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Proceedings of the 16th

Italian Association of Equine Veterinarians
Congress

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

Italian Association of Equine Veterinarians – SIVE

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Examination of the equine foot

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

A thorough examination and assessment of can be localized to the hoof. The evaluation of
the equine foot forms an essential part of both the horse with foot pain like all examinations
the physical and lameness evaluation. Since requires a thorough history.
foot problems are the most common cause of
lameness, the examiner must have an accurate
knowledge of foot anatomy and must be will- HISTORY
ing to perform a “hands on” approach to fully
appreciate the problems they may encounter. Any examination begins by getting a history
There are numerous causes of pain in the foot of the individual.1 One needs more informa-
of the horse. These causes can be arbitrarily tion than just age, breed, and sex. Obviously,
divided into: (1) Conditions of the hoof wall the questions that should be answered would
and horn producing tissues, (2) Conditions of apply to any lameness examination, but some
the third phalanx, and (3) Conditions of the will have greater significance when dealing
podotrochlear region. with foot problems.
Hoof problems would include: hoof wall de- The foot is dynamic and responds rapidly to
fects, such as cracks that involve the sensitive both internal and external forces. The hoof cap-
tissue; laminitis (systemic), laminar tearing sule can change its shape (deform) and compo-
(local, due to hoof imbalance), separation or sition quickly; therefore, the examiner should
inflammation of the sensitive laminae from attempt to discover the factors affecting the in-
the insensitive laminae; abscess formation; dividual patient.
contusions of the hoof causing bruising or The examiner must know what the presenting
corn formation; neoplasia, and pododermati- problem is and how long it has been apparent.
tis (thrush or canker). It is an excellent idea to ask what the
Third phalanx problems include: fractures of owner/trainer suspect is wrong. The examiner
the coffin bone (types I-VII), deep digital flexor then can address these concerns while ascer-
insertional tenopathy, pedal osteitis (generalized taining the problem. The history taker then
or localized inflammation of the bone), and dis- needs to ask about the pattern of lameness (in-
ruption of the insertions of the collateral liga- termittent or constant), if the lameness were
ments, cyst-like lesion formation, and remodel- intermittent under what conditions would
ing disease. Conditions of the podotrochlear re- the lameness likely be seen i.e. at the begin-
gion have been reported to include distal inter- ning of exercise or after hard work.
phalangeal synovitis/capsulitis, deep digital An appreciation of the breed and the use of the
flexor tendinitis, desmitis of the impar (distal horse will also provide information relative to
navicular ligament) or collateral sesamoidean the incidence of certain foot problems. Thor-
ligaments, navicular osteitis or osteopathy, and oughbred and Quarter Horse racehorses have
vascular disease of the navicular arteries, and a relatively high incidence of foot bruising, ped-
navicular fractures. al osteitis, distal phalanx fractures, heel bulb
The common denominator of all these condi- damage from overreaching, quarter cracks, nail
tions is that they are characterized by pain that problems, underrun and sheared heels. Stan-
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dardbred racehorses also have similar foot Rocky Mountain region (hard, dry surfaces).
problems but have a much higher incidence of The horse’s foot simply is too slow to adapt to
quarter cracks. Racing combines extraordi- a change in stress. We have occasionally seen
nary speed with surfaces that are more con- the same problem in horses coming from Eu-
ducive to speed rather than cushion, thus cre- rope. The hoof appears to need acclimatizing
ating tremendous force on the hoof. to the new environment.
It is helpful to determine when the horse was Look at the current type of shoe being used, as
last shod or trimmed. In order, to evaluate the well as the type of shoe used in the past. Is it
shoeing you must know when it was per- steel or aluminum? The answer may be as
formed. Often, a normal healthy hoof will simple as the horse appears to perform best
grow over the shoe when it is due for a reset. with one particular type of shoe and poorly
The hoof also does not necessarily grow uni- with another. However, the farrier may also
form, so the way the horse was shod by the have recognized a problem and begun to make
farrier may not be what you see as an examin- adjustments. On the other hand, the shoe may
er weeks later. Foot problems that arise with- simply be a trainer’s preference without a
in a few days of shoeing may indicate sole good reason for using it. It is the author’s
pressure, a poorly placed or over-clinched opinion that you need to inquire why any spe-
nail(s), or excessive trimming. Find out cial shoe or addition to a shoe (calk, grabs, ex-
whether the farrier has encountered any recent tensions, or bars) was used. Bar shoes, for ex-
problems or has had to deal with ongoing ample, are often useful in treating various foot
shoeing problems. This might include horses problems, but can be essentially useless for
that are difficult to shoe because of behavioral some horses trying to race, in other instances,
problems, thin walls, continual evidence of we see bar shoes as a fad (all the dressage
bruising, or thrush. horses in a barn wear egg-bar shoes). Is the
It is important to ascertain the environment in bar shoe fitted appropriately? First and fore-
which the horse lives, trains, and competes. most it must be remembered, a shoe has no
The environment plays a major role in the magical properties, it is more important how
quality of the horn of the hoof and as such any shoe is applied rather than the type of
serves as the catalyst of many foot problems. shoe i.e. “the application is more important
The time of year and the surface can dramati- than the appliance”. Some horses simply do
cally change the feet as well as the shoes. For not get sufficient traction on some surfaces or
instance, a horse training on a stone dust track travel as well in certain types of shoes. Prior
will show very rapid wear of the shoes, the knowledge of a shoeing history as it affects an
groove or fullering may be completely gone in individual horse is useful information. It
less than 2 weeks; whereas, the shoes of a should suggest to the examiner that an alter-
horse training on a deep, soft sand track may native should be sought or that an individual
show very little evidence of wear in as many horse should be trained at speed to see if he or
as 6 to 8 weeks. Foot bruising, pedal osteitis, she can “handle” the surface with the type of
and distal phalanx fractures are much more shoe that is employed.
