Complete Guide to Pre-Purchase Exams: Everything Buyers Need to Know

A thorough pre-purchase exam is your best protection when buying a horse—but only if you understand what you’re getting. The pre-purchase veterinary examination (PPE) provides critical information about a horse’s current health, physical condition, and potential future soundness, enabling you to make an informed buying decision rather than an emotional one. Importantly, a PPE is not a pass/fail test; it’s a detailed risk assessment that helps you determine whether a horse’s physical reality aligns with your intended use and management capacity. The information gathered during this examination—combined with your understanding of what it means—can save you from purchasing a horse that will never meet your goals, or give you confidence to proceed with a well-suited partner.

This guide covers everything you need to know: what happens during the examination, which tests to request for your specific situation, how to interpret findings, and the practical considerations around cost, veterinarian selection, and negotiation.

What happens during a pre-purchase examination

The PPE is a systematic clinical evaluation performed by a veterinarian on behalf of a prospective buyer. Understanding the structure helps you know what to expect and ensures you receive a comprehensive assessment.

The examination structure varies by region and purpose

In the United Kingdom, the British Equine Veterinary Association (BEVA) and Royal College of Veterinary Surgeons (RCVS) have established a standardized 5-stage protocol that veterinarians follow consistently. In the United States, protocols vary by practitioner, though the American Association of Equine Practitioners (AAEP) provides reporting guidelines that most veterinarians follow. The core components remain similar across regions.

A full 5-stage examination takes approximately 1.5 to 3 hours without additional diagnostics and is recommended for all riding horses. A limited 2-stage examination (covering only rest and basic movement) takes 45 minutes to an hour and may be appropriate for unbroken youngstock, companion animals, or lower-value horses where comprehensive assessment isn’t practical.

Stage 1 evaluates the horse at rest in detail

The examination begins with the horse stabled for at least 2-3 hours before the appointment (no exercise beforehand). The veterinarian first verifies the horse’s identity against its passport and microchip, then conducts a thorough physical examination.

In a darkened stable, the vet uses an ophthalmoscope to examine the eyes for cataracts, uveitis, corneal lesions, and chorioretinitis—conditions that can significantly impact a horse’s future. The dental examination verifies age and checks for major abnormalities. Cardiovascular assessment includes listening to the heart for murmurs and arrhythmias, while the respiratory system is evaluated by auscultating both lung fields and the trachea.

The musculoskeletal examination during this stage involves systematic palpation of all four limbs—joints, tendons, and ligaments—as well as the back, pelvis, and neck. The vet assesses hoof condition, shoeing quality, and uses hoof testers to check for sensitivity. Throughout the examination, the veterinarian looks for scars indicating previous surgery (including colic surgery), lumps, bumps, sarcoids, and signs of asymmetrical muscle development that might suggest compensatory movement due to pain. This stage typically takes 20-30 minutes.

Stage 2 assesses movement on a firm surface

The horse is led to a firm, level surface of at least 30 meters. The handler walks and trots the horse in a straight line while the veterinarian observes from behind, in front, and from the side—watching for gait abnormalities, head bobbing (indicating forelimb lameness), or hip drop (indicating hindlimb lameness).

Flexion tests are a critical component of this stage. Each limb is held in a flexed position for 30-60 seconds (some veterinarians use up to 2 minutes), and the horse is immediately trotted away in a straight line. The vet grades any lameness response and compares left and right limbs. Flexion tests stress joint capsules, soft tissue structures, and surrounding ligaments, potentially revealing subtle issues.

Lunging on both hard and soft surfaces, in both directions, allows the veterinarian to assess lameness that may be more apparent on circles. Sharp turns and backing evaluate neurological function and limb coordination. This stage typically takes 15-20 minutes.

A 2-stage vetting concludes here. Buyers choosing only a 2-stage exam should sign a disclaimer acknowledging that problems detectable only under exercise may be missed.

Stage 3 tests the horse under strenuous exercise

The horse is preferably ridden (or lunged if unbroken) through walk, trot, canter, and if appropriate, gallop. The exercise level should be appropriate to the horse’s fitness and intended job.

During this phase, the veterinarian assesses the respiratory system by listening for abnormal breathing sounds such as roaring or whistling, which may indicate laryngeal issues. Cardiovascular performance is evaluated through heart rate and rhythm during exertion—some arrhythmias and murmurs only become apparent under exercise. Subtle lameness may be more visible when the horse is ridden, and behavioral changes that suggest pain or discomfort are noted. This stage takes 15-25 minutes.

