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Forelimb Lameness in the horse 1 An approach to diagnosis

Article  in  In practice · September 1986

DOI: 10.1136/inpract.8.5.176

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176 IN PRACTICE . SEPTEMBER 1986

Equine Practice
Forelimb lameness in the
horse 1: An approach to
diagnosis *- m

by Sue Dyson
FORELIMB lameness in the horse is a condition commonly use of a chain shank over the nose gives effective restraint.
encountered in practice. An accurate history may often Conformation and foot shape are best assessed with the horse
suggest the cause of lameness and, apart from obvious details standing squarely on a flat surface.
such as age and breed, a number of points deserve particular
attention (see table below).
Stance and attitude
Important points for case history
The way in which the horse stands may be significant. A
Length of ownership horse with laminitis will tend to stand with the hindlimbs
Veterinary examination at purchase further under the body than usual, with the forelimbs slightly
outstretched and the weight rocked back on to the heels.
Type and amount of work A horse with navicular disease may stand either with straw
Previous occurrence of lameness stacked under the heels, artificially raising the heels, or with
one foot slightly in front of the other (pointing) with or
Onset and duration of present lameness, wi.th any without the heels slightly lifted. A horse with radial nerve
preliminary signs paralysis stands with the elbow 'dropped' and in severe cases,
When last shod; uneven wear of shoes the carpus and fetlock are semiflexed with the dorsal wall of
Response to treatment by the owner the foot resting on the ground. This position may also be
adopted by a horse with a fracture of the olecranon or after
trauma to the shoulder region and these conditions must not
Where to start be confused.

As a high proportion of lameness is related to the foot this

is a logical place to start the examination. Nevertheless,
lameness may originate elsewhere and it is important to carry
out a thorough examination of the whole limb, starting at the
top of th, limb and working down, finally concentrating upon
the foot. Although this sounds a lengthy procedure it takes
surprisingly little time and facilitates detection of less
common causes of lameness. The problem may be bilateral
although appearing overtly as a unilateral lameness so
examination and comparison of both forelimbs is often
helpful.
The duration of lameness will, to an extent, determine the
thoroughness of the first examination; if the horse has been
lame for only 24 hours and a careful clinical examination
reveals nothing obvious, a few days box rest with or without
the shoe removed may resolve the lameness. If the lameness
has been present for several weeks than a more detailed
investigation is warranted.

Clinical examination at rest

It is valuable to examine the horse at rest and in some
instances the diagnosis may be reached without seeing the
horse walk or trot. The examination is most easily performed
in a stable or relatively confined space but a proper A properly applied chain shank to provide additional
examination is difficult if the horse does not stand still. The restraint
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IN PRACTICE . SEPTEMBER 1986 177

In the majority of lamenesses the horse's attitude is
unchanged, but a horse in severe pain may be dull and show
patchy sweating. Pus in the foot or infection in a joint often
cause considerably more pain and distress than a fracture.

Muscle atrophy
The presence of muscle wastage can be misleading. Slight
disuse atrophy of the supraspinatus and infraspinatus muscles
does not necessarily reflect shoulder lameness but may be
associated with any chronic forelimb lameness.

Conformation
Abnormal conformation predisposes to lameness. When
viewed from the front, the 'normal' forelimb is straight.
Lateral positioning of the metacarpal region relative to the
forearm and carpus ('bench knee') may predispose to the
development of a 'splint' involving the second metacarpal
bone and also stresses abnormally the lower limb joints as
does either toe-in or toe-out conformation. Likewise a
'broken' pastern-foot axis places unnatural strain on the distal
limb joints and also the suspensory apparatus.

