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Topic:Exercise Physiology

Exercise physiology in horses involves the study of the physiological responses and adaptations of horses to physical activity. This field examines how exercise impacts various systems in the equine body, including the cardiovascular, respiratory, muscular, and metabolic systems. Researchers focus on understanding how these systems interact during different types and intensities of exercise, and how they contribute to performance and recovery. Key areas of interest include the assessment of aerobic and anaerobic capacity, muscle fiber composition, energy metabolism, and thermoregulation. This page compiles peer-reviewed research studies and scholarly articles that explore the mechanisms of exercise physiology in horses, with an emphasis on performance optimization, training regimens, and the prevention of exercise-related disorders.
Is a standalone inertial measurement unit accurate and precise enough for quantification of movement symmetry in the horse?
Computer methods in biomechanics and biomedical engineering    August 15, 2013   Volume 18, Issue 5 527-532 doi: 10.1080/10255842.2013.819857
Brighton C, Olsen E, Pfau T.Standalone 'low-cost' inertial measurement units (IMUs) could facilitate large-scale studies into establishing minimal important differences (MID) for orthopaedic deficits (lameness) in horses. We investigated accuracy and limits of agreement (LoA) after correction of magnitude-dependent differences of a standalone 6 degree-of-freedom IMU compared with an established IMU-based gait analysis system (MTx) in six horses for two anatomical landmarks (sacrum and sternum). Established symmetry measures were calculated from vertical displacement: symmetry index (SI), difference between minima (MinDif...
Patterns of horse-rider coordination during endurance race: a dynamical system approach.
PloS one    August 5, 2013   Volume 8, Issue 8 e71804 doi: 10.1371/journal.pone.0071804
Viry S, Sleimen-Malkoun R, Temprado JJ, Frances JP, Berton E, Laurent M, Nicol C.In riding, most biomechanical studies have focused on the description of the horse locomotion in unridden condition. In this study, we draw the prospect of how the basic principles established in inter-personal coordination by the theory of Coordination Dynamics may provide a conceptual and methodological framework for understanding the horse-rider coupling. The recent development of mobile technologies allows combined horse and rider recordings during long lasting natural events such as endurance races. Six international horse-rider dyads were thus recorded during a 120 km race by using two t...
Unwise human intervention in the physiology by neglecting venous return may possibly contribute to lung hemorrhage and vein remodeling in racing horses.
Journal of applied physiology (Bethesda, Md. : 1985)    August 3, 2013   Volume 115, Issue 3 412 doi: 10.1152/japplphysiol.00470.2013
Pancheva AV, Panchev VS, Pancheva MV.No abstract available
Changes in blood coagulation induced by exercise training in young athletic horses.
Research in veterinary science    August 2, 2013   Volume 95, Issue 3 1151-1154 doi: 10.1016/j.rvsc.2013.07.005
Assenza A, Tosto F, Casella S, Fazio F, Giannetto C, Piccione G.Prothrombin Time (PT), Activated Partial Prothrombin Time (APTT), Fibrinogen concentration (Fbg) and Platelet number (Plt) were evaluated in 20 young athletic horses during a training program. A standardized exercise test (SET) was performed every month for three months. The V4 variations (the speed, in m/min, reached at the blood lactate concentration of 4 mmol/l) obtained for each test were calculated to assess the effect of training program on athletic performance. Blood samples were collected at 20-day intervals over a period of 80 days from the beginning of the training program. The V4 (P...
Effect of a Pessoa training aid on temporal, linear and angular variables of the working trot.
Veterinary journal (London, England : 1997)    July 30, 2013   Volume 198, Issue 2 404-411 doi: 10.1016/j.tvjl.2013.07.005
Walker VA, Dyson SJ, Murray RC.Development of core muscle strength is important for training and during rehabilitation following injury. A Pessoa training aid (PTA) is a system of ropes and pulleys which is commonly used during equine training and rehabilitation, but there is limited information on its effectiveness. The objective of the study was to determine the effect of the PTA on the temporal, linear and angular kinematics of the working trot. Influence of testing order on effect of a PTA was assessed in four horses. Twelve riding horses were lunged at working trot on a 16 m diameter circle without (WO) and with a PTA ...
Comparison of the lactate minimum speed and the maximal lactate steady state to determine aerobic capacity in purebred Arabian horses.
