Close this window to return to IVIS

www.ivis.org

Proceedings of the 16th

Carrara, Italy
January 29-31, 2010

Next SIVE Meeting:

Feb. 4-6, 2011 – Montesilvano, Pescara, Italy

Reprinted in the IVIS website with the permission of the

http://www.ivis.org
Published in IVIS with the permission of SIVE Close window to return to IVIS

Treatment strategies for palmar foot pain

Tracy Turner
DVM, MS, Dipl. ACVS
Anoka Equine Veterinary Services - Elk River, Minnesota

Thorough examination of the horse affected nate the pain and stop or decrease the stresses
with palmar foot lameness syndrome is impor- that are causing the problem.
tant not only to determine that the horse has the Six hoof balance abnormalities have been de-
syndrome but also to try to determine which scribed: broken hoof axis, underrun heels, con-
type of disease process is at work. Treatment tracted heels, shear heels, mismatched hoof an-
then should be based on the type of injury. gles, and small feet. Some authors have at-
The treatments of navicular syndrome vary tempted to define these hoof abnormalities ob-
widely, which probably reflects the treatment jectively. A broken hoof axis exists when the
of multiple causes. By determining the most slopes of the pastern and hoof are not the
likely cause of the syndrome, the most specif- same. This condition is further defined as bro-
ic problem can be treated. The treatment of ken-back, when the hoof angle is lower than
caudal hoof lameness is as controversial as the pastern angle, and as broken-forward
any aspect of this syndrome. However, it has when the hoof angle is steeper than the pastern
been shown that correct shoeing should be ba- angle. Underrun heels have been defined as
sis of all treatment. Any medicinal or surgical angle of the heels of 5o less than the toe angle.
therapy should be as an adjunct to shoeing. A contracted heel was defined as frog width
The most successful approach to shoeing is less than 67% of the frog length. Sheared
that based on individual case needs rather than heels were defined as a disparity between the
a standard formula. The following principles medial and lateral heel lengths of 0.5 cm or
should be followed: (1) Correct any pre-exist- more. Small feet (small feet to body size)
ing problems of the hoof, such as underrun were defined as a weight to hoof area ratio of
heels, contracted heels, sheared heels, mis- greater than 78 pounds per square inch.
matched hoof angles, broken hoof/pastern ax- Numerous factors contribute to the balance of
is. (2) Use all weight bearing structures of the an equine hoof. Toe length is important be-
foot. (3) Allow for hoof expansion. (4) De- cause it determines the length of the lever arm
crease the work of moving the foot. Shoeing is over which the limb rotates and the timing of
most effective when corrections are made hoof lift. Hence, a long toe, that would delay
within the first 10 months of lameness, up to breakover, could be expected to increase the
96% success. This is in contrast to when shoe- pressure of the deep flexor tendon over the
ing changes are not made until after 1 year of navicular bone, increase the tension on the
lameness, where only 56% of the cases have proximal suspensory ligament of the navicular
been successfully treated. bone, and increase the dorsal rim pressure on
These principles can be accomplished using the joints of the leg. The optimal toe length
many different methods and techniques. Shoe- has not been determined. Toe length to a cer-
ing is of utmost importance in dealing with tain extent will be dictated by the horse’s use
hoof pain causing the signs associated with as well as the horse’s height and weight.
navicular syndrome or remodeling of the bone Guidelines have been described that relate toe
(osseous form). It is necessary to insure prop- length to body weight. A graph of hoof meas-
er hoof balance and support in order to elimi- urements will document disparities in hoof
161
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Published in IVIS with the permission of SIVE Close window to return to IVIS