Foot shape
Foot shape, symmetry and balance is assessed both with the
foot weightbearing, when it is viewed from all angles, and
non-weight bearing. The leg is picked up and held at the
fetlock and the foot is allowed to hang down freely. The foot
should be trimmed so that there is a straight pastern foot axis, Assessment of foot balance
to which the heels of the foot are parallel. The medial and
lateral halves of the foot should be symmetrical with the heels
of equal height so that, when the horse is standing, the foot is diagnosis but also when considering treatment. A poorly
is the same sagittal plane as the rest of the limb with the lower fitted shoe can be a direct cause of lameness. If the branches
limb joints parallel to each other. If one heel is higher than of the shoe are too short this effectively decreases the surface
the other this may predispose to bruising, damage to the area over which forces are distributed, increasing the force
sensitive laminae or disease of the lower limb joints. per unit area. This may predispose to bruising at the heels,
Horses which have been lame for some time, either especially if the heel of the shoe is poorly finished, and also
clinically or subclinically, often have asymmetrical front feet. gives no support to the heels which will tend to collapse. If a
The foot of the lame leg is narrower with more upright walls branch of the shoe has shifted towards the frog, or the wall is
than the contralateral foot. This asymmetry may reflect both overgrowing the shoe, this can cause bruising, splitting of the
increased weightbearing by the foot of the sound limb, with hoof wall and damage of the sensitive laminae.
spreading of the foot and decreased weightbearing by the foot
of the lame limb resulting in contraction. Although this
usually reflects a foot lameness, it does not do so invariably.
Although navicular disease has classically been associated
with a narrow, upright, boxy foot, it is frequently seen in the
horse with long toe and low heel conformation, with or
without collapse and contraction of the heels. This conforma-
tion probably predisposes to navicular disease and osteoar-
throsis of the distal interphalangeal joint and abnormally
stresses the suspensory apparatus.
Assessment of foot shape and balance, and the way in
which the foot is shod, is important not only for reaching a
Left. A foot with an excessively long
toe and low collapsed heel. The
branches of the shoe are too short
and provide no support to the heels

Right. Distention of the medial pal-

mar vein
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IN PRACTICE SEPTEMBER 1986 179

