PODIATRY PAGES

PART 2: CAUDAL FAILURE AND

NEGATIVE PALMAR/PLANTAR ANGLES
Sarah Daly
drsarahdaly@gmail.com

Podiatry Pages is a 7-part series overviewing some commonly seen hoof abnormalities in sport and racehorse practice
using case examples demonstrating an approach to their treatment and management. Topics in this series include:
• Approach to the physical examination of the hoof • High-low syndrome
• Caudal failure and negative palmar/plantar angles • Angular limb deformities affecting hoof balance
• Contracted heels and other capsular deformities • New technologies and materials – the future of
• Thin soles, weak walls equine podiatry

CAUDAL FAILURE unsupported, resulting in an insidious inward-and-downward

– A NEW NAME FOR AN OLD CONDITION? progression of the caudal structures of the foot. This leads
to collapse of the heel and atrophy of the digital cushion
and frog (Diagram 1). Caudal failure is prevalent in at least
75% of the equine population and is frequently correlated to
lameness.3 The caudal structures of the hoof are important
in dampening the forces of impact and maintaining the
haemodynamics of the digital cushion which contribute to
healthy hoof morphology and correct function. However,
expansion of the hoof capsule is restricted with a traditionally
shod hoof compared to a barefoot hoof,4 causing changes in
hoof morphology5 which could alter phalangeal alignment and
predispose to lameness.3,6
Lupton JI. Mayhew’s Illustrated Horse Management,
WH Allen Co. London. 1876, p97.

“Long-Toes, Low-Heels,” “Underrun Heels,” “Flat-Footed,”

“Thoroughbred Feet” are all colloquialisms for a phenotype
that is extremely prevalent in the general equine population.
The question is, why is it so common?
The earliest forms of horseshoes have been dated back as
far as 400 BC,1 and use of the traditional iron, U-shaped
horseshoe became increasingly common from 900 AD
onwards.2 An ancient profession, farriers first organised as Figure 1: Caudal (A) and lateral (B) views of a horse with
a guild in 1356, and became one of the City of London’s 110 caudal failure in the hind feet.
royal-chartered livery companies in 1674, The Worshipful
Company of Farriers. The metal, U-shaped horseshoe has AT WHAT POINT SHOULD WE INTERVENE WITH
remained an iconic symbol of the craft, even into modern CAUDAL FAILURE?
times, but is this type of open-heeled shoe creating a problem?
Due to anatomical and conformational variations amongst
Caudal Failure (Figure 1), also termed caudal heel collapse, the many breeds and types of horses, defining exactly when
is postulated to be caused by the long-term use of standard, to intervene is difficult. 75% of the equine population may
open-heeled shoes, which peripherally load the dorsal exhibit some degree of caudal failure, but 75% of the equine
hoof wall whilst the central structures of the foot remain population may not be overtly lame…yet.

