse of these medications can lead to significant risks.

Markell cautioned against overrelying on medications, pointing out that masking pain can exacerbate injuries. “For example, bone edema (fluid within the bone) can progress to fractures if horses live on Banamine while competing,” he said.

Bisphosphonates are FDA-approved for treating podotrochlosis (navicular disease) in horses, but veterinarians sometimes use them off-label in equine athletes. Bidwell advocates for strict regulation and responsible administration of these drugs, which slow down bone turnover.

Alternatives to Pain Medication

Bidwell and Markel stressed the importance of using the least amount of medication necessary to keep a horse pain-free. Drug-free alternatives such as acupuncture and homeopathic remedies, though less conventional (and only legal under certain governing bodies in the case of homeopathy), might offer safer ways to manage pain and inflammation in horses. For example, while Traumeel (a homeopathic remedy containing plant and mineral extracts designed to address pain and inflammation) is not considered legal under United States Equestrian Federation (USEF) rules, Zeel and arnica are allowed, said Bidwell.

Both veterinarians agreed that extracorporeal shock wave therapy (ESWT) provides valuable benefits, particularly for treating back and sacroiliac pain in horses. However, its ability to mask pain calls for careful oversight. Recent changes to USEF rules now mandate that only veterinarians or their supervised technicians can administer shock wave treatments on show grounds.

Regulations to Protect Horses

Regulatory frameworks from organizations such as the Fédération Equestre Internationale (FEI) and USEF help curb unethical pain management practices for sport horses. These regulations notably restrict NSAID use to prevent overmedication and level the playing field. Because misuse of medications—particularly in high-stakes environments—sometimes stems from misguided client expectations, Bidwell stressed the need to educate horse owners and young veterinarians to prioritize long-term welfare over immediate results. “We must advocate for the horse’s health, not just its performance,” she said.

Take-Home Message

Treating pain in performance horses remains a controversial topic. New innovations and improvements in equine medicine extend equine athletes’ careers. In addition, new regulations from USEF and the FEI aim to protect horses from inappropriate and unethical use of pain-masking medications and modalities at competitions. Bidwell and Markel encouraged equine practitioners to advocate for the horse above all else when faced with ethical dilemmas in pain management.