Does Your Horse Have Long Hind Toes?

Long hind toes in hind hooves seem to be an epidemic with horses today, and coincidentally, so is hind limb arthritis/stiffness/lameness. Long hind toes can also cause back stiffness because the horse literally has to brace their entire hind musculature to keep from falling backwards. 

The fix for long toes is easy; it is really a simple trim, and not rocket science at all. You will want to pay special attention if your horse tends to stand "camped under" behind; that is, with the cannon bones forward under the body. If this is the case, run your fingers firmly down either side of your horse's hindquarter just below the backbone. Often, these horses will flinch and "duck away" from pain in these muscles.

Below is a blog post on a new client of mine, who has been having hind-limb lameness off and on for several months now, including "gluteal pain;" that is, she flinched strongly when these muscles were palpated. An hour after her shoes were pulled and her feet trimmed, Lacey no longer had any pain in her gluteal muscles.

Lacey is a new client of mine. We pulled her shoes on June 28th, 2012. Lacey has been having issues with hind end stiffness/lameness. She also showed pain when her "gluteal" muscles, on either side of her tail, were palpated. Here is Lacey's typical stance with shoes:

This stance is typical of horses with long toes on their hind feet. A 2011 study showed a correlation between gluteal pain and long hind toes. The abstract is available here.

Here is how Lacey immediately stood when the shoes were removed:

Do you see the sigh of relief and relaxation? I believe that Lacey was accustomed to going right into this stretch when her shoes were removed. The change in her stance was literally immediate.

Here is a photo of her left hind hoof. This has been the leg she has been "off" on. The vet diagnosed hock arthritis based on a positive lameness exam after a flexion test of the hock. The photo has been marked to show the broken line made by the front of her hoof and the front of her pastern, and the approximate the position of the coffin bone inside the hoof capsule. Notice the "negative palmar angle;" that is, the bone is tipped back (the bottom is supposed to be "ground parallel" on the hind feet):

Here is Lacey's left hind hoof after the trim. Notice the improved palmar angle. To note how much height was taken off the toe region, notice how much closer the nail holes are to the ground. Lacey's hindquarter muscles had to pull all her weight over this 1/2 inch (minimum) of extra height in her toes, overworking them with every stride. Also notice that the hoof and pastern are now more or less in line with each other:

Now check out Lacey's left to right ("medial" to "lateral") balance on this foot. Can you see how much higher the inside wall is than the outside?

The horse's "live sole" (the waxy stuff under the chalky stuff) grows to the same thickness throughout the hoof, so is a good indication of where the actual inner structures sit in relation to the ground. I therefore balance the wall to the "live sole plane," e.g. the sole plane after the chalky soft stuff is scraped away. Here is what we came up with after trimming:

The balance is still "off" as you can see, but it is much closer. Because Lacey had such an extremely imbalanced hoof and was just coming out of shoes, I was a bit conservative with this first trim. Once she begins wearing her feet the way she wants without a shoe in the way, it will be easier to gauge exactly how much more medial (inside) wall can come off.

Now here are the sole shots. These were marked with a marker. To measure how much toe needs to come off the front, I find the widest part of the sole, then the very back of the frog material, and measure this distance forward on the toe and mark it. I learned this method at a very informative clinic put on by the folks at Daisy Haven Farm and it has proved invaluable when assessing deformed hooves to determine exactly how much toe to take off. The front line marks where Lacey's sole should end. Often on the hind feet, the sole can stretch past this spot and if you don't know better, you would think it is "live" but it is really extra material that should be removed:

And here is her left hind hoof after the trim:

Lacey's right hind had similar issues, and was also longer on the inside. You can see how crooked her right hind leg is when viewed from behind. Her left hoof has been trimmed, and her right has not. Part of the reason that her left hind is so crooked is because of all the height that was taken off. When one hoof has lots more height than the other, the horse stands with that hoof further under the body to compensate for the additional height:

You can see how much straighter and more open she is standing after the trim. Although I unfortunately didn't take before shots from behind before the trim, she was much more "base-narrow" due to her imbalanced hooves:

Here are the before and after shots of Lacey's right hind hoof for comparison. The after shot, the coffin bone didn't change position as much as I drew it to, but you can compare the different angle by noticing the position of the nail holes (it is now probably ground-parallel or close to it):

After her trim, this was Lacey's stance:

Our goal with trimming the hind feet is to get the cannon bones as close to perpendicular as possible, and we have almost done so. This is the only way the hind muscles can get a break. Lacey has been standing "under" with her hind feet for so long, that I have a feeling she will take a few trims to fully change the way she stands, and may always have a tendency to "camp under" from time to time.

