This is my first post here (recommended by my farrier to reach out) Searching for help & suggestions on getting my 17 year old mustang comfortable on his front feet. 

- Came down with laminitis June 2020 
(had previous episodes first ever in 2015, second in 2018 - but thankfully recovered and was sound from 2015-2018 and 2018-2020) the cause seemed to be spring grass despite muzzle / restricting time on grass.

in June 2020 he was wearing shoes when he had his third attack — my vet and farrier did not want to change from the shoes, and recommended he keep them on. He had sinking in both fronts. My vet started him in Thyro L and 1 prascend tablet daily. 

he remained sore despite trying different shoe set ups (glu shoe, reverse shoe) updated x rays showed dangerously thin soles, and bone density loss from not being comfortable enough to move around. I then switched to cloud boots, and put him on bonewise supplement to help bone density. Blood Mineral test at that time showed he was high in IRON and deficient in zinc/ copper. So started to supplement with madbarn copper and Zinc. Blood test showed his PPID was normal range, and we assumed Insulin was high based on his high iron results 

May 2021 - my farrier at the time had let his heel height go out of control despite my vet telling him to trim every 2 weeks and slowly bring the heel down/ balance the feet. I was incredibly lucky to find a rehab specialist to take over his trims - and slowly lower his heels (and give me guidance). We tested his insulin at that time and it was 148. After a few months of trims we were finally able to hand walk since he was happy/ comfortable in his cloud boots. He was even trotting/ cantering on his own outside for the first time in over a year.

we retested PPID and insulin in November - cushings was normal range, Insulin came back at 67 

He was doing great, daily handwalking / trotting in hand - then in January 2022 he became sore on LF. 

treated for abscess, and had one drain from heel/ frog area - but he really struggled over the extreme cold winter in Canada. Kept him wrapped and blanketed to try to help with his circulation. 

He gets trimmed every 3 weeks, but we still haven’t been able to get him landing heel first, and he’s still foot sore. He is stalled at night, and been in a dirt paddock since 2020 (no grass at all). We are going to recheck his PPID and insulin blood work this week. 

I was unable to soak his hay in the cold weather, but have been soaking most of it since the nice weather. 

My farrier and I aren’t sure what is causing the continued foot soreness/ inflammation. He’s never tested positive for PPID, but he hasn’t fully shed out yet this year. I’ve had x rays taken every 3
months. There weren’t much change between February and May radiographs. My vet thinks he’s foot sore from walking on his soles with not enough wall support (based on how his feet are growing out/ where the laminar wedge is at the toe). We are looking into doing some easycare composite shoes, with pour in pads  to see if that can help his sore soles? However we are worried there is still something driving inflammation so going to get updated blood tests. 

Thank you for your time, it is so much appreciated 
Janice Blacquiere-Delong 
Ontario, Canada June 2022

Hello Janice and welcome to the group!
Your first post here triggers this welcome message where you will get tons of valuable information that can help you manage your boy, we realize it is a lot to read, so please keep this handy for future reference. The blue hyperlinks will take you even deeper into the subject line.
The backbone of the ECIR group is based on DDT/E which is diagnosis, diet, trim and exercise. But exercise is only recommended when everything else is in order and your horse is comfortable, as you mentioned thin soles are sometimes painful, if he is reluctant to move, please don't encourage it as it will cause even more damage to those fragile feet.
I wouldn't let him on grass at all without a completely sealed muzzle, what does your hay test at? We recommend starch and sugar to be under 10% combined but some horses need much lower. So, if it is helping, I would continue to soak his hay. 
We do also suggest covering their feet with socks and lined leg wraps to help with circulation when the temps dip, you can also try Jiaogulan to help with circulation since you're on a good trim schedule. 
It sounds like you have been battling this for a while, I'm sorry to hear that. Mustangs are one of those thrifty breeds that need close attention as you can see.
Have you and your vet discussed metformin to help with his insulin? 
 EVJ 07-146 Durham (groups.io)
Metformin 08.08.20 FINAL (groups.io)
It's also worth noting that those numbers for PPID are not "normal" to us, we like to see those numbers in the low twenties at most. 
For more information on that, please read this recent article from Dr.Kellon
Laboratory Reference Ranges are NOT the Same as Normal | Dr. K's Horse Sense (wordpress.com)
It would really help if you can get a case history filled out with all your test results and the x-rays so we can take a look to better advise you. We have awesome experts here that can look at his x-rays and advise you with the trims.
You do have a lot going on but we're here to help, we know how stressful this can all be but hang in there. What follows is your welcome message, please let us know if you have any questions.

Hello 

Welcome to the group! 

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and Equine Metabolic Syndrome (EMS)/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.

Have you started your Case History? If you haven't done so yet, please join our case history sub-group. We appreciate you following the uploading instructions so your folder is properly set up with the documents inside. Go to this CH message with info on how to use various devices and forms. If you have any trouble, just post a message to let us know where you are stuck.

Orienting information, such as how the different ECIR sections relate to each other, message etiquette, what goes where and many how-to pages are in the Wiki. There is also an FAQs on our website that will help answer the most common and important questions new members have. 

Below is a general summary of our DDT/E philosophy which is short for Diagnosis, Diet, Trim and Exercise.

 

DIAGNOSIS: There are two conditions dealt with here: Cushings (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or EMS/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 EMS/IR is diagnosed by testing non-fasting insulin and glucose.

The fat-derived hormone leptin is also usually abnormally elevated in insulin resistance but because there are many other things which can lower or increase leptin ECIR is not recommending routine testing for this hormone. Leptin is the hormone that says "stop eating".

In Europe, adiponectin is tested instead of leptin. Adiponectin helps regulate glucose and fat burning, and maintain insulin sensitivity. Low levels are associated with EMS. It has come to be preferred over leptin because it is not influenced by things like weight or exercise, and also because it was the only factor other than insulin levels that predicted laminitis risk

*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: EMS 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 EMS/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 (look under the Hay Balancing file if you want professional help balancing). 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 EMS/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 EMS/IR individuals.

We do not recommend feeding alfalfa hay to EMS/IR 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.

EXERCISE: The 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.

For members outside North America, there are country specific folders in the files and many international lists in the wiki to help you find local resources.

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

Bobbie and Maggie 
Desi (over the rainbow bridge 7/21) 
Utah, Nov 2018
NRC Plus 2020, NAT, C&IR March 2021
ECIR Group Primary Response 

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Maggie
https://ecir.groups.io/g/CaseHistory/album?id=271156

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi 
https://ecir.groups.io/g/CaseHistory/album?id=78821

Bobbie has already given you a ton of good advice and direction. I would like to address the issue of shoes. The rationale for shoes with sinking is they get the foot off the ground. However, by depriving the foot of the support from sole and frog you leave the coffin bone suspended from the weak laminae and predisposed to more sinking. Sinking causes the thin soles/poor ground clearance, usually complicated by overly long toes. Pour in pads may or may not help. To help, they would have to be level with the bottom of the shoe. Otherwise, boots and pads are a proven solution.

I don't want to overwhelm you but inflammation is not driving the laminitis, insulin is. When you get a chance, read the  2017 proceedings on Endocrinopathic Laminitis and Inflammation in EMS. They are free. https://www.ecirhorse.org/proceedings-2017.php
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001