LAMENESS

How to Apply the Appropriate Farriery Principles

to the Horse with Low Heels in the Hind Feet

Stephen E. O’Grady, DVM, MRCVS*;

Tracy A. Turner, DVM, DACVS, DACVSMR; and Jeffery T. Ridley, CJF, TE

Authors’ addresses: Virginia Therapeutic Farriery, 833 Zion Hill Rd., Keswick, VA, 22947
(O’Grady); Turner Sports Medicine and Surgery, 10777 110th St., Stillwater, MN 55082 (Turner), Ridley
Horseshoeing, 1984 Fisher Avenue, Leighton, IA 50143 (Ridley); e-mail: sogrady@[Link]. *Corre-
sponding and presenting author. © 2018 AAEP.

1. Introduction hind foot conformation can also have an adverse

Farriery for the hind limbs of the horse has not been effect on the musculoskeletal system of the hind
studied to the extent of fore limbs farriery, and there limb.2,4 – 8 The low heels in the hind feet often lead
is minimal information published in the clinical or to a subtle bilateral lameness or poor performance,
research literature. The low heel “bull nose” con- which is often attributed to the proximal suspensory
formation of the hind foot has become so prevalent ligament, hock, stifle, or back pain.6,8 However,
in performance horses that it is often considered horses presenting with subtle bilateral hind limb
normal (Fig. 1). The correlation between low or lameness or poor performance with this abnormal
underrun heels and soundness has been well docu- foot conformation are not approached in the same
mented in the forefeet, giving little reason to believe manner as the horse with similar forefeet conforma-
the same syndrome does not occur in the hind feet tion, where reliance is placed on evaluating hoof
when the structural integrity of the hoof capsule is conformation, hoof testers, perineural anesthesia,
compromised.1–3 Horses with structural damage to and radiographs to localize the region of discomfort.
the plantar section of the hoof capsule will suffer the Due to the temperament of many horses, diagnos-
same consequences associated with the hoof cap- tic nerve blocks and radiographs of the hind foot/
sule as the forefeet; however, the hind feet are not digit are often challenging for the clinician to
generally affected with diseases that affect the perform and are, therefore, often avoided. Treat-
internal structures of the foot as noted in the ment in these cases is often based on assumptions,
forefeet. This difference may be due to the anat- manipulations/flexions of the hind limb, and previ-
omy of the hind limbs and the propulsionary func- ous experience of the clinician or trainer rather than
tion of the hind feet vs. the weight-bearing a definitive diagnosis. With or without a definitive
function in the forefeet. Not only can this low diagnosis, appropriate farriery to correct this low
heel “bull nose conformation of the hind feet be a heel hind foot conformation should always be part of
source of hind limb lameness, but this abnormal the treatment, especially when a lameness such as

