Secondary Laminitis - advice please #understandingtrim


drvmitchell@...
 

Hi.  I'm after some advice for my horse with laminitis.  
4 months ago he suffered a penetrating injury to his off hind resulting in infection of his coffin joint and surrounding structures.  This was treated with systemic antibiotics, local antibiotics injected into the distal veins whilst a tourniquet was applied, flushing of the joint with saline, intraarticular antibiotics and pain relief.  He was given a poor prognosis for ever being sound again.  At the time my vet and my farrier in collaboration placed a heal-raising shoe on his other hind foot to prevent secondary laminitis.   This was unsuccessful, and as the originally injured hind foot healed, he became shifting leg lame, and eventually obviously rather lame on his near hind.   He was xrayed and both the vet and the farrier diagnosed "catastrophic pedal bone rotation and sinking with 1mm of sole remaining between the tip of the pedal bone and the ground".  For the second time in 2 months I was advised to euthanize my horse.  
Both the Vet and farrier in collaboration have placed both his hind feet in raised heel shoes and we are monitoring his progress with 7-10day xrays.    It is coming up 10 weeks since diagnosis (of laminitis) and we have radiographic evidence of the sole detaching.  Which we are monitoring.  I was told at last weeks xrays we had 4mm of sole growth at the tip of the pedal bone but when I look at the xray I struggle to see any difference.   The more I read the more want to pull these shoes off and fire the farrier.  
My question(s) are:
(1).  I dont want to just pull these shoes off and whack off his heals.  How 'quickly' would you advise I do this process? 
(2) Assuming I can get blood supply back to beneath the coffin bone, over what sort of time frame would we be looking , on average, (realizing that it's all individual), that i could start to see sole growth?  I.e. at what point do we say 'well this isnt working either'.  Given hes had no blood supply for 10+ weeks now. 
(3) can you offer any polite ways of saying to my farrier hes fired? I cant fire my vet because I still need follow up xrays and there is no other equine vet in the area.  I need to stay on his good side despite firing his accomplice.


 
Edited

Hello ??,
This group is an excellent resource for you. I'm sorry that your horse is going thru this. You need to begin reading the new member protocols below and get started on a case history for your horse. Out moderators need a detailed history for your horse, xrays, photos, etc. Also consider sending this link to your vet and farrier:
https://www.ecirhorse.org/

I apologize for the short post but we are in the middle of a snowstorm here and our electricity is going in and out. Please start by creating a signature for your self with your basic location included. This way we know your name! 

Welcome to the group! 

The ECIR provides the best, most up to date information on Cushing's (PPID) and Insulin Resistance (IR). Please explore our website where you'll find tons of great information that will help you to quickly understand the main things you need to know to start helping your horse. Also open any of the links below (in blue font) for more information/instructions that will save you time.

In order to help you and your equine quickly and effectively, we need you to explain your equine's situation by following the instructions you were sent upon joining. Your completed case history form and ECIR Signature will save days of back and forth questions. If you haven't done so yet, please join our case history sub-group. Follow the uploading instructions so your folder is properly set up and then upload your case history. If you have any trouble, just post a message or email the case history group explaining specifically where you are stuck.

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DIAGNOSIS: There are two conditions dealt with here: Cushings (PPID) and Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or IR, neither or both. While increasing age is the greatest risk factor for developing PPID, IR can appear at any age and may have a genetic component. Blood work is used for diagnosis as well as monitoring the level of control of each.

PPID is diagnosed using the Endogenous ACTH test, while IR is diagnosed by testing non-fasting insulin, glucose and Leptin. Leptin is the hormone that says "stop eating". Knowing this helps to differentiate if a horse is IR "at baseline" or if an elevated ACTH is "driving" the insulin up. In Europe, substitute adiponectin for the leptin test.

*Before calling your vet to draw blood for tests, we suggest saving time and wasted money by reading these details and then sharing them with your vet so that everyone is on the same page regarding correct testing and protocols.

*Please remember to request copies of the results of all the tests done rather than just relying on verbal information. Your vet should be able to email these to you. If you have previous test results, please include those as well. All should go in your CH, but if you are having any trouble with the CH, just post in the messages for now. 