likely on hard “fast” surfaces than on grass or Information regarding previous foot problems
deeper surfaces. Horses that are subjected to must be obtained. The horse may have expe-
wet grass in the morning and hot, dry condi- rienced a foot abscess 3 or 4 weeks ago or
tions later in the day often develop weak hoof “foundered” 1-2 years ago-all of which would
walls and lose shoes easily. Adverse environ- suggest to the examiner that the same prob-
mental factors can negatively influence the lem might have resurfaced. Obtaining reason-
outcome of some foot problems. We have seen able detail on the previous treatments is es-
where horses move from one environment to sential when examining an ongoing problem
another the feet become a problem. This has for the first time. This will help to prevent the
been a particular problem of horses moving use of a similar but previously unsuccessful
from the Midwest (soft, moist surfaces) to the treatment.
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EQUIPMENT commonly encountered failings in hoof tester

design are: tips too large to accommodate a
Specific equipment is necessary to thoroughly small foot; too small and of insufficient
examine the foot. Obviously this equipment strength to handle a large foot; poorly hinged
requires expertise or, at least, experience to (too loose, too tight, or bent); insufficient grip
avoid misuse. The following is a suggested list at the heads, resulting in slippage; too heavy
of equipment needed in the examination and to be used comfortably. Therefore, it is best to
treatment of the foot. try many different types before purchasing
hoof testers or have then hand made.
(1) Shoeing apron The examiner also should individually select
(2) Hoof testers hoof knives. They come in various sizes to ac-
(3) Hoof knives commodate different hand sizes and they have
(4) Shoe pullers different blades. Personally, I carry 4 knives,
(5) Crease nail pullers one for paring the sole and general hoof work
(6) Rasp plus a spare, another is a fine small blade for
(7) Clinch cutters doing surgical dissection of the hoof and the
(8) Hoof nippers other is a small loop (5 mm diameter loop).
(9) Shoeing hammer Sharp knives are essential and I carry a Tas-
(10) Probes or horse shoe nails manian sharpener with a rat-tail to sharpen the
(11) Foot wedges curl at the end of the knife or sharpening the
(12) Dremel tool inside of the loop.
(13) Foot brushes Flexible probes are cheap and useful for ex-
ploring hoof wall and sole defects, cavities and
Most of this equipment has obvious applica- tracts. However, I prefer to use small horseshoe
tion and requires very little explanation or dis- nails because they can be bent to accommodate
cussion; some, however, requires careful se- the direction of a tract and the sharp tip comes
lection by the individual examiner. in handy for cleaning away debris.
It is most prudent to use a shoeing apron. It The crease nail puller is designed to elevate an
protects the examiner and also helps to grip individual nail head so it can be removed
the limb being examined or treated. The pro- without loosening the shoe and the rest of the
tection factor is foremost whether evaluating a nails. This is often used when dealing with a
young foal with a tendency to kick, or protect single nail problem or when removing shoes
the examiner from any sharp edges or nails. carefully from the poor-footed horse to pre-
Hoof testers come in a large variety of shapes vent hoof wall breakage.
and designs. They are an absolutely necessary A shoeing hammer is a very useful diagnostic
piece of equipment and should, therefore, tool. Focal percussion of the hoof wall, sole,
be preferentially selected for the individual and frog will often help to localize a focal area
examiner and his/her practice. I prefer hoof of inflammation or damage by producing a
testers where the tips are sufficiently pain response.
grooved for a good grip on the hoof wall and Hoof wedges are small blocks approximately
the tips are no larger than 5-7 mm in diameter. 3 cm wide by 2 cm thick. I prefer using the
I use 2 different types of hoof testers, one a handles of old hoof knives where the blade
simple hinge that I use on the sole and a chan- has been cut off or the whole knife is taped for
nel lock type that can be opened or closed to safety reasons. The wedges are typically
accommodate the broader areas of the foot or placed under the frog and the toe but can be
can be used on the large footed horses as well placed under any part of the hoof wall or sole
as foals. The tester should be light and small to specifically apply weight-bearing pressure
enough to allow comfortable operation with on a certain area.
one or both hands, and strong enough to en- Dremel tools are portable motorized rotary
dure the years and circumstances. The most tools with cutting attachments. Several manu-
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facturers make these tools. The ideal tool, in my symmetry and alignment. Is the hoof cen-
opinion, is one capable of at least 25,000 rpm, tered under the cannon bone or is it offset?