NOTES

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 LAMENESS
The stance phase of the stride starts with foot
impact. Initially, the vertical impact stops but
horizontal movement continues, which means the
hoof slides forward before full weight bearing
takes place. At full weight bearing, the retractor
muscles continue to be engaged and drive the
horse’s body forward with the foot fixed to the
ground. An important part of the forward pro-
pulsion provided by the hind limb is the opening or
extension of the hock joints during the second half
of the stance phase.
At landing, the forefeet have the greatest vertical
Fig. 1. A moderate to severe low heel “bull nose” conformation of force and also experience peak DIP joint flexion,
a hind foot. while the hind feet have a greater vertical force
during the stance phase, with peak DIP joint flexion
following horizontal movement; this would imply
the forelimb is a pendulum that is swinging and
proximal suspensory ligament desmitis or distal tar- absorbing force, while the hind limb is grabbing and
sitis has been diagnosed. generating force.10
Accepted farriery for low heels in the hind feet has
been to provide heel elevation regardless of the foot 3. A Good Hind Foot
conformation or integrity of the hoof capsule. Long The authors are reluctant to use the term “normal”
egg bar shoes with wedge pads are generally used to describe hind foot conformation. The terms
for this purpose. This is also the farriery that is good, ideal, or functional may be more appropriate,
generally prescribed for lameness localized to the as foot conformation with its inherent shape is as-
hock or stifle, yet there is no documentation that sociated with many variables such as genetics,
confirms that heel elevation exerts any significant breed, limb conformation, and farriery. The hind
influence on any section of the hind limb above the foot has a steep hoof angle, the shape is narrow or
distal interphalangeal (DIP) joint.9 Furthermore, conical, the toe is pointed, and the sole has a much
heel elevation will tend to exaggerate a heel first deeper concavity when compared with those of the
landing and thus increase the pressure exerted on front foot. In the well-conformed hind foot, the lat-
the hind feet that have existing low or underrun eral wall will have some degree of flare while the
heels, which appears to compromise the structures medial wall will be straight, the amount of which
of the hoof capsule further and lead to additional will be conformationally dependent. The shape of
lameness problems. the hind feet is an indication of being designed for
primary propulsion/traction and secondary weight
2. Hind Limb Movement bearing. The front foot is generally as wide as it is
Before discussing farriery for the hind foot, a brief long, whereas the hind foot is longer than it is wide.
description of hind limb movement is essential to Looking from the side, a good hind foot will have a
understand the propulsionary function of the hind straight hoof pastern axis, even growth rings distal
limbs.10 Protraction, the foot lifting from the ground, to the coronet from the toe to the heel, and approx-
begins with the flexion of the hip, stifle, and hock; imate proportions on either side of the widest part of
this action overcomes the inertia of the hind limb so the foot (Fig. 2A). Looking at the solar surface of
minimal muscular work is done. The hip joint is the foot, a line drawn across the widest part of the
flexed by the iliopsoas muscle, the stifle is flexed by foot should divide the foot into approximate propor-
the biceps femoris muscle, and the hock flexes as a tions on either side of the line. Considering the
result of the reciprocal apparatus. The fetlock also shape of the foot, it appears that the widest part of
automatically flexes because of the tendinous nature the foot is located further plantar in the hind foot
of the superficial digital flexor tendon that travels when compared with that of the front foot (Fig. 2B).
from the hock to the pastern. As the widest part of the foot is generally located
Retraction is accomplished by the middle gluteal 5–10-mm dorsal to center of rotation (COR), this
muscle, which is attached to the femur above the difference between the fore and hind feet could be
center of rotation (the hip joint).10 As the middle verified using lateral radiographs.a The first au-
gluteal muscle contracts, it rotates the whole limb thor did a small extempore study on a limited num-
backward. The hamstring muscle group (semiten- ber of hind foot lateral radiographs supplied by two
dinosus, semimembranosus, and bicep femoris) runs large equine referral centersb,c that were considered
behind the center of rotation, so they form the sec- to be representative of acceptable conformation for a
ond part of retraction. This movement is accompa- hind foot. The radiographs were measured and the
nied by contraction of the quadriceps muscles, which proportions on either side of the COR were com-
extends the stifle and, consequently, the hock and pared with forefoot lateral radiographs. The pro-
fetlock. portions generally found on a front foot with good
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Fig. 2. A, Lateral view of a hind foot with good conformation. Black line is the hoof pastern axis, red line is the middle of the foot,
yellow line is the proportions of foot on either side of the middle of the foot, and green line is the appropriate length of a hind shoe.
B, Solar view of a hind foot. Red lines are the widest part of foot and the proportions of ground surface on either side, and the yellow
line is the base of the frog. Note the widest part of the foot is located further plantarly compared to the forefoot.