Eq Vet Pract 2022 September; 47 (3) 21


Diagram 1: TOP
- barefoot horse in
stance, both the hoof
wall and frog contact the
ground and distribute
the weightbearing
load. MIDDLE - an
open-heeled shoe only
provides peripheral
support, and the frog
is floating above the
ground. BOTTOM - over
time, this leads to caudal
failure, where the central
structures sink downward
with gravity and the
heel collapses. Figure
modified from Wayne
Turner, Progressive
Equine Services.
Though there is not a consensus on the definition of caudal
failure, a difference in heel angle relative to the dorsal hoof
wall angle of greater than 5o has been shown to affect the
hoof-pastern axis (HPA) due to heel collapse.7,8 Turner (1992)
references an ideal toe:heel height ratio of 3:1 which, in most
cases, maintains HPA close to a straight line, largely agreed
as the ideal for biomechanical functionality.8,9,10
PREVENTION IS BETTER THAN CURE.
As vets, we often see horses that have been suffering from
chronic, unaddressed caudal failure and end up treating the
pathologies that are the result. Farriers are at the front line
of preventative interventions, but awareness of the issue or
a lack of understanding the cause of caudal failure appears
to be limiting progress in the field. Farriers do not have the
luxury of radiography for each patient but striving to achieve
a straight HPA relative to the horse’s conformation is a good
anatomical baseline, as it usually correlates closely with
phalangeal alignment (see Figures 2 & 3).
Figure 2: Visualisation of the ideal Hoof Pastern Axis (A)
in relation to radiographic Phalangeal Alignment (B) where
P1-P2-P3 are aligned through the centre of the bony column.
Figure modified from Wayne Turner, Progressive Equine
Services.
22 Eq Vet Pract 2022, September; 47 (3)
However, to treat more subtle pathologies and imbalances,
vets and farriers working as a team to quantify and modify
an individual patient’s phalangeal alignment with the aid of
radiography and photography can vastly improve outcomes
and document progress by enabling accurate measurement
of palmar and plantar angles, hoof wall:heel angles, and other
techniques to restore alignment.
Figure 3: An example of a broken back HPA (A & B, red
line) and how it relates to phalangeal alignment (A, yellow
line). This horse has a 1.64o negative palmar angle which
is affecting phalangeal alignment and creating a broken back
HPA physically.
CASE STUDY
Signalment: 6yo WB gelding showjumper presented with
progressively worsening behavioural issues, refusing jumps,
and jumping “flat” over the fences.
Examination: The horse was 1/5 lame left fore in a straight line
and 2/5 lame left fore on a left circle. Flexion tests revealed
a moderate positive response to left fore distal limb flexion, a
mild positive response to both hocks, and a moderate positive
response to left stifle flexion. When observing the horse
trotting, he appeared to trot with “duck feet”, with very hard
heel-first landing and toe-flipping and landing more medially.
He also had a heaviness to his gait when a horse of his type
should have more elasticity through his movement. Examining
the horse’s posture revealed he preferred to stand “camped
under” both in front and behind. He was toed-out on both
front feet and the feet were laterally offset from the cannon,
right fore worse than left fore. He also was observed to have
very poor hoof quality, with brittle horn and abnormal growth
rings. A blood sample to measure selenium was taken but
returned normal levels, so a recommendation to feed a hoof
supplementa was given. He had been shod in rocker-toed,
open-heeled shoes with 3-degree wedge pads seven days
prior to examination. Lameness was isolated to the left fore
foot with a palmar digital nerve block.
A thorough before-and-after podiatry examination of all four
feet was conducted with the farrier at the clinic to ensure
accurate trimming and realignment. Follow-up radiographs
and photographs were obtained every 12 weeks (every other
shoeing cycle) with the farrier in attendance as part of the
horse’s treatment team. The initial radiographic findings on
this horse were a 1.5o negative palmar angle on the left fore,
a flat (0o) palmar angle on the right fore, and 3o negative
plantar angle on the right hind, and a 4o negative plantar
angle on the left hind. The right fore also had a severe
mediolateral imbalance due to underlying conformational
issues with a toed-out and a laterally offset foot. The left stance which relaxes the pull on the DDFT in the painful
fore DIPJ was medicated with 10mg of triamcinolone at the navicular region and alleviates discomfort. In contrast, with
second examination due to an improved but persistent 1/5 heel pain due to unsupportive shoes, the horse stands with the
left forelimb lameness on the left circle. After correcting the foot underneath itself and leans forward onto the toe, taking
negative plantar angles at the first shoeing, the response to pressure off the structures at the back of the heel.
hock and stifle flexions resolved by the second examination
and further treatment was not required.
Approach to the caudal failure: For brevity, this discussion
will only address the horse’s treatment approach to caudal
failure using the lame left forelimb as an example (see Figure
4). However, all four feet had the negative palmar/plantar
angles corrected using this method.

