Equine Podiatry: Gaining a Foothold
All horses benefit when veterinarians, researchers, and farriers meet to share information and learn from each others' experiences. One of these notable meetings is the annual Bluegrass Laminitis Symposium, hosted in Louisville, Ky., by Ric Redden, DVM, and his wife Nancy, of the International Equine Podiatry Center in Versailles, Ky. The Symposium is held specifically for those equine hoof care professionals who live to improve the care of normal and problem horses' feet.
The field of equine hoof care, or podiatry, is one steeped in long tradition from its roots in coal forges and one-stop blacksmith shops, and it is also one that benefits greatly from the newest hoof and podiatry research. While it might seem that tradition (i.e., time-honored practices) and continuing education (i.e., the latest and greatest) don't have a lot in common, the two combine quite smoothly in the Symposium. The continuing education comes from the recent experiences and findings of dedicated equine podiatrists related in lectures, discussions, and demonstrations; the tradition lies in the consistently top-notch, practical information presented and the camaraderie and open information sharing among repeat attendees.
Events like this are needed to further the field of equine podiatry. One common complaint about the field is that there are no hard and fast rules for what is best for a horse, or what to do in a crisis. The reason for this is that equine podiatry is still in its infancy, and while there are a lot of very intelligent people working to better understand the horse's foot, it's still a very complex structure with no real analogue in the human physique, making it harder for us to comprehend its workings.
Add that to the fact that managing the equine foot involves treatment that varies with the practitioner, since treatments are often mechanical in nature and subject to more variation than, say, injecting a certain dose of a medication. Thus, studying treatments in typical standardized studies is difficult at best.
There are many things we still don't know about the optimal and suboptimal forms and functions of the equine foot, but here is some of the latest on what we do know.
Making it Happen
Ric Redden, DVM, a veterinarian and farrier who founded the International Equine Podiatry Center, kicked off the symposium with a discussion on "How to Make it Happen: Evaluation, Strategy, Planning, and Execution." His discussion centered on the mind-set and focus an equine podiatrist (either veterinarian or farrier) needs in order to gather the most information about a horse and treat him with maximum success.
"There is a tremendous range of normal (anatomy) and pathology," he began (see page 42 for normal and laminitc foot examples). "If you don't know the range of normal, how can you deal with pathology? Preparation (having the knowledge to adequately handle a foot problem) comes with a price, and there are no shortcuts to a successful career. Vets must learn their way around a foot much the same way farriers do--on-the-job training."
He explained that going to veterinary or farrier school alone doesn't give one all the information he or she needs to be a good podiatrist; only practice makes perfect.
"A farrier with 10 years' experience will easily handle 250,000 feet in that time. What will your hands tell you if you touch something 250,000 times?" Redden asked. "Understanding simple (equine) body language also requires months to learn and years to develop. Without it, though, the thought process is stifled when you're under a horse for a routine exam."
But speaking of routine exams, he added, "Think of all foot exams as routine and you'll miss the majority of them. All are unique, and almost all problems are relative to the overall health of the foot. Therefore, the basis of my exam is to look for all the healthy areas. What is left over is what you want to further explore, as that is where the problem lies. Seldom do we find simple primary diagnoses with the foot.
"Education and training in the field of equine podiatry is the answer. From this point on, we must concentrate on how we can all become more knowledgeable and effective in the field of podiatry."
Anatomy and Injuries of the Foot
Renowned equine anatomist Jean-Marie Denoix, DVM, PhD, of Centre d'Imagerie et de Recherche sur les Affections Locomotrices Equines (CIRALE) in Goustranville, France, presented twice, beginning with a discussion on hoof anatomy with a focus on the distal interphalangeal joint (DIPJ), also called the coffin joint.
He explained that the dorsal or toe area of the hoof is very hard, the palmar or heel area is deformable, and the area in between provides the transition. The particular characteristics of the foot undergo myriad stresses during locomotion, which he has studied in the laboratory and on live horses. He summarized that study's results as follows.