conformation are 53–57% dorsal to the COR and ful method to evaluate stance is to view a trajectory
43– 47% palmar to the COR.c,11 In all radiographs, by using a line starting at the ground through the
the COR was found to be further plantar in the hind angle formed by the coronet of the hind foot. With
foot, which significantly decreased the ground sur- low heels, this trajectory line will project to the
face of the foot plantar to the COR. Furthermore, elbow of the forelimb rather than to the palmar
in all radiographs, the digital alignment was not com- surface of the radius just above the carpus with good
pletely straight, as the middle phalanx was mildly hind foot conformation (Fig. 4).12 In motion, the
displaced in a distal plantar direction relative to the horse may show a short, stilted gait with a markedly
distal phalanx (Fig. 3). shortened cranial phase of the stride; there may be
frequent stumbling noted and the signs of discom-
4. Clinical Examination
fort may increase when the horse is trotted in a
Observations circle. On hoof tester examination, the horse may
Performance problems or soundness issues that show discomfort at the inner part of the sole just
have been associated with this hind foot conforma- dorsal to the apex of the frog and at the angle of the
tion are a subtle bilateral lameness, poor perfor- sole at the heels. The sole/heels may also deform in
mance, a stiff hind limb gait, lack of impulsion, these areas when pressure is applied depending on
change in attitude, or bad behavior. If the “bull the amount of structural damage. If the abnormal
nosed”/underrun heels hind foot conformation is hoof conformation is suspected as a source of any of
moderate to severe, the horse may assume a stance the above problems, the authors suggest, if possible,
where the foot is placed further forward than normal to do a posterior digital nerve block and then with
in relation to the vertical axis of the limb and the the rider/trainer mounted, rule out a hind foot lame-
main mass of the hindquarters, thus giving the ness. An experienced rider will immediately be
horse a “sickle hocked” appearance. In one recent able to tell if there is a difference in the movement of
report, it was stated that this type of stance could be the horse and its attitude. It should be noted that
consistently related to gluteal pain.4 Another help- many horses with low heels in the hind feet do not

Fig. 3. A, Acceptable conformation for a forefoot (Courtesy Dr. Andrew Parks). B, Acceptable conformation for a hind foot (Courtesy
Dr. Kurt Selberg). Yellow line is COR, green line is widest part of the foot, brown line is distance from COR to dorsal hoof wall, and
red line is ground surface on the solar surface of the foot.

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 LAMENESS
in the growth rings below the coronet from the toe to
the heel, with the growth rings wide apart at the toe
and then tightly packed at the heel. The dorsal
hoof wall will assume a “bull nose” appearance (Fig.
5A). Looking at the foot from behind, the frog will
be large and bulbous from the constant stimulation
with the ground, a ledge will form in the frog from
bearing weight, and it will be situated well below the
hoof wall with the bulk of the frog now located be-
tween the two branches of the shoe (Fig. 5B). The
solar surface of the foot will show an inclined plane
of the entire frog from the base to the apex in a
dorsal cranial direction toward the coronet. This
inclined plane or angle will match the angle of the
solar border of the distal phalanx in the hoof cap-
sule. The toe area on the solar surface of the foot
will show a deep or exaggerated concavity between
the apex of the frog and the inner branch of the shoe
instead of a steep, yet smooth transition of the sole
from the frog to the sole wall junction. There will
Fig. 4. A line drawn through the angle of the coronet of a horse usually be a palpable “trough” located just dorsal to
with low heel “bull nose” conformation forms a trajectory to the the apex of the frog (Fig. 5C). Upon removing the
elbow of the forelimb. A horse with good foot conformation will
shoe, the end of the heel of the hoof capsule is lo-
form a trajectory to a point just above the carpus.
cated well forward from the base of the frog and the
horn tubules will be parallel with the ground. The
hoof wall at the heel will be thin, the bars may be
block sound with posterior digital nerve blocks be- damaged or missing, and the angle of the sole will
cause this hind foot conformation may lead to pain be absent. Lightly paring the area adjacent to the
in the hocks, proximal suspensory ligament and glu- hoof wall at the end of the heel with a hoof knife will
teal and lumbar region.4 – 6,8 often show moderate to severe hemorrhage from the
pressure of the damaged hoof capsule against the
The Low Heel “Bull Nose” Foot Conformation shoe. When the foot is placed on the ground, total
This abnormal conformation of the hind feet is easy weight bearing will be placed on the frog, which is
to recognize. When looking at the limb from the located distal to the ground surface of the hoof
side, the digit will show a broken back hoof pastern capsule, and many horses will be reluctant to
axis. The slope of the coronary band from the toe to stand on it when the opposing limb is lifted off the
the heel will have an acute angle of 40 – 45°, and the ground. As noted previously, hoof testers placed
coronet will bend distally at the heel to become al- on either side of the heel at the angle of the sole
most vertical. The bulbs of the heels will be pro- will often elicit a painful response and the struc-
lapsed plantar to the heels of the hoof capsule and tures will deform (Figs. 6A, 6B).
will form a “knob”-shaped appearance that can be
seen lying against the shoe. The hair on the coro- Radiographs
net at the heels may project horizontally rather than A lateral radiograph of the hind foot will show a
lying flat against the hoof due to excessive load on broken back hoof pastern axis, with the middle pha-
the associated hoof wall. There will be a disparity lanx (P2) being displaced plantar and distal relative