small enough to be operated with one hand, rea- If the hoof is offset then the stresses on the hoof
sonably quiet, and able to be fitted with several will change. Does the hoof rotate on the leg
size cutting burrs, drum sanders, and drill bits. (toe-in or toe-out)? If it does rotate, where does
Variable speed capability is also useful. Exam- it rotate from, knee, fetlock, pastern, or hoof?
iners who do a great deal of footwork are ad- This will determine where the torque is occur-
vised to have a spare set because these tools ring on the hoof. Does the ground surface of the
will wear out, break, or malfunction. hoof appear symmetrical? If not, this indicates
The author looks at five steps in the evaluation stresses on the hoof. Most commonly, one sees
of foot pain, (1) subjective evaluation of the the medial wall more upright. Is the coronary
hoof, (2) objective assessment of the hoof bal- band straight and parallel to the ground sur-
ance, (3) assessment of pain, (4) the response face? If not, this indicates a stress on the wall
to diagnostic analgesia, and (5) imaging of the below the coronet.
equine foot. The next factor to observe is the hoof align-
ment. This is viewed form the dorsal and lat-
eral aspect.2 The average horse (60%) will
SUBJECTIVE EVALUATION have a hoof angle between 50-55 degrees. The
OF THE HOOF hoof axis is how the cannon bone, pastern, and
hoof line up. Ideally, when the horse is stand-
Like any physical examination this is not sim- ing square; the cannon bone, pastern and hoof
ply measuring a few parameters and determin- should line up straight as seen from the front.
ing where on the scale of normality they fall From the side, the pastern and hoof should be
but rather this is a systematic evaluation of the straight with the angle created by the dorsal
hoof capsule and the structures within. It tells hoof wall the same angle as the pastern and
the examiner about the general health of the the angle of the heels within 5 degrees of the
hoof, the stresses that have been placed on angle of the toe.4 Horses that have a low hoof
it and how the hoof has responded to these angle compared to the pastern have a broken-
stresses. The hoof is a dynamic structure that back hoof axis and fall into a group of horses
grows continuously and therefore has the abil- called long toe and low heel. On the other
ity to deform continuously to stresses that are hand, horses with a steep hoof and sloping
applied to it. The physical examination of the pastern have a broken-forward axis and are
hoof determines what the hoof has to tell the called “clubby”. Unfortunately, horses do not
examiner. normally stand with their cannon bones per-
The examination begins simply by looking at pendicular, so evaluation of hoof alignment
the hoof, preferably from sufficient distance to must be done with the horse standing com-
compare all four feet at once.1 The size, shape, fortably. The purpose is not to determine right
toe length, heel length, hoof pastern axis, and and wrong but to determine what is comfort-
position of each foot relative to the each limb able for the horse.
and to each other are assessed. This is the best The next area to evaluate is the shape and lev-
time to evaluate the horse’s “balance”, that is elness of the hoof. Generally the front hoof
what are the differences in each of the horse’s should be round or circular in shape, while the
legs and how does the horse stand on the hoof.2 rear hoof is more triangular or “pear” shaped.
One could consider this a conformational Front and rear hooves should be shaped like
analysis but in fact the examiner is simply inverted cones. Both hooves should be evalu-
evaluating the position of the hoof on the end ated for differences in length and width.
of the limb. This analysis must be evaluated Hooves of equal width and length tend to look
from 3 directions, the front (dorsal), the side circular but as the length becomes greater than
(lateral), and the back (palmar/plantar).3 From the width the hoof wall in the quarters be-
the front, the hoof needs to be assessed for comes more upright and the stresses on the
145
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hoof will naturally be different. The levelness This begins by palpating the pastern. Palpa-
of the hoof has two aspects. One, is the tion for any obvious heat, pain or swelling
ground-bearing surface flat? This determines goes without saying. More subtly, the examin-
how evenly the hoof wall will bear weight. er needs to palpate the bones and tendonous
Two, is the ground-bearing surface perpendi- structures. Generally the flexor tendons are
cular to the upper limb? This determines how not as wide as the pastern bones and there is a
the leg is loaded during weight bearing. These fingers width difference medially and lateral-
factors are the basis for determining medial to ly. Follow the tendons down the leg until they
lateral hoof orientation. disappear at the heel bulb.
The final observation is to evaluate the heel Next palpate the digital arteries, vein and
support. This is done by evaluating the loca- nerve. It is normal to feel a digital pulse but
tion of the ground-bearing surface of the heels not a bounding pulse, which is abnormal and
relative to the remaining hoof capsule, relative an indicator of foot inflammation. The strength
to the pastern and relative to the fetlock and of the pulse can be compared to other limbs
cannon bone. Does the ground-bearing sur- if one is in doubt. A symmetrical abnormal
face provide sufficient support to the palmar pulse indicates generalized inflammation
(plantar) aspect of the digit? Are the heels of whereas; an asymmetric pulse indicates the
the hoof centered under the cannon bone inflammatory process on the side of the
(from the palmar/plantar aspect) or are they stronger pulse. In addition, the skin should
offset. This can be important in determining to be carefully palpated for the presence of
how the horse loads the heels, whether they neurectomy scars.
