Navicular disease in horses, what had change since the 90's

1. Navicular disease
or
Foot pain syndrome

2. What happen???

3. 1990’s
“Degenerative changes in structure,
composition and mechanical function of the
cartilage, subchondral bone and surrounding
soft tissues, i.e. DDFT, impar ligament, collateral
ligaments, navicular bursa and distal
interphalangeal joint”
EQUINE VETERINARY JOURNAL
Review Article: Navicular disease: a review of what’s new
A. B. M. RIJKENHUIZEN

4. •
The navicular bone central role
•
Diagnosis: clinical examination, analgesia (DP, DIP
joint or bursa and Xr)
•
Etiopathogenesis: interaction of biomechanical
stress and circulatory disturbance
•
Treatment:
o
orthopaedic shoeing
o
intra-articular or intrabursal injection
o
peripheral vasodilators (e.g. isoxuprine,
pentoxifylline, warfarin)

5. 1990’s
•
Surgical treatments:
o
Desmotomy of the navicular suspensory ligaments
o
Cutting the navicular suspensory ligaments
o
Perivascular sympathectomy for the digital arteries,
with or without fasciolysis
o
Palmar digital neurectomy

6. Troy Trumble
Nick Ernst

7. Today
•
Ultrasound
•
Nuclear scintigraphy
•
Computed tomography (CT)
•
Magnetic resonance imaging
•
Biomarkers

9. Diagnostic analgesia
•
Palmar digital nerves: No
desensitized dorsal part of the hoof,
DIP joint, bursa and tendon sheath
•
DIP joint or navicular bursa:
desensitizes joint  diffusion, the
associated structures
•
Palmar foot syndrome, a lameness
can remain due to pathology within
the palmar part of the foot.

10. RADIOGRAPHS
•
Only technique to evaluate the hoof.
•
Radiograph: limited assessment of mineralised
tissues, 40% change in bone density is required
before it can be identified
•
Navicular bursography identifying adhesions
between the DDFT and navicular bone

11. Ultrasound

12. •
Frogs were trimmed down to moist and soaked in
water for 12 hours

13. Results
Horses Bursitis Thicken Nav
bursa
Adhesion
DDFT to
navicular
Hypoechoic
to anechoic
areas DDFT
and DDAL
Navicular
lame (28)
Increase vol
fluid
yes 3 horses 5 fore feet
Navicular
No Lame (7)
None No No No

14. Nuclear Scintigraphy

15. Horse
/Path
ology
Increase
IRU nav
bone
IRU
pool
phase
DDFT
IRU
insertio
n DDFT
Focal IRU
insertion of
the medial
CL of the
DIP joint
Focal IRU
insertion of
the lateral CL
of DIP Joint
IRU in
the
medial
palmar
process
of the
distal
phalanx
Focal
IRU med
and lat
palmar
process
es
36.6% 13% 14.3% 9.4% 15% 7.6% 3.4%
•
Positive correlation between scintigraphy and total MRI
grades

17. MRI

18. •
15 horses no definitive diagnosis
(radiography, ultrasonography and nuclear
scintigraphy)
•
Lameness exam Perineural analgesia: palmar
digital and abaxial sesamoid, intra-articular
analgesia : DIP joint / navicular bursa
•

21. •
Lameness: PD or abaxial , analgesia DIP navicular
bursa, proximal interphalangeal and fetlock
•
Radiograph: Navicular views
•
US
•
Nuclear scintigraphy
•
MRI

22. •
Treatment:
1) Corrective trimming and shoeing,
2) Box-rest and controlled walking (1 h daily ) for 6
months for all primary soft tissue injuries.
3) Medication of the navicular bursa, DIP joint or
digital flexor tendon sheath: hyaluronan, with or
without triamcinolone.
4) Shockwave

23. Injury DDFT Desmitis
CL
Primary
injuries
middle
or distal
phalanx
DSIL Navicular
bone
abnormali
ties
primary
abnorm
alities
of the
DIP
3 or
more
structu
res
33% 15% 7% 6% 5% 2.5% 17%

24. Outcome of treatment
•
28% primary DDF tendonitis: Excellent
•
53% had persistent or recurrent lameness.
Prognosis:
o
Markedly worse: combined NB and DDFT 95%
suffering persistent lameness.
o
Abnormalities of the NB 22% resumed full work
fracture.
o
Collateral desmitis: 29% excellent
o
Lesions of the DIP joint: Poor.

25. •
DDFT: lesions 1 or more sites 82.6% of limbs.
•
Most frequently
1) level of CSL and NB: 59.4%
2) level of the DSIL or insertion 35.1%,
3) level PIP joint 29.1%
4) level of the proximal phalanx 6.2%.

