This review presents the veterinary physiotherapist’s approach to assessment and treatment of back pain in horses, while supporting veterinary care as part of the multidisciplinary team. Veterinary physiotherapists aim to restore painless optimal function using their scope of physiotherapy treatments, which are individualised to the patient, including manual therapy, the use of electro-physical and specific therapeutic exercises, as well as the prescription of a rehabilitation plan. The combination of pain relief and acquisition or maintenance of the required range of motion, along with ensuring postural stability and muscle activity, are the initial principles of treatment. A chartered physiotherapist can also assess the rider and their ability to function optimally, potentially providing interventions to ensure riders do not negatively influence their horse. Following clinically reasoned use of manual and electro-physical therapies for the horse with back pain, re-education of positive movement patterns and subsequent muscle strengthening is required. Successful physiotherapy will ensure that a horse is comfortable and capable of carrying a rider, and is thus able to perform the functional tasks required.