wall length between feet. Lengthening one ground contact should be even with the base
hoof over its opposite has been suggested as a of the frog. Underrun heels are the most com-
treatment for limb length disparity in the monly encountered hoof abnormality. In one
horse. However, this condition has not been study of foot related lameness it was found in
scientifically documented in the horse. It has 77% of the horses and in another study of nor-
been the author’s experience that apparent mal performance horses this condition was
limb length disparities are more commonly found in 52% of the horses. The necessity of
due to mild flexural deformities (contracted correcting underrun heels has been well docu-
tendon) rather than actual differences in limb mented. If left uncorrected underrun can cause
length and that this condition is most com- alterations in hoof wall growth that can be
monly manifested as mismatched hoof angles. very difficult to correct and it can predispose
One study indicated that 28% of normal per- to lameness problems that range from bruised
formance horses might be affected in this heels to navicular syndrome.
manner. This can most easily be documented One of the most difficult parameters to assess
utilizing the lateral radiographs. is the hoof’s ability to expand. Applied clini-
The hoof angle should be the same as the hoof cal studies have shown that the frog length to
axis. Utilizing the lateral radiographic projec- width ratio is useful for this purpose; when the
tion, the ideal hoof angulation to properly frog’s width is at least two-thirds its length,
align the second and third phalanges can be the hoof has normal expansive abilities. When
measured accurately. The appropriate correc- the frog is narrow, hoof expansion is reduced.
tion can be determined by measuring the de- Whether this is a function of frog pressure is
gree of malalignment (flexion or extension) not known, although both reduced and exces-
present in the coffin joint and raising or low- sive frog pressure have been shown to cause
ering the hoof angle that amount. For instance, hoof contracture. Identification of a narrow
if the lateral radiographic projection showed frog should alert the clinician that steps need
4o flexion of the coffin joint, then the hoof an- to be taken to promote hoof expansion. These
gle should be lowered 4o. In most cases, the may vary from simply ensuring proper heel
aligned hoof axis is 52o±2o for the front feet support to encouraging hoof expansion
and 55o±2o for the back feet. Intentional low- through the use of slipper heels.
ering of the hoof angle has been used to in- Medial/lateral imbalance or shear heels have
crease stride length in racehorses but studies been shown to cause, or predispose to, a num-
have shown that this is not true; therefore, ber of hoof related lameness. Medial/lateral
there is no reason not to shoe for a correct balance can be assessed by both the hoof
hoof axis and a broken hoof axis can predis- measurements and the radiographic examina-
pose to lameness problems and it has been as- tion. The graph of hoof wall measurements
sociated with a greater risk of breakdown in will clearly show if one side of the hoof is
racehorses. longer than the other. The obvious correction
In addition to hoof axis deviations, the lateral is to make the walls equal, although it is not
radiographic projection can be used to docu- always that simple. The dorso-palmar radi-
ment problems of heel support, i.e. underrun ograph will also clearly demonstrate any im-
heels. In horses with hoof angles between 50 balance. Since this projection will also show
and 55 degrees, the hoof length graph also the effect the imbalance has on the coffin
documents underrun heels if toe length to heel joint, this radiograph can be used to empha-
length ratio is less than 3:1. Either drawing a size the need for correction. The magnifica-
bisecting line through the metacarpus to the tion in most radiographs makes even subtle
ground, or measuring the appropriate position disparities more obvious. It is accepted that
on the radiograph can determine the proper conformation can alter this balance. The radi-
position of the heels. Where these lines con- ograph will help determine if the imbalance is
tact the ground is the point where the heels hoof related or conformational. Hoof related
should be. From a practical point, the heel- imbalances will show medial/lateral hoof
162
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Published in IVIS with the permission of SIVE Close window to return to IVIS