are landing simultaneous or whether one heel Palpation is then continued to the coronet
may strike before the other. These observa- (hairline / hoof capsule junction). I prefer to
tions are helpful for the examiner to under- palpate from the central toe region caudally on
stand how the hoof capsule has grown and re- the medial and lateral aspects. Normally one
modeled to adapt to the forces on it. should appreciate a “spongy” feel to this area
Watching the horse at a walk will enhance these and deviation such as swelling, discharge, fo-
previous observations. Observing the foot in cal pain or heat, absence of tissue (loss of
motion should determine the manner the horse sponginess or a “trough”) should be examined
lands and breaks over, as well as the path of the more closely. The examiner should feel that
foot during the flight phase of the stride. Toe the hairline forms a smooth edge with the hoof
first landing or excessively heel first landing in- capsule. Any area where the hoof capsule is
dicates either compensation for pain or dor- prominent indicates an area of stress. The au-
sopalmar hoof imbalance. Similarly, medial or thor believes that these edges indicate a prox-
excessively lateral heel/quarter first landing imal movement of the hoof capsule (“jam-
suggest either compensation for limb confor- ming”) into the hairline. In many breeds par-
mation or pain leading to mediolateral hoof im- ticularly in the gaited breeds that carry longer
balance. The flight of the foot during the stride lengths of hoof this seems to be normal. As
is correlated with rotational deviation of the the edge becomes more prominent the exam-
limb and imbalance of the foot. The horse that iner can be sure that the vertical distance from
wings-in or “dishes” is either toed-out or break- the hairline to the extensor process of the third
ing over the inside toe. Conversely the horse phalanx is increasing (measurement that is
that paddles or wings-out is either toed-in or made from a lateral radiograph).
breaking over the outside toe. From the coronet the examiner moves to the
Once the above observations are made the ex- collateral cartilages where they are palpated
aminer needs to make a closer evaluation of and manipulated. The palmar and proximal
the hoof. This evaluation needs to be per- edges should be easily defined. The thickness,
formed first with the horse in weight bearing density, and pliability of the cartilages need to
position and then with the foot in non-weight- be assessed. Palpation of this area not only
bearing position. will determine if there is any pain but also can
146
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give an impression of the flexibility of the ceded frog is often associated with upright
hoof. For instance, generally speaking a very narrow feet, whereas, the convex frog is asso-
stiff inflexible collateral cartilage is associated ciated with weak and under run heels. The au-
with a narrow, upright hoof. On the other thor has long since thought that this confor-
hand, flimsy cartilages are commonly seen in mation is associated with a poorly constructed
the hoof with collapsed heels and a narrow, digital cushion and therefore a poor hoof sup-
convex shaped frog. port mechanism but this has yet be proven.
The entire hoof wall must be examined for the The medial and lateral bars of the foot usual-
presence of cracks, fissures, bulges, growth ab- ly require light paring with a hoof knife to ap-
normalities, focal heat, wall loss, or breakage. preciate problems such as bar cracks. Do not
A high percentage of quarter and heel cracks pare the bars totally as it weakens the foot.
begin as small very fine fissures at the coronet. The entire sole of the foot should be carefully
They may extend less than 1 cm distally and examined for fissures, punctures, consistency,
are easily missed if this area is not carefully discoloration (bruising), and the degree of
examined. In fact, the author pays particularly concavity. The shape of the sole should be
close attention to any area of the hairline that concave. If it is not, then the sole will be ei-
is not straight. These small fissures are a defi- ther flat or convex. A flat sole may signify
nite cause of foot pain and usually associated either poor hoof conformation (a weak hoof)
with deeper injury to the coronet and/or lami- or coffin bone displacement. A concave sole,
na below. however, indicates a displaced coffin bone.
The exit of all shoeing nails from the hoof The consistency (relative degree of stiffness)
capsule needs to be evaluated. The higher the is usually determined using digital pressure as
exit point the more likely the nail is impinging well as hoof testers. At this point it is neces-
on sensitive tissue. This is an excellent time to sary to evaluate the texture of the sole. By
use the hammer and gently percuss the hoof grasping the quarters with your fingers the
wall to determine wall defects, hollow sounds thumbs can be used to gently press on the
or painful areas. sole. If the sole moves under this pressure, it
From this point it is natural to begin manipu- is thin and the examiner knows that there is lit-
lating the foot in the non-weight bearing posi- tle space between the coffin bone and the out-
tion.1 Begin by cleaning the bottom of the side environment. On the other hand, if the
hoof, using the dull side of a hoof knife. Turn sole does not move the examiner knows there
the hoof knife to use the blade to lightly pare is at least some thickness and depth to the
away any debris that obscures an accurate vi- sole. The true sole depth can be determined
sualization of the frog, sulci of the frog, sole, later via radiography.