"During locomotion, the interphalangeal joints undergo a variety of combined movements in the sagittal, frontal, and transverse planes, especially on uneven surfaces or during turns," he explained. "Each movement induces specific stresses on the articular surfaces and ligaments. Asymmetric elevation of one quarter induces collateromotion (sideways movement of P3, or the coffin bone, relative to P2) and sliding on the same side and rotation on the opposite direction."
Various movements of the bones are limited by the numerous soft tissues present in the foot. Sometimes movement is forceful enough to damage those limiting structures, causing varying degrees of pain and lameness.
"With this knowledge, the biomechanical causes of every injury of the interphalangeal joint structures can be determined, and a rational corrective shoeing procedure can be established," Denoix concluded.
His second presentation described in detail common tendon and ligament injuries of the foot. "Tendon and ligament lesions are major causes of foot pain that are poorly documented with X rays," he said. "Now a real definitive diagnosis is possible with ultrasonography and magnetic resonance imaging (MRI). Collateral ligament injuries (those of small ligaments that help stabilize joints) have occasionally been reported in the literature. Injuries of other ligaments in relation with the distal interphalangeal joint (DIPJ) may induce lamenesses which can be confused with a DIPJ arthropathy (joint disease) or a podotrochlear (navicular) syndrome."
Denoix described a study in which he evaluated a number of horses with ultrasound and radiographs, and in many cases with MRI as well. He found many lesions, and drew the following conclusions.
"Ultrasonography was found particularly useful in horses presenting a foot lameness without significant radiographic finding. A specific diagnosis of several foot conditions can be made with this technique.
"Severe collateral desmopathy (ligament disease) of the DIPJ was found in patients with a sudden, severe distal limb lameness. A differential diagnosis between this condition and other bone or ligament injuries in relation with the DIPJ can be made. Acute as well as chronic tendinopathies (tendon problems) of the deep digital flexor tendon have been diagnosed in a lot of patients and were confirmed in some of them using MRI.
"Ultrasonographic examination of the foot requires a deep knowledge of the descriptive and topographic anatomy as well as adequate equipment and technique," he said. He also recommended that practitioners employ a double square comparison when evaluating symmetrical structures, comparing the injured structure with the symmetrical one of the same limb and the equivalent one of the opposite limb.
Legality of Radiographs
With more and more owners requesting that their farriers use radiographs to prescribe the best shoeing for their horses, and more farriers choosing to work with radiographs especially on problem cases, it's almost inevitable that the question of who can legally take and use radiographs should arise. Thomas W. Miller, an attorney with Miller, Griffin, and Marks, PSC, in Lexington, Ky., discussed the dilemma.
"Although a common practice, the taking of radiographs in order to properly fit a shoe may expose a farrier to liability under the laws of various states regarding the use of X ray equipment and the practice of veterinary medicine," he began.
He discussed the applicable laws of several states including Kentucky, Florida, and California. These laws can vary considerably from state to state, so anyone wishing to understand regulations that apply to them needs to seek out their area's laws.
In Kentucky, for example, it could be risky for non-veterinarians to shoot radiographs because the Kentucky definition of veterinary medical practice is as follows:
"To diagnose, treat, correct, change, relieve, or prevent: Animal disease, deformity, defect, injury, or other physical or mental conditions, including the prescription or administration of any drug, medicine, biologic, apparatus, application, anesthetic, or other therapeutic or diagnostic substance or technique..."
"In many cases, the chances of getting caught are remote, as well as the chances of full prosecution and jail time," Miller said. "But it still exposes you to significant civil liability.
"Most regulations provide that the owner of the X ray equipment is responsible for safety measures," he went on. "If you loan out equipment and it causes injury to anyone or any horse, the owner is liable. And if you purchase equipment, you must register it within 10 days (in Kentucky; regulations might differ elsewhere)."
