Veterinarians generally focus on keeping the performance horse in work but they need to be mindful of ways in which the work itself may jeopardise the animal's welfare and health. Elements of a horse's work may expose it to the risk of injury but insults to wellbeing, which are far more common and far more sustained, although less overt, also deserve consideration. A good example is the way in which chronic physiological stress responses arising from inhumane training techniques may compromise immunity and tissue repair. This article explores the physiological and musculoskeletal insults that can result from ridden work, alongside the gear and training paradigms that can compromise welfare. It also considers issues relating to the use of pharmaceuticals in the ridden horse. With stress reduction as a primary focus, it emerges that veterinarians are uniquely placed to comment on the somatic effects of psychological stressors, including the social and ethological challenges resulting from the work required of the so-called elite equine athlete. Whether the profession will step up to meet this significant challenge is also discussed.