Application of the Fetlock Support Shoe forSuspensory Desmopathy

Nathaniel A. White II, DVM, MS, Diplomate ACVS*;Jennifer G. Barrett, PhD, DVM, Diplomate ACVS; and Paul Goodness, CJF

Suspensory ligament injuries are a significant cause of lameness in performance horses and race-horses. Although treatments to decrease inflammation and stimulate ligament healing are used totreat most injuries, stress on these structures is unchanged as the result of normal weight-bearingrequired during rest. Use of a fetlock support shoe can facilitate healing by preventing excess stresson the suspensory ligament. This technique is particularly helpful in supporting the rear fetlockduring treatment of suspensory ligament desmopathy. Authors’ address: Marion duPont ScottEquine Medical Center, Virginia Tech, PO Box 1938, Leesburg, VA 20177; nawhite2@vt.edu. *Cor-responding and presenting author. © 2013 AAEP.

1. Introduction

The fetlock support shoe or brace (also known as the“Roberts Shoe”) is depicted in books published in theearly 1900s for treatment of tendon or suspensoryrupture (Fig. 1).1,2 In more recent texts, the vari-ous modifications of the support shoe are described.Although there are numerous descriptions in text-books, there are few reports in the literature de-scribing success or failure with different types ofinjuries.3,4 A support shoe used for support of ten-don lacerations was reported to be successful in re-storing use in 60% of horses.5

Dorsal support of the fetlock can be provided bysplints such as the Kimzey Splinta or in a cast,however, these are normally used during the initialphase of support but do not allow the partial loadingof the suspensory ligament needed for healing overthe long term. Attempts to attach a splint on thedorsal aspect of the limb have been used by theauthors, but these splints do not allow normal flex-ion of the fetlock, and tension applied by the ban-

dage behind the metacarpus/metatarsus and fetlockcan result in pressure sores (Fig. 2).

Treatment for proximal rear suspensory ligamentdesmopathy (injury at the origin) is reported to beless successful in horses with straight rear limbs andexcessive dorsiflexion of the fetlock, causing con-stant stress on the suspensory ligament (Fig. 3).6

To facilitate healing in cases of suspensory des-mopathy, a fetlock support shoe was used by theauthors to limit fetlock dorsiflexion and relievestress on the suspensory ligament(s) during healing.

2. Materials and Methods

Chronically lame horses with rear-limb suspensoryligament lesions at the origin or in the suspensorybranches (diagnosed by ultrasonography) weretreated with a fetlock support shoe. All the horseshad rest and surgical or regenerative medical treat-ment of the hypoechoic lesions. Selected horseswith excessive fetlock dorsiflexion associated withproximal suspensory desmopathy were fitted with a

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NOTES

fetlock support horseshoe for 1 to 2 months during arecommended period of stall rest.

The fetlock support shoe, which requires experi-ence and skill for proper construction, was designedas a bar shoe with toe clips, an extended heel (3–5cm), and two hex nuts welded to the heel extension.Two support rods were designed and measured witha length to reach just past the level of the fetlock foreach horse. The rods were welded together nearthe shoe and inserted into the hex nuts. A setscrewin the side of the hex nut was used to keep rods frommoving. This allows the rods to be removed formanagement of the bandage, which is needed forpadding (Fig. 4). A support wrap with several lay-ers of sheet cotton was applied from the coronaryband to the proximal metacarpus/metatarsus. Anelastic adhesive bandageb was wrapped from side toside around the support rods and positioned tightlyto support the fetlock when the horse bears weighton the limb. An alternative is the use of rubbertubing around the supports to provide more flexibil-ity during weight-bearing. The brace can be leftopen or covered with a light bandage placed to coverthe support rods, which allow the fetlock to flexduring walking without any pressure on the limb.Adequate padding on the limb is required to preventpressure sores on the back of the fetlock.

3. Results

Seven horses with excessive rear fetlock dorsiflexionand chronic suspensory ligament desmopathy weretreated with a fetlock support shoe and rest. Threeof six horses with proximal suspensory ligamentdesmopathy were treated with desmoplasty/fas-

Fig. 1. Horseshoe with extended heels and a support brace (A) isdesigned to have a leather strap between the bars to support thefetlock as it descends in extension (B).1

Fig. 2. Dorsal splint (A) was successful in increasing the pastern angle during full weight-bearing but resulted in pressure sores onthe back of the fetlock (B).

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ciotomy, two with platelet rich plasma (PRP) injec-tion, and one with desmoplasty/fasciotomy, PRP,and stem cells.7 One horse with chronic suspen-sory branch desmopathy had a fetlock support shoeapplied and had no treatment other than rest (Fig.