The first few steps that Lacey took with her shorter toes were very strange. She placed no weight on her heels and walked on her "tippy toes." Initially I thought she was sore in her heels due to the shoe removal, but this seemed odd since I took almost no height off of her heels and she had decent frogs and heel structures. I now think that her muscles were so tight from battling those long toes that she took a few strides to realize that she could relax. She started walking normally after a few steps.

Another amazing thing about this first trim was that when her gluteal muscles were palpated after the trim (along the sides of her croup), she showed absolutely no pain. I really didn't expect these muscles to improve so quickly.

Finally, what we couldn't catch on camera (because it was dark) was Lacey tearing around the outdoor arena, showing no hoof tenderness, and very little hind-end lameness, 20 minutes after her shoe removal/first trim. Lacey's owner said she couldn't remember the last time Lacey was so animated and "like her old self" running around free in the arena.

Lacey's owner is giving her horse a break to get used to no shoes, after wearing them nonstop for about 10 years. When she begins ring and trail work again, she will purchase boots to help Lacey over the rocky trails near her home.

Rehab Project: Gee I'm Fancy

Meet Gee I'm Fancy, a.k.a. "GG." GG is an 11 year old quarter horse gelding (yes, he is a boy, even though he is called "GG!") In November of last year, I acquired him as a rehab project.

In his former career as a riding horse, GG was trained in various disciplines including dressage, hunter/jumper, and Western. He turns on a dime, knows piaffe and tempi changes, and was also used as a lesson horse. He was shod for many years in regular keg shoes, and was reasonably sound.

However, about 2 years ago GG started showing intermittent lameness in his left front foot. He was then shod in special wedge shoes designed to treat "navicular syndrome," a mysterious "disease" characterized by heel pain that most vets and farriers consider to be irreversible. This seemed to work for awhile, but the lameness returned, and eventually GG was given up as a lost cause.

His owner at the time, a not-for-profit youth and lesson program, pulled GG's shoes and decided to wait for the time when enough money came in to pay to "nerve" GG, meaning to severe the nerves that go to the back of the foot. This expensive, last-resort measure often needs to be redone in several years because the nerves grow back and the pain resumes. This is a photo of GG in his paddock before I adopted him:

In November 2011, I decided to adopt GG in an effort to try an alternative method to help him, that is, a barefoot, booted approach. This method attempts to correct soft-tissue changes in "navicular" feet. Many "navicular" horses have underdeveloped, weak structures in the back of the foot. When a horse is shod for many years without a break, the rigid shoe prevents the back part of the foot from flexing, which is how the cartilage in the back of the foot develops (sort of like using a muscle to make it stronger). When this occurs, the concussive forces of exercise can damage the blood vessels in that area, resulting in further degradation of the tissue and the vicious cycle continues.

Trimmers remove the shoes, provide more frequent trims, and use padded hoof boots to protect the weak foot so that it can flex again and begin to repair itself. Depending on the severity of the soft tissue deformation, the process of growing a new and better hoof, inside and out, can take a year or more. Some horses can go right back into work with hoof boots for riding, but GG has a significantly deformed hoof and so he is currently at a farm in Lincoln University, PA to "rest up." He is booted for turnout in his grassy paddock when the ground is hard, and barefoot when it is soft.

Here is a photo of GG in his big new field with his buddies! He was barefoot that day, and walking really well, since the ground was soft:

Below are before-and-after shots of the changes to GG's hooves. There is still a long way to go, but the results are promising so far! GG is generally pasture sound unless the ground is hard. His soles are very thin so he bruises easily, particularly on the left front, problem hoof. Because GG's walls have severely flared away from the sole, the hoof wall is made passive at every trim so that it can grow down straighter. As a result, he is walking on his soles. Boots (specifically Easyboot Rx's) are an essential way to protect his feet during the transition process.

The first photo is GG's left front hoof in November, 2011, right after he was adopted. He had already received several trims by me. His toe (which was about an inch too long) has been brought back, but otherwise not much flare has been removed. The image has been marked to compare with the "after" shot. On first glance, it doesn't look too bad:

When I saw the second image, taken on March 3, 2012, I was not very impressed with the changes. In fact, the hoof looks worse from this angle. It is clear that GG is having a tough time growing in a well-connected wall, as evidenced by the rings in this foot. He is currently on a low-starch diet and we are working on a supplement program to address this. However, there are subtle improvements to the hoof despite this challenge. The arch in the hairline has apparently relaxed a bit; also, and more importantly, there is heel material starting to fill in. This is shown much more clearly in the other photos, but you can still see it here:

So, clearly this hoof still has a long way to go. You probably noticed the significant arch in the quarters at ground level. The reason I have done this is because GG's main problem, besides his underdeveloped heel area, is that he has "quarter flares," or flares on the sides of his hooves. The "lateral" outside quarter flare was by far the worst. Aggressively working back these flares has been a major goal for his rehab.

