Previous history
Ridden work progressing, trot work established, working up to 45 minutes 5 days a week. CL remains stable and non reactive.
Assessment
Seen in walk and trot on the straight and circles; gait characteristics remain largely static; good in trot on small circles with a good degree of elevation and suspension phase is well marked even on small circles.
On palpation there is a good improvement with the epaxial muscles of the back although showing a degree of hypertonicity shows resumption of a more normal tonicity in particular the lumbar region is much soft and good flexibility in the lumbar sacral regions. The pelvic muscles show moderate degrees of shortened tightened muscle but once again this is an improvement with correct tone in the hamstrings.
The base of the neck palpates with a degree of hypertonicity but responds well to myofascial techniques. Range of motion techniques show a correct degree of flexibility in the main junctions of the spine and the RF shows a correct posture; the tendency to stand over this limb is not apparent today.
Treatment and plan
Manual therapy including massage, myofascial release and trigger point techniques with emphasis to the regions highlighted combined with active stretches and mobilisation to the neck, back.
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