Swellings Causes of diffuse swelling in the metacarpal region

Each leg is viewed from all angles in order to identify any
abnormal swellings. The position and extent of the swellings Strain of the superficial digital flexor tendon
are related to normal anatomical structures and the limbs are Strain of the deep digital flexor tendon
compared. There are some abnormal swellings which are not Sprain of the accessory (inferior check) ligament of the
necessarily clinically significant. It is not unusual for the
deep digital flexor tendon
Sprain of the suspensory ligament
medial palmar vein on the proximomedial aspect of the Bruising caused by direct trauma
metacarpal region to be distended in sound horses. This slight Cellulitis
soft tissue swelling is often poorly demarcated and must not Puncture wound
be confused with swelling around the deep digital flexor Foreign body
tendon or its accessory ligament (inferior check ligament). Fractured splint bone
Many normal horses have either distention of the digital Cracked heels
flexor tendon sheaths (tendinous windgalls) and, or, disten- Pus in the foot
tion of the fetlock joint capsules (articular windgalls). Thesea regular sequence for every examination, so that no structure
may be unilateral or bilateral and may fluctuate in size, is overlooked. The purposes are to establish the presence and
depending upon the amounit and type of work the horse is nature of abnormal swellings, to detect areas of heat and to
doing, the ground conditions and the environmental tempera- assess whether pressure applied to a site causes pain.
ture. Although tendinous windgalls rarely cause problems,
enlargement of a fetlock joint capsule may sometimes be Many horses have firm enlargements on the second and
associated with lameness. fourth metacarpal (splint) bones and, unless pressure applied
to the area causes pain, it is unlikely that the swelling is the
The site of swelling does not necessarily reflect accuratelycause of lameness.
the location of the problem. There are multiple causes of
diffuse soft tissue swelling in the metacarpal region, including Interpretation of any reaction to palpation must be
not only local pathology, eg, cellulitis or strain of the deep assessed carefully and this can be difficult in an apprehensive,
digital flexor tendon, but also problems elsewhere, eg, hyper-reactive horse. The reaction is compared with the
oedema associated with pus in the foot. This oedema may contralateral limb and is usually repeatable if it genuinely
extend proximally as far as the carpus. reflects pain.
Initial assessment of the size of the suspensory ligament
and the size and contour of the flexor tendons is best done in
Palpation the weightbearing limb. The width of the suspensory ligament
should be uniform from top to bottom and this can be judged
by running both thumbs simultaneously down the dorsal and
Each leg is felt from top to bottom, both with the limb palmar
weightbearing and non-weightbearing. It is useful to establish sides ofaspects of the ligament on both the medial and lateral
the limb. The palmar aspect of the superficial digital
flexor tendon should have a straight contour. There is often a
slight enlargement in the middle of the palmar aspect of the
superficial digital flexor tendon, where the communicating
branch between the medial and lateral palmar nerves runs
and pressure applied to this nerve may cause pain.
If there is a larger discrete swelling on the palmar aspect of
the superficial flexor tendon, it is important to know whether
the horse has been wearing bandages or boots. Excessive
pressure localised to a small area can cause peritendinous
A RAPID CURING PLASTIC ON A METHYL- swelling and it is critical to try to differentiate this from a true
METHACRYLATE BASIS. QUICK SETTING & tendon strain. Any enlargement of a flexor tendon should be
NON-TOXIC. SUPPLIED IN LIQUID/POWDER viewed with concern, unless it is obviously firm and painless.
FORM. DOES NOT PREVENT RE-GROWTH If a flexor tendon is damaged it is often possible to detect
OF HEALTHY TISSUE. some alteration in its consistency and shape if the leg is held
semiflexed. An acutely injured tendon is softer at the site of
Treatment of bone fractures, large and damage and its margins are less sharply defined than usual.
small animals: Horses doing a lot of fast work, performing on hard ground or
Extra-cutaneous Becker splinting in dIIi jumping, may show increased reactivity to palpation of both
osteosyntheses the suspensory ligament and the flexor tendons of each
transversal fixation by means of forelimb.
Kirschner drill wires
for radius-ulna fractures,
for tibia-fibula fractures, Digital blood vessels
for jaw fractures
hoof bone fractures (Technovit capsule) The size of the digital blood vessels and the intensity of the
Fixation of teeth pulse in the digital arteries are assessed by palpation at the
Strengthening of dressings level of the proximal sesamoid bones, with the limb weight-
SUPPLY UNITS bearing. In normal, shod, sound horses the vessels are
Sets - for 2-3 treatments: Set consists of:- 100gr. powder, palpable with a detectable pulse. A normal unshod horse
80mI. liquid, 2 spatulas, 2 mixing beakers, 2 wooden blocks. which is turned out on hard ground, may have slightly
enlarged blood vessels, with a readily palpable pulse over the
ALSO AVAILABLE:- Separate packs of: 1,000 qr. powder, digital arteries.
500ml liquid and boxes of 5 wooden blocks. The vessels may be enlarged in a 'footy' horse or a horse
a Obtainable from your wholesaler or contact: I
with navicular disease. There are several conditions including
laminitis and infection in the foot, in which these vessels will
VVAin1. S become more prominent and have a strong, bounding pulse.
., , ..g .1 Comparison of the medial and lateral vessels may indicate
whether a focus of infection is medial or lateral.
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18( IN PRACTICE . SEPTEMBER 1986

Causes of enlargement of the digital blood vessels and
changes in the amplitude of the pulse

Pus in the foot

Laminitis
Severe solar bruising
Nail prick/nail bind
Navicular syndrome
Fracture of the distal phalanx