Stage 4 provides a critical rest period

Following exercise, the horse stands quietly for 20-30 minutes. This rest period allows any stiffness or strain from exercise to become apparent. The veterinarian monitors recovery of heart and respiratory rates and re-auscultates the heart and lungs as they return to resting levels.

This is typically when blood samples are drawn—ideally stored for 6 months in case later testing for sedatives, pain killers, or anti-inflammatories becomes necessary. Blood must be drawn before any sedation for radiography.

Stage 5 reveals exercise-related changes

The final stage repeats the walk and trot in-hand, sharp turns, backing, and potentially flexion tests. The purpose is to detect strains or injuries made evident by exercise and rest, check whether subtle lameness has been exacerbated, and compare pre- and post-exercise soundness. This stage takes 10-15 minutes.

Which tests should you request for your specific situation

Beyond the clinical examination, optional diagnostics significantly expand what the PPE can reveal. The tests you choose should be guided by the horse’s intended use, age, price point, and any concerns arising during the clinical examination.

Radiographs reveal bone and joint conditions

X-rays are the most common additional diagnostic in pre-purchase examinations. A full radiographic series for sport horses typically includes 40-42 views: front feet (4 views each), all four fetlocks (4 views each), both hocks (4 views each), and both stifles (2-4 views each). Additional views of the carpi (knees), cervical spine, and dorsal spinous processes may be added based on discipline or clinical concerns.

Research from Virginia Equine Imaging analyzing 700 PPEs found that hock osteoarthritis appeared in 73% of horses that passed examination, and fetlock osteoarthritis in 37.5%. Other common findings include navicular bone changes, dorsal spinous impingement (“kissing spine”), and osteochondritis dissecans (OCD) lesions. The same study found that fetlock cysts had an 80% failure rate, while stifle OCD had a 62% failure rate—demonstrating that location and type of finding significantly impact assessment.

For racehorses, carpi radiographs are always included due to the stress racing places on the knees. Dressage and sport horses increasingly have cervical spine and back radiographs included. Recent research in the Equine Veterinary Journal suggests that lateromedial and oblique views detect most fetlock pathologies as effectively as a full series, though some subchondral bone changes may require additional views.

Ultrasound evaluates soft tissue structures

Approximately one-third of sport horses undergoing PPE receive ultrasound screening. This imaging modality evaluates the superficial digital flexor tendon (SDFT), deep digital flexor tendon (DDFT), suspensory ligament, and joint capsules—structures not visible on radiographs.

Ultrasound is recommended when there’s a history of tendon or ligament injury, palpable soft tissue abnormalities, swelling in the lower limbs, or when radiographs don’t explain observed lameness. For racing and sport horse prospects, suspensory ligament screening is commonly requested.

Endoscopy reveals upper airway function

Upper airway endoscopy is commonly performed for racehorses and sport horses, and whenever respiratory noise is detected during the exercise phase. The examination identifies laryngeal hemiplegia (“roaring”), epiglottic entrapment, dorsal displacement of the soft palate (DDSP), and pharyngeal lymphoid hyperplasia.

Gastroscopy—examination of the stomach for ulcers—is not routine in PPE because it requires fasting but is recommended for Thoroughbreds coming off the track, where ulcer prevalence is high.

Blood work provides metabolic and drug screening

The Coggins test for Equine Infectious Anemia is required for interstate transport in the US and is the most common blood test in PPE. A complete blood count (CBC) detects infections, anemia, and inflammation, while a chemistry panel evaluates liver, kidney, and muscle enzyme function.

Drug screening tests for NSAIDs (phenylbutazone, flunixin, firocoxib), long-acting tranquilizers (reserpine, fluphenazine), sedatives, and upon request, anabolic steroids. Basic screening takes 4-5 days; reserpine and fluphenazine detection requires 5-10 days. Critically, blood must be drawn before any sedation for radiography—this order matters.

For senior horses, ACTH testing for Cushing’s disease is strongly recommended. In areas where Lyme disease is endemic, testing is advised. Muscle enzyme testing before and after exercise evaluates for myopathies.

Discipline-specific testing recommendations

Dressage horses require particular attention to hind fetlocks (heavy use during collection), hocks, and stifles. Cervical spine and back radiographs are often included for advanced horses. Suspensory ligament ultrasound screening is recommended. For schoolmasters with established show records, expect and accept some arthritic changes—focus on manageability.