A "flare" means that the hoof wall is tearing away from the bone inside, essentially a "mechanical founder." GG's wall is almost completely separated from the bone. Flared walls cannot bear the weight of the horse without ripping away further over time, so it is essential to make them non-weight bearing until the flare grows out, another reason why we use a barefoot approach, since a metal horseshoe puts all the horse's weight on the hoof wall.

No need to mark the following photo, the flare is huge. Also note the way the hairline makes a "ridge" at the top of the hoof wall, particularly on the "lateral" (righthand) side. This indicates that the bone inside the hoof has "sunk" down too low in the hoof capsule, a very serious problem (it's no wonder this foot hurts him!)

Now we can see why these photos are exciting to me! Below is the March 2012 photo. The flare is gone, the hairline is no longer showing that ridge, and the walls are considerably more balanced:

Excited with those photos, let's move onto the one that I am most excited about! As mentioned previously, we view "navicular syndrome" as having a lot to do with the fact that the soft tissue structures at the back of the foot are underdeveloped and weak. Our entire goal with a navicular horse, therefore, is to grow heel from the "inside out" that is, to build mass in the heel: not just a longer wall, but a more robust structure in its entirety. Of course, we also want external growth, but the main area I am looking to build with GG is frog material. GG came to me with paper-thin frogs, about 1/4 inch of skin covering blood (I know because once with my knife, doing what I thought was "routine frog cleanup," I saw pink meaning that I nearly drew blood, to my absolute horror. Luckily, I stopped in time and vowed never to take a knife to his frogs again!)

GG's before photo from November shows just what we are talking about: the area in the middle of the heel looks practically like goop propped up by his walls, and his frog is not touching the ground even though it is apparent that his heel walls are themselves too low. Also, note the severe imbalance that we saw from the front. GG really doesn't want to put any weight on the outer wall, where that significant flare is:

Now note the happy after-shot! Again, GG still has a ways to go with this hoof, but note how the whole heel area just looks thicker and more robust. Also note the wonderful new frog growth, reaching for the ground (when before it looked like it was hiding from it). Finally, notice how the hoof capsule is much more centered around the structures inside:

Finally, let's take a look at GG's soles. GG has very thin soles and tends to move "toe-first." Horses are supposed to walk like people do, with their heel hitting the ground first. The heel of the hoof is where all the shock-dissipating structures are.

Now you see GG's problem; since these structures are underdeveloped, landing "heel-first" would cause him to damage them. To protect himself, he lands "toe-first." The problem with this strategy is that the heel structures are developed through use. So, there is sort of a chicken-and-egg issue. Also, landing "toe-first" puts significant stress on structures that weren't designed to dissipate the shock, namely, tendons, ligaments, and bone. We believe that the classic "navicular changes" on the navicular bone, are the result of this vicious cycle, not the cause of it. When the horse lands "toe-first," the tendon along the back of the leg is tight on impact, causing greater friction on the navicular bone. Landing heel-first, the tendon is relaxed and there is less friction.

We break this cycle with the judicious use of padded hoof boots to help cushion the sensitive heel structures so the horse will hopefully feel comfortable enough to use his heels more. We also are very conservative with trimming down the heels.

Ok, so here are GG's soles. The November photo has been marked to show the approximate place where the bone is inside the hoof, since it is a little difficult to see. You can then observe how deformed the lateral (righthand) side of the hoof is, how stretched away from the bone:

In the March photo, you can clearly see the ridge under which the coffin bone sits like a miniature "hoof" and that the rest of the hoof is more centered around it. A note about this ridge: GG has thin soles, and at first glance you might think that the bone is about to break through the sole! However, this ridge is rock-hard and there is no bruising present, indicating that is this not the bone pressing down but a protective callus. Since his toe wall is still flared forward, it doesn't provide the height necessary to protect the bone, so GG's sole is growing this ridge to protect the tip of the coffin bone from the constant abuse of landing on his toes. Because of this, it would be a cardinal sin to take a knife or rasp to this "toe callus on steroids." I let GG break over this callus and am very careful to make sure his hooves are protected on any hard or rocky ground.

This is Fun!

Hi folks out there in internet land.