Treatment: IR is a metabolic type - not a disease - that is managed with a low sugar+starch diet and exercise (as able). The super-efficient easy keeper type breeds such as minis, ponies, Morgans, Arabs, Rockies are some of the classic examples. PPID is a progressive disease that is treated with the medication pergolide. Some, but not all, individuals may experience a temporary loss of appetite, lethargy and/or depression when first starting the medication. To avoid this "pergolide veil" (scroll down for side effects), we recommend weaning onto the drug slowly and the use of the product APF. The best long term results are seen when the ACTH is maintained in the middle of the normal range at all times, including during the annual seasonal rise. To accomplish this, the amount of medication may need to increase over time. Neither condition is ever "cured", only properly controlled for the remainder of the equine's life. If your partner is both PPID and IR then both medication and diet management will be needed. 

 

DIET: Almost all commercial feeds are not suitable - no matter what it says on the bag. Please see the International Safe Feeds List for the safest suggestions.

No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:

  • low carb (less than 10% sugar+starch)
  • low fat (4% or less) 
  • mineral balanced  

We use grass hay, tested to be under 10% ESC + starch, with minerals added to balance the excesses and deficiencies in the hay, plus salt, and to replace the fragile ingredients that are lost when grass is cured into hay, we add ground flax seed and Vitamin E. This diet is crucial for an IR horse, but also supports the delicate immune system of a PPID horse. 

*Until you can get your hay tested and balanced we recommend that you soak your hay and use the emergency diet (scroll down for it).  The emergency diet is not intended for long term use, but addresses some of the most common major deficiencies. Testing your hay and getting the minerals balanced to its excesses and deficiencies is the best way to feed any equine. If you absolutely cannot test your hay and balance the minerals to it, or would like to use a "stop gap" product until you get your hay balanced, here's a list of "acceptable" ration balancers

There is a lot of helpful information in the start here folder so it is important you read all the documents found there. The emergency diet involves soaking your untested hay for an hour in cold water or 30 minutes in hot water. This removes up to 30% of the sugar content, but no starch. Starch is worse than sugar since it converts 100% to glucose while sugar only converts 50%, so starch causes a bigger insulin spike. Make sure you dump the soaking water where the equine(s) can't get to it. 

What you don't feed on the IR diet is every bit as, if not more important than, what you do feed! No grass. No grain. No sugary treats, including apples and carrots. No brown/red salt blocks which contain iron (and sometimes molasses) which interferes with mineral balancing, so white salt blocks only. 

No products containing molasses. No bagged feeds with a combined sugar and starch of over 10% or starch over about 4%, or fat over about 4%. Unfortunately, even bagged feeds that say they are designed for IR and/or PPID equines are usually too high in sugar, starch and/or fat. It’s really important to know the actual analysis and not be fooled by a name that says it is suitable for IR/PPID individuals.

We do not recommend feeding alfalfa hay to IR/PPID equines as it makes many of them laminitic. Although it tends to be low in sugar, many times the starch is higher and does not soak out. Additionally, protein and calcium are quite high, which can contribute to sore footedness and make mineral balancing very difficult.

 

TRIM: A proper trim is toes backed and heels lowered so that the hoof capsule closely hugs and supports the internal structures of the foot. Though important for all equines, it's essential for IR and/or PPID equines to have a proper trim in place since they are at increased risk for laminitis. After any potential triggers are removed from the diet, and in PPID individuals, the ACTH is under control, the realigning trim is often the missing link in getting a laminitic equine comfortable. In general, laminitic hooves require more frequent trim adjustments to maintain the proper alignment so we recommend the use of padded boots rather than fixed appliances (i.e. shoes, clogs), at least during the initial phases of treatment.

Sometimes subclinical laminitis can be misdiagnosed as arthritis, navicular, or a host of other problems as the animal attempts to compensate for sore feet. 

You are encouraged to make an album and post hoof pictures and any radiographs you might have so we can to look to see if you have an optimal trim in place. Read this section of the wiki for how to get a hoof evaluation, what photos are needed, and how to get the best hoof shots and radiographs.

 

EXERCISEThe best IR buster there is, but only if the equine is comfortable and non-laminitic. An individual that has had laminitis needs 6-9 months of correct realigning trims before any serious exercise can begin. Once the equine is moving around comfortably at liberty, hand walking can begin in long straight lines with no tight turns. Do not force a laminitic individual to move, or allow its other companions to do so. It will begin to move once the pain begins to subside. Resting its fragile feet is needed for healing to take place so if the animal wants to lay down, do not encourage it to get up. Place feed and water where it can be reached easily without having to move any more than necessary. Be extremely careful about movement while using NSAIDs (bute, banamine, previcox, etc.) as it masks pain and encourages more movement than these fragile feet are actually able to withstand. Additionally, NSAIDs (and icing) do not work on metabolic laminitis and long term NSAID use interferes with healing. Therefore, we recommend tapering off NSAIDs after the first week or so of use. If after a week's time your equine's comfort level has not increased, then the cause of the laminitis has not been removed and keeping up the NSAIDs isn't the answer - you need to address the underlying cause.

