Stromsholm Laminitis Clinic
Gathered in the impressive Sefton Barn at Horse Trust’s Home of Rest for Horses, attendees at the Stromsholm Laminitis Awareness Clinic were warmly welcomed by Managing Director, Carl Bettison. Approximately 50 farriers, farriery apprentices, vets, nutritionists, veterinary university and farriery college representatives were present for this half day clinic focusing on the advancing area of laminitis; its recognition, treatment, management and prognosis. The first half of the session focused on the current knowledge and research.
Understanding the Laminae
Dr Sue Kempson BSc PhD
Dr Sue Kempson reviewed the structures within the equine foot and their role and involvement in laminitis. The whole of the foot is affected and an examination at cellular level of what happens within the hoof capsule was provided. Fluid escapes from the blood vessels in the foot and the pressure of this fluid causing necrosis and an ischaemic situation leading to neuropathic pain pressure in the nerves. The toe region is affected more and, as the fluid cannot escape, there is an upwards pressure towards the coronary band. An examination of the disruption in the coronary region was provided and the importance of the coronary band attachment to the pedal bone was highlighted in terms of supporting weight and acting as a significant suspension mechanism within the foot.
A line on the hoof around the entire circumference of the foot is typically seen on an equine that has suffered from previous instances of laminitis. It was noted that stretched laminae are seen on the toe but not the heel region and that the heel region has more expansion than the toe.
Dr Kempson provided an insight into an incidence of laminitis which occurred following turn out on pasture previously fertilised which highlighted the importance of immediate action on an owner’s behalf. Frozen peas wrapped around the fetlock, changed three times a day, were in this case deemed to have been beneficial at reducing the temperature of the blood. In addition this equine was allowed very restricted movement, if it wished to do so, to promote circulation and assist in the dispersal of the fluid in the hoof. Furthermore prolonged massage of the belly of the flexor muscle was advocated to encourage relaxation and reduce the contraction of the muscle and therefore the tendon, pulling upwardly. This point was further endorsed by the use of muscle relaxants and physiotherapy in the US. Lastly, Dr Kempson, advocated the supplementation of magnesium as nitrogen blocks the absorption of magnesium which results in ‘leaky’ cells (oedema) within the hoof. In this isolated case, the horse recovered completely with no rotation of the pedal bone and no stretching of the white line.
First Response to Laminitis
Robert Eustace BVSc Cert EO Cert EP FRCVS
Robert Eustace defined laminitic cases as acute founder, sinker and chronic type I and II. Their study showed a 100% success rate for laminitis cases, 80% for acute founder, 20% for sinker and 79% for chronic founder cases. Laminitics may present with lameness in one, two, three or four feet and the severity of lameness can vary from slight with a reduction in stride length to recumbency. Diagnosis is made on the basis of a changed gait, a heel loading stance (as the front part of the foot is the most painful) and an increase in the strength of the pulsation of the digital arteries most easily felt at the fetlock.
Acute founder cases show a palpable supra-coronary depression. Should a finger ‘lodge’ in this depression the chances of successful treatment reduces. The deeper the depression and the further round toward the heels, the deeper the founder. Dr Eustace uses a calculation of the founder distance in evaluating cases and does so with the use of a marker on X-rays with the top of the wire marker being on the hoof wall where the horn changes from hard to soft. (The periople may be rasped to show this clearly.) A loss of cohesion in the laminae results in the dip at the coronary band and is signigicantly related to the founder distance. The horse should be x-rayed stood square on a flat surface with the limb in a vertical position, the lateral view being the most helpful. The founder distance is the only statistically significant radiological parameter of success rate for acute founder and sinker cases. As the founder distance increases the success rate decreases. Acute founder cases are usually treated with a heart bar shoe and a dorsal wall resection.
In sinker cases the coronary depression extends all around the coronary contour to the heels, The recovery rate of sinkers is 20%. Radiographs usually demonstrate large founder distances and entire hoof capsules have been known to come off. If these horses survive, a concentric ring around the hoof becomes apparent as the hoof grows.
Chronic laminitics have a history of acute founder. They present with high heels, a concave dorsal hoof wall and flat soles. Growth rings are more widely spaced at the heels than the toes. A radiograph shows a stretched white line which typically possess gravel and pus in the foot.
