Nonspecific performance and rideability issues are more likely a manifestation of pain in the ridden horse rather than a true behavioural problem. A systematic and thorough investigation focusing on the potential presence of pain-related conditions is thus crucial in horses with such complaints. It can, however, be challenging to determine whether the complaint is indeed related to pain, where the pain is located, and what the underlying cause is. This review describes the challenges of pain recognition in ridden horses and summarises the recently developed ridden horse ethograms that might enable pain to be assessed in an objective, valid and reliable way. Furthermore, the differential diagnosis and diagnostic approach to horses presenting potentially pain-related performance and rideability issues are discussed.