Progress in Lameness Therapy: Bluegrass Laminitis Symposium 1997
Imagine a large ballroom in a downtown hotel. Fill it with long rows of tables and chairs. Now open the doors. Have about 800 or so farriers and veterinarians from all over the world--some not even speaking English--rush in and take their seats. Then within minutes, it's so quiet you can hear a pin drop.
The business of continuing education is a serious one when it comes to horses' feet. It is a process, mostly, of self-education, and it is a little bit lonely, as professionals learn by reading journals, watching videotapes, and trying other people's successes and failures with their own adept hands. Because each horse and each problem is so different, successful farriers and veterinarians must have two key ingredients on their side--one is the willingness to experiment and to learn from each case; the second is to have a network of trusted fellow professionals to call on for help.
In the past 11 Januarys, an international professional network has been woven through the efforts of Versailles, Ky., veterinarian Ric Redden. A self-described "scout on the horizon," he is an expert at creating controversy, but continually succeeds at bringing people together in one huge room, and letting them talk it out for a few days. No matter which side of the theoretical foot science fence you are on, you'll find plenty of sympathizers and adversaries in this outspoken audience.
The 1997 offerings ranged from the microscopic ("Structural and Material Properties of the Equine Hoof Wall") to the mechanical ("Advantages of Working from a Super Rig Truck") to the zen-like ("What is the Perfect Shoeing Job?"). In between were presentations from distinguished academic veterinary surgeons, thoughtful farriers from the field, and even an artist-blacksmith who spoke on the body language between farriers and their anvils.
It's not as technical as it might at first sound. The primary requirement for admission to this cadre of foot lovers is an interest in horses, their soundness, and their feet. No matter how esoteric the lecture titles might sound in the program, the goal is to help a horse become a sound, athletic animal.
At the Four Corners of the Foot
Redden describes arriving at a farm, picking up a horse's foot, and the foot saying to him, "Doc, please do NOT shoe me the way they did the last time!"
If the hoof is round, how can it have four points? The four point trim was, at first, a practical outgrowth of the theoretical work of a British (now U.S.) farrier named David Duckett, who proposed that the foot had a three-dimensional mechanical center point, unforgettably named Duckett's Dot. Duckett's work was extrapolated to a study of the feet of wild horses by Montana farrier Gene Ovnicek. When, two years ago, Redden started using both men's ideas to trim hundreds of barefoot broodmares in Kentucky, a household word was born.
Four-point trimming requires the horse to have a substantial depth of sole and is often compared to sculpting a horse's foot instead of mechanically trimming it. Farriers and veterinarians who have been properly trained usually find it successful on horses which meet the requirements; in unskilled hands or on a thin-soled horse, it can backfire on a well-meaning practitioner's desire to help a horse.
Redden has incorporated the theory of the four point-trim into a de-rotation process for treatment of laminitis where the third phalanx (P3 or coffin bone) has partially or fully detached from the hoof wall. Key to the process is lowering the heels to the widest point of the frog, easing breakover by bringing the toe back to the "pillars" of the foot, and providing a thin, straight-branched, three-dimensional "rail" shoe. The sole is evenly covered with a synthetic "Advance" cushion, similar to dental impression material, to equalize weight-bearing across the width and length of the bottom of the horse's foot.
Redden also is an advocate of cutting the deep flexor tendon in horses affected by severe laminitis, the treatment of which is his specialty. Most of the shoeing examples shown in his lectures were dependent on having the deep flexor tendon surgically separated from its insertion at the base of P3.
Specific tips from Redden on the use of the four point trim include:
- Do not remove sole over vital, sensitive structures of the foot. Only breakover is removed.
- The largest nail used in Redden's shoe is a 3 1/2 race nail; one-eighth-inch nail holes are drilled in shoes so that nails fit tight and do not move in the foot.
- The four-point trim is designed to provide the horse with a short toe, but the foot is "long" (deep) in the sole under P3
- The sole needs to be protected and kept dry in order to grow; Redden recommends a British product called "Keratex" for horses in wet environments.
Soft Tissue Injuries in the Foot
Bill Moyer, DVM, head of Texas A&M University's College of Veterinary Medicine large animal clinic, opened his lecture with the query: "Are horses' feet getting worse, or am I just getting older?
"We have successfully bred the feet right off our Thoroughbred horses," he continued. "It's a bad product with a lousy set of wheels."
A typical case brought to Moyer's attention for diagnosis would be a lame horse which shows no exterior damage to the foot, nor any radiographic abnormality. When the horse improves with a heel block, Moyer is still left with a long menu of possible causes of the pain--navicular syndrome or navicular disease, or non-specific soft tissue damage or soft tissue inflammation of the joint capsule.
"Well, I can tell the owner what the problem isn't," he quipped, "but I sure don't know what it is."
Moyer's innovative techniques for anesthetizing, or "blocking," the coffin (distal interphalangeal) joint have helped equine practitioners distinguish between injury sites and helped popularize the therapeutic practice of injecting corticosteroids or polysulphated glycoaminoglycans (Adequan) or sodium hyaluronate (Legend). New research is comparing the effects of intra-articular, intramuscular, and intravenous use of different compounds to help horses with coffin joint pain.
Reaching still deeper into the horse's hoof capsule, Moyer warned that submural (beneath the hoof wall) laminar tearing is not well-defined as a clinical entity. Literally a small hemorrhage under the hoof wall, bruising can occur by a horse simply rapping a foot on a stall wall. On a black foot, the hemorrhage is invisible.
