After a foot or leg injury, often the horse owner, veterinarian and farrier must work together as a team to facilitate the most effective way to medically treat the injury (if anti-inflammatory drugs are needed, for instance) and trim/shoe and rehabilitate that horse for optimum recovery. Careful rehabilitation therapy will often speed healing and help ensure that the horse recovers more fully, returning to its former capability as an athlete. Sometimes a special shoe may help until the foot or leg is healed.
ANATOMY AND LIMB FUNCTION
Scott Morrison, DVM (Rood and Riddle Equine Hospital, Lexington, Kentucky) says that a good understanding of the functional anatomy of the lower limb can help enable farriers to create a special shoe to take pressure off a certain area, for instance.
As stated by Julie Bullock, DVM (a podiatrist at Mt. Sidney, Virginia), for a deep digital flexor tendon injury the farrier would usually try to raise the angle of the foot to take the pull off that tendon. “Wedge pads can be helpful in this situation. With a suspensory injury or a superficial flexor tendon injury, however, you must be careful not to raise the heel. The farrier has to know this, however,” says Bullock. Farriers need to understand the anatomy of feet and legs and how the various leverage forces work.
“Just knowing what the effects of different shoe modifications may have, on different structures of the lower limb, is important,” says Morrision. “For instance, we know that wedging a foot up and taking strain off the deep digital flexor tendon and inferior check ligaments can be helpful when those structures are injured. Yet wedging a foot up probably puts more strain on the other structures such as the superficial flexor tendon and suspensory ligament,” he explains.
“For deep digital flexor tendon injuries we’ll use small wedges or ease the breakover on a shoe to help take strain off the deep digital flexor tendon. For a suspensory ligament injury, we need to do the opposite,” he says. It becomes a matter of trying to create the proper leverage to reduce strain in a certain area to help the injured structure heal.
“What you do with the foot will also depend on what the horse is doing, and how severe the injury is. Some horses have injuries so bad that they need to be confined to strict stall rest. Some will be hand walking, and some will be just walking and trotting for a long period of time before they can progress to faster work,” explains Morrison.
“How extreme/severe a shoe you make for the injured foot/leg really depends on the severity of the injury. We’re usually trying to match our therapy to the severity of the lesion. Therapeutic shoes also have a downside. Every time you manipulate a foot to take pressure off one area, you are loading something else. You are especially loading the hoof capsule (and putting more force in the heel region) when you elevate the heel to unload the deep digital flexor tendon. I hate to wedge horses up if they don’t need it because it can lead to secondary complications,” he says. You walk a fine line, doing the least manipulation that will still do the job.
TAKE ADVANTAGE OF LAY-UP TIME
Some horses that are laid up for an injury have bad feet. “I suggest using lay-up time to try to restore the foot and get better heel function. Often the horseman is trying to get the horse to compete at a higher level and we are shoeing to enhance that athletic performance. Sometimes it’s not the best thing for the horse’s foot. If the horse will be laid up for a significant amount of time, I always take that opportunity to pull him out of those shoes and try to restore normal function back into the foot,” says Morrison.
This can often be done by just letting the horse go barefoot. “This is probably the best way to rehabilitate a horse with low heels. Pull the shoes and let the foot function more normally while the horse is laid up. Often the foot will get better structure and form when allowed to be barefoot for a period of time,” he says.
This varies with individual cases. “With some, you can’t simply pull the shoes and let them go barefoot. Some would get too footsore because they are not used to going barefoot. Sometimes we just try to fit them into a more normal, wider-webbed shoe to give more support, to try to get a healthier foot under them.”
Morrison feels it’s very important to evaluate the feet if a horse is laid up for recuperation after an injury, and see what can be done to improve them during that time period. “This is a good window of opportunity to focus on improving the health of the foot because you don’t have to worry about the horse competing. You take that factor out of the equation and do what’s best for the foot,” he explains.
RISKS FOR RE-INJURY
With some injuries the horse needs strict stall rest to avoid the stress of movement, as for a fracture or a bad tear in the soft tissue (tendon or ligament). How soon the horse can start using the limb again will depend on the injury, and care must be taken to avoid excessive stress or movement that might disrupt healing. Yet the horse needs to start moving again as soon as possible, so you walk a fine line on determining when and how much, to begin the rehab process.