Jumpers and show hunters need a full radiographic series of all joints, tendon and ligament ultrasound (critical for landing stress), and upper airway endoscopy at upper levels. Focus on front feet and fetlocks (landing impact), hocks (take-off stress), and stifles.

Eventers warrant the most comprehensive evaluation due to their high athletic demand across multiple disciplines. This includes full radiographs, upper airway endoscopy (essential for horses working at speed requiring endurance), cardiac evaluation, and drug screening.

Racehorses always receive carpi radiographs, upper airway endoscopy, and drug screening. Standardbreds have higher incidence of tendon and ligament injuries than Thoroughbreds, making ultrasound screening particularly valuable.

Pleasure and trail horses may require only a basic examination with focused radiographs if clinical concerns arise. Extensive imaging may not be cost-effective for lower-priced horses—focus on safety and basic soundness.

Western performance horses (cutting, reining, barrel racing) need full radiographs with particular attention to hocks (heavy use in sliding stops and spins) and stifles. Genetic testing is critical for Quarter Horse breeds: the 5-6 panel tests for HYPP, PSSM1, GBED, HERDA, MH, and MYHM—conditions that can significantly impact health and performance.

Age, price, and intended use guide your choices

For weanlings and yearlings, a basic examination usually suffices, focusing on eyes, heart, umbilical hernias, and angular limb deformities. For horses 2-5 years old, complete examination plus full radiographs screens for OCD lesions and developmental orthopedic disease. Mature performance horses (5-15) warrant complete examination with radiographs providing both baseline documentation and identification of existing conditions. Senior horses (15+) need complete physical examination with blood work including ACTH testing; accept some joint changes if the horse performs its intended work.

For lower-priced horses under $5,000, minimum evaluation includes physical exam, soundness exam, flexion tests, and Coggins—adding targeted radiographs only for clinical concerns. Mid-range horses ($5,000-$25,000) warrant complete examination with standard radiographic series and optional drug screening. High-value horses ($25,000+) justify comprehensive examination with full radiographic series (40-42 views), ultrasound screening, endoscopy, drug screening, and board-certified radiologist review.

Emerging technologies expand diagnostic capabilities

Standing CT scanning represents a major 2024-2025 development. Systems like the Asto CT Equina and Hallmarq Vision CT provide high-resolution 3D imaging without general anesthesia, scanning both limbs in minutes. Standing CT is increasingly used for complex fracture detection, stress fracture screening, and cases where radiographs prove inconclusive.

Standing MRI remains the gold standard for soft tissue imaging of the distal limb and is used when suspected soft tissue injury isn’t visible on ultrasound, for detailed navicular disease evaluation, or for complex lameness cases.

Standing PET scanning, available at select centers, offers high sensitivity for detecting rapid bone turnover—useful when nerve blocks remain inconclusive or multiple lameness areas are suspected.

How to interpret pre-purchase exam results

Understanding what PPE findings actually mean is essential for making sound decisions. The most important concept: veterinarians do not “pass” or “fail” horses. According to AAEP guidelines, the veterinarian’s role is to identify and communicate findings—the purchase decision remains solely with the buyer.

The “fit for intended use” framework guides interpretation

A finding that would be a deal-breaker for a Grand Prix jumper may be completely acceptable for a trail horse. A 15-year-old schoolmaster’s mild hock arthritis from years of showing differs fundamentally from the same finding in a 3-year-old intended for decades of competition.

The Merck Veterinary Manual notes that “a comprehensive PPE will identify some abnormal findings in almost every horse.” The question becomes whether you can accept and manage those imperfections for your specific goals.

Factors affecting interpretation include: your intended use and competition level, the horse’s age and current workload, performance history, your willingness and ability to manage maintenance requirements, your budget for ongoing veterinary care, and whether you plan to keep the horse long-term or eventually resell.

Understanding common radiographic findings and their significance

Osteochondritis dissecans (OCD) involves developmental abnormalities where cartilage fails to ossify properly, creating loose fragments in joints. Common locations include stifles, hocks, and fetlocks. Subclinical OCD found incidentally—without lameness, joint effusion, or positive flexion tests—may cause no issues throughout a horse’s career. Small, smooth fragments in non-weight-bearing locations are less problematic than multi-fragmented lesions or those in high-motion joints. Many lesions heal spontaneously if diagnosed before 18 months, and surgical arthroscopic removal has good outcomes for most joints.