Ringbone and sidebone

Firm enlargements in the pastern region must be inter-
preted with care. Horses may have hard, fibrous swellings
which mimic bone, but which are unassociated with lameness.
Degenerative joint disease of the proximal interphalangeal
joint (ringbone) can only be diagnosed definitively by
radiography.
The ease with which the cartilages of the hoof can be felt
above the coronary band, and their flexibility, are difficult to
correlate with the degree of ossification seen radiographical- Palpation of the intercarpal joint capsule
ly. Ossification of these cartilages (sidebone) is seen in many
normal horses, especially heavier hunter and cob types. The palpated using two hands. Subtle distention may indicate
cartilages may ossify from more than one centre and separate joint disease.
islands of bone must not be confused with a fracture.
Sidebone is rarely a primary cause of lameness, although
asymmetrical ossification of the medial and lateral cartilages Manipulation
of the hoof may be associated with lameness related to
chronic imbalance of the foot. The range of movement and flexibility of each joint and the
reaction to manipulation of the joint are assessed. Many
normal horses resent pulling of the whole leg backwards or
Joint capsule distention abducting the limb. The normal carpus can be flexed so that
the fetlock touches the back of the elbow and resistance is
The size of the fetlock joint capsules is most easily significant. Resentment of slight flexion of the fetlock is
appreciated with the limb weightbearing. Although a soft highly suggestive of a fetlock problem but in some horses with
fluctuant swelling between the palmar aspect of the cannon fetlock pathology the joint may be flexed maximally before
bone and the suspensory ligament (the proximal outpouching causing pain.
of the fetlock joint capsule) may be present in normal horses,
unilateral distention or one which is much larger in one leg
than the other may be significant and reflect underlying joint Hoof testers
disease. The absence of enlargement or distention of the joint
capsule does not preclude the existence of fetlock joint Hoof testers must be used with care. It is easiest to place
disease. the horse's leg between your own legs in order to have both
Distention of the radiocarpal or intercarpal joint capsules is hands free to manipulate the hoof testers. In this way one can
best appreciated by viewing the knee obliquely. Holding the feel if the horse reacts to applied pressure. It may be
leg semiflexed between one's knees, each joint space is necessary to bend your knees in towards the horse so as not to
cause discomfort by applying undue torque on the fetlock and
carpal joints.
The hoof testers are applied gently at first; a horse with pus
in the foot, or laminitis, may show considerable pain to
relatively light pressure, even thumb pressure. The area of
maximum pain is localised carefully remembering that hoof
testers apply pressure at two points. If there is infection in the

Left. Assessment of the width of the

suspensory ligament

Right. Asymmetrical ossification of

the cartilages of the foot associated
with chronic foot imbalance
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IN PRACTICE SEPTEMBER 1986 181

foot, it is sometimes possible to hear pus squeaking beneath

the sole as pressure is applied to it.
The consistency of the sole is assessed. The soft, readily
compressible sole is more prone to bruising than a hard,
unyielding sole, but the absence of reaction to hoof testers
does not preclude the existence of a bruise. Pressure applied
across a single heel may elicit pain caused by a corn, or a wing
fracture of the distal phalanx (pedal bone). In the author's
experience it is unusual to get a pain reaction in a horse with
navicular disease, unless it also has corns. Percussion applied
to the wall of the foot with the limb weightbearing may
identify a site of pain associated with an incorrectly placed
nail, or damage to the laminae.

Excessive swelling
If there is considerable, diffuse, soft tissue swelling in an
area, such that the individual structures cannot be palpated,
and there is no obvious primary cause (eg, pus in the foot,
cracked heels or a puncture wound), it is often useful to hose
the leg with cold water two or three times daily over the next
24 to 48 hours, to bandage the leg and to confine the horse to
a box. The horse is reassessed when some of the swelling has
dispersed.
An anti-inflammatory analgesic drug such as phenylbuta-
zone (2 g twice daily for one to two days) is also helpful. It
may then be possible to identify which structure(s) are
swollen and the extent of the damage. Even at this stage it
may be impossible to make an entirely accurate diagnosis or
prognosis and further examination may be necessary.