Figure 4: Left Fore foot showing: A, mild, laterally offset foot

and coronary hairline is not parallel to ground (medial high);
B, preferred stance, camped under, also notice broken back
hoof pastern axis and lack of heel support with too small a
shoe; C, shod in a rocker-toe shoe, notice how this creates
the appearance that the horse is leaning back on its heels.

Referring to Figure 5 TOP, taken at the first examination prior

to shoeing, there is an obvious broken back hoof pastern axis
and a “banana-shape” to the phalangeal alignment on the
radiograph. This misalignment is due to caudal failure, i.e., Figure 5: TOP - initial examination; MIDDLE - first shoeing;
collapse of the heel. BOTTOM - 3 months post-treatment.
The radiograph in Figure 5 TOP shows a 1.57o positive palmar
angle with the original 3o wedge pad in place, meaning if the
horse were standing on a level surface, there would be an
approximate 1.43o negative palmar angle. After the shoe was
removed and the horse trimmed in a manner that preserved
heel but removed excess toe, the palmar angle was improved
to 1.64o positive when standing barefoot (refer to Figure 6 A).
From further examination of the radiograph in Figure 5 TOP, it
is obvious that the shoe is not supporting the caudal structures
Figure 6: A, first trim prior to shoes; B, at 6 months post
of the foot and the heel is falling off the back of the shoe.
trimmings.
Measuring the ratio of shoe around the centre of rotation
(COR) of the coffin joint, 60% of the shoe is dorsal to the To address the caudal failure, alleviate the heel pain caused
COR, leaving only 40% of the shoe to support the caudal hoof. by lack of support, and to promote growth of the heel and
This creates a large lever arm at the toe. It is also apparent digital cushion, a specialised 3o half-mesh, frog support pada
that a lot of heel bulb is hanging over the edge of the shoe was used in conjunction with dental impression material
because the shoe is too small, creating a large pressure point (DIM) covering the entire caudal half of the foot and filling the
at the heel and exacerbating the caudal failure. In the author’s collateral grooves of the frog (Figure 7). This combination
opinion, this may be why some horses with broken-back HPAs provides dynamic support, simulating the weightbearing forces
wearing severely unsupportive shoes, tend to stand camped of a barefoot hoof, improving the haemodynamics of the digital
under in front, to relieve the pressure at the heels. This is cushion and promoting heel growth and expansion when the
opposite to horses with navicular syndrome, which tend to shoeing package is correctly applied.4 The pad is paired with
point the toe forward. The pointing is a lightly weightbearing an aluminium shoe that has a more anatomical breakover