“If the horse is able to walk, I try to have them keep moving if possible—unless it’s contraindicated by that particular lesion,” says Morrison. “I try to have them hand walking as much as possible.” How quickly the horse can go back to work will depend on the injury. It’s also important to not rush a horse back into competition too soon.
“Bringing them back is the tricky part after the lesion is healed,” he says. A horse can easily become re-injured—whether it’s that same lesion over again or they injure something else because the rest of their body is no longer fit, due to the time off and lack of activity.
“Many horses get laid up for an injury, then during the recovery or the process of bringing them back to work they end up with a suspensory ligament injury. This is very common. The suspensory ligament atrophies when not in use. The strength of that structure changes very quickly and it becomes weak,” he explains. The owner or trainer must be very careful that this ligament is not injured when the horse goes back to work. The horse must be brought back very slowly and carefully.
Many injuries heal more quickly with use of complementary therapy such as cold water to reduce swelling and inflammation, and warm water therapy in later stages of healing, to help increase circulation. “Various types of medication can reduce swelling and inflammation,” says Morrison
“Regarding rehabilitation after an injury, we now have a lot more tools for this than we did earlier. There are various types of injections that can be used for different kinds of lesions now. We’re using things like stem cell therapy, platelet rich plasma, and extra-cellular matrix products. These can potentially help a horse heal more quickly, and better, with less scar tissue,” explains Morrison.
The body has an amazing ability to heal, and sometimes strict stall rest is not the best for all lesions, for optimal healing. Many body structures need to have a little bit of stress to heal properly with the best strength and least scar tissue. “The body has to be moving so the new fibers that are forming in a tendon or ligament will heal with proper alignment along stress lines. Sometimes horses that are given strict stall rest can’t heal the best; there is definitely a period in which those tissues are reorganizing and lining up along the way that tendon or ligament is being pulled and stretched. So some kind of movement is beneficial,” explains Morrison.
There are many tools to help facilitate movement in ways that put minimal stress on certain structures. Swimming is often a good way to exercise a horse and help get tendons, ligaments and muscles back to fitness without the stress of concussion. “Other tools include underwater treadmills, treadmills or just hand walking. You travel a fine line between rehabilitating/putting adequate stress on healing structures and overdoing it. The method you select depends on the horse and the type of injury,” he says.
You can keep horses really fit by swimming, keeping their muscles, heart and lungs in great shape, but it’s important to realize that this doesn’t keep their bones strong. The body needs some weight bearing and concussion to build bones and keep them strong. “The horse may become really fit from swimming after an injury, and then wants to run, and may injure the structures that haven’t been loaded. So it is important to keep all these things in mind,” he says.
Some of the complementary therapies offered at equine rehabilitation centers include electromagnetic stimulation of tissues (for faster healing, or to stimulate hoof growth), cold laser therapy, vibration therapy, hyperbaric oxygen chambers and cold saltwater therapy. These modalities are becoming more frequently used by horse owners, trainers and veterinarians (who may use these techniques themselves or refer a patient to a facility where these can be used), to ensure optimal healing in certain types of injuries.
“Footing is important when rehabbing a horse,” says Morrison. “If you rehab the horse on soft footing and then put him back into training on hard footing, this can be risky. The structures need to be rehabilitated on footing that’s harder or at least as hard as what the horse will be going back to for his work or competition.” If you started with soft footing you need to gradually get back to harder footing and work up to the athletic activity on hard footing.
“Walking a horse on hard surfaces or concrete is good for stimulating tendon and ligament injuries. An acquaintance in Holland tells me that for suspensory ligament injuries they make a shoe with a wider toe branch and thinner heel branches, and often they simply walk those horses on concrete for a long time every day. All the concussion and vibration, just at a walk, is probably helpful. Here, by contrast, we are always trying to find softer footings. Then if the horse has to compete on something that’s firmer he may break down. Horses adapt to their environment, and if you work them on soft fluff and train them on fluff, they turn into fluff,” he says.
“Footing is important, but softer footing is not always the answer. Grass is an ideal kind of footing. Trying to find a softer environment is not necessarily best. It’s more of a management issue in how we bring those horses back to work, and how we train them,” he says.