Fig. 5. A, Lateral view of a moderate low heel “bull nose” conformation of a hind foot. Note the disparity in growth rings and the
acute angle of the coronet. B, Plantar view shows the prolapsed frog as well as the incline of the frog. C, Solar view shows the incline
of the frog in a dorsal cranial direction (black lines), and the marked concavity of the sole (red arrow).

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Fig. 6. A, Hind foot from Figure 5 with shoe removed. Note the frog located below ground surface of the foot and the horse standing
on the frog rather than the hoof capsule. B, A necropsy specimen from a horse with severe low heels in the hind foot. Note the
hemorrhage in the sole. (Courtesy Michael Savoldi).

to the distal phalanx (P3) during weight bearing. as the amount of sole depth noted on the radiograph
This places excessive stresses on the plantar section or determined from the incline of the frog can be
of the hoof capsule. The COR is located further misleading. The dorsal margin of the bone mi-
plantarly with this abnormal foot conformation, grates dorsally and therefore stretches the width of
thus decreasing the ground surface in the plantar the dermis, a change which may not be recognized
section of the foot. The soft tissue structures (frog, on the radiograph (Fig. 8A). Therefore, aggressive
digital cushion) in the plantar section of the foot trimming at the toe will often result in seepage of
have prolapsed plantarly to the shoe, forming a blood at the sole wall junction as the dermal tissue is
“knob”-shaped appearance. The angle of the solar being encroached. It may be prudent to reduce the
border of the distal phalanx at the heels is lower amount of sole depth gradually over two shoeing
than the dorsal margin of the distal phalanx (i.e., a intervals. After the hoof wall is removed on the
negative plantar angle). The sole depth below the solar surface of the foot, additional horn is removed
dorsal margin of the distal phalanx is markedly from the outer hoof wall to create even or uniform
increased relative to the sole depth at the heel, and hoof wall thickness from quarter to quarter. The
the perimeter of the dorsal margin of the distal horse is then placed on a firm surface, which places
phalanx can be seen migrating toward the dorsal pressure on the frog that quickly assumes the same
hoof wall. The displacement of the distal phalanx plane as the heels on either side.
results in the “bull nose” appearance of the dorsal
hoof wall (Fig. 7).
Farriery
The amount of improvement that can be achieved
with the appropriate farriery will obviously be pro-
portional to the severity or the amount of distortion
present. Damage to the plantar section of the hind
feet is easier to improve than in the forefeet, possibly
due to the anatomy and the difference of the load
encountered on the hind limbs. The initial goal of
the farriery is to make the plantar section of the foot
“load sharing” such that the hoof wall and the frog
are on the same plane. The first step of the farriery
process will be to address the frog being located
below the hoof wall. This will depend on the sever-
ity; if mild, the horse could have its shoes removed
the day before being shod and housed on a firm
surface, or if more severe, allowed to go without hind
shoes for 3–5 days, which can be very effective. Fig. 7. Radiograph of a foot with low heels “bull nose” confor-
To begin the trim, the shoes are removed and the toe mation of the hind foot. Note the COR (red line) located further
length is reduced from quarter to quarter according plantarly than the forefoot and the decreased ground surface
to the sole depth. Caution is advised when decreas- (yellow line) plantar to the COR. Also note the negative angle of
ing the toe length in this type of foot conformation, the solar border of the distal phalanx.