5). All horses had absolute stall rest while wearingthe support shoe. All seven horses had improvedultrasonographic evidence of healing and subjec-tively had improved conformation (less abnormalfetlock dorsiflexion) after wearing the shoe for ap-proximately 8 weeks. All hypoechoic regions in thesuspensory ligaments had increased echogenicity 2months after the treatments and rest. The horsewith chronic suspensory branch injury was sched-uled to have PRP injection in the core lesions, butafter 2 months of support, intralesional treatmentwas not required. In the six horses for which short-term follow-up was available, lameness was resolvedin six horses at the time of the last recheck either byexamination or communication with the owner.Long-term follow-up included resolution of the lame-ness in four horses: one horse used for very lightriding, one for dressage, one sound in turn-out andabout to be returned to work, and one retired (soundin turn-out). Three horses were lost to long-termfollow-up.

4. Discussion

Recommended treatments for suspensory desmopa-thy include rest, support bandages, anti-inflamma-tory therapy, and a slow return to controlledexercise. Stem cells and PRP injection also anec-dotally help to stimulate healing. Although resolu-tion of lameness and return to exercise after lateralplantar neurectomy with fasciotomy or ultrasound-guided suspensory desmoplasty is approximately70% to 80%, horses with “dropped fetlocks,” either atrest or at the walk, are unlikely to return to any typeof exercise under saddle because of failure of healingor re-injury.6–8

Horses with an abnormal rear-limb conformation(straight angle in the hock with excess dorsiflexion

Fig. 3. Horse with a bilateral rear proximal suspensory liga-ment desmopathy. The prognosis for resolution of the desmopa-thy in horses with straight leg conformation and excessiveextension of the fetlock is poor.5

Fig. 4. Shoe is designed with hex nuts attached to the extended heel and locking screws inserted through the hex nuts to allowremoval of the support rods for adjustment and bandaging (A). Elastic adhesive bandage is used to create a flexible sling to reducefetlock extension (B).

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of the fetlock, as shown in Fig. 3) appear to placeexcess tension on the suspensory ligament, whichincreases the risk for injury or resistance to healing.The authors’ experience suggests that injury to theproximal suspensory ligament can lead to this al-tered rear-limb conformation, but it has not beendetermined if one problem precedes the other. Inthese cases, use of the fetlock support shoe hashelped to resolve the desmopathy and subjectivelyimproved rear-limb conformation in seven horsesduring the treatment period. Because all exceptone horse had multiple treatments, it is possiblethat the other treatments may have been successfulwithout the fetlock support. However, the clinicalresponse in these cases suggests that fetlock supportis an aid in the successful treatment of rear-limbsuspensory desmopathy associated with abnormalfetlock conformation. Critical assessment of thistechnique is needed to determine if it is successful inreturning horses to their previous level of work.6,7

References and Footnotes1. Lacroix JV. Lameness of the horse. Am J Vet Med 1916:146–

149.

2. Dollar JAW. Regional Veterinary Surgery and OperativeTechnique. Chicago: American Veterinary Publishing Com-pany; 1920:836.

3. Stashak TS, Lameness. In: Stashak TS, editor. Adams’ Lame-ness in Horses. Philadelphia: Lea and Febiger; 1987:584–586.

4. Ragle CA. Support shoes and braces for tendon and ligamentinjuries. In: White NA, Moore JN. Current Techniques inEquine Surgery and Lameness. Philadelphia: WB SaundersCo; 1998:523–527.

5. Whitfield-Cargile C, Dabareiner RM, Sustaire D, Use of afetlock support brace to manage lacerations of the equineflexor tendons. Equine Vet Educ 2011;23:46–52.

6. Dyson S, Murray R, Management of hindlimb proximal sus-pensory desmopathy by neurectomy of the deep branch of thelateral plantar nerve and plantar fasciotomy: 155 horses(2003–2008). Equine Vet J 2011;44:361–367.

7. Hewes CA, White NA. Outcome of desmoplasty and fas-ciotomy for desmitis involving the origin of the suspensoryligament in horses: 27 cases (1995–2004). J Am Vet MedAssoc 2006;229:407–412.

8. Bathe AP. Plantar metatarsal neurectomy and fasciotomy forthe treatment of hindlimb proximal suspensory desmitis. In:Proceedings: ACVS Veterinary Symposium. 2007:116–117.

aKimzey Leg Saver Splint, Kimzey Metal Products, 164 KentuckyAvenue, Woodland, CA 95695.bElastikon, Johnson and Johnson, One Johnson & Johnson Plaza,New Brunswick, NJ 08933.

Fig. 5. Arabian mare presented for a chronic right rear medial suspensory branch desmitis, which had not responded to PRP injectionand subsequent rest for 9 months. The fetlock support shoe was applied for 2 months: rear view (A), lateral view (B). After 2months, increased echogenicity was present on ultrasonographic examination and the previously abnormal fetlock extension (droppedfetlock) was improved.

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