Navicular Syndrome/Heel Pain
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- Dinah Knight
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1 Navicular Syndrome/Heel Pain
2 Navicular Syndrome/Heel Pain Clinical signs: Forelimb lameness, intermittent, progressive and insidious onset, usually bilateral. Stumbling Pointing toes to relieve pressure on DDFT Packing shavings under front feet Decreased performance/stopping Short, stiff gait Chronic sequela-contracted heels, increased concavity of sole, toe bruising, may have enlarged digital vessels and increased digital pulses.
3 Anatomy of the Navicular Apparatus Associated structures: Navicular/distal sesamoid bone 30% of distal articular surface, acts as a fulcrum with DDFT Navicular bursa Deep digital flexor tendon (DDFT) Coffin joint Collateral (suspensory) ligament of navicular bone Distal sesamoidean impar ligament
4 The Equine Hoof Coffin joint Impar ligament Navicular bursa
5 Predisposing factors Conformation: Low/under run heels Small feet Long toes Improper shoeing Hard work on concussive surfaces Nutrition imbalances during younger years
6 Pathophysiology why does it happen? 3 main theories - Contentious! 1. Concussion leading to bursitis Alters the flexor surface of the bone Villous hypertrophy, hyperplasia of synovial lining cells, venous congestion 2. Remodeling of bone due to increased pressure of deep digital flexor tendon (DDFT) 3. Vascular Arterial occlusion in foot, thrombosis and ischemic necrosis of navicular bone
7 Pathophysiology continued Syndrome most likely a mixed etiology: Age related changes-degenerative change in fibrocartilage on flexor surface of bone Adaptive remodeling of bone due to tendon stressescortical thickening Edema, congestion and fibrosis of marrow-cyst likelesions Loss of proteoglycans in articular cartilage Bursitis Adhesions between DDFT and navicular bone
8 Differential diagnoses for navicular syndrome Puncture wounds to foot Fracture of navicular bone or distal phalanx Bruised sole Pedal osteitis Arthritis of coffin joint Corns Soft tissue injury such as lesions in the distal DDFT, impar ligament, or collateral ligaments. Navicular bone
9 Diagnosis Lameness exam Hoof testers-pain over center 1/3 of frog Distal limb flexion test/toe extension Palmar digital nerve block Intra-thecal analgesia of navicular bursa Coffin joint intra-articular analgesia
10 Diagnosis Radiographs 5 standard views most sensitive view 45 palmar proximal-palmarodistal oblique (navicular skyline view) Most significant changes likely to reflect navicular disease: Cyst like lesions in medulla Medullary sclerosis, and reduced cortico-medullary demarcation New bone growth/erosion on flexor surface Mineralisation in ligaments
11 Radiographs
12 Normal
13 Abnormal
14 Abnormal
15 Diagnosis continued Nuclear scintigraphy Can see increased bone turnover MRI/CT More sensitive than radiographs Detects abnormal amount of fluid in coffin joint and navicular bursa Detects changes in bone such as fluid/edema Endoscopic evaluation of navicular bursa
16 Treatment options-no cure, only management Corrective trimming/shoeing Aim: balance the feet and straighten the pastern-hoof axis. Raise heels, shorten and roll toe to facilitate break-over Support across center 1/3 of frog Shoes: egg-bar, heart-bar, straight bar, natural balance
17 Treatment continued Drugs 1. Analgesia 1. NSAIDS-phenylbutazone, naproxen, banamine, aspirin 2. Vascular modifying drugs 1. Isoxsuprine / Pentoxyfylline-vasodilators, alter deformability of erythrocytes 2. Dicumeral-blood thinner 3. Intra-thecal injection into navicular bursa 4. Polysulfated glycosaminoglycans-adequan 5. Tildren-inhibits bone resorption
18 Treatment continued Chemical neurectomy /cryoneurectomy-ablation of sensory fibers of palmar digital nerves Sarapin Clinical improvement lasts 2-3 months Unreliable
19 Treatment continued Palmar digital neurectomy Last choice option Careful selection of case, only if peri-neural analgesia of PD nerve eliminates lameness Successful in 65-70% of horses and lasts approximately months Complications: Incomplete desensitization Regeneration of nerves Damage to DDFT Neuroma formation Change in hoof growth
20 Conclusion Multifactorial and controversial etiology No treatment is 100% successful Prognosis is always guarded: Many horses can continue to be useful if managed well, others may need to reduce level of work or even retire
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