Miller said that any time a horse is hurt, an attorney can find someone with the right qualifications to say that the treating professional did something wrong. "Someone can always be looking over your shoulder, especially with a valuable horse," he warned.
He related several cases of equine injury with and without obvious fault, explaining any liability in the eyes of the law. "I don't advise you how to run your business," he said. "I only tell you what the risks and the law are, and how to minimize those risks."
Redden added, "When you're treating a lame horse, you may be liable if you're not using the state-of-the-art treatment. You may be in more trouble if uneducated on these issues than if you're educated."
We're always trying to speed healing of injuries in our horses; two presentations at the Symposium focused on growth factor for treating various kinds of wounds, fresh and chronic, hoof and otherwise.
The first was by David Jolly of BeluMedX, makers of Lacerum growth factor treatment, a platelet-rich plasma product with growth factor provided by the platelets (blood components that aid in clotting).
"Research on the effect of platelet-rich plasma on wound healing was first done in humans," he said. "The most refractory cases of delayed healing studied included 10-year duration wounds on diabetic people with pressure sores. The growth factors provided by the platelet and did indeed promote wound healing. This new approach is proving to be significant to equine wound healing as well."
He described several hoof wound cases, including coronary band injuries and quarter cracks, that healed quickly following initiation of Lacerum treatment. The key, he says, is giving the horse enough time off to heal and avoiding caustic antibiotics that can damage healing tissue and kill the natural "flora" (bacteria), allowing pathogens (disease-causing bacteria) to take over.
"Care should be taken to keep the exposed laminae moist, and to prevent exposure of the regenerating tissue to any toxic or necrotizing agents," he concluded.
Redden also related his experiences with Lacerum in difficult wound cases, including the much-publicized treatment of an American Saddlebred injected with a necrotizing (tissue-killing) subtance in mid-2003 (see www.TheHorse.com/sbreds for more information). He described the procedure of mixing and applying the product in detail, as well as providing several case studies.
These cases included a catastrophic puncture wound with multiple articular fractures, a wire puncture in the foot, a wall crack from a coronary band abscess, an amputation stump, a hoof wall portion that was trimmed out following buckling from a coronary band abscess, septic laminitis, and the American Saddlebred's necrotizing lesion in the pastern area.
"If we can use growth factor to accelerate the normal healing response with foot problems, then we can bypass the normal secondary sepsis (infection) that is often devastating to a lot of foot injuries," he stated. "Since January 2003, we have treated approximately 50 different cases with the growth factor, and approximately 20-25 cases with the ACell. The Lacerum is a growth factor, and the ACell is a biological scaffold. I have found that they work well in conjunction with each other. I have also found cases where I didn't get the favorable response I expected. With anything new and innovative, there are often limitations."
Andrea Floyd, DVM, of Serenity Equine in Evington, Va., presented multiple case studies at the Symposium. The first was an account of a Quarter Horse gelding with severe flexor contracture in his left forelimb even after superior and inferior check ligament desmotomies (cutting of these ligaments) performed two years before the horse was presented to Floyd.
"Equine podiatry referral hospitals must be detectives," Floyd said. "Cases that reach referral podiatry hospitals are many times chronic and confusing. Attempting to make a diagnosis based on immediate findings, without good diagnostic material from the referring veterinarian and farrier, can lead to a misdiagnosis of the primary causal mechanism."
The gelding in question was walking on the front of his coronary band, and Floyd identified an old scar with suture lines in the upper foreleg near the shoulder. "The muscle had been torn loose from its attachment by the trauma and had dropped distal to (below) the scar," she reported. The horse had sustained this injury from going through a barbed wire fence at six months of age. At the time of Floyd's initial exam, the horse was three years old.
Although cutting the deep and superficial digital flexor tendons offered some relief and proximal and annular ligaments allowed a normal weight bearing stance, the leg continued to contract following the initial improvement. What finally allowed the horse "nearly normal" use of the lower limb was arthrodesis (fixation) of the fetlock joint with screws.
