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UNDERSTANDING GROUND IMPACT AND HEEL PAIN 
Scott Morrison DVM 
 
As many of us have witnessed the foot is a common source of lameness.  It has been estimated in multiple retrospective studies that the heel region of the foot alone accounts for more than one third of all chronic lameness in the horse. It shouldn’t be a surprise that the only region of the horse’s body in constant contact with the ground is most susceptible to trauma and injury.   The foot is the part of the body that first receives the forces generated during ground impact.  A healthy foot can dampen the vibrations generated during ground impact by as much as 80-90%. The role this small structure plays in shock absorption to protect the structures above it is amazing.
 
The heel region in particular is designed for this purpose and houses the structures most responsible for absorbing shock such as the frog, digital cushion, collateral cartilages, bars and an extensive vascular system.  All these structures work together to absorb and dissipate shock.  Therefore, for the heel to accommodate this task it needs to have healthy and fully functional structures.
 
At higher speeds, when shock absorption is most needed, the heel should contact the ground first.  Horses with poor heel structures and those which land toe first, don’t utilize the heel to absorb shock and as a result commonly present with lameness issues further up the limb.  Repetitive toe first landing is an inefficient and dangerous landing pattern.  It can be seen in horses that are fatigued or lazy and don’t fully extend the shoulder; it can also be seen in the long toe, low heel syndrome or in cases which have preexisting heel pain and land on the toe in an effort to protect the heel.  It is however, normal for horses to land toe first when landing from a jump.  Besides bypassing the heel’s shock absorption function, toe first landing has been shown to actually put more strain on the deep digital flexor tendon and navicular apparatus.  A normal heel first landing puts a gradual increase in strain on the deep digital flexor tendon, whereas toe first landing puts abrupt high peak strains on the tendon, almost like a snapping action.  Visualize a normal horse galloping, as the limb is fully extended the heel impacts the ground, as the horses body passes over the limb (and the limb is now in the vertical position) the toe region sinks into the ground and the fetlock displaces downward (full extension of fetlock joint).  This pattern slowly increases tension on the tendon; in fact as the limb is fully loaded the toe is sinking into the ground creating a heel wedge effect, which helps take some strain off of the tendon during this position.  In a toe first landing pattern the toe would impact the ground, then as the body passes over the limb the heel rocks backward as the fetlock descends downward.  This “out of phase rotation” of the foot and fetlock has been shown to put high strains on the deep digital flexor tendon and navicular apparatus. 
 
Horses which are used for jumping tend to be predisposed to “navicular region pain”.  MRI studies of horses with navicular region pain often show the damage and pain is to the deep digital flexor tendon.  Treatment of these cases requires shoeing to decrease strain on the tendon, rest and proper physical rehabilitation.  Acute injuries may benefit from intralesional injections such as stem cells, platelet rich plasma and extracellular matrix products. 
 
More importantly, how do we reduce or help minimize the occurrence of such injuries? First, make sure the foot is properly balanced and shod.  Ideally the coffin joint should be in the center of the foot’s weight bearing surface.  Many feet develop low heels and a longer toe.  This puts the foot out of balance, the coffin joint is placed more towards the back of the foot and a lengthy toe lever is created, putting more strain on the deep digital flexor tendon and potentially creating a toe first landing (image at right shows a foot with poor balance).  Some feet naturally have a low heel and longer toe and can’t be changed, but they can be managed and helped with trimming and shoeing.  Rolled toes, rockered toes and fitting the heels with adequate support are ways to compensate these feet and keep the coffin joint joint in the center of the foot’s weight bearing surface. 
 
Besides good farriery and foot balance, the ground condition or footing is also an important factor.  Footing that is too soft or too hard can interfere with the dynamics of limb loading.   Ideally, the footing should be soft enough to allow the toe to sink in. If you look at a hoof print in a grass field, you will notice the imprint is slightly deeper at the toe. Footing that is too soft will put more stress on soft tissue structures and footing that is too firm can cause foot bruising and generally causes more wear and tear on the boney column.
 
It is important to keep the feet on a strict shoeing schedule and not allow the toe to get too long.  Working a horse that is overdue for trimming/shoeing increases the risk of injury.  Finally, keeping the horse fit and well conditioned for his/her job can eliminate fatigue as a source of abnormal foot landing patterns. Understanding the biomechanics of the equine foot, and good management practices play an important role in the prevention of foot lameness.  