Any type of laminitis is an emergency, the quicker the owner takes action the better the chances of success. Dr Eustace recommends a deep (18”) clean and dry shavings bed (a must for avoiding sores whilst lying) covering the whole floor in a large stable allowing the horse to lie down. He recommends the horse should be kept stabled, on box rest for at least 30 days and believes that the more the horse is allowed to exercise freely the greater the chances of increased tearing of healthy laminae. In the first instance The Laminitis Clinic (TLC) Frog Supports can be used (whether the horse is shod or not) and shoes should be kept on particularly if a horse has a flat or convex sole. Dr Eustace has a “dislike” for cuffed shoes and uses a tabbed shoe which can be made tailored to suit individual requirements. The tabs can be positioned where you would like them and removed very easily especially in foundered cases.
There is no specific treatment that can reverse laminitis and no magic drug. Drugs may be used to reduce pain and anxiety although he believes bute (any NSAID) is overused and that we do not want a horse to feel totally numb. Horses allowed to feel mild discomfort will lie down to make themselves more comfortable and remove the weight borne by standing.
Dr Eustace advocates the use of Laminitis Trust Approved feeds; identified by their specific approval mark. He has a preference for not feeding haylage or products containing live yeasts to laminitic prone equines. A correct, balanced diet is important; Formula 4 Feet is the supplement recommended. For equines at a high risk of laminitis (from grain overload, a retained placenta, abdominal surgery) cryotherapy or an ice slush tank plus frog supports, applied for 72 hours may be beneficial.
Laminitis & Cushing’s Disease
Dr Nicola Menzies-Gow MA VetMB PhD DipECEIM CertEM(int.med) FHEA MRCVS
Dr Nicola Menzies-Gow provided an explanation of equine cushing’s disease, more accurately known as Pituitary Pars Intermedia Dysfunction (PPID). Equine ‘cushing’s’ is not the same as cushing’s in humans and dogs whereby the adrenal gland is affected; in horses it is the pituitary gland (responsible for hormone production). Whilst the previous focus was on ACTH it is now better understood that other hormones are now also involved. PPID is a loss of dopaminergic inhibition resulting in oxidative damage and is slowly progressive.
More commonly found in older horses, the average age is 19 years and rarely is it confirmed in equines younger than 10, with the youngest recorded as 7. There is no sex predilection and ponies are more likely to be affected than horses. Early signs may include a loss in performance, lethargy and delayed coat shedding. Whilst an equine that has a reluctance to shed its winter coat or exhibits a curly coat is fairly indicative of PPID, PPID equines do not always have coat problems. 10 – 32% of equines with PPID have recurrent or chronic laminitis which is attributed to excess cortisol and/or insulin. 88% of cases result in weight loss, increased drinking and urination. Supra orbital fat pads may be present and they become more susceptible to infections due to a compromised immune system.
Diagnosis is usually made on a history and signalment basis. Clinical signs plus hormone assays and dynamic tests are also taken for evaluation. The basal ACTH concentration test is still the most common however, no test is perfect. It is important to note that hormone levels vary naturally with the seasons. The TRH stimulation test is also used. Dr Menzies-Gow advises to “go with what you see” and encourages caution with the tests that are available.
The management/treatment will depend on the clinical signs present; laminitis is frequently the most limiting factor. Hair can be clipped, diet can be managed. Specific medical therapy is a decision for the owner and the vet; medication is not wholly effective and has side effects – it is essential to monitor individuals. Prognosis includes a lifelong management plan; 50% of cases are still alive 4 to 5 years after diagnosis in one study with laminitis usually being the reason for euthanasia.
Dr Robert Eustace BVSc Cert EO Cert EP FRCVS
Dr Eustace provided an insight into a “partial coronary epidermectomy (referred to as the coronary peel), a dorsodistal wall fenestration and deep digital flexor tenotomy” in a 13 year old Connemara which was referred to The Laminitis Clinic 13 days after the onset of acute laminitis. The pony was admitted receiving 6 grams bute, 500 mg flunixin and 100mg ACP and was overweight (condition score of 4 to 5)[Carroll and Huntington scale]. A grade 3/5 lameness was recorded in both front feet and an 8cm wide supra-coronary depression was present with convex front soles and a founder distance of 17.3mm and 19.2mm in the right fore and left fore respectively.