"I have strong feelings that there was a neurological component implicated in the flexor contracture of this gelding," Floyd said. "Due to the pain elicited by digital palpation of the axillary scar area (high in the forearm, up near the body) and the horse's tendency to hold the leg out laterally, I feel there may have been a pain problem that caused the horse to contract."
Her second case study involved a street nail surgery (opening and draining of a hoof puncture) with complications.
"For penetrating foot wounds, radiograph the foot before removing the foreign object," she said. "Be prepared to do a nerve block and explore the wound thoroughly after the X ray. Penetrating wounds through or near the frog are a red flag for infection--do a culture and use the appropriate antibiotic, and be prepared to use a patten shoe (which keeps the sole off the ground by elevating the heels, and allows the sole to be medicated, as well as allowing complete release of the deep flexor tendon that was necrotic in this case and needed to heal in a relaxed position)."
This horse was an eight-year-old Thoroughbred gelding that "arrived dog-sitting on the trailer and had great difficulty rising and walking. The left hind hoof had sustained a nail puncture to the depth of the navicular bone, obliterating 75% of the deep digital flexor tendon (DDFT) and causing necrosis of 50% of the navicular bone." The horse also had nearly uncontrollable pain and methicillin-resistant Staphylococcus aureus in the wound that had ascended along the flexor tendons to the pastern area.
The right hind hoof became severely laminitic from the overload and the hoof capsule sloughed, so the decision was made to place transcortical pins in the right hind cannon bone and build a fiberglass cast around them to support weight bearing on the pins and allow the hoof to heal while floating free within the cast.
Floyd noted that intensive care was critical for this horse, as he required intensive caloric intake to heal, had terrible pressure sores from staying down, and received anti-ulcer treatment as needed. She noted that spandex "sleepwear" was useful in protecting areas that were at high risk for ulcers including the hocks, elbows, and hips.
Following intensive management of the initial injury, multiple pin and cast changes, and ancillary problems, the horse recovered to soundness on rail shoes (these have a curved ground surface that moves breakover back further, to the center of the coffin bone's ground surface, and allows a "self-adjusting" hoof angle). "The total recovery time was about 12 months," Floyd reported.
"There will always be clients searching for hope for their horses," she added. "Don't give up on them. If you as a farrier or veterinarian do not feel that you can help the horse, search for a referral facility. You will become the hero for referring."
Heel, Navicular, Laminitis Pain
Gene Ovnicek, RMF, well-known farrier, clinician, and creator of the Natural Balance Shoe, presented twice at the Symposium as well. His first focus was on recognizing and treating heel/navicular pain.
"Navicular problems are the most common problems seen by veterinarians," he began. "Possible causes include genetics, hoof management, environment (simply restricting movement is one of the biggest culprits in this disease), and shoes (might barefootedness help fix things)?"
He described a common hoof condition associated with lower limb lameness as long-toe/low-heel syndrome, which often exhibits contracted, drawn-forward heels, curled bars (the bars are normally straight), a frog that's stretched forward at the apex and narrow, and a broken-back hoof-pastern axis. "This type of hoof distortion in the early stages is frequently associated with horses that stumble, forge, land toe-first, or have a decline in their performance level," he observed. "If these horses are not lame now, they will be before they die. All sound horses land slightly heel-first, and if they land toe-first you'll see a little puff of dirt in front of the toe.
"The curled heel is always the tallest one," he said. "If they're both curled, then they're both too high. And if you see red spots in the sole at the ends of the heels, these are small hemorrhages (bruises). Take down the heels a little, move the heels back behind that spot. No wonder they don't want to land on their heels!
"Horses that have been subject to this same type of hoof distortion for a long period of time are more often afflicted with navicular syndrome, coffin joint pain, ringbone, or pedal osteitis," he continued. "Horses that land toe-first usually have a longer-than-normal toe that causes a delay in breakover, and are inclined to momentarily sublux (partially dislocate) the distal end of P2 caudally (rearward) and cause undue strain on the navicular bone and impar ligament."