and white line if the horse is unshod. Once the The white line is examined to determine its
foot is clean, examine it in its entirety. The width and character. The white line is usually
frog should be examined for size, shape, con- wider at the toe and gradually tapers to a thin-
sistency, and to determine whether it is se- ner structure as it approaches the heels. It is
curely attached to the underlying tissue and its best visualized following either light paring
sulci (collateral and central). The examiner with the hoof knife or light rasping of the su-
needs to determine how much of the structure perficial portion of the foot. It is used to de-
could actually bear weight and how much rep- marcate the insensitive hoof from the sensitive
resents loose tissue. It is the author’s opinion hoof for the purpose of driving horseshoe
that the frog should be a resilient, rubbery nails. Everything outside the white line is in-
substance versus a hard flaky substance. The sensitive, everything inside is considered sen-
frog should be nearly even with the ground sitive. Widening of this area represents stress
surface of the hoof wall, particularly the cau- and separation of the laminar hoof wall from
dal two-thirds of the frog. The frog should not coronary hoof wall. The deeper the separation
be recessed deep in to the sulci of the foot nor goes the more severe the injury. This separa-
should the frog be convex at its apex. The re- tion can be seen any where on the solar sur-
147
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face and indicates a bending force on the wall at the heel on my left side and work around
that is pulling the wall away from the coffin the hoof in a clockwise fashion. Begin with
bone. Most frequently this separation is seen the bar, move to the heel, to quarter and then
at the toe and is referred to as “seedy toe” be- toe then back toward the heel on my right.
cause it looks like small seeds could fit be- Space the testers progress at approximately
tween the spaces created by the separation. one-inch intervals.
Examine the bulbs of the heels to determine Be sure to include each exit point of the
their relative position to one another. The shoeing nails. Next place the testers in each
strength of this tissue is assessed manually by of the collateral sulci and across the hoof to
attempting to distract the two bulbs from one the opposite hoof wall (I like to progressive-
another in a vertical direction. Digitally ex- ly move the hoof tester along the hoof wall
plore the heel bulbs for the presence of caudal to cranial to check for alterations in
swelling, heat, pain, or separation at the coro- the pain response, then place the testers in
net. The central sulcus of the frog needs to be the central sulcus to the hoof wall at the toe,
examined and probed to determine its depth. and then across the heels. Finally, using the
Normally this should be a shallow depression hammer gently rap the structures on the bear-
of no more than a centimeter. If the sulcus ing surface of the sole and frog.
goes deeper it can be due to either very serious Repeat the palpation of the cartilages of the
thrush or loss of structural support in heel distal phalanx and the coronet. Bringing the
bulbs (the heel bulbs can be distracted in op- limb forward and flexing the toe facilitate pal-
posite vertical directions). pation in the region of the extensor process of
Lightly support the limb at the metacarpus the distal phalanx region and the associated
(metatarsus) and allow the foot to drop natu- distal interphalangeal joint. The thumbs can
rally. Position your line of vision so as to ap- then be pressed over this area to feel for joint
preciate foot balance and levelness of the distension, heat, or pain. The foot also should
walls. The levelness of the hoof has two as- be rotated (twisted) medial and lateral around
pects. One, is the ground-bearing surface flat? the vertical axis of the pastern. A normal
This determines how evenly the hoof wall range of motion allows for 10-15 degrees of
will bear weight. Two, is the ground-bearing rotation each way. Injury to the joint capsule,
surface perpendicular to the upper limb? This collateral ligaments or chronic navicular pain
determines how the leg is loaded during tends to reduce this motion. Likewise distal
weight bearing (hoof balance). Examine the limb flexion should reveal 30-45 degrees of
entire ground surface of the foot to determine excursion. Again, injury to the joint capsule,
the divisions of the hoof (toe, quarters, and collateral ligaments or chronic navicular pain
heels) and their proportions. Generally the tends to reduce this motion.
front hoof should be circular in shape, while If the horse is shod, the exam should include
the rear hoof is more triangular or “pear” the following additions.1 First, determine the
shaped. Front and rear hooves should be security of the shoe to the foot, by gently rap-
shaped like inverted cones. Imagine a line ping the shoe at one inch intervals with a
drawn through the axial center of the limb, shoeing hammer. Make note of the shoe type
which transects the ground surface of the as well as the presence or absence of additions
foot, and then determine the relative propor- such as toe grabs, block heels, trailers, and so
tion of medial and lateral foot to this imag- forth. Carefully determine if abnormal shoe
inary line. For example, a given foot may wear exists. Position the hoof testers to in-
demonstrate a unilateral medial heel con- clude the hoof wall at the exit point of each
traction in combination with a flared lateral nail. Carefully record your findings as it is
quarter and toe (diagonal imbalance). easy to forget subtle discoveries that may ulti-
Examine the foot with hoof testers. Be sys- mately determine how the horse should be
tematic, how you perform the exam is unim- treated or shod. Keep in mind that hoof testers
portant but get use to a routine. I like to begin are essential but certainly not foolproof. The
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response the examiner gets on hoof testers is phasize these areas on the radiographs, mak-
dependent on many factors such as the hard- ing their identification much easier.
ness of the wall, depth of the hoof, thickness
of the hoof, and the stoicism of the horse.
