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Discussion on New Article: Keratoma of the hoof
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Moderator:
DrO
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Posted on Friday, May 26, 2006 - 12:04 pm:
Keratoma of the hoof is a uncommon cause of persistent lameness in the horse. They should be suspected whenever a horse is suffering from a acute lameness of the foot and no other cause can be found, particularly (but not only) if there is a history of past trauma. Often the onset of the lameness is insidious and intermittent however with time can get quite severe. This article discusses diagnosis, treatment, and prognosis of keratoma of the equine hoof. To access this article use the link at the top of this frame: "Hoof Keratoma".
DrO
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New Member:
ebmiquel
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Posted on Sunday, Jun 1, 2008 - 3:24 pm:
Dr. Oglesby,
I am a small animal veterinarian in Vermont that has been dealing with an intermittent waxing and waning lameness in my own 19 year old (newly acquired) paint horse. She was left unridden and unshod for 7 years until I began to ride her in the Spring of '07 and had her shod in front at about the same time.
She began last fall to be slightly off in her left front foot. Prepurchase rads of the front and hocks were all negative for degenerative changes and navicular.Digital radiographs of the left front also negative, although I am thinking of having a boarded radiologist take a look at them. She is supposedly negative on hoof testers and will block out on the medical side of the left front with DP block (I have seen this). Although I was not present, she supposedly went sound with a coffin joint block at another time. We injected the coffin joint (no effect), injected the navicular bursa (no effect)and the hocks (improved hind end stiffness). The lameness will wax and wane, increased with gel (or fiber)and pads and she has only really been sound completely once for 3-4 weeks in the last nine months when the farrier (he has her in a 3 degree wedge pad and an egg bar shoe in a attempt to reduce heel pressure)actually cut out the pad under part of the medial side of the foot so that her foot has a gap between it and the shoe (floating?). As the foot grows down (I am assuming) she becomes increasingly lame to the point she is head bobbing at the walk).I have digital films if they are of use to you. I was reading up on keratomas-possible stone trauma one year ago...any advice would be helpful I am desperate! Early on in the course of the lameness she was sound at walk trot and only went off after having been cantered. Also she seemed (early on) to be worse going to the RIGHT. Now that is no longer the case.Aggressive shoeing seems to make her worse.
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Moderator:
DrO
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Posted on Monday, Jun 2, 2008 - 6:48 am:
Hello and Welcome EB,
Let me see if I can summarize: You have a chronic progressive though inconsistent LF lameness that blocks 100% on a medial PDN block and also coffin jt block. As the foot gets longer the lameness worsens. On physical exam and radiographically there are no abnormalities. The lameness is unresponsive to coffin jt and navicular bursa injections of steroids(?).
You present a very common picture of disease of one of more of the soft tissue supporting structures of the foot. These structures all work harder as the foot grows longer and best explains this part of the history. I would be suspicious of the medial collateral ligaments of the coffin jt but any of the medial aspects of the supporting structure of the navicular bone, ddf tendon, and/or impar ligament are suspect.
However there is nothing diagnostic here and the diagnosis of a keratoma is covered in the article on keratomas associated with this discussion. I am interested in what radiographic views of the foot have been taken and what is the overall conformation of the foot and horse. But the next best diagnostic step would be to have an MRI of this foot done. Ultrasound might be helpful but often difficult to interpret accurately.
DrO
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New Member:
ebmiquel
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Posted on Monday, Jun 2, 2008 - 8:42 pm:
Dr. O,
Would you expect to have pain just above the coronary band, medially with the medial collateral ligament of the coffin joint? She has no pain, either pressing on this area or the foot (just above the hoof) or not really with hoof testers (possibly mild heel bulb pain).
I have a vet in the area that is a former racetrack vet at Belmont and supposedly very experienced with ultrasound of the distal limb. Even without being able to elicit pain, would you recommend US of the ligaments?