length disparities, and the first and second These hoof balance issues have importance
phalanges can be bisected equally. If the me- relative to prognosis. Caudal hoof lameness
dial/lateral disparity is conformationally relat- treated with shoeing alone within the first 10
ed the first and second phalanges will appear months of lameness has been 97% successful
oblique on the DP radiograph. in managing the lameness. However, horses
The final assessment of balance is the weight that have been lame for one year or more
of the horse in proportion to its feet. Small feet shoeing is only 54% successful. The presence
have been a commonly described problem, of underrun, contracted and sheared heels in
particularly in Quarter Horses, that predispose the feet makes it four times less likely to be
the horse to lameness. One study identified successful. Finally, horses with a hoof area to
small feet as an indicator of poor prognosis in weight ratio of 83 lbs/in2 or more, none were
the treatment of navicular syndrome. Most de- successfully treated with shoeing.
scriptions of what actually constitutes a small Horses that respond to coffin joint anesthesia
foot are quite subjective. However, studies should be treated for inflammation of that
have been performed utilizing simplistic for- joint. This may include systemic non-steroidal
mulas to make this assessment objective. anti-inflammatory therapy but intra-articular
These studies measured the circumference of therapy or specific joint therapy should be
the hoof immediately below the coronary considered. The use of hyaluronic acid and
band. This was done to get a rough idea of the corticosteroids as anti-inflammatories within
hoof cross sectional area. This was then com- the joint is well documented. I prefer to use a
pared to the horse’s weight and statistical combination of high molecular weight
analysis was performed. A ratio of seventy- hyaluronic acid (10 mg) and triamcinolone (8
eight pounds per square inch was determined mg) injected intra-articularly followed by a
to be the maximum weight to hoof area ratio second shot of hyaluronic acid in 2 weeks. In
for a normal performance horse. The steps to addition, the use of intra-articular or intramus-
determine this number have been simplified to cular polysulfated glycosaminoglycans has
the following formula: been useful in the control of joint disease.
12.56 X wt(lbs)/C2(in2). Most frequently I use PSGAGs if I suspect
Once identified, a high weight to hoof area ra- cartilage damage (500 mg IM, weekly for 4
tio can be used to show a client that their horse weeks). Cartilage damage, at least on the flex-
should lose weight. In addition, it can be used or surface, can most easily be assessed by
to show the necessity of fitting a shoe as fully contrast navicular bursagraphy.
as practical in order to produce the largest sur- Occasionally horses affected with coffin joint
face area as possible for that particular horse’s synovitis also have a chronic broken forward
hoof. hoof axis. Many of these cases appear to be
The author believes there is a hierarchy of mild flexural deformities. Because of the
hoof problems, in other words when dealing malarticulation of the short pastern and coffin
with these problems which is the most impor- bones, the joint remains inflamed despite ther-
tant. The most important problems relate to apy. In these cases, inferior check desmotomy
heel support and this means not simply adding to allow correction of the broken forward axis
shoe but improving the ability of the quarters has been very useful in treatment of these
and heels of the hoof capsule to bear weight. types of cases.
The next most important issue to deal with is Treatment of vascular forms of the disease
that of medial to lateral balance. Improving will need to be treated with vasoactive drugs.
the ability of the hoof to expand follows this. Four drugs have been used for this purpose.
This is followed by body size to foot size mis- Warfarin is used to improve the circulation to
matches. The least important of the hoof prob- the podotrochlea by increasing the one-stage
lems appears to be hoof pastern axis. Oddly prothrombin time by 20% up to 50% if im-
enough this is the one most commonly and provement not seen within 8 weeks. The
easily treated. drug is administered orally at a dose of 0.2
163
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Published in IVIS with the permission of SIVE Close window to return to IVIS

mg/kg daily (total daily dose 6-85 mg daily to become popular in Europe and has been effec-
the 500 kg horse). Vitamin K1 must be avail- tive on selected cases of navicular syndrome.
able at all times because of the possibility of The surgical approach is made just proximal
fatal hemorrhage caused by warfarin. This is to the collateral cartilages, just cranial to the
also why this drug has fallen out of favor. digital vein. A 2 cm incision is made, the vein
Isoxsuprine HCl is the most common drug is retracted in a palmar direction, and the CSL
used to increase the circulation to the can be located as it courses proximally and
podotrochlea. Although there is some contro- dorsally over the short pastern bone. A hemo-
versy as to the effectiveness of oral adminis- stat is used to dissect around the ligament and
tration. It is dosed at 0.6-1.2 mg/kg b.i.d. un- then transection is performed. Closure is stan-
til sound, then decreased to s.i.d. for 2 weeks dard. The horses are allowed to rest for 2
then further decreased to every other day. My weeks for skin incision healing, and then they
approach to using this drug has been to dose are returned to work.
at 1.2 mg/kg b.i.d. for 2 weeks, followed by Similarly, when the deep flexor tendon is in-
1.2 mg/kg s.i.d. for 1 week, and then 0.6 volved, raising the heels of the hoof will de-
mg/kg s.i.d. for 1 week. The drug is discon- crease strain on the tendon. But in addition,
tinued after the fourth week and the effect re- desmotomy of the inferior check ligament has
assessed. If the horse becomes lame after dis- also recently been shown to be effective in
continuance the drug is restarted at 1.2 mg/kg treatment of these cases. But if tendonitis is
s.i.d. then reduced weekly to the minimum ef- diagnosed the tendon needs to be rested.
fective dose. Podotrochlear bursa lavage has been suggest-
Other drugs have been studied. Metrenperone ed for the treatment of true cases of navicular
is a serotonin antagonist and thereby increas- bursitis. Ingress and egress needles are placed
es circulation. It has been used at a dose of 0.1 in the bursa and isotonic fluid is flushed
mg/kg b.i.d. However, the drug has not been through the bursa to remove any inflammato-
shown to be as efficacious as isoxsuprine. A ry debris.
new drug that is showing promise is pentoxi- When all other treatments have failed or have
fylline which increases RBC deformability not had the desired affect, palmar digital
and decreases blood viscosity thus aiding cir- neurectomy remains a viable treatment alter-
culation. The drug is dosed at 4.5-7 mg/kg native. Numerous techniques are available but
t.i.d. Clinical trials in Canada have shown all follow some basic rules. First, the neurec-
much promise. However, the research failed to tomy will not improve the lameness any more
determine which patient profile is best suited than a palmar digital nerve block. Therefore,
to this treatment. it is highly recommended that the nerves be
Some surgeries have been suggested to be anesthetized with the owner/rider present so
useful in the treatment of vascular forms of that they can decide whether the horse has
the disease. Palmar digital neurectomy causes sufficiently improved. Second, neuromas are
vasodilation and the effect lasts as long as the a common problem but can be avoided by
neurectomy. Fasciotomy of the palmar digital atraumatic surgical technique. Atraumatic
nerve has also been suggested but the effect surgery can really only be learned by prac-
does not last and may cause more damage to tice. Neuroma formation can be decreased by
the nerve. allowing the surgical wounds to heal as well
In cases where desmitis of the navicular sus- as possible before returning to work. This
pensory ligament is suspected there are basic usually requires 4 to 6 weeks rest after the
2 treatment alternatives. Treatment is de- surgery. Third, the horse will lose skin sensa-
signed to reduce strain on the ligament. This tion in the back half of its foot but probably
can be achieved by either raising the heels of loses all or most of its sole sensation. Howev-
the horse’s foot or by cutting the collateral er, the horse will always know where the foot
sesamiodean ligaments (CSL). Collateral is. The foot then should be protected some
sesamoidean desmotomy is a surgery that has how, usually by a pad.
164
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Published in IVIS with the permission of SIVE Close window to return to IVIS