I've posted some pictures of one of my client horses. His name is Dakota. Dakota had 4 shoes pulled on March 27th, 2011. No photos were taken that day, and he was given a really minimal trim since he had just had a big change to his feet! When I came back out 6 weeks later, I took some photos of his hooves and the trim. Two trims later, on July 31st, I took another set of photos. Here are the comparisons of his left front foot on 5/8/11 and 7/31/11 (just under 3 months).

The first two lateral views, both post-trim, show how is foot has migrated back under his leg, and his toe and heel are shorter, all without removing any live sole. Also, you can get a sense for the new, post-shoe hoof growing in by noticing the very top of the rasp marks from the previous farrier (barely visible near the bottom of the hoof on 7/31/11). About 1 1/2 inches above the rasp marks is a growth ring marking about when we removed the shoes (about 1/2 way up the hoof wall). Notice how the new hoof is growing in at a taller angle than the previous hoof:

The next comparison shows how his heels have opened up and shortened, and his frog has become wider. I think his whole frog/heel region looks less "stressed" and stretched down between the contracted heels:

The sole views again show the decontracted, wider frog. Also notice in the after photos how the toe is less stretched forward, the "white line" (here filled with dirt) is more uniform in thickness, and the hoof is nice and round. The white chalkiness of the sole on the 7/31 photo is exfoliating sole, loose and soft, that I removed some of to balance his heels:

These are front views of the same hoof. The first one is pre-trim in May. Notice the poor quality of the hoof wall, that appears dry and dead. Now look at the new, strong, living hoof wall in the 7/31 photo. Next time I go trim Dakota, I will probably pay attention to the fact that the lateral (outside) wall on this hoof looks a little longer than the medial (inside) wall. This may just be his conformation, but I generally like to have the medial and lateral walls around the same length in a balanced hoof. If the live sole, however, doesn't allow for this I will always defer to that, because it grows directly from the bottom of the coffin bone:

The last two photos, while not great quality, are kind of my favorites. They really show how his heels have opened up and decontracted considerably in less than 3 months. Notice how the wall at the heels bends in in the 5/8 photo, and the frog is sending out "shoots" to reach for the ground. Imagine how it must feel to have all the internal structures of your heel smoosh between these pinched walls every time you load your hoof, with little ground support to stop the descent of the fetlock. The digital cushion can't serve it's function "cushioning" the bones of the hoof (including the navicular bone) without the positive pressure of the ground at peak impact.

Now look at the second photo, and how much more cone-like this hoof is shaped. The walls angle slightly out instead of in, so as the fetlock descends there is room for the digital cushion to expand and aid in support and circulation. Also note how the frog is just a millimeter or so above the ground, perfect for our soft Delaware Valley environment. Once Dakota moves out into grass, sand or dirt, he will have just the frog support he needs:

Dakota was sound from day one in the sand arena and grassy fields during this transition, and was ridden and jumped regularly, with the exception of an unrelated ligament injury in July. His owner refrained from riding on rocky trails since he was a little sensitive on them. Another option of course is booting for trail riding. I think this regular work was just as important as the trim in facilitating the transformation of his hooves. Horses were designed to move!

Smiley Trim 6-18-11

Here are some before and after photos of Smiley, a mini I trim in Sewell, NJ. As you can see he has some issues! He is very base-narrow behind, with a big barrel, so he weights his lateral walls and has wall separation there. This has been invaded by white line disease, an infection of the inner hoof wall.

For several trims I was doing wall resections to try to heal the white line disease; however the lack of wall support on the outside of his leg has pushed his hooves in and created quite a flare on the medial side of both hooves, particularly the right hind. In this trim you can see how much flare was removed. It will be interesting to see if his hooves straighten out now that the medial flares have been reduced; post trim the medial walls were floating off the ground as you can see.

We have put Smiley on a shorter trim cycle to try and get his hooves back under him, and are also consulting with other hoof care professionals as to ways to minimize this problem in the future, while still treating the white line disease/separation. In the meantime, Smiley remains sound on both his weird hind hooves!

The above photo shows how the distortion effects the two hind hooves, and also how base-narrow his is.

The next two views show his base-narrow stance, pre- and post- trim. The following photos are before and after shots of his right hind hoof, the most distorted one.

Looking at the above photo and the fact that his medial wall was floating at the end, I am thinking of taking off more lateral (left) heel next time... to even out the weightbearing on the hoof. It would be helpful to have radiographs!

Long Toes in Hind Feet Cause Gluteal Pain

I've been thinking a lot about long toes lately, and especially about how long toes on hind feet can lead to hind end issues. There's an article out now that really sheds light on this issue! Read the article here.