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Fig. 8. A, Lateral radiograph of a low heel “bull nose” foot conformation. Note the limited ground surface on the plantar side of the
COR and the leverage created on the dorsal side of the COR. Lucent area under the red arrow shows the dermis being stretched as
the margin of the distal phalanx migrates dorsally. B, Illustrates a frog plate created from a degree pad placed over the frog.

If the frog prolapse is severe, the approach can be and the frog are on the same plane, the load is
modified and the time frame shortened. The hind shared across the plantar section of the foot. The
shoes are removed a day or two before the horse is foot is now ready to have a sturdy steel shoe fitted
due to be shod, and the foot is trimmed as described and applied. The first author fit shoes to the hind
above. A frog plate is cut from a degree pad to feet in a similar manner to the front feet by using
match the frog, and the front of the pad is left intact the line drawn across the widest part of the foot
to form a half moon design. The pad is attached to placed in the middle of the shoe. However, in the
the foot with two small nails at the toe, and the foot hind feet, the widest part of the foot will be located
is wrapped in a medicated poulticed that has been further plantar than the forefeet; therefore, addi-
soaked in hot water and then secured to the foot tional shoe length is required to create the desired
with brown gauze and elastic tape (Fig. 8B). The proportions on either side of the COR (Figs. 9 –11).
horse is placed in a stall on a firm surface for 24 – 48 Looking at the shod hind foot from the side, the
hours. When the wedge pad is removed, the frog branch of the shoe should extend to or close to the
will be compressed between the heels, forming a flat point that coincides with a vertical line dropped
even plane which includes the frog and both heels. from the hairline at the bulb of the heel. If the
The horse will then be ready to have shoes applied, branch of the shoe extends beyond the vertical line
paying strict attention to the trimmed foot. or if the foot is not trimmed appropriately, the
A line is now drawn across the widest part of the length of the shoe will create excessive leverage on
foot. Any additional horn at the heels can be re- the heels. In order to keep the frog and hoof wall on
moved using the rasp in a horizontal direction across the same plane for the first shoeing interval or if
the heels and frog so the hoof wall approaches the mild heel elevation is necessary, a metal or alumi-
base of the frog to create as much ground surface as num heel plate or a 2° leather wedge can be placed
possible. Care must be taken to keep the frog and under the shoe at the heels as long as the shoe is
both heels in the same plane. When the hoof wall fitted in the manner described above. This will con-

Fig. 9. A, Lateral radiograph of a hind foot that shows the concept of increasing the ground surface plantar to the COR using a shoe.
(Courtesy Dr. Sarah Puchalski). B, Trimmed foot shows how the length of shoe (green arrows) will create approximate proportions
on either side of COR foot.

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Fig. 10. Lateral radiograph of a low heel “bull nose” conformation of the hind foot before and after farriery. Note the difference in
the foot conformation after the appropriate trim and a size larger shoe. Again, note the increased ground surface plantar to the COR.
(Courtesy Dr. Hans Castelijns).

centrate the load across the frog and heels rather have an effect on hind limb biomechanics, as there is
than behind the heels, which is the case with a long no research or current literature to support these
shoe or trailers. The plate or wedge will also pre- modifications. It is the authors’ opinion that farri-
vent the frog from descending toward the ground ery begins with the appropriate trim, with the cor-
between the branches of the shoe. This is usually a rect size/placement of the shoe with any subsequent
temporary measure and it can be discontinued once modifications being secondary. The appropriate
the heels have stabilized. trim improves many hind limb issues by providing
increased ground surface in the plantar section of
5. Summary the foot combined with a shoe of sufficient length so
The low heel “bull nose” foot conformation of the that the transition from loading to propulsion min-
hind feet is often overlooked as a cause of poor per- imizes dorsiflexion of the fetlock and hock. In turn,
formance or lameness in the hind limbs. This ab- this allows the toe to push off, elevating the limb
normal foot conformation may play a dual role in into the swing phase, resulting in a smoother tran-
hind limb soundness. Firstly, the overload and sition of force from the hind limb through the sacro-
damage to the plantar section of the foot can cause iliac and lumber regions.
pain and a subtle bilateral lameness. Secondly, The incidence of this low heel “bull nose” hind foot
pain and/or the altered biomechanics of the foot will conformation in performance horses has reached ep-
cause changes in hind limb movement. The idemic proportions in recent years. There are a
changes appear to affect flexion of various joints, myriad of theories/thoughts regarding how to trim
strain on ligaments, hoof and limb flight, hoof land- the palmar/plantar section of the foot; however, the
ing/loading, and muscle tension. Veterinarians authors feel that inappropriate trimming of the
and farriers frequently use specialty shoes or modify heels decreases the ground surface in the plantar
existing shoes in an attempt to relieve pain and section of the hind foot and the application of shoes
therefore improve overall hind limb mechanics. that are too small may be the inciting cause of this
However, it is unclear whether these modifications foot confrontation.