ASSESSMENT OF PAIN

OBJECTIVE ASSESMENT The next step in developing a logical approach

OF THE HOOF to the evaluation of the hoof is an accurate as-
sessment of pain and careful evaluation of
As part of the overall evaluation of these hors- hoof structure that may predispose to or cause
es an objective assessment of hoof balance is the pain.5 First, examine the horse in motion;
important. Eleven measurements are made of watch the foot strike for each foot. Determine
each foot.4 The horse’s weight is determined if the foot lands flat, heel or toe first, medial or
with a weight tape or scale. Seven measure- lateral quarter first. The landing position of
ments are made of the hoof length with a tape the individual foot relative to the vertical axis
measure: medial and lateral heel lengths; medi- of the respective limb should be noted. Evalu-
al and lateral quarter lengths, dorsomedial and ate the path the individual foot takes from foot
dorsolateral toe lengths, and sagittal toe length. breakover to strike. The character of motion
These measurements are recorded on a graph to may be a clue as to where on the foot or the
illustrate the general shape of the foot. In addi- limb the problem exists. Always include this
tion, the frog’s length and width are measured examination at the walk because it is the one
at their longest and widest points. The hoof cir- gait that is sufficiently slow to permit the de-
cumference immediately below the coronary termination of fine movement error. Repeat
band, and the hoof angle (using a hoof gauge) the same process when reviewing the horse
are also measured. From these measurements, from the left and right side. The horse is then
two additional measurements can be calculat- trotted (or paced) and visualized in the same
ed: the frog ratio (frog width divided by length) manner. Circling the horse will often exacer-
and the body size to hoof area [horse’s weight bate foot problems.
(pounds) X 12.56 / square of the hoof wall cir- Four diagnostic tests should be performed:
cumference(C) (inches)]. hoof tester examination, distal limb flexion,
A dorsopalmar(plantar) and a lateral radi- hoof extension wedge test, and palmar hoof
ograph of the hoof can also be used to deter- wedge test.5 A positive response to any of
mine valuable information about hoof bal- these tests is important but a negative re-
ance. The horse must be standing with the sponse is equivocal and does not rule out any
metacarpus (tarsus) perpendicular to the problem. Hoof tester examination should be
ground, which can most easily be determined performed as previously described. Remem-
by either the use of a level placed against the ber that the closer the ends of the hoof testers
cannon bone or the use of a weighted string to are the more accurate the exam is in localiz-
align the leg. The radiographic beam should ing pain. A positive response should be re-
be horizontal and centered on the hoof. Rest- peatable, and in the distal sesamoid region
ing the horse’s foot on a block to raise the the pain response should be uniform over
hoof off the ground facilitates these exposures those areas and must be evaluated in rela-
(the opposite limb should be similarly elevat- tion to examination of the remaining foot.
ed). For easy identification of landmarks, ra- That is, a positive response in the heels and
diopaque markers can be attached to the hoof. quarters of the sole would also be expected to
A wire or radio opaque paste placed sagittally cause a positive response across the distal
(midline) along the toe from the coronary sesamoid region in the same area of the foot.
band to the ground, a thumb tack in the apex Percussion utilizing a small hammer can also
of the frog and thumb tacks in the most caudal provide important information regarding pain
point of the ground contact of each heel em- in the hoof wall or sole.
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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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Distal limb flexion test may exacerbate lame- The palmar digital nerve block is frequently
ness if any of the three distal joints of the leg performed midway between the fetlock and
are affected by synovitis or osteoarthritis. A coronary band. The author prefers to perform
positive response could also be expected by this block at the level of the collateral carti-
any condition that causes induration of the tis- lages. The neurovascular structures can be
sues of the foot. This has been shown to be palpated in a groove between the pastern
positive in over 95% of horses’ foot pain. bones and flexor tendons and 1.5-2 ml of
The hoof extension test is performed by ele- anesthetic are injected over the nerve. This de-
vating the toe with a block, holding the oppo- sensitizes the caudal 1/3-1/2 of the skin at the
site limb, and trotting the horse away after 60 coronary band, plus the heels and quarters of
seconds. The palmar hoof wedge test is per- the hoof wall, as well as, the entire sole. The
formed by placing the block under the palmar effects of regional analgesia are usually evalu-
two-thirds of the frog and forcing the horse to ated 15 minutes after injection.
stand on that foot. The test can be further The pastern ring block is a simple extension of
modified so that the wedge can be placed un- the palmar digital nerve block. Simply inject
der either heel to determine if the pressure anesthetic around the dorsal surface of the
there causes exacerbation of the lameness. pastern from nerve to nerve. This anesthetizes
These test simply allow the examinaer to eval- the entire hoof and pastern from the block dis-
uate the horses response to a particular stress. tally. The abaxial sesamoid nerve block is per-
None have been shown to be pathognomonic formed on the palmar aspect of the abaxial
for any one lameness. surface of the proximal sesamoids. The neu-
rovascular structures are very easily palpated
and 1.5-2 ml of anesthetic are injected over
ANALGESIC INJECTION the nerve. This should make a small bleb that
is easily seen. The abaxial block desensitizes
Regional analgesia will provide the evidence the hoof capsule and the caudal pastern.