Eq Vet Pract 2022 September; 47 (3) 23

 patternb to allow smoother movement through the point of
breakover, i.e., where the maximum moment force of the
horse’s bodyweight is propagated up the limb at the terminal
part of the stance phase. Aluminium was chosen in this case
to provide less weight on the feet since the horse already has
a heavy-footed gait. The shoe is large enough to support
the foot in an approximate 50:50 split over the COR of the
coffin joint. The shoe is also large enough and wide enough
to allow for heel expansion and growth over the shoeing
cycle. Using these principles, the horse’s first set of shoes
(Figure 5 MIDDLE) resulted in an immediate improvement in
palmar angle (4.59o) and phalangeal alignment, as well as a
change in posture to standing square. 12 weeks later (Figure
5 BOTTOM), there is visible improvement in alignment, horn
tubule quality, growth pattern, and hoof shape. Alignment and
HPA are nearly straight and the palmar angle is 5.41o. The
final result (Figure 6 B) shows the true improvement in palmar
angle and wall/hoof angles from the start of remedial farriery
to 6 months later when the horse graduated to flat pads.
Figure 7: The shoeing package used to provide caudal
support.
Ongoing approach: This horse will remain in flat, frog-support
pads on all four feet and the aluminium breakover shoe in the
forelimbs during the summer (dry season) whilst the ground
is firm. However, in the winter (wet season), pads are harder
to manage for optimal hoof health. But there is theoretically
some increased mechanical support from mud packing in the
hooves as well as standing on softer ground, which makes
the gravitational forces that cause caudal failure less severe.
In these instances, horses that have healthy hooves can be
shod in standard rim shoes for 2-3 shoeing cycles during
the wetter months.11 For horses that have exceptional hoof
balance and horn quality, going barefoot at certain times of the
year, depending on seasonal competition schedules, would
be better than shoeing without caudal support. Regardless of
seasonality, if shod, the author recommends breakover shoes
on the front feet for all horses due to their efficacy at improving
biomechanics in the forelimb.12,13
24 Eq Vet Pract 2022, September; 47 (3)
CONCLUSION
Caudal failure is an extremely prevalent condition affecting
most horses presented to equine veterinarians. Awareness
of the aetiology and the methodologies toward effective
treatment and prevention can vastly improve equine welfare.
Diligent podiatric examinations can provide a wealth of
information for both the veterinarian and farrier and enable
documentation of successful outcomes. Evidence-based
podiatry should become standard of care.
References
1. Bates, W. N. (1902). Etruscan Horseshoes from
Corneto. Am J Archaeol, 6(4):398–403
2. Clark, B. (1831). An essay on the knowledge of the
ancients respecting the art of shoeing the horse, and
of the probable period of the commencement of this
art. Royal College of Surgeons Wellcome Collection.
pp. 36. b22392750 (wellcomecollection.org)
3. Dyson, S., Tranquille, C., Collins, S., Parkin, T. and
Murray, R. (2011) An investigation of the relationships
between angles and shapes of the hoof capsule and
the distal phalanx. Equ Vet J, 43(3): 295-301
4. Roepstorff L, Johnston C, and Drevemo S. (2001) In
vivo and in vitro heel expansion in relation to shoeing
and frog pressure. Equ Vet J Suppl. Apr, 33: 54-7
5. Gunkelman, M.A and Hammer, C.J. (2017) A
Preliminary Study Examining the Digital Cushion in
Horses. J Equ Vet Sci (56):6-8
6. Uhl, E.W., Blas-Machado, U., Kirejczyk, S.G. and
Osborn, M.L. (2018). Correlating Increased Mechanical
Forces with Tissue Lesions in Equine Navicular
Disease. FASEB Journal, 32: 816.14
7. Dyson S.J., Tranquille C.A., Collins S.N., Parkin T.D.,
and Murray R.C. (2011). External characteristics of the
lateral aspect of the hoof differ between non-lame and
lame horses. Vet J. 190(3):364-71
8. Snow, V. E., and Birdsall, D. P. (1990). Specific
parameters used to evaluate hoof balance and
support. Proc AAEP Ann Mtg, 36: 299-311
9. Turner, T. (1992). The use of hoof measurements for
the objective assessment of hoof balance. Proc Ann
Mtg AAEP, 38: 389-395
10. Brown, S.M. (2020). Feet from a different angle. Equ
Health, 51: 11-12
11. Pers comm: Wayne Turner & Chris Diedericks,
Progressive Equine Services
12. Page, B and Hagen, T. (2002). Breakover of the hoof
and its effect on structures and forces within the foot. J
Equ Vet Sci, 22: 258-264
13. Hagen, J., Bos, R., Brouwer, J., Lux, S., and Jung, F.T.
(2021). Influence of trimming, hoof angle and shoeing
on breakover duration in sound horses examined with
hoof-mounted inertial sensors. Vet Rec, 189(4): e450
https://doi.org/10.1002/vetr.450
Footnotes
a.
HoofGold®. http://www.HoofGold.de
b.
3 degree 3DHoofcare® Half Mesh Pad.
http://www.3DHoofcare.com
c.
Mustad® Equilibrium Shoe. http://www.Mustad.com
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