Rehabilitating the laminitic horse

Raul J. Bras, DVM, CF

Podiatry Department
Rood and Riddle Equine Hospital
Lexington, KY

Despite significant research and recent findings over the past decade, a
complete understanding of laminitis and its complex pathophysiologic processes
remains uncertain. Although preventative measurements and strategies of this
devastating disease remains largely empirical and anecdotal with little information
from evidence-based medicine, recent technological advances offer some promises
towards the effective treatment or the rehabilitation process of the lamintic horse.
Laminitis can be one of the most frustrating and also rewarding diseases to treat.
Anybody interested in working with foot problems in the horse must have an
effective treatment strategy for treating the laminitic horse. It is these cases in
particular which are in the most need of our services. There are a few instances
where we have the opportunity to so dramatically improve the quality of an animals
life. With the appropriate treatment approach a large proportion of laminitic horses
can be rehabilitated to pasture soundness, light use, and even some degree of
athletic performance. However, some advanced cases cannot be rehabilitated to an
acceptable level of comfort where euthanasia is advised to prevent needless
suffering.
Laminitis is the failure of the attachment between the distal phalanx and the
inner hoof wall causing unrelenting pain and characteristic lameness. It is the most
serious disease of the equine hoof that lead to devastating loss of function. In order
to understand how to rehabilitate the laminitic horse we should have an
understanding of the normal supporting structures of the digit, the disease process,
and the structural failure that results.
It is very important to be specific when describing the clinical presentation or
scenario of the lamintic horse because treatment goals and strategies are different
in each phase. Drug choice and shoeing protocols are also affected by the stage of
laminitis. A complete and thorough examination of the horse should be performed.
The Obel grading system has been used to best categorize the laminitic horse. Obel

grade 1 the horse seems to thread his feet at stance, still walk normal, but remains
short at the trot. Obel grade 2 the horse is willing to walk with a short stilted gait,
and can easily pick up each foot. Obel grade 3 the horse is reluctant to walk, and
struggle to pick up a foot. Obel grade 4 the horse is unwilling to walk or recumbent.
A thorough examination of the outer hoof capsule and coronary band should also be
performed. External examination of the foot should include growth ring pattern,
hoof testers sensitivity, and coronary band palpation. Good quality radiographs
provide useful information, aid with diagnosis, and serve as a baseline to monitor
the healing process or to detect further deterioration. Some of the parameters
measured on radiographs are the horn-lamellar (HL) zone which is the distance
between the hoof wall and the coffin bone just below the extensor process and the
apex of the coffin bone. Palmar angle (PA) is the angle between the bottom of the
coffin bone and the ground. Sole depth (SD) is the amount of sole beneath the apex
of the coffin bone. Coronary-extensor process (CE) is the vertical distance between
the dorsal coronary band and the extensor process of the coffin bone. Digital break
over (DB) is the horizontal distance between the apex of the coffin bone and the
fowardmost point of the foot. Venograms clearly outline the blood circulation in the
foot, and will illustrate if perfusion deficits or compromise areas are affected during
laminitis providing information that could help with prognosis. Prognosis depends
on many factors such as amount of lamellar damage (sinkers), hoof conformation
and integrity, coronary band (shear lesions) and sole quality, health of the coffin
bone (demineralization, infection), vascular damage (assessed with venograms),
clients goals, economics, and aftercare.
In order to understand how to minimize further damage during laminitis, or
rehabilitate the the laminitic horse, the veterinarian should have an understanding
of the normal supporting structures of the digit, biomechanical forces on the foot,
and the structural failure that results when these forces act on a diseased damaged
foot. The laminae and the deep digital flexor tendon (DDFT) work in harmony to
balance forces with each other in a healthy foot. During lamintis this forces in the
foot are thrown out of balance allowing the stronger force, most of the time the
DDFT, to pull the bone away from the wall making it unstable. Some of the
immediate goals to rehabilitate the lamintic foot are decreasing the pull of the DDFT