Therapeutic Flow Chart.

There are other treatments for caudal hoof pain 6. Turner TA, Kneller SK, Badertscher RR, et al. Ra-
but these treatments are the core of the therapy diographic changes in the navicular bone of normal
horses. in Proceedings. 32nd Annu Conv Am Assoc
that is available. Drugs that effect bone remod- Equine Practnr 1986; 309-316.
eling are being tested, new analgesic drugs are 7. Pool RR, Meagher DM, Stover SM. Pathophysiolo-
under investigation and extracorporeal shock- gy of navicular syndrome. Vet Clin No Am, Eq
wave are being tested. But where these treat- Pract 1989; 5:109-129.
ments will fit in the treatment of caudal hoof 8. Lose MP, Hopkins EJ. The pathogenesis of navic-
ular disease: a theory. Mod Vet Prac 1987; 2:106-
pain has yet to be determined. 108.
9. Fricker CL, Hugelshofter J, Attinger P. Fasziotomiel
neurolyse als therapie der strahlbeinahmheit
REFERENCES (podotrochlose) des pferdes. Schwiez Archir fur
Tierheilk 1986; 128: 87-90.
1. Turner TA: Diagnosis and treatment of the navicu- 10. Colles CM. Concepts of blood flow in the etiology
lar syndrome in horses. in Yovich JV (ed): The and treatment of navicular disease. in Proceedings,
Equine Foot, Vet Clin of NA: Eq Prac, Philadelphia, 29th Annu Conv Am Assoc Equine Practnr 1983;
WB Saunders Co, 1989: 131-144. 265-275.
2. Turner TA: Navicular syndrome. in Robinson NE 11. Lose MP. Contracted flexor tendons as related to
(ed): Current Therapy in Equine Medicine III, the etiology of navicular disease. Eq Vet Sci 1991;
Philadelphia, WB Saunders Co, 1991: 11:308-311.
3. Trotter GW: Therapy for navicular disease. The 12. Turner TA. Navicular disease management: shoeing
Compendium on Cont Ed, 13(9): 1462-1465, 1991. principles, in Proceedings. 32nd Annu Conv Am
4. Colles CM. Navicular disease and its treatment. In Assoc Equine Practnr 1986; 625-633.
Prac 1982; March: 29-35. 13. Turner TA. Caudal lHoof Lameness, in Floyd AE
5. Stashak T. Adams’ Lameness in Horses. Philadel- and Mansmann RA: Equine Podiatry. Saunders-El-
phia: Lea & Febiger, 1987;499. sevier, St. Louis, 2007, 294-312.

165
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010