Navicular changes present particular interpretive challenges because the severity of radiographic changes doesn’t always correlate with clinical signs. Findings include enlarged vascular channels, medullary sclerosis, synovial invaginations, distal border fragments, and flexor cortex erosions. Navicular changes are more concerning in Quarter Horses, Thoroughbreds, and Warmbloods. While radiographic changes can exist before clinical lameness develops, it’s uncommon for a horse with significant changes to never develop associated lameness at some point.

Arthritis and degenerative joint disease require location-specific interpretation. High-motion joints (coffin, fetlock) are more concerning than low-motion joints (pastern, lower hock). Mild hock changes in older working horses often cause no clinical lameness. Some joints can be surgically fused if necessary (pastern, lower hock) with good outcomes; others (fetlock) cannot.

Bone cysts near joints are typically major red flags. The most common location is the medial femoral condyle (stifle). Weight-bearing locations cause more lameness than non-weight-bearing locations.

Flexion test interpretation requires careful context

Flexion tests have significant limitations that buyers must understand. Research found that 40% of clinically sound horses showed positive responses to regular flexion, and 49 of 50 showed lameness with firm flexion. Duration (30 seconds to 3 minutes) and force applied vary between practitioners, and there’s poor correlation between abnormal radiographs and positive flexion tests.

The key interpretive questions: Was the response symmetric between left and right limbs (asymmetric response is more significant)? Did other parts of the exam support concerns? What is the horse’s current workload? Did the response improve after warming up?

A positive flexion test should prompt additional diagnostics—radiographs, nerve blocks, ultrasound—rather than be treated as definitive. “Positive results of flexion tests in a horse that does not demonstrate lameness before flexion may not be a cause for termination of the examination,” notes current research.

Heart murmurs occur commonly and are often insignificant

Flow murmurs caused by normal blood flow turbulence appear in 60-80% of horses and have no clinical significance when Grade 1-2. Pathological murmurs require more careful evaluation. Mitral regurgitation most impacts performance and can significantly reduce exercise tolerance. Tricuspid regurgitation is common in athletes and typically well-tolerated. Aortic regurgitation develops slowly, usually after age 10, and horses often tolerate it well.

Grade 3-4 or louder murmurs warrant echocardiogram. The key measurement is left atrial diameter, which should be under 14 cm—normal size with a murmur indicates a well-tolerated flow issue. Over 90% of horses presented for cardiac PPE evaluation have mild heart disease unlikely to affect athletic career.

Eye findings, particularly uveitis, carry significant implications

Equine recurrent uveitis (ERU) is the leading cause of blindness in horses worldwide, affecting 2-25% of horses. This is generally considered a major red flag. The veterinarian looks for corneal scarring, synechiae (adhesions between iris and lens), cataracts, evidence of previous inflammation, and vitreal debris.

Appaloosas have 8 times higher risk, especially those homozygous for the LP gene. Fifty-six percent of affected horses eventually become blind, and 60% cannot return to previous performance levels. Ongoing management is required; the condition is not curable.

Red flags versus manageable findings

Major red flags that often warrant walking away include: severe navicular changes with clinical lameness, kissing spine (especially severe cases), OCD with joint effusion and lameness, bone cysts near joints, evidence of uveitis, evidence of previous neurectomy (nerve cut to mask lameness), undisclosed colic surgery, negative palmar angle, signs of laminitis or founder, cardiac abnormalities with chamber enlargement, neurological deficits, and current unexplained lameness.

Often manageable findings include: mild hock changes in older horses in work, old set splints, mild arthritic changes without clinical lameness, low-grade heart murmurs (Grade 1-2), positive flexion tests without supporting radiographic findings, small smooth OCD fragments in non-weight-bearing locations, age-appropriate wear consistent with work history, and cosmetic blemishes.

Essential questions to ask the veterinarian

About specific findings, ask: “Is this finding likely to change with time or use?” “What management will this require—joint injections, special shoeing?” “What’s the estimated annual cost of managing this?” “If this worsens, what are my treatment options?” “Would you recommend additional imaging or specialist consultation?”

About prognosis: “How do horses with this finding typically perform at my intended level?” “Is there a surgical option if needed in the future?” “What signs should I watch for indicating this is becoming a problem?”

About overall assessment: “What are your main concerns about this horse for my intended use?” “Are there findings you would want to monitor or recheck?” “Given everything you found, what would you recommend?”