26. •
Type of lesions:
o
Level proximal phalanx: core lesions 90.3%
o
PIP joint core lesions 43.1% alone or in
combination.
o
DSIL : 38.2%
o
CSL: 10.5%
o
Medial and lateral CLs of the DIP joint: 28.2% and
12.4%
o
DIP joint and navicular bursa: 42.3% and 49.4%

27. •
Clinical examination, Xr, BS, and MRI ( aspect NB,
spongiosa, dorsal, palmar, proximal and distal
border was graded on a scale of 0–3)
•
(22 horses) 3 clinical categories
-Group 1, navicular pathology pain and lameness
Group 2, navicular pathology association with other
lesions
Group 3, horses with other causes of foot lameness.

29. Increased signal in the spongiosa of the NB MRI
may occur in association with lesions of the
fibrocartilage with or without subchondral bone or
reflecting a variety of alterations of trabecular
bone

30. Synovial fluid biomarkers

31. •
Pathology develops and a change in pattern of
the biomarkers will be detectable.
•
Joint damage: Decrease GAG, lower
GAG/cartilageoligomeric matrix protein ratios,
increased HA and relative increase in the
activity of the matrix and MMP

32. •
COMP: No significant changes between horses with
navicular disease and control horses.
•
DIP: navicular disease less GAG and lower
GAG/COMP ratio
•
HA, HA/COMP ratio, MMP-2/COMP ratio and
MMP-9/COMP ratio higher DIP of horses with
navicular disease.
•
Navicular bursae (navicular disease): lower GAG
GAG/COMP ratio and HA/COMP ratio was increased
and no difference HA. Higher relative activities of
MMP-2 and MMP-9 and the MMP-2/COMP ratio
and the MMP-9/COMP ratio.

33. Conclusion
“It is currently unknown what biomechanical
factors predispose to the lesions of the
podotrochlear apparatus and DDFT. It has been
proposed that reduction in the angle of the distal
phalanx within the hoof capsule may be related to
increased strain on the DDFT and navicular bone
and thus predispose to injury”

34. 1990 2015
US
CT
MRIBS

35. Treatments

36. •
Therapeutic trimming and shoeing to reduce
biomechanical forces on the navicular/heel:
•
Of 30 (73%) horses with clinical signs of navicular
pain improved one grade of lameness within 6
weeks of corrective shoeing.
•
There is no standard shoeing technique for horses
with navicular pain

37. Shoes:
o
Arim shoe or half-round shoe has a rounded edge that
enhances breakover
o
The Natural Balance Shoe has a rockered toe
o
Egg bar shoe: heel support and more surface-to-ground
contact.
•
Raised heels: Heel wedge pad, reduces the tension between
the DDFT and navicular bone
•
Acute ligamentous injuries: 3 to 4 wedge pad decrease
tension of these soft tissue structures and gradually
decreases the quantity of heel elevation over time.

38. •
There were detectable concentrations of
triamcinolone acetonide in navicular bursa synovial
fluid of all groups after injection

39. •
All horses were treated with corticosteroids (40 mg
of methylprednisolone acetate) and hyaluronan (10
mg of sodium hyaluronate)
•
Rest 6 months

41. Force Plate 3000 pulses/ 10Hz 1/2 the pulses
between the heel bulbs, and the other were applied
over the middle third of the frog with the limb
elevated  FP
•
ESWT did not produce immediate analgesia or any
such effect during the week after treatment.

42. •
Corrective shoeing: wedge full pad, egg bar, heart
bar, open wide webbed or natural balance shoes
•
Injection: DIJ or DFTS, NB.
•
4–8 weeks of stall rest, control exercise
•
shock wave therapy: 1500 impulses per treatment
every 2 weeks for 3 treatments.

43. •
Only 22 of 56 (39.3%) horses had a successful
outcome.
•
Unsuccessful outcome (44.1%) had concurrent
DDFT, NB and NBU lesions, poor response
•
Therapeutic protocol for horses with combined
DDFT and NB lesions was not greatly

44. •
Single injection of BTXB: Alleviate
lameness for at least 14 days without
causing systemic adverse effects

45. Inclusion examination  FP Foot trim
 Wide
•
Web aluminum horseshoes (3o wedge)
•
Heel-elevation shoeing and
phenylbutazone
•
The DIPJ was injected 6 mg
triamcinolone

47. 1990 2015
US
CT
MRIBS
SHOE
NSAID
TA+HA
SHOE
NSAID
TA+HA

48. QUESTIONS???