HEADING OFF LAMINITIS
Brenda McDuffee is general manager of The Sanctuary Equine Sports Therapy and Rehabilitation Center (an equine rehab center in Ocala, Florida) and says that laminitis is a frequent aftermath of many types of injury, just because the horse is carrying too much weight on the good leg. “This is often the biggest problem we have to contend with,” she says.
In some instances laminitis is the end result that seals the horse’s fate. An example is what happened to Barbaro, who won the Kentucky Derby and then shattered a hind foot during the Preakness race. Heroic efforts to repair the fractures and save him were progressing and there was hope for recovery—until he developed laminitis from excessive weight-bearing on his good legs and eventually lost his battle with founder.
As stated by Bullock, “There are numerous instances in which laminitis is the deal breaker. Horses are unique in that they must be able to bear weight on all four feet to distribute the load and to keep foot circulation healthy.” You can’t just have the horse elevate an injured foot or leg (like a human patient can) to prevent circulatory problems and swelling.
The problem in a lame leg must be resolved so the foot can be used more normally again and without pain, or there will be too much weight on the opposite foot. Much of the rehab that the farrier helps with is to find a way to address/resolve the hoof problem or deal with it in such a way that the horse can travel comfortably again. If laminitis occurs in spite of all preventative intentions, it must be dealt with swiftly.
If laminitis can be treated in earliest stages with an aggressive complementary therapy such as extremely cold water or sessions in a hyperbaric oxygen chamber, the horse has a much better chance for avoiding the damaging effects of founder. “Usually, with founder, you are playing catch-up,” says McDuffee. “You are merely treating the symptoms and hoping the damaging process stops. The farrier will be doing everything possible on that end, the veterinarian will be doing everything medication-wise, but if there’s something else you can do proactively to add to that treatment, it can be amazing,” she says.
For instance, if a laminitic horse can be given a hyperbaric oxygen treatment within the first 12 to 24 hours after symptoms are noticed (which is usually about 72 hours after the actual process begins), it can generally be turned around with 3 or 4 treatments. If begun early enough, oxygen therapy can prevent the damage that generally occurs. This doesn’t mean that a rotated coffin bone will be corrected, if it has already dropped, but the oxygen treatments will halt the laminitic cascading process.
“It’s hard to get people to try the oxygen therapy early,” says McDuffee. “Most people want to stick with traditional therapies and only use the hyperbaric chamber as a last resort. But it can still halt the inflammation process and help with all the medications being given, to make them more effective,” she explains.
“We also treat founder in our cold saltwater leg spa. Last year we had a horse come in when the owners caught it really early and we treated it very aggressively—20 minutes (standing in the machine) every couple hours through the first 3 days, then just a few treatments per day. The mare was also on DMSO, acepromazine and other medications; the veterinarian was here every day treating that horse. This mare went home 18 days later, completely sound. She was wearing special shoes, but was actually back in training within the month,” says McDuffee.
“A recent study on the effects of cold water therapy on laminitis, done by veterinarians using a control group, showed that cold saltwater works to reverse the laminitic process. They were able to halt it in all the horses in the group in which they used the cold saltwater therapy,” she says.
Traditionally people have stood horses in cold water or deep sand, and that helps, but the cold saltwater therapy is even more beneficial. “We can get the feet down almost to the freezing point, and this halts the inflammation completely,” says McDuffee.
COLD SALTWATER LEG SPA
Horsemen for many years have used cold water as a treatment for injuries, to reduce heat, inflammation, swelling and pain. Modern technology has taken this a step farther with a technique combining cold water and salt. A cold saltwater leg spa for horses was developed in 1998. The horse is walked into the spa and then it is filled to a level above the knees and hocks with water from the adjacent holding tank–520 gallons of saltwater (containing 150 pounds of Epsom salts and 100 pounds of sea salt) which is continually circulated through a cooling unit that keeps it at 35 degrees F. The super-saturated salty water acts as a poultice to draw heat and infection out of the tissues. The horse stands in the cold water for about 10 minutes after the water level is brought to desired height. After leaving the spa, the legs stay cold awhile, and then there’s a massive rush of blood and circulation back into the cold feet and legs, even into areas there normally isn’t much circulation. This helps facilitate healing. Frequency of treatment will depend on the type of injury, severity, and how recently it occurred. Once or twice a day for several days is usually adequate, but acute laminitis cases can be helped with more frequent treatments.