At day 16 a DDFT (deep digital flexor tendon tenotomy) and a coronary peel was performed under a local anaesthetic with the horse standing. A glue on tabbed shoe with a posterior extension was used with sole packing and the dorsal area packed with Gamgee tissue. The right foot was operated on a day later and by day 19 the horse was led out in hand, was comfortable and receiving just 0.4 grams suxibuzone.
By day 42 the horse was receiving no medication but started to show some discomfort and a dorsal distal resection was carried out. A painful seroma had formed under the horny sole. The feet were kept clean in tubs of warm water with an iodine soap solution which was encouraged to move in and around the foot by carefully encouraging the horses to move its weight on and off the foot. At day 96 the leg bandages were replaced with stables bandages and the founder distances had reduced to 9mm. At day 102 and 106 the remaining left and right ‘bridges’ on the front of the feet were removed. The horse was discharged on day 195, having become a more appropriate weight and had suffered no abscesses nor solar prolapses. The increase in comfort was immediate following surgery and continued to improve. The horse is back in full work and competing.
Of a previous study of 166 acute founder cases treated with a heartbar shoe and a dorsal wall resection, 21 had founder distances of >15mm and of those 1 was successful. Dr Eustace considers the success of this case was largely due to the speed of referral; many cases are not presented until much later. The coronary peel needs to be performed at the “earliest possible window”.
This full case report may be accessed –
Eustace. R.A., Emery. S. L., (2009) Partial coronary epidermectomy (coronary peel), dorsodistal wall fenestration and deep digital flexor tenotomy to treat severe acute founder in a Connemara pony. Equine Veterinary Education Volume 21, Issue 2, pages 91–99.
A lively question and answer session followed with the guest speakers defending their opinions and providing further consideration to each other’s theories. A short break, including a light lunch followed, before the afternoon recommenced with the practical sessions.
Dean Bland DipWCF Hons
“Farriery for the Laminitic Journey” was the title of the practical lecture and demonstration given by Dean. A description of the forces which act upon the foot, the transference of those forces including the role of heel deformation was described and placed in the context of ischemia and laminal inflammation resulting in a weakening and tearing and instability of the pedal bone. Describing a “deteriorating welfare picture” in the early onset of laminitis, Dean described the pedal bone as the “condemned man” with a trap door under his feet which could go at any point. In order to “neutralise gravitational force” a chair can be placed under his feet.
As a first aid response Imprint Repair Granules may be used to provide non compressible 3D support. The granules are easily malleable in warm water and may be formed around the frog to provide immediate relief. Following radiography the hoof may be trimmed to “reinstate equilibrium” and the Imprint First Shoe heart bar applied. Made from the same malleable thermoplastic and including the same features as a steel shoe it can be easily moulded and fit to the foot without the trauma of nailing on. Additional granules can be used to provide extra support to the frog if it is required and once the shoe has hardened it can be shaped with a rasp. Dean reasons that providing action is taken within the first 24 hours the chances of a horse returning to full work within a 6 week shoeing period is promising.
A hoof wall avulsion, referred to as the second crisis, can follow. Often confused with a second acute onset this ‘dip’ is as a result of lamellar death followed by detachment leverage forces resulting in pain, trauma and tearing; P3 will be sitting lower in the hoof capsule. Adverse hoof morphology can occur in chronic laminitics (stereotypical of pottery, sore and older equines) whereupon the foot needs to be maintained to combat the effects of adverse forces to allow normal function to occur. Hoof rebuilds may be necessary to reinstate normal function.
Dean’s full lecture may be obtained by registering on his website www.wellequine.co.uk.
Styrofoam & Suport Systems
David Nicholls AWCF
David Nicholls expressed the different approaches that “work on individual cases the majority of the time”. He has used a number of techniques himself but strives to treat horses as individuals, influenced by their environment. A plethora of new products appeared in the 1970’s and 80’s and admits to having used most.
In the first instance plasticise with duct tape may be applied to provide crucial support and is fitted slightly larger than the foot itself. David advocates utilising the client and enlisting their help in this application. If the horse is shod, sole support may be added with caution and should not cause additional pressure. The use of hoof testers may be employed to demonstrate areas that are particularly painful. Support material can be pressed directly onto the foot to provide a reasonable load platform. Referring to earlier opinions, David has a personal view that shavings are unstable and advocates limited exercise.