Ovnicek next compared the chronically laminitic foot to the club foot, and noted the similarities between his treatments for both.
"Over the last 10-15 years that I've been dealing with primarily lame or pathologic horses, I've found that the treatment for chronic laminitis (using Natural Balance guidelines) has helped me better understand and manage these clubbed and mismatched feet," he began. "Chronically laminitic feet are often mistaken for club feet. The hoof distortion that occurs is part of the natural defense to protect internal hoof structures."
He stated that about 60% of domestic horses exhibit clubbed or mismatched feet. Of those, he said 30-40% are minor, 50-60% are moderate, and about 10% are severe. The traditional treatment for these upright feet, he said, includes lowering the heels and leaving the toe longer. The problem with that treatment is that tendons don't stretch easily or much, muscles contract when tension is applied, and the inferior check ligament limits the length of the DDFT below that attachment, he explained. The result is that the horse doesn't land heel first, the heels contract, the dorsal wall becomes distorted, the frog loses ground contact and contracts, the overloaded sole at the toe can't protect the border of P3, and pedal osteitis develops from landing toe-first on thin soles.
The better treatment is to trim the heels back to live, functional sole, leave good hoof length at the toe, and move breakover back (to the tip or P3 or further back) to slow heel regrowth by increasing weight bearing on the heels, he said. The goal is to get the horse to land equally heel-first on both feet, regardless of what the hoof looks like.
"In time, the two feet will look more alike, but will never be the same," he said. "I've created a lot of problems in horses over the years just trying to make them look the same. But horses very often have mismatched feet just like humans do."
Wild Horse Feet
"Much has been written and discussed about using the feral or wild mustang horse's foot as a model for balance and shape for optimal form and function," said Tom Hartgrove, DVM, of Las Vegas, Nev. "The feral mustang's feet have served as a blueprint for the technique referred to as natural balance trimming and shoeing. These techniques have undoubtedly benefited lame horses and helped form the basis for many different approaches to treating laminitis.
"Given this blueprint for success, feral mustang feet are usually only brought up during lameness discussions as a model for prevention and treatment," he continued. "This leads to the impression that feral mustang feet do not suffer from pathology. However, at times, even optimal form and function can fail. This report deals with the study of feral mustangs from the Nevada National Wild Horse Management Area that were presented for treatment for lameness and/or necropsy."
Hartgrove presented many examples of wild horse feet, ranging from what one might consider normal to the wildly abnormal, and often these horses get along pretty well with these odd feet. Others, however, do not; he related a trend of more than 20 foals presented in three years' time that were presented for necropsy following severe gravel (migration of a piece of gravel up the laminar interface from the toe to the coronary band; along the way it causes severe inflammation, infection, and pain).
"These were foals that were either abandoned by the herd, or collapsed during a gather," he said. "The foals that survive gravel develop deep flexor contracture syndrome and change their mechanics of motion, and if they survive long enough they develop bizarrely shaped feet. This then becomes their new natural balance and it is not uncommon to see these horses leading the pack during roundups.
"Further study is needed to define the pathophysiology of some of these (and other) fascinating hoof conditions," he concluded.
Insurance and Laminitis
While to most of us insurance means something bad has happened and we're trying to recover from it, there is the silver lining of having planned for this kind of problem and being somewhat protected--not that it makes it any easier to handle illness or disease in your horse. Don Blackburn, an insurance adjuster with Livestock Claims, Limited, in Citra, Fla., discussed the insurance adjuster's role in your claim on your horse's insurance, and said that the more helpful the owner can be, the easier the process will go.
"Don't wait to call your insurance agent until the horse is really in a bad way and you've been treating him for awhile," he stressed. "The adjuster has to build a medical record from the beginning.