ADVANCES IN EQUINE ORTHOPEDIC SURGERY 
Alan J. Ruggles DVM, Dipl.American Collegeof Veterinary Surgeons 


Equine athletic activities can be the some of the most exhilarating events in all of sports. Secretariat’s immortal Triple Crown campaign, the athleticism of jumping, the  precision of dressage and the epic duel of Affirmed and Alydar in the 1978 Belmont (I was fortunate enough to witness this in person as a teenage railbird) come to mind as the best our industry offers. Unfortunately, equine orthopedic injury can occur in of all types of equestrian activities.  Injuries range from minor requiring minimal to no treatment or rest, to those that are career ending and / or life threatening. As an equine orthopedic surgeon I am routinely asked about our ability to deal with orthopedic injury.  Most people are genuinely surprised at the types of injuries that are routinely treated and what can be expected after surgery.  As one looks back in the evolution of equine orthopedic surgery advances in anesthetic techniques, the application of arthroscopic surgery, the use of plates and screws for fracture repair, and the development of specific implants for horses, have been watershed events.  In order to understand this better it is important to reflect on the history of equine orthopedic surgery and realize that like human orthopedic surgery we are constantly advancing.  These advances, coupled with the dissemination of knowledge regarding appropriate splinting of injuries and prompt referral for treatment have led to greater success in treating equine orthopedic patients.

Veterinary Specialization 
In the 1960’s and 70’s techniques in equine anesthetic techniques, fluid therapy, internal medicine and surgery began to advance. The driving force behind these advances was the need for specialty training programs (specialty colleges) aimed at developing specialists in various fields of veterinary medicine. At present 20 specialty colleges are recognized by the American Veterinary Medical Association (AVMA) covering many different disciplines. Specialty colleges include anesthesiology, dermatology, internal medicine, neurology and surgery.  In the United States in order to promote yourself as a specialist you must be certified by examination by one of these colleges.  In the surgical field, 4 years of advanced training in an approved program by board certified specialists, publication of a manuscript in a referred journal, documentation of performance of specific surgical procedures and passing a certification examination are required prior to receiving board certification.   All in all the process of developing specialty colleges with specific requirements has advanced veterinary medicine as a whole. 

 Anesthesia 
In the 1960’s and 70’s techniques in equine anesthetic techniques, fluid therapy, internal medicine and surgery began to advance. The driving force behind these advances was the need for specialty training programs (specialty colleges) aimed at developing specialists in various fields of veterinary medicine. At present 20 specialty colleges are recognized by the American Veterinary Medical Association (AVMA) covering many different disciplines. Specialty colleges include anesthesiology, dermatology, internal medicine, neurology and surgery.  In the United States in order to promote yourself as a specialist you must be certified by examination by one of these colleges.  In the surgical field, 4 years of advanced training in an approved program by board certified specialists, publication of a manuscript in a referred journal, documentation of performance of specific surgical procedures and passing a certification examination are required prior to receiving board certification.   All in all the process of developing specialty colleges with specific requirements has advanced veterinary medicine as a whole. 

Arthroscopic Surgery 
Arthroscopic surgery is routine and now the state of the art for equine joint surgery.  Arthroscopy first came on the scene in human surgery in the early 20thcentury thanks to the innovations of Swiss and Japanese physicians.   It was widely forgotten until the 1970’s when it gained wide acceptance in Western surgical practice, particularly for knee surgery in humans.  The development of arthroscopic surgery in the horse was pioneered by Dr. Wayne McIlwraith at Colorado State University, among others.  During the 1980’s he and a whole generation of equine surgeons developed expertise in arthroscopic techniques with such success that today arthroscopic surgery is commonplace for horses of all activities with high rates of return to function.  While the carpus, fetlock, hock and stifle are the joints most commonly operated on, the pastern, coffin joint and shoulder are also accessible arthroscopically.  Arthroscopic surgery offers tremendous advantages compared to previously performed arthrotomies (open incision into a joint to remove a fragment). The minimally invasive nature of arthroscopy requires smaller incisions, usually requiring one or two sutures to close, thereby greatly reducing the risk of intra-operative infection. Another benefit of arthroscopic surgery is the improved outcome for athletic activity because of better access to damaged areas and virtual absence of scar tissue secondary to surgery.  The use of the arthroscope improves joint examination and reduces surgical times allowing multiple joint procedures to be performed safely in one session.  Arthroscopic surgery is performed to remove bone fragments from trauma or osteochondrosis, as an adjunct to fracture repair, for diagnostic purposes and in the treatment of infected joints.   Depending on the nature of the problem return to athletic function can be up to 90% and with generally significantly reduced lay off times.  Post operative comfort is usually excellent requiring minimal use of analgesics. 