 

There is lots more information in our files and archived messages and also on our website. It is a lot of information, so take some time to go over it and feel free to ask any questions. If you are feeling overwhelmed, don't worry, you will catch on, and we are always here to help you! Once you have your case history uploaded, we can help you help your equine partner even better.

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If you have any technical difficulties, please let us know so we can help you. 

--
Bonnie Snodgrass 07-2016

ECIR Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album


Eleanor Kellon, VMD
 

That's quite a situation you have going here! My first impression is you will need someone competent to work on these feet with you. Going barefoot with a realigning trim is preferred but not always the best move,  depending on hoof wall quality, wall connections, myotendinous contractions. That said, elevated heels is never the answer IMO. It wasn't then and it isn't now but you may have to wean him out of those heels after all this time and if the wall is very weak and damaged you may  need an appliance of some sort at least temporarily.

What do you  mean by the sole detaching? Penetration. Could you post these radiographs and some photos?

Your questions:

1.  Really need to see the rads and photos but in general you do it as quickly as the horse will allow depending on how much you can actually safely take off
2.  He's not deprived of blood flow, just compromised. The hoof wall can't grow down properly because it is bearing all the weight without assistance from the frog and sole, and all the weight of the horse is being directed to the tip of the coffin bone. Once you get the forces redirected he'll grow sole like crazy.
3.  It sounds like you can't criticize the farrier without also criticizing the vet. If you had someone lined up with an alternative approach you could then request the vet to go along because what you are doing now is obviously not working. If you can get even a long distance orthopedic consultation that would be someone to direct both your vet and your farrier.

Complicating this picture, as you have probably been told, is that he will always have pain and likely progressive arthritis in the coffin joint that was penetrated even if the infection has been eliminated. It may not be the most pressing immediate problem but it will be a consideration moving forward. Did you get films of both hind feet this last time?

Without a comfortable leg to stand on behind he's looking at a high laminitis risk for the fronts next. (Think Barbaro.) I'm not trying to sound negative, just full information.

--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


 

Back on-line. If you are going to take shoes off you need to consider being prepared with therapy type boots on hand. https://www.easycareinc.com/
have Cloud boots that many of us have used for our own horses. https://www.softrideboots.com/index.php
is another type of therapy boots. The softride boots have a variety of insert pads available. You would need to decide on the style of pad best for your horse. The Easy Care Clouds have a moderate wedge pad which is fairly soft and will mold to your horse's soles. 
--
Bonnie Snodgrass 07-2016

ECIR Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album


Lavinia Fiscaletti
 

Hi,

So sorry to hear that you and your boy are going thru this. It sounds like you are a strong advocate for your horse so he is a lucky boy.

Agree with Dr. Kellon that we need to see the rads and some hoof photos (if possible) before being able to make any more specific suggestions for you. Also that it may be necessary to wean him off the shoes and elevated heels. This may require some intermittent appliances of some sort  - or not.  The Easycare line of rehab boots, which do have wedging available that can be snapped onto the bottoms of the boots may be an option depending on your specific circumstances.

If you let us know where you are we might be able to recommend a hoof pro in your area who could work with you.

--
Lavinia and George Too
Nappi, George and Dante Over the Bridge
Jan 05, RI
ECIR Support Team


Lavinia Fiscaletti
 

Although this would normally be a case that belongs on the EC Hoof subgroup, we are continuing it here as it has it is an extreme case of laminitis that is of interest to all members.

The radiograph of the LH foot has been uploaded into the Photos section here:

https://ecir.groups.io/g/main/album?id=83978

There doesn't appear to be much bony column rotation but the toe is much too long. Coffin bone appears to have penetrated. That "space" circled in red is likely blood.
Need to back up the toe to remove the lever forces on the hoof capsule. If the clog is going to continue being used, need to substitute one with an anterior bevel that is set much further back, correctly aligned with where the bony column needs it to be. Also would benefit from using padding that has a cut-out under the location of the tip of P3 to relieve the pressure being placed on it.

Because the actual heel of the hoof has been trimmed to make the coffin bone virtually ground parallel (0* palmer angle), the wedged shape of the clog isn't really creating a raised heel. Are there any rads available that include all the pastern bones so that the overall alignment of the bony column is more visible? Would it be possible to see any of the earlier rads to compare this one to?

Would it be possible to see the radiographs of the RH as well?

