Managing Equine Foot Pain

What can an owner do to control a horse’s foot pain? We turned to two equine veterinarians that spend a lot of time managing horses’ feet to find out.

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Managing Equine Foot Pain
It's crucial to have your veterinarian perform a complete lameness evaluation to pinpoint the problem before trying to treat it. | Photo: Kevin Thompson/The Horse

Current ways veterinarians control pain associated with foot lameness

For a horse to perform at his best, his musculoskeletal system must be strong and pain-free. Hooves are especially important parts of this equation. Feet can be painful for a variety of reasons, from the simplest bruise or an abscess to more critical concerns such as issues with the navicular bone and associated structures, a condition now referred to as podotrochlosis, or laminitis, which is when the tissues supporting the coffin bone within the hoof wall become inflamed and potentially fail.

What can an owner do to manage a horse’s foot pain? We turned to two equine veterinarians that spend a lot of time managing horses’ feet to find out.

Localizing the Problem

Rob Boswell, DVM, is president of Equine Sports Medicine Group, in Wellington, Florida. To track down the source of a potential hoof problem, he recommends having your veterinarian perform a comprehensive lameness evaluation that begins by watching the horse led straight on a level hard surface. Longeing in circles at the trot helps identify the affected limb(s). Then compare the horse’s movement on a soft, packed surface, such as an arena, to movement on a hard surface, such as firm dirt or nonslippery asphalt. Flexion tests, thorough palpation of all limb structures, and hoof testers further yield important diagnostic ­information.

Based on his experience, Boswell says that in the lame limb with no apparent injury, 75% of the time the problem is likely in the hoof. “Swelling within hoof structures isn’t visible due to a tough hoof capsule,” he says.

He adds that it is often difficult to pinpoint the various intricate parts of the hoof; the best way to do this is to use diagnostic nerve blocks systematically, starting at the bottom of the limb and working upward, keeping in mind that it’s possible to have a concurrent leg problem that is causing soreness.

Ted Vlahos, DVM, MS, Dipl. ABVP, Equine Regent ABVP, of Yellowstone Equine Hospital, in Cody, Wyoming, also stresses the importance of an accurate diagnosis: “I cannot emphasize enough the importance of a complete examination that includes stress flexion tests, diagnostic anesthesia (nerve blocks), and a complete radiographic (X ray) study.”

Digital radiographs are important for identifying issues associated with the navicular bone, he says. However, he notes that even high-quality radiographs have their limitations, particularly when imaging soft tissues.

If your veterinarian suspects a soft tissue injury ­affecting such structures as the deep digital flexor tendon (the DDFT, which connects to the coffin bone), the impar ligament (which connects the navicular bone to the coffin bone) or distal interphalangeal collateral ligaments (connecting the pastern and coffin bone), that’s grounds for thorough ­imaging.

MRI is the gold standard for documenting soft tissue pathology (disease or damage) in the foot and is the only way to evaluate these structures, says Kyla Ortved, DVM, PhD, Dipl. ACVS, ACVSMR, assistant professor of large animal surgery at the University of ­Pennsylvania School of Veterinary Medicine, in Kennett Square. Ultrasound can provide limited information about the soft tissues within the hoof capsule by imaging through the frog; however, she says, it is best used to examine lesions above the hoof capsule. Unfortunately, she adds, many lesions in the DDFT and collateral ligaments occur below this region.

Focusing on Farrier Work

Trimming and shoeing are some of the most important components of managing foot pain, says Vlahos.

“I often tell clients that we can do an accurate job in diagnosis and treatment of equine foot pain, but nothing in our arsenal is ultimately going to help the horse unless we first establish proper balance in the foot,” he says. “We often see horses with severe misalignment of hoof-pastern and palmar angles (the angles of the pastern relative to the hoof wall and of the bottom of the coffin bone and the ground, respectively); many of these issues are manmade. I am a believer in the idea that most of the time horses don’t need corrective shoeing but, instead, they just need correct shoeing. A competent farrier is an essential part of the team in managing hoof pain.”

Besides maintaining each foot’s medial-lateral (side-to-side) orientation, the farrier should aim to improve breakover (how the horse’s heel lifts off the ground and rotates over the toe during movement) to help relieve pressure on the coffin joint and supporting ligaments within the foot, while reducing the energy required for the horse to pick up and move his foot forward. Some horses fare better with synthetic shoes, which dampen the impact of hoof concussion on the ground more than steel or aluminum. Some horses do better without shoes at all. Results from one report by Willemen et al. suggest that horses with podotrochlosis experience 14% less force on the navicular apparatus if barefoot than if shod with standard shoes.

However, not every horse can go barefoot without sole bruising.

Boswell cautions against trimming barefoot horses too often. “The ground wears out the sole, and repeated trims remove more than a horse can grow and replace between trims,” he says. “This results in a thin sole,” a common cause of foot pain. 

Optimal sole depth is 18-20 mm, with deep bruising occurring if the sole gets thinner than 15 mm, says Boswell. He has radiographed the feet before and after a trim and found that even an ultracareful farrier might remove 6 mm of sole in a single trim. 

Providing Rest and PT

If a horse hurts, give him a break.

“Rest is not a four-letter word” in the taboo sense, says Vlahos. “For acute soft tissue injuries, it is often appropriate.”