Application of Plates and Screws
The large size, occasional fractious nature of horses as well as the requirement to be standing and the risk of laminitis in the opposite limb due to pain put tremendous pressure on equine orthopedic surgeons to reconstruct fractured bones in horse for immediate and maximum comfort.  In general fractures come in 2 categories. The first consists of stable fractures that require compression on the fracture with bone screws but no or minimal risk of limb instability, these include metacarpal condylar fractures and third carpal slab fractures.  The second category consists of fractures that prevent weight bearing and are often inherently unstable or carry a high risk to become unstable; these include complete metacarpal, radial, olecranon and femoral fractures (images show radial fracture, left, and post-surgery stabilization, right).  The important distinction of these categories of fractures is that the former generally require only bone screws to compress the fractures, while the latter require bone plates to counteract forces that would make the leg unstable, cause discomfort and prevent proper bone healing and alignment.  The plates and screws used to repair fractures today are generally designed for human patients and have been adapted to use in the horses.  In addition there are some specific implants that are manufactured specifically for horse.  Implants come in titanium and stainless steel. Although titanium implants are often used in humans they are weaker and less effective than stainless steel, making stainless steel the best, as well as most cost effective choice for repair of equine fractures. Bone screws are used to compress fracture fragments together or hold plates on bones.  Bone plates are used to counteract forces that would tend to disrupt the fracture, improve comfort and allow bone healing under stable and comfortable conditions.  Recently a new type of plate has started to be used in horse. The Locking Compression Plate or LCP uses screws that lock into the plate as well as into the bone to provide a very stable environment for bone healing.   Casts are sometimes applied after fracture repair in the horse but are not always necessary or appropriate. The use of a cast alone for equine fracture management is not generally indicated because of problems with cast sores, discomfort and secondary laminitis on the weight bearing limb.

Continuing Education
Each year many conferences are held to discuss equine medicine, surgery and welfare.  These venues as well as professional journals are the main source for the dissemination of new knowledge regarding equine fracture management. Each year in Columbus, Ohio the AO-ASIF course is held to instruct veterinarians (chiefly surgical residents) of state of the art methods of fracture repair.  This year is the 37thedition of this course in the United States. This is the longest running course on AO-ASIF (including for physicians) in the United States.  Meetings such as the American College of Veterinary Surgeons and the Annual Meeting of the American Association of Equine Practitioners are also used to disseminate information regarding equine orthopedics.  The willingness of veterinarians to share their knowledge and listen to their colleagues has led to great advancements in equine orthopedic surgery specifically and horse health in general.
 
Equine orthopedic surgical advances are the result of a multidiscipline approach to horse welfare spearheaded by specialty colleges of the AVMA, and supported by state and national equine organizations such as the American Association of Equine Practitioners, The application of research funded by organizations such as the American Quarter Horse Association and the Grayson-Jockey Club Foundation supports the advancement of new knowledge.  The utilization of equipment first developed for surgery in humans such as the arthroscope and plate / screw systems by innovative equine surgeons applies the knowledge gained through research.  The emergence of private companies to develop and supply equipment and implants for use specifically in horses allows equine surgeons the opportunity apply this knowledge and skill for their patients.  Many techniques used today would be not recognized by equine surgeons 30 years ago and advances in equine orthopedic surgery continue in a deliberate fashion to provide the best in welfare for patients and quality and value for clients.  


LET THE GAMES BEGIN!

In the fall of 2007, Rood & Riddle Equine Hospital joined Alltech as sponsor of the 2010 Alltech FEI World Equestrian Games. As the Official Equine Hospital and Veterinary Partner for the Games, Rood & Riddle will work closely with Dr. Kent Allen, the official veterinary coordinator of the Games. Veterinarian Dr. Chris Newton, a partner at Rood & Riddle and avid equestrian and eventing competitor, heads the Rood & Riddle team of veterinarians and veterinary technicians assembled to provide medical support to the Games.
 
When the over 800 equine athletes arrive in Kentucky from all over the world, their handlers will pay close attention to how well they have handled the stress of travel and are settling in to their new surroundings. However, these horsemen and their equine charges will have access to one of the most extensive arrays of advanced veterinary services available at a competition. In addition to the on-site veterinary clinic that will provide 24-hour care ranging from basic medical treatment to high-level diagnostics, the Rood & Riddle Equine Hospital, less than 6 miles away, will be staffed and ready, prepared as always, to address any emergency or injury in need of specialized medical care.
 
During the Games, a minimum of 6 Rood & Riddle veterinarians with numerous veterinary technician assistants will be onsite daily. During the more taxing competitions, such as Eventing Cross-Country, Endurance, and the Driving Marathon, the veterinary staff will increase with additional support from the Rood & Riddle medicine and surgery specialists at the on-site veterinary clinic.
 