New Zealand veterinary journal    July 22, 2013   Volume 62, Issue 1 15-20 doi: 10.1080/00480169.2013.815103
Miranda MC, Queiroz-Neto A, Silva-Júnior JR, Pereira MC, Soares OA, Borghi RT, Ferraz GC.To compare five different protocols for estimating the lactate minimum speed (LMS) with that for estimating the maximal lactate steady state (MLSS) in Arabian horses, in order to obtain a more rapid method for monitoring aerobic capacity and prescribing training schedules. Methods: Eight purebred Arabian horses were conditioned to exercise on a treadmill for 12 days then submitted to three to five exercise sessions to determine the MLSS. Blood samples were collected from a jugular catheter at specific intervals for measurement of lactate concentrations. The MLSS was the velocity maintained dur...
Acetazolamide attenuates transvascular fluid flux in equine lungs during intense exercise.
The Journal of physiology    July 1, 2013   Volume 591, Issue 18 4499-4513 doi: 10.1113/jphysiol.2013.257956
Vengust M, Staempfli H, Viel L, Swenson ER, Heigenhauser G.  During intense exercise in horses the transvascular fluid flux in the pulmonary circulation (Jv-a) represents 4% of cardiac output (Q). This fluid flux has been attributed to an increase in pulmonary transmural hydrostatic forces, increases in perfused microvascular surface area, and reversible alterations in capillary permeability under conditions of high flow and pressure. Erythrocyte fluid efflux, however, accounts for a significant fraction of Jv-a. In the lung the Jacobs-Stewart cycle occurs with diffusion of CO2 into alveolar space with possible accompanying chloride (Cl-) and water ...
Genetic analysis of haematological and plasma biochemical parameters in the Spanish purebred horse exercised on a treadmill.
Animal : an international journal of animal bioscience    May 24, 2013   Volume 7, Issue 9 1414-1422 doi: 10.1017/S1751731113000955
Escribano BM, Molina A, Valera M, Tovar P, Agüera EI, Santisteban R, Vivo R, Agüera S, Rubio MD.The novel aim of this study was to describe the reference values of different haematological and biochemical parameters in the Spanish purebred horse (Andalusian, SPB) in each of the stages of a programmed exercise on a treadmill system, and to establish heritability and genetic correlations for these haematological and biochemical parameters. For this, 94 young SPB male horses (4.22 ± 2.27 years old) were used. An increasing intensity exercise test at 4, 5, 6 and 7 m/s was carried out on a treadmill (6% inclination). Total red blood cells, total white blood cells, neutrophils and lymphocytes...
Atrial natriuretic peptide and cardiac troponin I concentrations in healthy Warmblood horses and in Warmblood horses with mitral regurgitation at rest and after exercise.
Journal of veterinary cardiology : the official journal of the European Society of Veterinary Cardiology    May 16, 2013   Volume 15, Issue 2 105-121 doi: 10.1016/j.jvc.2012.12.003
Trachsel DS, Schwarzwald CC, Bitschnau C, Grenacher B, Weishaupt MA.Atrial natriuretic peptide (ANP) and cardiac troponin I (cTnI) serve as biomarkers for increased cardiac pressure/volume loading and for myocardial stress or damage. The objective was to describe the time course of plasma ANP concentrations (CpANP) and plasma cTnI concentrations (CpcTnI) in horses with mitral regurgitation (MR) compared to healthy horses at rest and after exercise, and to describe the relationship of CpANP with cardiac dimensions and intracardiac pressures. Methods: 15 healthy Warmblood horses and 7 Warmblood horses with MR. Methods: Cardiac dimensions at rest were measured us...
Transit of micro-bubbles through the pulmonary circulation of Thoroughbred horses during exercise.
Research in veterinary science    May 2, 2013   Volume 95, Issue 2 644-647 doi: 10.1016/j.rvsc.2013.04.002
La Gerche A, Daffy JR, Mooney DJ, Forbes G, Davie AJ.It has been observed that microbubbles may pass through the pulmonary circulation of dogs and humans during exercise. In humans, this phenomenon has been associated with lower pulmonary artery pressures, enhanced right ventricular function and greater exercise capacity. In the exercising Thoroughbred horse, extraordinarily high cardiac outputs exert significant pulmonary vascular stresses. The aim of this study was to determine, using contrast echocardiography, whether Thoroughbred horses performing strenuous exercise developed pulmonary transit of agitated contrast microbubbles (PTAC). At res...