to localize the region of pain. The perform- The low volar nerve block is performed at the
ance of regional analgesia needs to be per- level of the distal enlargements (buttons) of
formed in a logical manner. Intra-articular in- metacarpal (metatarsal) II and IV. The nerves
jections anesthetize joint regions; whereas re- are located between the suspensory ligament
gional analgesia desensitizes skin segments.6 and flexor tendons. Two methods are used in-
Intra-articular injection is more accurate and jections can be made over each nerve or a sin-
does not interfere with regional analgesia. Re- gle injection where 2-3 ml is injected over
gional anesthesia desensitizes local nerves each nerve. The second method is to inject 5-
that innervate areas of the limb. They provide 7 ml, filling the space between the ligament
indisputable evidence of the location of lame- and tendons. This injection desensitizes the
ness. The most important point is to have pastern and palmar fetlock.
some idea of what areas have been desensi- The low volar ring block (4 point block) is per-
tized. This is most often accomplished by pin- formed by either injecting anesthetic around the
prick after the procedure. dorsum of MC III (similar to pastern ring) after
Clipping is usually not necessary. A surgical performing a low volar block. An alternative
scrub of the area is a must. The author likes method is after performing a low volar block,
to apply a pressure bandage at the end of the then inject 2 ml of anesthetic just distal to the
exam to decrease swelling because local buttons of MC II and IV. There is little differ-
anesthetics are irritating and can cause the ence between the two blocks, the ring block is
leg to swell. For most peripheral nerve more effective but more difficult and causes
blocks a 22-25 gauge 5/8 – 1.5-inch needle is more post injection swelling. The 4-point
used. Lidocaine (xylocaine) and mepivacaine block is easier and causes less swelling. The
(carbocaine) are the most popular anesthetic blocks will anesthetize the fetlock soft tissues
solution. and tissues distal.
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Joint blocks provide evidence of specific joint or from the lateral aspect. Regardless some
involvement. Typically the author does not type of radiographic control is needed to in-
clip the hair as long as the horse has a short sure the bursa has been injected. The lameness
haircoat. A surgical scrub of the area is an ab- is evaluated 5 to 10 minutes after injection. It
solute must. Always be sterile (needles, anes- is thought that this injection desensitizes the
thetic solution, syringes, etc.). The supplies navicular bone and its ligaments plus the en-
that you will need are 20-23 gauge 1-1.5 inch tire solar aspect of the third phalanx including
needles. Lidocaine and mepivacaine are most the insertional area of the deep flexor tendon.
commonly used.
For the distal interphalanged (DIP) joint (cof-
fin joint) there are 2 good techniques. Regard- IMAGING
less, of the technique it is frequently ques-
tioned as to what is desensitized by a DIP After localization of the lameness to the foot
block. It is the author’s opinion that the DIP some type of imaging will be necessary. Radi-
block desensitizes the DIP joint, the navicular ographic examination of the hoof requires a
bone and the innervated portions of the navic- minimum of 5 radiographic views of each
ular bursa. foot.8 The views consist of a dorso-60o-proxi-
Schumacher showed that the interpretation of mal to palmarodistal (D60PrPD) of the navic-
diagnostic analgesia into the distal interpha- ular bone, a dorso-45o-proximal to palmaro-
langeal (DIP) joint must be done carefully.7 distal (D45PrPD) of the third phalanx, a later-
He performed an experiment where he in- al to medial projection, a horizontal dorso-pal-
duced lameness by forcing setscrews into the mar projection, and a palmaro-proximal to
sole of a horse’s foot. The subsequent lame- palmaro-distal navicular bone projection.
ness was alleviated by DIP analgesia. This led Further, each of these views must be assessed
the authors to conclude that local anesthetic for any significant changes in any of the bone
into the DIP joint could alleviate pain in the surfaces. It is the authors opinion that the ra-
sole. This information was contradictory to diographs should be assessed for change and
what this author (Turner) had observed. In a what the change means from a pathologic
separate experiment, Turner used a dremel sense. Most of the time radiographs are exam-
tool to expose sensitive sole on horses’ feet. ined for signs consistent with the tentative di-
The exposure was adequate so that “pin prick- agnosis. Once the basic films have been ex-
ing” of the exposed area would cause pain. amined, it may be necessary to take addition-
Turner then injected the DIP with anesthetic al oblique views to completely appreciate any
and noted the sole remained sensitive. On the pathologic change.
other hand, when the palmar digital nerve was A new method of assessing navicular patholo-
anesthetized the sole was desensitized. One gy is through the evaluation of the flexor sur-
other observation was that the sole was not as face of the navicular bone by contrast arthrog-
sensitive as the author thought it would be. raphy.9 In fact, contrast arthtorgraphy can be
This observation led Turner to believe that the useful in many ways. The DIP joint can be
setscrews model creates lameness by causing evaluated for cartilage defects or the commu-
the horse to land abnormally away from the nication of subchondral cysts with the joint.
pressure but that the pain the horse perceives Defects or punctures into the hoof can also be
as a result of this is via the DIP joint. examined using contrast radiography, which
The proximal interphalangeal joint (pastern) can give much better insight into the struc-
can be injected either through the dorsal or tures that may be involved.
palmar pouches. At this time most everyone Recently it has become possible to examine
agrees that injection of the pastern only de- the hoof region sonographically.10 The collat-
sensitizes the pastern joint. eral ligaments of the DIP joint can be clearly
Podotrochlear bursa analgesia can be per- outline by ultrasonography as can the deep
formed either from the palmar(plantar) aspect flexor insertion on the third phalanx, the distal
151
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

deep flexor tendon, the impar ligament, and REFERENCES

the navicular bursa. In order to examine the
podotrochlea the superficial horn must be 1. Turner TA, Fessler JF: The anatomic, pathologic
pared from the frog to expose soft, spongy and radiographic aspects of navicular disease.