In addition to the Rood & Riddle veterinarians, every National Federation will send a minimum of one team veterinarian. The Fédération Équestre Internationale(FEI), the governing body of equestrian sport, will also have veterinarians in attendance. The FEI veterinarians’ primary function is to ensure that all rules are being followed, allowable medications are administered correctly and the horse’s welfare is placed above the competition.
 
After years of planning and anticipation for the big event, Rood & Riddle is ready. The Kentucky Horse Park is ready. Lexington is ready. We are honored to participate in this extraordinary event and eager to see World Champions crowned in 8 disciplines. Let the Games begin!
 
Coming to the Games? Please Stop By and See Us!
 
One of the most exciting aspects of the Alltech FEI World Equestrian Games is the opportunity to educate the world about Rood & Riddle Equine Hospital and the advances in Equine Veterinary Medicine. World Games attendees will find the Rood & Riddle Pavilion, located within the Alltech Experience compound, to be a must-see destination on their tour of the extensive exhibit areas at the Kentucky Horse Park. The pavilion will provide an educational experience for young and old with multiple interactive stations and video displays covering the latest veterinary technology including diagnostic imaging, equine medicine and surgery, and stem cell therapy. Visitors can use touch screen controls to choose which type of horse they would like to see on a treadmill followed by the endoscopic view of the throat, use an ultrasound probe on a phantom uterus to locate a pregnancy, and see an actual surgery table and anesthesia machine set up complete with a 900-lb. model of an equine patient in position and ready for surgery. The pavilion also includes a theater section where daily lectures will be presented by Rood & Riddle veterinarians and other equine professionals including Hall of Fame jockeys and World Games competitors.
 
Rood & Riddle is also hosting tours at the hospital, Monday through Friday, at 10am and 12pm. Tours are by reservation only and booked at www.HorseCapitalTours.com. Tickets are $12.95 per person (ticket required for children aged 5 and up; strollers not permitted) with $5 from every ticket purchase going to the Kentucky Equine Humane Center and the Kentucky Horse Park Foundation.


  
 
LESSONS LEARNED FOR THE PRACTICE AHEAD
Robin Murray 


Dr. Dan Carter has been on a long educational road but has returned home to Georgia to build a practice with the experience and knowledge learned. Dr. Carter, a recent graduate of the Rood & Riddle Equine Hospital internship program, opened Carter Veterinary Services in Newborn, Georgia offering full ambulatory and podiatry services to horse owners in Georgia and South Carolina.
 
A native of Augusta, Georgia, Dr. Carter earned a B.S. in Animal Science from the University of Wyoming. Upon graduation, he pursued his interest in farrier work and completed a one year apprenticeship with Certified Journeyman Farrier, Bill Sanders in Colorado. Since that time, Dr. Carter earned his CJF credentials from the American Farriers Association and has shod some of the top performance and sport horses in the business for more than 10 years.
 
As a practicing farrier, Dr. Carter encountered multiple cases where both the farrier and the veterinarian were involved. On these collaborations he noticed the gap between the farrier and veterinarian’s knowledge. The farriers and veterinarians knew their areas very well but the bridge connecting the two professions was missing. After several frustrating cases, he knew he wanted to understand veterinary medicine and be able to apply both professional disciplines to resolving problems of the foot.  Enrollment in veterinary school at the University of Georgia was the next step on the journey.
 
With his newly earned DVM in hand, Dr. Carter traveled next to Lexington, Kentucky in June of 2009 for a one year rotating internship receiving advanced training in surgery and medicine with primary focus in podiatry. Under the guided mentorship of Dr. Scott Morrison, head of the Rood & Riddle podiatry department, and podiatry associates Drs. Raul Bras, Vern Dryden, and Bob Agne, Dr. Carter expanded his knowledge of the equine foot and learned the latest advances in treating problems of the foot by combining the art and science of farriery and veterinary medicine. “Dan came here with very good farriery and forging skills,” said Dr. Morrison. “His internship exposed him to a large variety of podiatry cases and  different techniques to manage them.  I'm sure in practice Dan will be able to combine his exceptional skills with the techniques he learned here to help many horses and have a successful career.”
 
“The internship gave me confidence and taught me persistence,” said Dr. Carter.  “I learned to never give up on a case, to always look for answers and solutions, and often these answers are in the basics.  Dr. Bras taught me to keep to basics, Dr. Morrison to be persistent, Dr. Woodie to always take a look no matter what it sounds like on the phone, the medicine clinicians to never forget the power of a physical exam, and Dr. Reed to always enjoy what you do.”
 