Examination at exercise
Examination of the horse moving is best done on a hard, Flexion of the fetlock and interphalangeal joints
level, non-slip surface, preferably roughened concrete or
tarmac. This allows the examiner both to see the way in which unusual unless the lameness is very severe, or the source of
the horse moves and how each foot is placed to the ground, pain is proximal to the carpus.
and also to listen to the rhythm. Sometimes lameness is more The speed of the trot is important because subtle lameness
easily heard than seen. may be difficult to detect if the horse trots too fast. The stride
The horse must be adequately restrained but the handler length, foot placement and limb flight are assessed. A
must interfere minimally with the horse's head movement. bilaterally short, shuffly stride is suggestive of foot pain. If the
The horse may best be restrained in a bridle but the handler lameness is unilateral the stride length is usually not
must take care not to pull excessively on the mouth via the significantly shortened, unless the pain is very severe and the
reins. horse is anticipating weightbearing, or the lameness origin-
The gait is difficult to assess if the horse is not moving ates in the upper forelimb.
forwards freely. It can be helpful to encourage the horse with A horse with navicular disease tends to land toe first. The
a lunge whip and although the horse may at first become degree to which a fetlock sinks during weight bearing may be
hurried, it usually settles quickly. reduced if the joint is painful. If there is carpal joint pain, the
lame limb may be swung outwards to minimise carpal flexion
as the limb is advanced.
At walk The horse should be observed for long enough to appreci-
ate the degree of lameness and to assess whether the lameness
The horse is first observed at the walk, both from beside, is consistent or variable, if it improves or deteriorates with
behind and in front. The slow sequence of foot falls enables exercise. A young horse with osteochondrosis of the shoulder
the examiner to watch carefully the flight of the limb, the may show an extremely variable degree of lameness. Only
height of the arc of the foot, and the placement of the foot to when at its worst is the lameness characteristic of an upper
the ground, be it flat, the inside wall or outside wall first, toe forelimb lameness (shortened stride, lower limb flight.
first or heel first. The horse with laminitis takes short strides, marked head lift and nod). Lameness associated with a splint
tending to place the feet to the ground heels first. Repeated may deteriorate with exercise whereas lameness caused by
landing on one heel first can predispose to bruising or damage navicular disease is usually consistent or may improve.
of the sensitive laminae. The horse is watched as it turns both
to the left and to the right, because this may accentuate
lameness, especially if it is associated with a foot problem. Flexion tests
Flexion tests are used to assess whether lameness can either
At trot be accentuated or produced. When flexing the fetlock and
interphalangeal joints, the author finds it easiest to face
Unless the lameness is severe, the affected limb is best caudally and hold the foot. In this position it is easy to move
identified with the horse trotting. The head nods downwards with the horse if it moves. The joints are flexed with
as the sound limb is weightbearing and may be lifted slightly moderate, but not excessive pressure for approximately 30 to
as the lame limb bears weight but a pronounced head lift is 45 seconds.
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182 IN PRACTICE SEPTEMBER 1986