"Dealing with an insurance company is like dealing with a 6-year-old child," he continued. "The company is going to ask 'why, why, why?' I can't stress enough the importance of being cooperative--we have state regulations to satisfy, and we need your help to do it. We don't ask for documentation because we don't trust you. Our job is to take the information you give us and filter it through your contract. All policies have clauses and endorsements that require proper care and treatment throughout the illness. We have to document that too. There's a saying--'If it ain't in a file, it ain't.' "
Redden commented, "If you ask clients about their horse's policy before surgery, they think it's life-threatening. Most think you're supposed to call just before you euthanize the horse, but you need to know what's going on way before that."
The last day of the Symposium featured a panel discussion in which farrier Danny Dunson and veterinarians Liz Maloney, DVM; Brad Root, DVM; and Mark Wooten, DVM, were called upon to comment on cases Redden presented. A lively discussion ensued, during which several interesting points were made.
- "My phone is always on. Otherwise, I'm leaving them (the veterinarians) to do things by themselves. You never learn anything by hiding."--Dunson
- "You have to have a suitable place for farriers to work. People can spend millions of dollars working on horses, but have no good place to work on the horse's feet out of the rain."--Redden
- "I've heard rumors that this will be the last Symposium--they couldn't be any more false."--Redden
- "A common problem is that you fix a horse, then he goes home to an owner and farrier who just don't know what to do with him. It's nobody's fault, just the system. We haven't completed the plan (and provided for educating the horse's owner and farrier so they know what after care he needs.)"--Redden
- "Equine podiatrists are like the emergency room in a hospital. That's how you've got to start thinking."--Redden
- "Severe sinker syndrome in a halter horse--I've never had one live more than two years. All that excess body weight just presents too many challenges."--Redden
- "Always work on the good foot first--it works out much better in a lot of cases. If you work on the bad one first, the horse may be in a lot of pain and not likely to stand on the bad foot so you can work on the good one after you've hurt him. Sometimes I'll just lay a shoe on the foot and hit it once with a hammer to see how he'll react, so I can plan for it."--Redden
The live shoeing demonstration that wraps up the convention is always a popular session, with multiple veterinarians and farriers demonstrating solutions to common (and not-so-common) problems via television feed to the symposium attendees. The demonstrations always provide a wealth of practical information for farriers and veterinarians striving to improve their techniques.
This year's experts were Wooten, Dunson, Redden, and Ovnicek, and their topics included "A Team Approach to Treating Laminitis (including casting for transport)," "Foot Dissection: Taking a Look at the Vital Internal Structures," "Shoeing a Horse With Typical Heel Pain," and "How to Properly Use the Rock-n-Roll Shoe for Rehabilitation and High-Speed Sports."
What's Coming Up?
Amid rumors that this was the last year for the Bluegrass Laminitis Symposium, as Redden said, that just couldn't be farther from the truth. What will be different next year, however, is that the Reddens will likely not be hosting it--they'll be taking a much deserved break. In their stead, several people have discussed putting on future Bluegrass Laminitis Symposia with Redden's input. Whoever takes it over, you can look forward to a continuing tradition of cutting-edge, practical hoof care education for equine podiatry professionals.
Thanks for All the Help
At the 2004 Bluegrass Laminitis Symposium, farrier Danny Dunson, Eric Parsons, Rob Spencer, and Shannon Redden (not pictured) presented Symposium hosts Nancy Redden and Ric Redden, DVM, with a plaque to thank them for their longtime service and dedication to the field of equine podiatry.
The plaque and recognition were inspired by Dunson, a long-time friend of Doc and Nancy and a farrier at Nolensville Vet Clinic in Nolensville, Tenn. Parsons, Spencer, Shannon Redden, and Dunson each spoke briefly at the presentation of the plaque.
"They're there for you any time, all you have to do is just pick up the phone," said Dunson.--Christy West
MORE LAMINITIS SYMPOSIUM REPORTS: www.TheHorse.com/BGLS
About the Author
Christy West has a BS in Equine Science from the University of Kentucky, and an MS in Agricultural Journalism from the University of Wisconsin-Madison.