With their travels behind them, Dr. Carter and his wife Ashley are happily settled in Jasper County, Georgia, looking forward to the work ahead building Carter Veterinary Services. Although he will offer routine primary and preventive care, as well as emergency service, Dr. Carter hopes to focus on podiatry, providing his podiatry services to both horse owners and to other veterinarians seeking consultation. What is not behind him is the relationship forged with his mentors at Rood & Riddle. “I continue to consult with the Rood & Riddle clinicians on a regular basis,” Dr. Carter stated. “There is a wealth of knowledge and experience in one place and it is nice to know that if you step off into unfamiliar territory, they are behind you.”
 
Through its internship and residency programs, Rood & Riddle Equine Hospital is a proven training ground for equine veterinarians. Podiatry is an important aspect of equine care and a growing field in veterinary medicine. The combination of advanced farrier training and a degree in veterinary medicine, make the Rood & Riddle podiatrists and Dr. Carter uniquely qualified to address problems in the equine foot.
 
The Rood & Riddle Equine Hospital Internship program has graduated 209 veterinary interns since instituting the program in 1986. We are very proud of the achievements of these individuals who have gone on to very successful careers in academia and private practice, and earned board certifications in surgery, internal medicine, radiology, theriogenology, anesthesia, and emergency and critical care. 



ROOD & RIDDLE HOSTS USEF YOUTH SPORTSMAN AWARD WINNERS 
Robin Murray

Rood & Riddle hosted two very special guests from the USEF Youth Sportsman’s Award program in June. Hannah Randall, and Taylor Nedurian spent a day at Rood & Riddle, shadowing the veterinarians and staff throughout the hospital, including time spent in side the operating room (shown below, fron left to right Taylor, Dr. Bramlage, Hannah).
 
The USEF Youth Sportsman’s award is designed to encourage youth to be come leaders in the equine industry from all breeds and disciplines. The award recognizes young equestrians who exhibit exceptional leadership potential; demonstrate commitment to the USEF, a USEF Recognized Affiliate and to equestrian sport.This job shadowing experience is part of a special career workshop for the national winners from each of our Recognized Affiliates.  The career workshop provides hands-on opportunities to learn about careers within the equine industry, the opportunity to meet and connect with industry professionals, visit area horse farms and operations and tour equine businesses.
 
Taylor is 17 years old and from Muncy, Pennsylvania.  She is the national winner from the American Driving Society.  With future career considerations leaning towards becoming a veterinarian or college professor focused on Equine Science, spending the day at Rood & Riddle was a natural choice for her career workshop.
 
Hannah, age 18, from Jefferson, Georgia, is the national winner from the Paso Fino Horse Association.  Her future career plans include having her own breeding operation and becoming a nurse.  After her career day Hannah reported that  “I now carry a new perspective on equine hospitals and surgeries which I will carry with me forever. It made me realize how much I love medicine and how much helping horses means to me.”
 
Rood & Riddle is proud to participate in the USEF’s Youth Career Workshop and congratulates these two exceptional young women for their past and future achievements.


AROUND THE PRACTICE 
Rood & Riddle recently welcomed the Intern Class of 2010-2011 to the practice. Seven hospital and 5 ambulatory interns entered their training program in late May and June. Joining the hospital internship program are Brian Beasley DVM, graduate of the University of Illinois School of Veterinary Medicine; Kevin Claunch DVM, Texas A&M University   College of Veterinary Medicine; Ashley Hamilton DVM, University of Florida College of Veterinary Medicine; Ali Hiett DVM, Texas A&M University College of Veterinary Medicine; Jennifer Newman DVM, MS, University of California-Davis School of Veterinary Medicine; Jon Nordberg DVM, Ross University College of Veterinary Medicine; and Kindra Orr DVM, Colorado State University College of Veterinary Medicine. This year’s ambulatory interns are Katie Farrell VMD, University of Pennsylvania School of Veterinary Medicine; Cecilia Jonsson DVM, University of Missouri College of Veterinary Medicine; Jeff Marsh DVM, University of Georgia College of Veterinary Medicine; Kristen Roza DVM, North Carolina State University College of Veterinary Medicine; and Julie Vargas DVM, University of Georgia College of Veterinary Medicine.
           
Rood & Riddle also welcomes Dr. Taralyn McCarrel to the surgical residency program.  Dr. McCarrel is a 2006 graduate of the Ontario Veterinary College. She also completed a one year internship at OVC and spent one year at Cornell University working in equine research. 

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