Brenda McDuffee says any kind of wound can be helped to recover faster with use of a cold saltwater spa. “We’ve treated hoof injuries and foot abscesses, including a horrendous abscess in an old race mare. The top of her coronary band kept abscessing out.” They used maggot therapy to eat away the dead tissue and brought the mare to the cold saltwater spa to help draw out the rest of the infection.
Jeff Gorsak, who operates a rehab facility (High Pointe Equine Center) in Pittstown, New Jersey, has worked with a number of veterinarians and farriers on treating injured and foundered horses, using various therapies including the cold saltwater spa. “We’ve had several interesting founder cases. One was a horse that had surgery on a deep digital tendon, and another was a horse that had almost complete rupture of a hind suspensory,” says Gorsak.
A few years ago he treated a horse that was injured in Florida and had surgery on the deep digital tendon at NC State University. “By the time the horse got up here to New Jersey it was not bearing weight on the surgical leg and foundered on the good foot. This situation didn’t have a good prognosis but the owner didn’t want to put the horse down and wanted to give it every chance,” says Gorsak.
“In a deep digital tendon injury there’s a tendency for the tendon to shorten as it heals. We started a very intensive rehab for the tendon, as well as treating the injury itself in the hydrotherapy. After several days we halted the laminitis and that foot was bearing weight, and the mare was soon bearing weight on the surgical leg. After 3 weeks it was time for her farrier to trim her. He’d worked with her during the 4 months after the injury, before she came here. When he saw her here he was astounded that she could bear all her weight on the surgical foot when he picked up the other one. He put special pads on the feet and corrective shoes. She was here 4.5 months and during that period went from completely unsound to being ridden again,” says Gorsak.
Another case was a reining horse that came to his rehab facility with an 80% rupture of a hind suspensory, injured during a sliding stop on bad footing. “On that case the treatment was a combination of stem cell therapy, shoeing modifications to lift the toe so it had less tendency to stick (on bad footing) and hydrotherapy. That horse was here in therapy for 4 months. Initially the veterinarian gave it zero percent chance of ever competing again, and only a 25 percent chance of being sound enough to use.”
After 4 months, that horse was back under saddle and qualified for the AQHA Youth World Show. The key to that kind of recovery is a team effort between the owner, veterinarian, farrier and the rehab facility–to help ensure the best possible chance for the horse. Some of the horrific injuries that in earlier days automatically brought a horse’s athletic career to an end can now be treated and rehabilitated more fully to enable the horse to go back to competition.
HYPERBARIC OXYGEN CHAMBERS
In any injury where there is damage and compromised blood flow, the use of pure oxygen under pressure can be beneficial. Tissues like bones, tendons and ligaments that have limited blood circulation to begin with are greatly helped during the healing/rehabilitation process. Hyperbaric oxygen therapy can increase oxygen saturation in the body 12 to 15 times normal levels and this puts oxygen into areas that normally don’t have good oxygen supply. This facilitates quicker healing since tissues need oxygen to function and heal.
Brenda McDuffee tells of a case involving a horse that had undergone surgery at University of Florida to remove a keratoma inside the foot. “They took out the growth and we treated the mare in our chamber once a week. At first you could actually see the coffin bone, after they took out the tumor. The oxygen treatment stimulated tremendous hoof growth and healing from the inside out,” she says.
“We also treated a young horse that ran into a fence and had to have 2 surgeries to remove wood splinters from the shoulder joint. When she came to us, the incision was from the top of the shoulder to the top of the leg, laid open to the bone and joint. We were treating her in the hyperbaric chamber for the horrific wound, then she went into renal failure and we were treating her for that. The left front leg was bearing all the weight because the right front was literally hanging from the shoulder,” says McDuffee.
“We finally pulled her through the renal problem and this whole time she was standing with all her weight on the good leg. I think the only reason she never foundered on that leg was because of the oxygen therapy. Usually in a situation like this, the good leg is ruined after about 30 days. You are always racing the clock trying to get enough improvement in the injured leg to where it can bear weight again,” says McDuffee.
The Sanctuary Equine Sports Medicine & Rehabilitation Center | Ocala, Florida | 352-369-HEAL (4325) | www.sanctuaryequinerehab.com/
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