Serum amyloid A (SAA) concentration after training sessions in Arabian race and endurance horses.
BMC veterinary research    May 1, 2013   Volume 9 91 doi: 10.1186/1746-6148-9-91
Cywinska A, Witkowski L, Szarska E, Schollenberger A, Winnicka A.Serum amyloid A (SAA) is the major acute phase protein in horses. Its concentration increases in various pathologies but also in response to prolonged, strenuous effort. The purpose of this study was to establish whether routine race and endurance training produces changes in the SAA level in Arabian horses. Additionally, the differences between SAA response in experienced endurance horses and endurance horses that were beginning their career were investigated. Results: There were no changes in SAA concentrations after race training and endurance training in experienced horses. In horses that ...
The Normandy field study on juvenile osteochondral conditions: conclusions regarding the influence of genetics, environmental conditions and management, and the effect on performance.
Veterinary journal (London, England : 1997)    April 29, 2013   Volume 197, Issue 1 90-95 doi: 10.1016/j.tvjl.2013.03.047
van Weeren PR, Denoix JM.Juvenile osteochondral conditions (JOCC) have a major impact on the equine industry and include many musculoskeletal disorders of the young horse, of which osteochondrosis (OC) is the most prominent. The Breeding, Osteochondral Status and Athletic Career (BOSAC) project is the first large, comprehensive, longitudinal field study on the subject conducted in three breeds of performance horses (Thoroughbreds, Standardbred Trotters and Warmbloods) that were monitored in their natural environment where they were reared under common field conditions. The BOSAC study used a radiographic protocol desi...
Amino acid utilization by the hindlimb of warmblood horses at rest and following low intensity exercise.
The veterinary quarterly    April 19, 2013   Volume 33, Issue 1 20-24 doi: 10.1080/01652176.2013.775833
Peters LW, Smiet E, de Sain-van der Velden MG, van der Kolk JH.In particular branched-chain amino acids might limit muscle protein loss in pathological conditions. Little is known on basic amino acid utilization of muscle in horses. Objective: To assess amino acid utilization by the hindlimb of horses at rest and following low intensity exercise. ANIMALS & METHODS: Amino acid uptake by the hindlimb was investigated using the arteriovenous difference technique. Blood from six warmblood mares (mean age 12 ± 3 (SD) years and weighing 538 ± 39 kg) was collected simultaneously from the (transverse) facial artery and from the caudal vena cava. Food was wi...
Effect of Treadmill Exercise and Hydrogen-rich Water Intake on Serum Oxidative and Anti-oxidative Metabolites in Serum of Thoroughbred Horses.
Journal of equine science    April 16, 2013   Volume 24, Issue 1 1-8 doi: 10.1294/jes.24.1
Tsubone H, Hanafusa M, Endo M, Manabe N, Hiraga A, Ohmura H, Aida H.The present study aimed to clarify changes of oxidative stress and antioxidative functions in treadmill-exercised Thoroughbred horses (n=5, 3 to 7 years old), using recently developed techniques for measurement of serum d-ROMs for oxidative stress, and BAP for antioxidative markers. Also, the effect of nasogastric administration of hydrogen-rich water (HW) or placebo water preceding the treadmill exercise on these parameters was examined. Each horse was subjected to a maximum level of treadmill exercise in which the horses were exhausted at an average speed of 13.2 ± 0.84 m/sec. Blood samples...
Peeling back the evolutionary layers of molecular mechanisms responsive to exercise-stress in the skeletal muscle of the racing horse.
DNA research : an international journal for rapid publication of reports on genes and genomes    April 11, 2013   Volume 20, Issue 3 287-298 doi: 10.1093/dnares/dst010
Kim H, Lee T, Park W, Lee JW, Kim J, Lee BY, Ahn H, Moon S, Cho S, Do KT, Kim HS, Lee HK, Lee CK, Kong HS, Yang YM, Park J, Kim HM, Kim BC, Hwang S....The modern horse (Equus caballus) is the product of over 50 million yrs of evolution. The athletic abilities of the horse have been enhanced during the past 6000 yrs under domestication. Therefore, the horse serves as a valuable model to understand the physiology and molecular mechanisms of adaptive responses to exercise. The structure and function of skeletal muscle show remarkable plasticity to the physical and metabolic challenges following exercise. Here, we reveal an evolutionary layer of responsiveness to exercise-stress in the skeletal muscle of the racing horse. We analysed differentia...