It is important to compare the reaction of the twQ limbs. Lameness associated with navicular disease is usually
The sounder of the two limbs is tested first because if the lame accentuated on a circle. The horse is lamer on the left
leg is flexed first, the lameness may be accentuated to such an forelimb on the left rein and on the right forelimb on the right
extent that the reaction to flexion of the other leg is masked. rein. If the horse is lamer with the affected limb on the
If there is a significant reaction to flexion, the accentuation of outside of the circle, it is unlikely that the cause is navicular
lameness will be apparent despite the horse walking a couple disease. However, other foot problems, high suspensory
of steps before trotting. Although the horse may need desmitis and shoulder lameness should be included in the
encouragement to trot freely, it should not be rushed. differential diagnosis.
A normal horse may take a few unlevel steps after
prolonged flexion but more than four or five lame steps is Ridden exercise
considered significant. The test is not specific because not
only will pain from the fetlock or interphalangeal joints cause Ridden exercise is occasionally useful but an inexperienced
an accentuation of lameness but many horses with navicular rider may complicate the picture by inadvertently moving his
disease also show exacerbation of lameness. By holding the or her hands in rhvthm with the trot, thus influencing the
leg just distal to the fetlock rather than by the foot, the test movement of the horse's head. Nevertheless, sometimes
becomes more specific as the fetlock joint is flexed indepen- ridden exercise is invaluable for accentuating a lameness
dently of the lower joints. which is otherwise barely detectable.
Although most horses with fetlock joint problems will show The veterinarian must beware of drawing too many
increased lameness after flexion, a negative response does not conclusions about a chronically lame horse which has been
preclude the fetlock joint as the source of pain. Likewise, without shoes for some time. The horse may be slightly foot
carpal flexion may accentuate lameness associated with carpal sore which may influence its way of moving. A horse which is
joint pathology, but a negative response does not exclude the in regular work may show a very different degree of lameness
carpus from further investigation. to a horse which has been rested for some time, and the
reaction to flexion tests is likely to be greater. If the horse has
been rested, and demonstrates only subtle lameness, it is
Circles often best if the horse resumes work with a view to
accentuating the lameness before further investigation is
Lameness which is barely detectable, or is inapparent in carried out.
straight lines, may be obvious when the horse moves in circles
especially, with the affected leg on the inside. It is easiest to
lunge the horse because many horses are reluctant to trot in Further investigation: What to do next
circles if led. Ideally it is useful to compare the horse lunged
both on a soft surface (grass) and a hard surface (roughened At this stage, or earlier in the examination, many potential
concrete). The 'footy' horse or horse with bruising may problems have been excluded, and there may be strong
improve substantially on a soft surface. indications of where the source of pain is. If there is evidence
of pain in the foot, it may be useful to remove the shoe and
explore further. This is inadvisable if it is intended to use local
anaesthesia because with one shoe on and one off, the
LOOKING TO lameness is more difficult to assess and the horse may become
foot sore. If the source of lameness is unknown it is helpful to
THE FUTURE establish whether the problem originates in the foot or
elsewhere and this is readily achieved by performing palmar
Dynamic Imaging's (abaxial sesamoid) nerve blocks. If a fracture is suspected the
area should be examined radiographically.
ultrasound scanners
for veterinary use... Removal of the shoe
Concept is an advanced ultrasound Removal of a shoe without damaging the foot is easily
accomplished by the veterinary surgeon, but it is acknow-
scanner whose veterinary applications ledged that a skilled farrier may be better able to explore the
range from pregnancy detection in ewes to foot than an inexperienced veterinarian. If the horse has been
tendon scanning in horses. Transducers in a recently shod and the clenches are well knocked down, the
shoe may be removed more easily by rasping the clenches
range of frequencies may be selected to suit than by elevating them with a buffer. It if is suspected that
your individual needs and more may be lameness is related to recent shoeing, each nail is removed
added as your needs grow. This gives individually. The horse may show resentment as a nail which
was placed too close to the sensitive laminae is removed.
Concept an unrivalled level of flexibility for a After removal of the shoe the sole is pared and inspected
veterinary scanner. for the presence of haemorrhage along the white line,
For more details contact us today..... separation at the white line (which may reflect higher laminar
damage) and subsolar haemorrhage. The absence of visible
We have the experience and versatility to reddening of the sole does not preclude the presence of
fulfill all your ultrasound requirements. deeper bruising and corns may be missed without paring away
several of the superficial layers of horn at the heels. The hoof
testers are used again to try to identify a focus of pain.
The shoe which has been removed is inspected for signs of
- Dynamic Imaging Ltd abnormal wear. A horse with navicular disease which lands
1 B Young Square, Brucefield Industrial Park, toe first may have excessive wear of this part of the shoe. The
Livingston EH54 9BX levelness of the bearing surface is assessed; an unlevel surface
Telephone (0506) 415282 concentrates pressure at points, rather than distributing it
evenly and this may predispose to low grade bruising.
If lameness has been present for four weeks or more, and
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IN PRACTICE SEPTEMBER 1986 183

has failed to respond to rest, further investigation is indi-
cated, either by the original veterinarian or a specialist. This
investigation includes local anaesthesia and radiography and
in many instances can be performed usefully earlier in the
course of lameness. The earlier the cause of lameness is
established, the more likely it is that appropriate therapy will
be effective.