Comp Cont Ed, 4(8): S350-S355, 1982.
frog tissue. and 1.5-2 ml of anesthetic are in- 2. Turner TA, Fessler JF, Lamp M, Pearce JA, Geddes
jected over the nerve. Ultrasonographic exam- LA: Thermographic evaluation of horses with
ination of the DIP collateral ligaments and podotrochlosis. Am J Vet Res 44(4):535-539, 1983.
joint capsule is performed utilizing a 7.5 MHz 3. Turner TA, Kneller SK, Badertscher RR, Stowater
convex linear or straight linear probe follow- JL: Radiographic changes in the navicular bones of
normal horses. Proceedings, 32nd Annual Meeting
ing a previously described protocol. The area
of Am Assoc of Equine Practnr, 32: 309-314, 1986.
of the coronary band was clipped and the lig- 4. Turner TA: Predictive value of diagnostic tests for
aments were located at the 10 and 2 positions navicular pain. Proceedings 42nd Annual Meeting
along the hair hoof interface. Am Assoc Eq Practnr, 42: 201-204, 1996.
The metabolic activity of the foot can be eval- 5. Turner TA: Use of navicular bursography in 97
horses. Proceedings, 44th Annual Meeting Am As-
uated through the use of scintigraphic exami-
soc Eq Practnr, 44: 227-229, 1998.
nation.11 Scintigraphy involves the injection of 6. Sage AM, Turner TA: Ultrasonography of the soft tis-
radiopharmaceutical and subsequent uptake sues of the equine foot. Eq Vet Educ, 4: 278-283, 2002.
into the extracellular fluid and bone. Assess- 7. Moyer W: Clinical examination of the equine foot.
ment is based on the detection of radiation In Yovich JV:Vet Clin N.A.: Equine Pract., 5(1): 29-
from the radioisotope. The technique provides 46, 1989.
8. Balch O, White KK, Butler D: Factors involved in
information on relative vascularity and rate of the balancing of equine hooves. J Am Vet Med As-
tissue metabolism. This is particularly useful soc, 198(7): 1980-1989, 1991.
in studying bone pathology and can help dif- 9. Turner TA: The art and frustration of hoof balance.
ferentiate sites of injury in the foot. Am Farriers J, 28 (6): 1A-8A, 2002
Thermography provides information regard- 10. Turner TA: The use of hoof measurements for the
objective assessment of hoof balance. Proceedings
ing skin temperature.12 This technique is 10
38th Annual Meeting of Am Assoc of Eq Practnr,
times more sensitive than the human hand in 38: 157-164, 1992.
detecting heat. It can be an early detector of 11. Turner TA: Predictive value of diagnostic tests for
inflammation in the foot. It has also been navicular pain. Proceedings 42nd Annual Meeting
shown to be useful in assessing the relative Am Assoc Eq Practnr, 42: 201-204, 1996.
12. Turner TA: Intra-articular and regional anesthesia
blood flow to the foot. This information is of
of the forelimb. Proceedings 10th Annual ACVS
particular interest when pre- and post exer- Symposium, 2000: pp 255-257.
cise temperatures are determined. Exercise 13. Schumacher J, Schramme M, Schumacher J, et al:
will normally cause a 0.5oC rise in skin tem- Abolition of lameness caused by experimentally
perature. Whenever, the skin temperature induced solar pain in horses after analgesia of the
does not rise to this degree, poor blood flow distal interphalangeal joint. Proceedings 45th An-
nual Meeting Am Assoc Equine Practnr, 45: 193-
should be considered a factor in the disease 194, 1999.
being assessed. 14. Butler JA, Colles CM, Dyson SJ, et al: Clinical Ra-
diology of the Horse, Blackwell Scientific, London,
1993, pp 25-99.
CONCLUSION 15. Turner TA: Use of navicular bursography in 97
horses. Proceedings, 44th Annual Meeting Am As-
soc Eq Practnr, 44: 227-229, 1998.
The examination of the foot must be based on 16. Sage AM, Turner TA: Ultrasonography of the soft tis-
observations of the hoof, followed by a care- sues of the equine foot. Eq Vet Educ, 4: 278-283, 2002.
ful determination for areas of pain. This must 17. Ross MW: Observations in horses with lameness
be followed by an assessment of the biome- abolished by palmar digital analgesia. Proceedings
chanical forces on the hoof and limb. Finally 44th Annual Meeting Am Assoc Eq Practnr, 44:
230-232, 1998.
imaging gives insight into the nature of the in- 18. Turner TA, Fessler JF, Lamp M, Pearce JA, Geddes
jury and allows the examiner to prognosticate LA: Thermographic evaluation of horses with
the outcome. podotrochlosis. Am J Vet Res 44(4):535-539, 1983.

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