Clinical and diagnostic features of inflammatory airway disease subtypes in horses examined because of poor performance: 98 cases (2004-2010).
Journal of the American Veterinary Medical Association    April 4, 2013   Volume 242, Issue 8 1138-1145 doi: 10.2460/javma.242.8.1138
Nolen-Walston RD, Harris M, Agnew ME, Martin BB, Reef VB, Boston RC, Davidson EJ.To determine whether there are important differences relating to seasonality of signs or clinical features between subtypes of inflammatory airway disease (IAD) in horses caused by neutrophilic and eosinophilic-mastocytic inflammation having dissimilar etiopathologic pathways. Methods: Retrospective case series. Methods: 98 horses. Methods: Data were compiled from medical records of horses examined because of poor performance from 2004 through 2010. Horses underwent a standardized high-speed treadmill test, lameness evaluation, cardiac evaluation, and postexercise bronchoalveolar lavage (BAL)....
Scoring of sweat losses in exercised horses–a pilot study.
Journal of animal physiology and animal nutrition    March 28, 2013   Volume 98, Issue 2 246-250 doi: 10.1111/jpn.12073
Zeyner A, Romanowski K, Vernunft A, Harris P, Kienzle E.Based on a series of exercise tests which included the estimation of sweat losses, this article proposes a novel sweat scoring system for exercising horses. This provides a practical estimate of individual animal exercise-induced sweat losses, based on visible appearance of sweat on the coat after work, which takes into account the effect of various influencing factors. In terms of accuracy and flexibility, the score seems to provide advantages over estimates based on current general recommendations from reference books. Additional studies are needed to validate this scoring system and its use...
Histomorphometric evaluation of the effect of early exercise on subchondral vascularity in the third carpal bone of horses.
American journal of veterinary research    March 28, 2013   Volume 74, Issue 4 542-549 doi: 10.2460/ajvr.74.4.542
Kim W, McArdle BH, Kawcak CE, McIlwraith CW, Firth EC, Broom ND.To investigate histomorphometric changes in the cartilage and subchondral bone of the third carpal bone associated with conditioning exercise in young Thoroughbreds. Methods: Nine 18-month-old Thoroughbreds. Procedures-Both third carpal bones of 9 horses (4 exercised spontaneously at pasture only and 5 given additional conditioning exercise beginning at a mean age of 3 weeks) were evaluated. Histomorphometric variables (hyaline and calcified cartilage thickness and collagen orientation; vascular channel area, number, and orientation; and osteochondral junction rugosity) of the third carpal bon...
Effect of acute exercise on monocarboxylate transporters 1 and 4 in untrained and trained Thoroughbreds.
American journal of veterinary research    March 28, 2013   Volume 74, Issue 4 642-647 doi: 10.2460/ajvr.74.4.642
Kitaoka Y, Endo Y, Mukai K, Aida H, Hiraga A, Takemasa T, Hatta H.To evaluate the effects of a single incremental exercise test (IET) on mRNA expression and protein content of monocarboxylate transporter (MCT) 1 and MCT4 in the gluteus medius muscle of Thoroughbreds. Methods: 12 Thoroughbreds (6 males and 6 females; age, 3 to 4 years). Methods: Horses underwent an IET before and after 18 weeks of high-intensity exercise training (HIT). Horses were exercised at 90% of maximal oxygen consumption for 3 minutes during the initial 10 weeks of HIT and 110% of maximal oxygen consumption for 3 minutes during the last 8 weeks of HIT. Gluteus medius muscle biopsy spec...
Behavior of renin angiotensin aldosterone axis during pulling exercises in euhydrated and dehydrated horses.
Research in veterinary science    March 21, 2013   Volume 95, Issue 2 616-622 doi: 10.1016/j.rvsc.2013.02.012
Tofé E, Muñoz A, Castejón F, Trigo P, Castejón-Riber C, Gómez-Díez M, Riber C.The influence of hydration prior to exercise on hormonal response to exercise was investigated in horses, divided into two groups, control (n=11) and dehydrated (n=53). They were also classified according to their body weight in A (≈ 350 kg), B (351-450 kg) and C (≈ 451 kg). Horses covered 60 m on a track pulling a carriage loaded with 2, 2.25 and 2.5 times their body weight, for A, B and C. Blood samples were taken at rest, after exercise and during recovery. Electrolytes, albumin, renin, angiotensin and aldosterone concentrations were measured. Dehydrated and control horses had higher al...