I am considering a semi-long term PD block (one that would last 3-6 months) because we have no radiographic abnormalities no heat, no swelling. Would this preclude me from continuing with diagnostics (ie: bone scan/MRI/CT) until the block wears off?
Last question, she is in a three degree wedge pad and is extremely upright in her stance with short toes. I am tempted to take everything off and see how she does. Any additional thoughts? Here an 8 week old video of her lameness, she is about the same now.
https://www.youtube.com/watch?v=G5uUfP8kY-s&NR=1#
Thanks ELizabeth
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Moderator:
DrO
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Posted on Tuesday, Jun 3, 2008 - 8:27 am:
Remember the joint is deep to the lateral cartilages and at the point of collateral ligament attachment almost covered by the hoof wall. Together this makes direct pressure on the ligaments impossible. Reaction on deep palpation is not a consistent finding with chronic collateral ligament desmitis and imaging for signs of problems the only way to consistently rule this in or out. Concerning the block, no it will not preclude further imaging techniques. It will preclude using a specific block of the abnormal structure to determine its significance.
In such cases I like to go with a balanced foot with a rockered and rolled toe.
DrO
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New Member:
ebmiquel
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Posted on Thursday, Jun 5, 2008 - 9:51 pm:
Dr. O,
I recently received the following e-mail from my farrier regarding the last shoeing of my lame mare, and I was wondering if what he is talking about makes more sense to you. The first is my reply, his e-mail to me regarding the last shoeing follows:
Hey J,
Thanks for checking in. What exactly do you mean by "when the heel gets jammed upward"? I can't visualize what you mean by that. I have had some advice that it could be the medial collateral ligament. My understanding of the anatomy is not good enough (it's getting better) to understand whether your description of the area of pain might be consistent with the MCL. Any thoughts? I'd love to hear them . It is very strange that she WAS SO SOUND for that approximately 4 weeks period-I had never seen her move better. Randy and I are intending to do a long term block on the medial side tomorrow so she can be ridden in a show. If we only do the medial side, are you concerned that we would be doing any harm to her? I would love to hear your thoughts.
Elizabeth
Hows everything.
As for your question about her white line, Keratoma or any thing i can see.... like you said i would have been discussing that and for the most part know how to deal with it... I see nothing in the foot at all and i can go you one better and tell you that its not really in the hoof capsule itself. I can apply all the pressure i want to the heel and the medial wall and she doesn't blink at all but when that heel gets jammed upward thats when she expresses pain. medial cartilage? if you do want to try barefoot i think that it would be a long time of not looking at her and waiting... a couple months were you kick her in a field and wait...I didn't love the way she trotted out to the field, and as i DrOve away it weighed on me a bit and i made it to joes snack bar before turning around re-catching her and floating that heel a bit more...i don't think it helped a ton but it made me feel better...
J
Thanks again Dr. O for your advice.
Elizabeth
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Moderator:
DrO
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Posted on Friday, Jun 6, 2008 - 8:26 am:
I read that he sees nothing wrong except when the horse trots out in the field and "when that heel gets jammed upwards". I am not sure what this means.
DrO
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New Member:
ebmiquel
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Posted on Saturday, Jun 21, 2008 - 5:42 pm:
Dr. O,
I wanted you to know that we just ultrasounded her ligaments last week and indeed we found "mixed echogenicity" on the collateral ligaments, especially the medial. She had been shod for several months with a three degree wedge and egg bar shoes which I think have actually accentuated the problem. I changed farriers and had a square toed aluminium shoe (no wedge) with pads put on her that has a very wide heel. She seems more comfortable already, we are resting her as the situation is complicated by a bad case of thrush (yes, I'm a vet and yes I feel ashamed for not realizing the severity of it )in her off foot that is complicating things. I was using Thrush Buster but clearly this is irritating sensitive tissue; after reading your article on thrush have changed to using chlorhexi scrub twice a day and malaseb wipes in the cleft of the frog. Thank you for your very sound and accurate advice, I could have used it months ago, but didn't know you were on the web! I'll keep you posted on her progress. Thanks Elizabeth
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