Fig. 11. The goal of hind foot farriery is to create a foot that has approximate proportions or ground surface on either side of the
widest part of the foot. Note the branches of the shoe used to increase ground surface in the plantar section of the foot.

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Treatment to address this foot conformation is a 4. Mannsman RA, James S, Bilkslager AT, et al. Long toes in
joint venture between the veterinarian and the far- the hind feet and pain in the gluteal region: an observa-
tional study of 77 horses. J Equine Vet Sci 2010;30:720 –
rier. It is essential for both professions to be aware 726.
of this problem and its effects not only on the foot but 5. Turner TA. Rear hoof imbalance and its effect on hind limb
the hind limb above. Perineural analgesia, when pos- lameness, in Proceedings. Am Assoc Equine Pract 2017;63:
sible, will show the prevalence of foot pain in the hind 455– 459.
6. Dyson SJ, Murray RM. Management of hindlimb proximal
feet and the increased use of radiographs, when pos- suspensory desmopathy by neurectomy of the deep branch of
sible, will help guide the appropriate farriery. A the lateral plantar nerve and plantar fasciotomy; 155 horses
working knowledge of foot biomechanics and good ba- (2003–2008). Equine Vet J 2012;44:361–367.
sic farriery principles make the treatment for this con- 7. Ross MW. The hind foot and pastern. In: Ross MW, Dyson SJ,
dition straightforward. ed. Diagnosis and management of lameness in the horse. 2nd
ed. St Louis: Elsevier, Saunders, 2011:475– 476.
8. Dyson S. Diagnosis and management of common suspen-
Acknowledgments sory lesions in the forelimbs and hindlimbs of sport horses.
Clin Tech Equine Pract 2007;6:179 –188.
Declaration of Ethics 9. Bushe T, Turner TA, Poulos PW, et al. The effect of hoof angle
on coffin, pastern, and fetlock joint angle, in Proceedings. Am
The Authors have adhered to the Principles of Vet- Assoc of Equine Pract 1987;33:689 – 699.
erinary Medical Ethics of the AVMA. 10. Clayton HM, Back W. Hind limb function, In: Back W, Clay-
ton HM, ed. Equine locomotion. 2nd ed. Edinburgh: Elsevier,
Conflict of Interest Saunders, 2013:127–145.
11. Eggleston RB. Value of quality foot radiographs and their
The Authors have no conflicts of interest. impact on practical farriery, in Proceedings. Am Assoc of
Equine Pract 2012;58:164 –175.
12. Schumacher J, Taylor DM, Schramme MC, et al. Localization
References and Footnotes of pain in the equine foot emphasizing the physical examina-
1. Hunt RJ. Farriery for the hoof with low or underrun heels. tion and analgesic techniques, in Proceedings. Am Assoc of
Vet Clin N Am Equine 2012;28:351–364. Equine Pract 2012;58:140 –141.
2. Parks A. The foot and shoeing. In: Ross MW, Dyson SJ, ed.
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Diagnosis and management of lameness in the horse. 2nd ed. Parks AH. (personal communication) 2018.
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St Louis: Elsevier, Saunders, 2011:282–302. Texas Equine Hospital, Bryan, TX 77807.
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3. O’Grady SE. Basic farriery for the performance horse. Virginia Equine Imaging, The Plains, VA 20198.
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