Equine hoof slip distance during trot at training speed: comparison between kinematic and accelerometric measurement techniques.
Veterinary journal (London, England : 1997)    March 13, 2013   Volume 197, Issue 2 198-204 doi: 10.1016/j.tvjl.2013.02.004
Holden-Douilly L, Pourcelot P, Desquilbet L, Falala S, Crevier-Denoix N, Chateau H.Longitudinal sliding of horse's hooves at the beginning of stance can affect both performance and orthopaedic health. The objective of this study was to compare two measurement methods for quantifying hoof slip distances at training trot. The right front hoof of four French Trotters was equipped with an accelerometer (10 kHz) and kinematic markers. A firm wet sand track was equipped with a 50 m calibration corridor. A high-frequency camera (600 Hz) was mounted in a vehicle following each horse trotting at about 7 m/s. One of the horses was also trotted on raw dirt and harrowed dirt tracks. Lon...
Normal electrocardiographic QT interval in race-fit Standardbred horses at rest and its rate dependence during exercise.
Journal of veterinary cardiology : the official journal of the European Society of Veterinary Cardiology    February 22, 2013   Volume 15, Issue 1 23-31 doi: 10.1016/j.jvc.2012.08.002
Pedersen PJ, Kanters JK, Buhl R, Klaerke DA.Cardiac repolarization, measured as QT and Tpeak to Tend (TpTe) intervals on the ECG, is important, as irregularities caused by diseases, ventricular hypertrophy, drugs and genetic defects can trigger arrhythmias which predispose human patients to syncope and sudden cardiac death. In horses, repolarization is not well described and therefore QT analysis cannot yet be used diagnostically. Therefore, we sought to describe reference values for the normal QT and TpTe intervals in Standardbreds and to determine the best method for heart rate (HR) correction. Methods: 30 Standardbreds. Methods: QT a...
The application of exhaled breath analysis in racing Thoroughbreds and the influence of high intensity exercise and ambient temperature on the concentration of carbon monoxide and pH in exhaled breath.
Veterinary journal (London, England : 1997)    February 5, 2013   Volume 197, Issue 2 318-323 doi: 10.1016/j.tvjl.2012.12.022
Cathcart MP, Love S, Sutton DG, Reardon RJ, Hughes KJ.Analyses of exhaled breath (EB) and exhaled breath condensate (EBC) are non-invasive modalities for assessing the lower airways but these methods have not been applied to Thoroughbred racehorses in training. The aims of this study were to determine whether EB and EBC could be obtained from Thoroughbred racehorses in the field and to investigate the effects of exercise per se and during different ambient temperatures and humidity on exhaled concentrations of nitric oxide (eNO), carbon monoxide (eCO) and EBC pH. EB and EBC samples were obtained from 28 Thoroughbred racehorses pre- and post-exerc...
Cortisol release, heart rate and heart rate variability in the horse and its rider: different responses to training and performance.
Veterinary journal (London, England : 1997)    February 4, 2013   Volume 197, Issue 2 229-232 doi: 10.1016/j.tvjl.2012.12.025
von Lewinski M, Biau S, Erber R, Ille N, Aurich J, Faure JM, Möstl E, Aurich C.Although some information exists on the stress response of horses in equestrian sports, the horse-rider team is much less well understood. In this study, salivary cortisol concentrations, heart rate (HR) and heart rate variability (HRV), SDRR (standard deviation of beat-to-beat interval) and RMSSD (root mean square of successive beat-to-beat intervals) were analysed in horses and their riders (n=6 each) at a public performance and an identical rehearsal that was not open to the public. Cortisol concentrations increased in both horses and riders (P<0.001) but did not differ between performan...
Exercise-induced inhibition of remodelling is focally offset with fatigue fracture in racehorses. Whitton RC, Mirams M, Mackie EJ, Anderson GA, Seeman E.Bone remodelling is inhibited by high repetitive loading. However, in subchondral bone of racehorses in training, eroded surface doubled in association with fatigue fracture and there was greater surrounding trabecular bone volume suggesting trabecular modelling unloads the bone focally, allowing damage repair by remodelling. Background: Remodelling replaces damaged bone with new bone but is suppressed during high magnitude repetitive loading when damage is most likely. However, in cortical bone of racehorses, at sites of fatigue fracture, focal porosity, consistent with remodelling, is observ...