As far as the sole lamellae are concerned, Moyer said, "The lamellae of the hoof are perhaps the most frequently injured tissue in the entire equine musculoskeletal system. Some horses are incapable of laying down normal sole. There is an shrinking distance between P3 and the ground."
Moyer did not have a quick solution for soft tissue injuries.
"Remember," he said in conclusion, "to most horse owners, 'rest' is a four-letter word."
Function of the Foot: New Questions
Some farriers and veterinarians might have looked at the program and read the title of farrier Henry Heymering's lecture and sighed, "Well, time to check with the service and do some call-backs." But before they could get to the door, the unassuming farrier/author had them grabbing the nearest seat as he showed slide after slide of instances where the hoof wall was not bearing the horse's weight.
"I started to ask myself some serious questions," he began, "when I re-read all the books that said that the hoof wall alone bears the horse's weight. Tell me what the hoof wall has to do with this horse...and this horse...and this horse," he asked, showing slide after slide of deformed feet and chronically foundered horses who walked on heels, sides of feet, or who had no P3 bone at all.
"What's holding this horse up?" he asked provocatively. "The weight is traveling down through the leg, but it is not transferred through P3 by the laminae to the hoof wall. There has to be another way."
Heymering, a farrier in Maryland and author of an exhaustive bibliography on farrier literature, took his question to Duckett, who dissected a foot for him in a new way.
"He was looking for the chondronavicular ligaments, and gave me a good look at the chondrocoronal ligament in particular," said Heymering. "It is quite large and strong, and is in a perfect position (just behind the center of rotation of the foot) to transfer the body weight to the hoof wall. Just how much of the body weight it might carry is as yet unknown."
During the question-and-answer period that followed, electricity filled the room. Montana farrier Gene Ovnicek and Redden speculated on how alternative weight-bearing mechanisms might explain the success of the four-point trim in unloading large portions of the hoof wall traditionally covered by steel.
Within a few minutes, farrier author Doug Butler, DVM, had agreed to an impromptu dissection of a foot with farrier instructor Mitch Taylor of the Kentucky Horseshoeing School. Working in front of video cameras that projected them onto a screen in the auditorium, they located the chondrocoronal ligament for all to see. While no one actually knows what the ligament can do, new interest has been created in observing the foot in abnormal situations, and perhaps questions from the Laminitis Symposium will stir interest in researching how it and other elastic structures in the foot work and how they can be utilized in the shoeing process to assist lame horses in standing or being ambulatory, and in keeping horses sound.
Laminitis Therapy: More Options Than Ever
It's easy to feel sympathy for the symposium attendees in the final hours of their meeting. Their heads are reeling with new information from the speakers; their suitcases have swollen with samples of new products from more than 40 companies exhibiting in the trade show affiliated with the symposium, and their pockets probably are empty after purchasing all the new equipment, supplies, books, and videotapes that it takes to stay up to date until the next symposium.
Luckily for the attendees, one speaker did a terrific job of pulling together information from disparate camps in the war on laminitis. Don Mock, a farrier from Denton, Texas, does just that every day as he works on foundered horses for no less than six different veterinary hospitals in his Quarter Horse-rich part of America.
Often, there will be differences of opinion even between veterinarians working in the same clinic on what therapy is to be used on a foundered horse. To keep his clients--and the horses--happy, Mock has become proficient at several radically different types of therapy, and uses them with different veterinarians, for different purposes.
As Redden stated earlier in the seminar, any treatment of laminitis must be prefaced by answering questions such as: "Do I save this horse regardless of the cost? Is it imperative that this horse race again?" What sort of care will be available to the horse following application of special shoes and/or surgery is also a key question.
Mock's arsenal was fully loaded. Among the therapy techniques and devices he reviewed:
A four-point shoe with a toe-only
hospital plate and Redden's "Advance" cushion support for a case where P3 was penetrating the sole.
- An "Equine Digital Support System" shoe as designed by Ovnicek on a chronic founder case with protruding bars. Mock used the bars as additional support for the shoe system.
- A Burney Chapman-style heart bar shoe padded with the Advance cushion support material just under the heart bar area. "Don't let the horse stand on it until the material hardens," he warned.
- Impressionable styrofoam padding that cushions the foot while forming to the shape of the frog and bars, marketed by EDSS.
- A plastic "Lilly Pad" heartbar support taped on for acute laminitis.
- Rolled gauze under the frog for support in acute cases.
- A Redden "Ultimate Wedge" shoe screwed into the hoof wall instead of being glued or nailed on, used with Advance cushion support material.
- Double nail pads from the gaited horse world used with simple sheet rock screws.
- A Chapman-style heartbar with Advance cushion material, "Solepack" hoof packing, and a full hospital plate with four bolts.
Mock's presentation showed how sophisticated the field of laminitis treatment has become; a few years ago the choices would have been few, nor were many products available commercially. The next step will be to take Mock's arsenal and match each treatment to the case paramters in which it should be used.
The 12th Bluegrass Laminitis Symposium will be held in Louisville in January of 1998.
About the Author
Fran Jurga is the publisher of Hoofcare & Lameness, The Journal of Equine Foot Science, based in Gloucester, Mass., and Hoofcare Online, an electronic newsletter accessible at www.hoofcare.com. Her work also includes promoting lameness-related research and information for practical use by farriers, veterinarians, and horse owners. Jurga authored Understanding The Equine Foot, published by Eclipse Press and available at www.exclusivelyequine.com or by calling 800/582-5604.
POLL: Radiographs for Hoof Care