Local anaesthesia
Even after a thorough clinical examination it is frequently
impossible to define accurately the source of pain without the
use of regional anaesthesia, intra-articular anaesthesia or
local infiltration of anaesthetic. It is a vital part of clinical
diagnosis in the majority of cases of chronic lameness (more
than four weeks duration) and its use may be indicated at the
initial examination. Only when pain has been definitively Dorsopalmar radiographic view of the navicular bone of
localised to an area either by clinical signs and, or, by local a sound horse. There are several radiolucent areas along
anaesthesia can radiographs be interpreted properly. the distal border of the navicular bone
This subject has been considered in detail previously
(Dyson 1984) and will only be discussed briefly. The horse pain has been definitively localised to an area. Many normal
must be lame enough to block, so that improvement can be horses show radiographic changes which are not clinically
assessed, and each block must be tested to ensure that it has significant and which can only be interpreted in the light of
worked before its effect on lameness is judged. It is important the results of a detailed clinical examination. Small
to be sufficiently selective as opposed to being satisfied with osteophytes may be present on the dorsoproximal aspect of
making the horse sound. the proximal phalanx which do not always indicate clinically
Although a horse with navicular disease is rendered sound significant fetlock joint disease.
by desensitising the entire foot by palmar (abaxial sesamoid) There may be many small radiolucent areas along the distal
nerve blocks, many other causes of lameness are also border of the navicular bone, which represent nutrient
improved by these blocks. A horse with navicular disease is foramina and synovial fossae and do not necessarily indicate
usually sound after desensitising only the palmar (caudal) navicular disease. Thus radiographs are used to support or
part of the foot by bilateral palmar digital nerve blocks. It refute the clinical diagnosis. It must be remembered that the
must also be remembered that this block is not specific for absence of significant radiographic abnormalities involving a
navicular disease but can relieve pain associated with other joint does not preclude that joint as the site of pain. There are
conditions such as soft tissue damage. horses in which pain can be localised to the fetlock joint by
Just occasionally the results of local anaesthesia are regional and intra-articular anaesthesia, which show no
misleading, and if the clinical examination suggests strongly radiographic changes.
that, for example, pain originates in the foot, radiography of If the clinical signs are suggestive of a fracture then the
this area is indicated even if the horse was not rendered sound suspected area should be radiographed before local anaesthesia
by apparent desensitisation of the region. If there is extreme is employed. If a horse has laminitis and has been lame for
pain it may be impossible to eliminate lameness by regional some time before examination, or is failing to respond to
anaesthesia (eg, some cases of pus in the foot). treatment, then lateral radiographic views of each foot are
useful to assess whether or not the distal phalanges have
rotated and how much horn can be safely removed by
Radiographic examination: Where and trimming in an attempt to restore a more normal orientation
when to X-ray of the bones.
To be of any value there must be a sufficient number of
In most circumstances, radiographs are only useful once radiographic views of diagnostic quality. Two views of a joint