Respiratory diseases and their effects on respiratory function and exercise capacity.
Equine veterinary journal    February 1, 2013   Volume 45, Issue 3 376-387 doi: 10.1111/evj.12028
Van Erck-Westergren E, Franklin SH, Bayly WM.Given that aerobic metabolism is the predominant energy pathway for most sports, the respiratory system can be a rate-limiting factor in the exercise capacity of fit and healthy horses. Consequently, respiratory diseases, even in mild forms, are potentially deleterious to any athletic performance. The functional impairment associated with a respiratory condition depends on the degree of severity of the disease and the equestrian discipline involved. Respiratory abnormalities generally result in an increase in respiratory impedance and work of breathing and a reduced level of ventilation that c...
The mechanical consequences of load bearing in the equine third metacarpal across speed and gait: the nonuniform distributions of normal strain, shear strain, and strain energy density.
FASEB journal : official publication of the Federation of American Societies for Experimental Biology    January 25, 2013   Volume 27, Issue 5 1887-1894 doi: 10.1096/fj.12-216804
Rubin CT, Seeherman H, Qin YX, Gross TS.Distributions of normal strain, shear strain, and strain energy density (SED) were determined across the midshaft of the third metacarpal (MCIII, or cannon bone) of 3 adult thoroughbred horses as a function of speed and gait. A complete characterization of the mechanical demands of the bone made through the stride and from mild through the extremes of locomotion was possible by using three 3-element rosette strain gauges bonded at the diaphyseal midshaft of the MCIII and evaluating the strain output with beam theory and finite element analysis. Mean ± sd values of normal strain, shear strain,...
The relationship between body composition, training and race performance in a group of Thoroughbred flat racehorses.
Equine veterinary journal    January 7, 2013   Volume 45, Issue 5 552-557 doi: 10.1111/evj.12024
Fonseca RG, Kenny DA, Hill EW, Katz LM.Few noninvasive measures associated with performance assessment are available for racehorse trainers. Evaluation of body composition of superior human sprinters has revealed a lower fat mass (FM), percentage (%) fat and greater fat-free mass (FFM), but to date there have been few studies evaluating this in racehorses. Objective: To determine the effects of age, gender and training on body composition and the relationship between body composition, physiological measurements and performance in Thoroughbred racehorses. Methods: At 2, 5 and 8 months of training, rump fat thickness (RFT) was ultras...
The welfare of young Polish Konik horses subjected to agricultural workload.
Journal of applied animal welfare science : JAAWS    January 4, 2013   Volume 16, Issue 1 35-46 doi: 10.1080/10888705.2013.740997
Kȩdzierski W, Pluta M.Every year a new group of young Polish Konik colts are separated from the forest herds to be trained in the stable breeding system. The aim of this study was to evaluate how the young Polish Konik horses who had been born in a forest reserve adapt to and tolerate draft work. Two groups of 6 horses each were studied: (a) 3- to 4-year-old colts and (b) 7- to 13-year-old stallions. An effort response was estimated by heart rate (HR) registration and biochemical analysis of hematocrit; blood lactic acid (LA) level; and plasma concentration of glucose, triacylglycerols, uric acid, total protein, an...
Exercise affects joint injury risk in young Thoroughbreds in training.
Veterinary journal (London, England : 1997)    December 20, 2012   Volume 196, Issue 3 339-344 doi: 10.1016/j.tvjl.2012.11.014
Reed SR, Jackson BF, Wood JL, Price JS, Verheyen KL.The aim of this study was to identify exercise-related risk factors for carpal and metacarpo- and metatarso-phalangeal (MCP/MTP) joint injury occurrence in young Thoroughbreds in flat race training. In a 2-year prospective cohort study, daily exercise and joint injury data were collected from horses in 13 training yards in England. Four injury categories were defined: (1) localised to a carpal or MCP/MTP joint based on clinical examination and/or use of diagnostic analgesia with no diagnostic imaging performed; (2) localised to a carpal or MCP/MTP joint with no abnormalities detected on diagno...
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