on the coffin bone, unloading the laminar interface, reducing inflammation, easing
breakover, protecting sensitive tissue, and providing support to the bony column.
The degree of structural damage during laminitis depends on the inciting
cause, and treatment of that cause is often the most important part. Disintegration
of the lamellar attachment apparatus is initiated during the developmental phase of
laminits (Pollit 2007). Continuous cryotherapy by keeping the foot in an iceboot
containing water at 1C for 48-72 hours is well tolerated and has been proven an
effective and safe method in horses at risk of laminitis, when applied before
lameness develops. Cryotherapy have the potential to ameliorate the
pathophysiological process (laminitis trigger factors such as MMPs, cytokines,
interleukin) that have been hypothesized to occur during the developmental phase
of laminitis (van Epps, Pollit 2004).
Horses suffering from the acute phase laminitis are placed on strict stall rest
to minimize damage to the compromised lamina. The horse should be handled
delicately and not moved unnecessarily. Some type of temporary, easily removable
foot support, either styrofoam pads, velcro boots with soft pads, or dalric/dalmer
wedge cuffs and sole support should be used. Wedging horses up minimize
distractive forces of the deep digital flexor tendon. Horses in the styrofoam and
sole support pads will often crush the material at the toe more than the heel
producing their own wedge. Wedging the foot places more load in the quarter and
heel region. Horses in wedges should have their coronary bands examined
frequently for signs of sinking especially in the quarters. Medical therapy aimed at
reducing inflammation (NSAIDs, DMSO), improving lamellar blood flow
(acepromazine, isoxuprine, pentoxyphylline), and inhibiting MMPs activation
(doxycycline) should be considered. The horse should be kept on strict stall rest
with foot supports until they are sound and off anti-inflammatories with no
radiographic signs of rotation or displacement. Since it is unknown how
compromised the laminae are, it is very important to be conservative and cautious
on slowly increasing the horses activity level over the next month.
Restructuring the chronic compensated (stable) laminitic foot requires a
balance between the pull/ forces of the DDFT and the strength of the compromised
laminae. The long term goal is to increase the anterior sole depth, to promote even

toe/heel wall growth creating over time a more normal coffin bone palmar angle (PA
0-5 degrees), and to improve the comfort level of the horse. There are two
components to the management of the foot; the trim and the therapeutic shoe. The
goal of the trim is to establish the distal phalanx alignment, and to balance or even
weight distribution. The therapeutic shoes are designed to offer support, ease
breakover in all directions, and to address the pull of the DDFT. The trim usually
consists of trimming the heels back to the widest part of the frog as far as
comfortable and removing any gross hoof capsule distortions. Obviously as we trim
the heel down, we re-establish a more normal orientation of the coffin bone to the
ground and move the base of support further back. However in doing so, we put
more tension of the DDFT and can initiate further rotation. This issue is addressed
with the therapeutic shoe, which usually consists of a raised heel and a heavy rolled
toe to facilitate breakover (behind the diseased laminae at the toes). Additionally
the shoe should provide some form of axial support to unload the lamellar interface.
This system promotes sole growth and eventually rebalances the foot. Therapeutic
shoes are repeated as necessary until the sole depth in the toe matches the sole
depth in the heel (ground surface of bone parallel to shoe) and the new parallel
growth rings are at least 1/3 the way grown down the foot. At this stage the shoeing
mechanics are slowly scaled down. Most cases are maintained with a small wedged
(1-2) shoe with a rolled toe from the anterior coronary band forward. Many cases
are weaned down to just a barefoot trim pattern which consists of trimming the
heels down and rolling the toe from the anterior coronary band forward.
Radiographs taken 3-4 times a year to monitor maintenance of proper sole depth
and P-3 alignment are recommended.
Restructuring the unstable/uncompensated foot is often times very difficult.
This foot type often has massive vascular damage, secondary infections, and loss of
important tissue generating structures such as coronary and sole corium. The
approach to the unstable foot is often similar to the acute laminitic foot. The
information gained from the external examination of the foot, venograms, and
radiographs will dictate which treatment modalities need to be implemented.
Treating these feet require experience, good judgment, and a well coordinated effort
by the farrier, veterinarian, and owner combined with good nursing care. There are
several techniques available, which can be utilized to restore normal growth,

stability, distal phalanx alignment, and ultimately restructure this feet. The shortterm goals for the unstable laminitic foot are to preserve the integrity of the
coronary band and sole corium and thus its vasculature. Our ultimate goal is to
maintain health of the coffin bone and eventually re-establish normal coffin bone
alignment and adequate sole depth.
Secondary complications such as bruising, abscessation, osteomyelitis,
seromas, and coronary band shear lesions are a consequence of digital instability
and tissue compression. Depending on the extent of damage, most cases can be
treated by re-balancing the foundered foot with shoeing mechanics described in the
compensated and acute conditions. If the distal phalanx continues to displace
and/or if the foot fails to show continuous improvement with shoeing mechanics
alone, often times a deep digital flexor tenotomy is warranted. A deep digital flexor
tenotomy is the fastest way to counteract the rotational forces and restore perfusion
and tissue mass to the anterior regions of the foot. It is important to realize that
some horses cannot be rehabilitated to an acceptable level of comfort where
euthanasia is advised to prevent needless suffering.
Transection of the deep digital flexor tendon allows us to immediately re-align
the coffin bone in relation to the ground surface. Timing of the procedure is critical.
The procedure should be performed before the patient experiences advanced bone
disease. The most important aspect of the procedure is management of the foot.
Combination of the surgery with the appropriate trim and therapeutic shoeing is
imperative for a long term success. Performing the transection without the
realignment shoeing will only have a short term clinical improvement and most
likely wont affect the survival rate. Lateral radiographs should be used as a
blueprint, using several measurements to assure proper alignment. An aluminum
heel plate shoe is used for sole support and offer additional support to the palmer
aspect of the foot. The shoe is firmly placed in a position which places the shoe
parallel to the ground surface of the distal phalanx. Additionally, the shoe should
also provide enough heel extension to prevent the toe from hyper-extending
following transaction of the DDFT. The derotation shoeing method is imperative for
chronic uncompensated (unstable) laminitic horses with severe mechanical failure
limited to the toe region. These feet generally respond with significant anterior sole
growth over the next 4-6 weeks.