Practical considerations every buyer must understand

Cost varies significantly based on examination scope

Basic clinical exam only (no imaging): $200-$500. Clinical exam with limited X-rays: $500-$1,000. Full comprehensive exam with extensive radiographs: $2,000-$4,000+. In the UK, a full 5-stage vetting costs £350-£400+ plus travel fees.

Individual diagnostics range as follows: radiograph sets from $200 for single joints to $1,500-$2,500+ for a full 40-view series. Ultrasound averages $210. Upper airway endoscopy costs $200-$300. Drug screening runs $300-$500. Board-certified radiologist review adds approximately $200 but is highly recommended for high-value horses or complex findings.

Regional variations exist: higher costs in the Northeast US, California, and competitive show regions; lower costs in rural and Midwest areas. Farm call fees typically run $75-$150+ depending on distance.

Always choose an independent veterinarian

Using your own veterinarian provides an established trust relationship with someone who will communicate findings to you as their primary client, understands your goals and risk tolerance, and has no conflict of interest with the seller.

Using the seller’s veterinarian is not recommended. Potential bias exists—even unconscious pressure to “pass” the horse for their existing client. Pre-purchase examinations represent the second-highest area of equine litigation, and many reputable veterinarians refuse to perform PPEs on their own clients’ horses specifically to avoid this conflict.

For distant purchases, ask your regular veterinarian for referrals in that area, contact AAEP for their member directory by location, and ensure the chosen veterinarian has no prior relationship with the horse or seller. Modern technology allows your home veterinarian to review digital radiographs remotely for a second opinion.

Understanding legal limitations protects your expectations

A PPE is a “snapshot in time” of the horse’s health on that specific day—not a guarantee of future soundness or a warranty of fitness. Horses can develop issues minutes after the examination concludes. The veterinarian’s liability is typically limited to the fees paid for the examination.

Written documentation is essential: pre-exam seller disclosure forms regarding medications and history, buyer agreement forms outlining scope and limitations, detailed written reports, and blood sample storage (typically 6 months). All images, videos, and records are legally owned by the buyer; the seller cannot access results without written permission.

Many insurers require PPE before issuing mortality or major medical coverage. Pre-existing conditions identified during PPE may be excluded from coverage—request insurer requirements before the examination to ensure compliance.

What a PPE does not include

Standard examinations do not evaluate temperament or behavior with different riders, assess value or marketability, determine suitability for a specific rider, perform detailed dental examination with speculum, examine the sheath in stallions or geldings, check for pregnancy, or evaluate breeding soundness (unless specifically added).

Technical limitations mean that subclinical conditions may not be detectable, soft tissue injuries may not appear on radiographs, dynamic respiratory issues may only manifest during exercise, and horses not currently in work may not reveal problems that emerge under stress.

Using findings appropriately in negotiations

PPE should not be weaponized to bully sellers into lower prices. If findings are within acceptable risk for your intended use, pay the agreed price. Legitimate negotiation grounds include findings requiring ongoing maintenance costs, conditions limiting career longevity, issues requiring immediate intervention, or significant discrepancies between advertised condition and actual findings.

When negotiating, obtain written official findings, calculate estimated treatment and maintenance costs from your own veterinarian, present findings professionally to the seller, and propose a specific reduced price reflecting added risk. Be prepared for sellers to decline—they set prices based on training, performance record, and market value.

Walk away when major undisclosed conditions are incompatible with your intended use, when treatment costs approach or exceed purchase price, when findings would require significantly changing your goals, or when sellers refuse to disclose known medical history.

Making informed decisions

The pre-purchase examination provides essential information, but it cannot predict the future or guarantee soundness. “The correlation between radiographic changes and lameness or performance is really poor,” notes Dr. Tim Lynch of Peterson Smith Equine Hospital. “Some horses have terrible looking backs, but they are good, sound athletes.”

The value of a PPE lies not in seeking an impossible “perfect” horse but in understanding exactly what you’re buying. Armed with this knowledge, you can assess whether identified issues are acceptable for your intended use, budget appropriately for ongoing management, negotiate fairly based on legitimate concerns, and make a confident purchase decision.

Scale the examination to the horse’s value and intended use. Be present if possible. Discuss your goals thoroughly with the veterinarian beforehand. Understand that findings are the norm, not the exception—and focus on whether those findings are acceptable for your specific situation. The price tag on the horse, after all, is the cheapest part of the investment. A thorough PPE ensures that investment is made wisely.