Essential views for radiographic examination of the distal forelimb

Area View kV mAs Notes
Lateromedial 75 40 Lysholm focused
grid (8:1)
Dorsopalmar (upright pedal)
Foot (1) Distal phalanx 65 2-0 Lucidex focused
grid (4: 1)
(2) Navicular bone (x 2) 75 4-0 Lysholm 8:1 focused
grid. Frog packed
with Play-Doh
Latero medial 65 4.0
Dorso palmar 65 5-0
Pastern/fetlock Dorsopalmar lateromedial 65 32
Dorsopalmar mediolateral 65 3-2
Dorsopalmar 65 5.0
Second and fourth Dorsopalmar lateromedial oblique 60 2-5
metacarpal bones Dorsopalmar mediolateral oblique 60 25
Flexed lateromedial 65 4-0
Carpus Dorsopalmar lateromedial oblique 65 40
Dorsopalmar mediolateral oblique 65 4.0
186 IN PRACTICE SEPTEMBER 1986
are not enough to determine that there is no significant anatomy and its variations and if there is any doubt then the
pathology. The area to be X-rayed is suitably prepared to films should be referred for a second opinion.
avoid the presence of confusing artefacts. Mud is brushed off
and if a foot is to be examined the shoe is removed to avoid
obscuring the margins of the distal phalanx. After trimming Diagnosis
and scrubbing the foot it is useful to pack the frog clefts with a
slightly radio-opaque substance, such as Play-Doh, to elimin- A logical and systematic approach to lameness investiga-
ate confusing frog cleft shadows. tion usually results in an accurate diagnosis or at least in
Coning down the primary beam reduces scatter and this localising pain to an area. If it is not possible to be more
both improves definition and reduces the radiation hazard. specific about the cause of lameness, there is little to be
Although grids can also be useful to improve definition of a gained by allocating the condition a name. With the available
picture, especially in a dense area such as the navicular bone techniques, it is sometimes impossible to be more accurate.
region, it must be remembered that the use of a grid requires Nevertheless, every effort must be made to be as specific as
higher kV and mAs and a longer exposure time increases the possible.
risk of movement blur. For example, pain in the foot is often attributed to pedal
Each cassette is labelled using X-ray sensitive paper on osteitis, which is probably an over-diagnosed condition.
which is written the name of the horse and the date of There is tremendous variation in the normal radiographic
examination. Appropriate lead markers are attached so that appearance of the distal phalanges and many normal horses
each view can be clearly identified. Dark room technique is have irregular borders of the bone, broad vascular canals and
critical and errors may spoil otherwise adequate films. a large crena at the toe. The term pedal osteitis should be
Nevertheless, with attention to these details it should be restricted to those horses with periosteal proliferative reac-
possible to obtain good quality views of the carpus and distal tions on the dorsal surface of the bone, seen in a lateral view,
limb with a small portable machine, but if this is impractical and, or, multiple circular radiolucent areas within the bone,
the horse should be referred elsewhere. seen in the dorsopalmar (upright pedal) view. If pain is
The radiographs are viewed both on a viewing box and over localised to the foot and there is no obvious diagnosis based
a bright light otherwise subtle abnormalities may be missed. on the clinical examination and radiography, the next logical
Active periosteal proliferative reactions and newly developed step is to anaesthetise the distal interphalangeal joint for
osteophytes are not very radio-opaque and tend to be which specialist help may be required.
overexposed, but can be identified over a bright light. It is In many instances, sophisticated diagnostic techniques are
often useful to compare similar views of the normal, unnecessary and lameness diagnosis is well within the scope
contralateral limb. For example, separate centres of ossifica- of the thoughtful, thorough, non-specialist investigator. If
tion of the dorsoproximal aspect of the proximal phalanx may unable to reach a satisfactory conclusion either because of a
be present bilaterally unassociated with lameness and should lack of equipment or experience, specialist advice should be
not be confused with chip fractures. The interpretation of sought because the longer the duration of lameness, the
radiographs requires a good knowledge of radiographic poorer the long term prognosis tends to be.

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 Downloaded from inpractice.bmj.com on March 4, 2013 - Published by group.bmj.com

Forelimb lameness in the horse 1: An

approach to diagnosis
Sue Dyson

In Practice 1986 8: 176-186

doi: 10.1136/inpract.8.5.176

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