The Styrofoam support system is a non-shoeing treatment which will alleviate areas of pain and compress to the angle preferred by the horse. Styrofoam is not advised in deep bedding as it would be too unstable. It may be reused with a new one as the initial one has already been moulded to the foot. Erring on the side of caution he believes it wise to “promise low and achieve high” when discussing the case with the client.
The aluminium performance leverage reduction (PLR) shoe and steel PLR shoe were presented as shoes suitable following successful treatment due to their multi-directional breakover, caudal support and leverage reduction.
Aluminium Shoes & Packers
Alf Hall DipWCF
Alf Hall aims to relieve pain as, he believes, it is the pain that “kills them”. Whilst acknowledging that there is more than one way to care for the feet of a laminitic, he advises that no work is undertaken prior to x-rays being taken.
He has noticed a lot of sole pressure in the laminitic cases he has experience with which led to the design of the P4 laminitic shoe. This shoe has been made with a toe plate that extends back toward the point of frog, protecting the sole region from the ground. The outer edges are bevelled to allow for breakover in any direction and the toe plate and inner edges are recessed relieving sole pressure and reducing dorsal wall leverage. Prior to application the frog should be dressed and the shoe is fitted and nailed on with webbing for packing material. Areas of pressure are blocked off and Alf has a preference for using a ‘medium’ packing which is not too firm. He utilises an adhesive foam pad to level the packing within the foot.
Mark Aikens BSc(Hons) FdSc DipWCF
Mark demonstrated the application of EVA Clogs, used to treat moderate to light, chronic and acute laminitis – not to be used when the sole is dipping down. These leather backed clogs made from a compressible material conform under weight bearing. Featuring a bevelled edge and a leather pad on the weight bearing surface of the hoof wall these clogs help to spread the loading of the limb over a greater surface and bring ground reaction forces under the centre of the limb in addition to disseminating the forces quickly.
Prior to application, Mark advises that the foot is trimmed “appropriate for laminitis”. The clog is screwed down to the hoof capsule following the drilling of pilot holes in the white line in order to place the screws accurately. Mark uses two screws on either side. The hoof is then placed on the ground for comfort and to ensure that the clog is under the foot and that the heels are lined up. It is useful if the client is asked to lift the opposite limb. Packing the foot is unnecessary as the EVA is compressible and the clog features a leather sole. Dentist impression material is used to pack the heel to reduce the risk of pinching and is allowed to set before the hoof is cast with Equicast and wrapped in clingfilm to ensure a good set and finish.
In Mark’s experience these clogs can be successfully left for 8 to 10 weeks – the exact time before repetition depends on the horse. He has noted a large amount of sole growth following successful application of the EVA clog. In poor weather conditions and over long periods, Adhere may be used up the hoof wall to provide further security to the cast. In addition, he feels with this treatment deep bedding is not necessary. Following a successful outcome with the EVA clog he recommends a gradual move back to traditional farriery.
The practical sessions were complete with final notes from Dr Robert Eustace regarding the different nomenclature presented by individual cases. He reiterated his belief that timing was crucial to the success of any case, in addition to the severity. The management of each case is dependent on the individual and it is important to keep the horse happy. In general agreement –
· Cases of laminitis should be treated as an emergency, like colic
· Emergency frog support should be used as soon as possible
· Use ice packs around the fetlocks
· Provide the correct diet – seek advice from a nutritionist (most commercial companies will refer you to one)
· X-rays provide essential information to accurately measure the founder distance
· A hoofcare plan should be agreed between the farrier, veterinary surgeon and the owner
A final question and answer session explored the merits of the various applications further and gave the attendees a chance to view the products in more detail.
Carl Bettison concluded the day by thanking the speakers for their time and the attendees. An agreeable response was demonstrated by all who attended in recognition of the highly informative and thought-provoking afternoon. Whilst opinions differed, the importance of treating each case as an individual was highlighted and plenty was provided for consideration in that evaluation. An extremely worthwhile and valuable clinic.
To view the entire gallery from the day, please click here.