Soft tissue injuries in the feet usually need six to nine months of rest to heal. Successive imaging exams help veterinarians monitor healing. But even if the ligament appears full of collagen, which is a structural protein that’s the main component of connective tissue, that doesn’t necessarily mean it’s mature and able to withstand going back to work, says Boswell.

He attributes more than 50% of success (a horse being able to return to its original level or greater of work) to taking the time to implement appropriate physical therapy. He suggests leading the horse, if sound, at the walk, starting with 15-30 minutes a day. Then increase this to twice a day. Once the horse handles that well and is walking under saddle, introduce trotting for progressively longer periods if the horse accepts this challenge and remains sound. Next, increase duration and demand systematically to slowly work the horse back to its previous level.

There is no one recipe for implementing a physical therapy program in a horse recovering from foot pain; much depends on the injury’s severity, the horse’s cooperation, and the athletic endeavors you hope to pursue. Work with your veterinarian to fine-tune this process.

Controlling the Pain

Of course, some types of foot pain are more severe and acute than others. Cryotherapy (application of extreme cold) is particularly effective for treating and managing acute laminitis, says Boswell. Cooling the tissues slows their oxygen and glucose requirements and reduces inflammation. Boswell says he fills empty 5-liter intravenous (IV) fluid bags with ice, places the feet inside them, and secures them with a wrap. Commercial ice boots are also available. Foot support (therapeutic shoes or boots) is critical for horses with laminitis and might be useful for those with deep bruising, he adds.

Veterinarians commonly prescribe non-steroidal anti-inflammatory drugs (NSAIDs) such as phenylbutazone (Bute), flunixin meglumine (Banamine), and ­firocoxib (Equioxx) to break the pain cycle and control inflammation in throbbing feet. Yet other medications are helpful, particularly when the source of pain is coffin joint inflammation or osteoarthritis. Veterinarians might administer the intramuscular (IM) joint injectable polysulfated glycosaminoglycan (Adequan) for chronic conditions and IV hyaluronic acid (Legend) to manage acute joint inflammation. Vlahos says Adequan has been a mainstay therapy for the past 30 years for coffin joint arthritis.

For stubborn joint ailments some veterinarians turn to IRAP (­interleukin-1 ­receptor-antagonist protein) treatment. In this process, the vet incubates a horse’s blood with specialized beads, centrifuges it, and then injects the IRAP-protein-containing serum into the joint. The remainder can be frozen for subsequent treatments.

Boswell says he’s had success using IRAP and platelet-rich plasma together in coffin joints. PRP releases co-factors (biochemicals that initiate enzyme activity) from platelets, which he feels are reliable for pain control. Veterinarians can use extracorporeal shock wave therapy as an adjunct to PRP to stimulate platelets to release co-factors. He suggests treating the joint before soreness from chronic joint inflammation returns. 

Shock wave therapy might be useful for treating collateral ligament or suspensory ligament (of the navicular bone, which originates in the navicular bone and inserts onto the short pastern) lesions.

Though little published research exists on the efficacy of regenerative therapies for managing foot pain in horses, Boswell has also found through personal experience that a combination of PRP and stem cell therapy helps heal the impar ligament when injected into the navicular bursa—the cushioning fluid-filled structure between the navicular bone and the DDFT.

Other medical treatments for painful hoof ailments include bisphosphonates (Tildren or Osphos) designed to prevent loss of bone mass (resorption). These medications are approved only for use with podotrochlosis in horses over 3 years of age. They’re not approved for use in young horses due to possible effects on bone turnover, as well as potential compromise to kidney function.

Bisphosphonates have anti-­inflammatory and analgesic (pain-­relieving) properties, in addition to their anti-resorptive action on bone. Researchers have demonstrated improvement in a week due to the short-term anti-­inflammatory and pain-relieving effects.


Historically, equine practitioners have cut the palmar digital nerves (at the low point of the pastern) to interrupt the pain cycle from the foot and improve comfort. Some veterinarians no longer recommend this procedure for equine athletes because a neurectomized horse can’t feel the back third of his foot, and they believe it can continue to incur damage. Other veterinarians believe a neurectomy can be beneficial in certain cases and can return horses to athletic pursuits, says Ortved. 

Neurectomy can also make a horse pasture-sound that would otherwise be euthanized. Boswell says it should be a last resort, while other practitioners find it useful in the right population of horses.

Take-Home Message

The best management is prevention. It helps to start with well-balanced and trimmed feet. Radiology is a great tool to let both your veterinarian and farrier know what they are working with and to provide information and accurate measurements for vet-farrier collaboration.

If problems develop, then a thorough diagnostic workup can help the veterinarian identify the location and potentially the problem. Boswell stresses the importance of documenting all exam and diagnostic workup findings. “An effective response to therapy is best achieved with an accurate diagnosis,” he says.


Written by:

Nancy S. Loving, DVM, owns Loving Equine Clinic in Boulder, Colorado, and has a special interest in managing the care of sport horses. Her book, All Horse Systems Go, is a comprehensive veterinary care and conditioning resource in full color that covers all facets of horse care. She has also authored the books Go the Distance as a resource for endurance horse owners, Conformation and Performance, and First Aid for Horse and Rider in addition to many veterinary articles for both horse owner and professional audiences.

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