When the distal phalanx is severely displaced and the hoof capsule remains
unstable, often times the coronary band is internally compromise and compressed.
If displacement advances, the coronary band shears or separate, as the soft tissue
structures are further displaced beneath the fixed rigid hoof capsule. The area of
separation is called a coronary band shear lesion. Coronary band shearing and
compression can occur anywhere in the toe area in a rotational displacement, or in
the quarter area in a foot which is sinking medially, laterally, or vertically into the
hoof capsule.
To preserve the coronary band and restore normal hoof wall growth, proper
shoeing mechanics should first be implemented. Additionally, the technique of
coronary band grooving has proven to be a good adjunct treatment in this scenario.
Using the hoof wall growth rings as a guide to determine which area to groove is
most helpful. Following the constricted growth rings, the hoof wall is grooved using
a dremmel but just distal to the coronary groove. The entire wall thickness is
carefully grooved until small areas of hemorrhage are evident. This technique can
preserve the coronary band from developing a shear lesion if caught early and can
speed up hoof growth in that region.
If the coronary band develops a shear lesion and significant compression,
often times the coronary band cannot regenerate due to the severe pinching and
impingement by the proximal hoof wall. When coronary band separation is followed
by swelling and pain, a proximal hoof wall resection is required to regenerate the
coronary band and thus proper hoof wall growth. The resected area should include
all areas below the shear lesion and tapering off to healthy coronary band in either
end. The resected area should be about 1/2 1 distal to the coronary band at its
apex and taper off. A dremmel or cast cutters can be used to cut through the hoof
wall, then using forceps, the transected piece of hoof is removed and the area firmly
packed with antiseptic soaked gauze. Following the resection the area should
epithelialize over within 10-14 days. True stratum medium should regenerate by
the coronary band over the next couple of months. Failure of the tissue to
epithelialize or continued impingement of the corium by the proximal aspect of the
transected walls is an indication for further more distal resection. Often times the
use of a foot cast is required if resections are needed in the quarter and heel

regions. Immobilization of the hoof capsule and more uniform weight distribution by
the cast may help stabilize the foot for epithelialization to occur.
Depending on lower limb conformation, occasionally a laminitic foot will sink
to either the medial or lateral side. Some of these cases are caused by the use of
wedges to prevent rotation in the acute stage. Although wedging does decrease the
rotational forces on the coffin bone and thus the tension on the anterior laminae,
heel wedges shift the ground reaction force to the heels and puts stress on the
quarters. In this way, efforts to decrease rotation may inadvertently cause sinking in
the quarters. Sinking is most accurately detected by palpation of the coronary
band. A palpable cavitation or ledge is evident, and radiographs/venograms will aid
in the diagnosis. Once medial or lateral sinking is detected, the wedge should be
removed and the horse placed into a soft rubber pad. This allows the horse to mold
the rubber pad into the most comfortable configuration and take stress off the
compromised areas. Coronary grooving should also be implemented at this stage in
the appropriate regions. Feet that are sinking vertically, or medial/lateral sinkers
which are not responding to the forementioned treatment are placed into a foot cast
with sole support. PMMA-adhesive (Equilox) on the ground surface of the cast in a
mild dome shape allows the foot to breakover in all directions, loads the axial
regions of the foot, and unloads the perimeter hoof wall.
Due to chronic tissue damage, and decreased perfusion to certain areas of
the foot, tissue necrosis and infection of the foot is a common sequel in laminitic
horses. Infections can vary from a gravel or seedy toe due to the stretched white
line, subsolar/submural abscesation to osteomyelitis of the distal phalanx.
Formulating a mechanical plan with shoeing and/or surgery is critical to alleviate
compressed tissue, and restore perfusion before any other treatment for infection
can be effective. Most superficial infections are resolved with alleviation of tissue
compression and re-alignment of the coffin bone. Deeper infections are often times
more difficult to resolve. Light surgical debridement with appropriate antibiotic
treatment is often necessary. Maggot debridement therapy is also used as an
adjunctive treatment in some of these cases removing/debriding only
necrotic/infected tissue without structurally compromising the fragile foot.

Successful management of the laminitic horse begins with the understanding

of the normal supporting structures of the digit, the disease process, and the
structural failure that results in the laminitic foot. An early accurate diagnosis,
intervention, and treatment are imperative for a successful outcome. Rehabilitation
of the laminitic horse requires a dedicated and cooperative team work effort
between the farrier, veterinarian, and owner.

References:
1. Morrison S. Foot management. Clinical techniques in equine practice:
Laminitis 2004, 3; 71-82.