--
Lavinia and George Too
Nappi, George and Dante Over the Bridge
Jan 05, RI
ECIR Support Team


drvmitchell@...
 

Hi.  You will have to excuse the fact I am not replying nor have posted as per recommended protocol as there is a lot of information to wade through and my horse does not fit into your caregorised PPID/IR or otherwise groups. 

My name is Verona and I'm from Dunedin, New Zealand.  I still haven't had a chance to read thru the  instructions of how to create a signature nor an album, I will endeavour to do this at some point.

The farrier my Vet works with is apparently the most experienced in hoof rehabilitation and has worked overseas and has multiple qualifications in his field.  However I am also told he is very old-school and he will not change his beliefs.  His current belief is to raise the heel and remove the pull of the DDFT.  My Vet is also convinced that raising the heels are the only treatment.  He is the only equine vet in the region that I trust (he fixed the penetrated coffin joint injury) not only 

The spanner in the works is that I am also a veterinarian (albeit small animal) and I am very torn between trusting my profession, my training, my whole life, versus the biomechanical/classical principals to which I have been studying for the last 3-4 years.  


 
Eleanor- what I mean by the sole detaching is exactly that - the entire sole is detaching from the bottom of his hoof.  This started as a thin black line below the coffin bone and has slowly got bigger to his latest xray that I emailed.   The arrow points to this.  With the clog shoe removed you can clearly see the split between the dead/sloughing hoof and the fresh soft horn underneath.  

Thank you for confirming that the blood supply isnt cut off completely, but that its compromised.  This gives me hope that he will grow new sole.  I raised the question at the last xray as to why after 10 weeks there was no radiographic evidence of sole growth, my vet replied it will happen, give it time.   I would have thought 10 weeks in we would have had a minimum of 3-4mm sole growth by now?  As we have that at the heels, just not directly under the tip of P3.

Follow up xrays of the originally injured foot reveals hes now got navicular.  His prognosis from that initial injury was poor but there was no question as to this horse receiving absolutely every chance to fully recover, no matter how slim that chance is/was.  


He is currently paddock sound, I.e. he is not lame to a non-educated person, however I have not seen him trot let alone canter for 4 months and he rarely lies down now.   I am fully aware that either of these two injuries could result in a less than favourable outcome but as I said above, he will get every chance.

Lavinia - thank you. The coffin bone has not yet penetrated and the red circle is air.  Interesting that you say the foot has been trimmed so the coffin bone is ground parallel.  The farrier used the massive heel raising shoe then shoved a wooden wedge in at his toe to achieve ground parallel.  This confused me because one one hand he raises the heel but then he raised the toe, effectively cancelling  each other out.   I'm also confused as to is the trim supposed to parallel the solar surface of the coffin bone to the ground or the coffin bone to the surface of the sole?  I have been told both.  

I will try to send thru xrays of his other foot, both of the initial injury and the latest follow up xrays, and also of this foot from diagnosis of laminitis thru to the latest.  


UPDATE:
I have removed his current shoes and employed a farrier whom agrees with the theories of this group so am optimistically looking forward to improvement.


Jon and Heather Fowler
 

Mods and Verona, I am following your horse's case with interest as I have a laminitic mare, Marra, who now is showing signs similar to your boy, with possible space/defect/fluid between coffin bone and sole.  In her case, I don't have current rads but she was extremely lame LF, started flaking off chalky white sole, and then the hoofpick caught and lifted a flap of sole between toe and tip of frog.   Cloudy pink fluid spurted out.  No real change noted in her comfort level afterward.  I left the flap on to keep debris from entering the foot but after a week it died back becoming soft and black.  Removing sand from the subsequent defect one day later, hoofpick again caught an edge and lifted, releasing dark bloody fluid.  Now the sole is lifting off in a thick sheet from the defect toward the toe and there seems to be no attachment of the sole on either side of the defect/hole.  Dark bloody fluid with foul odor occasionally releases from the defect when cleaning her foot.  
Guessing this is a subsolar abscess and that treatment is to keep it clean and dry, padded and protected.  Leave the sole on until it exfoliates on its own.  Trust that new sole will grow and callous over time (how much time?).  Does that sound right?  Would rads be helpful at this point?   She had been on every 2-3 week trims but my trimmer is in Australia for a month, returning end of Feb.
--
Heather Fowler, DVM   January 2015   New River, AZ

 

https://ecir.groups.io/g/CaseHistory/files/Heather%20and%20Marra%20-%20Queenie/Marra

Marra's photos:  https://ecir.groups.io/g/CaseHistory/album?id=6013