Laminitis is one of the most serious and painful conditions that horses and ponies can suffer, and just recently it seems like I’m seeing more and more cases. But why? The answer lies in a mix of modern horse-keeping practices, climate change, and better awareness of the condition. Creating a perfect storm. However, with awareness, prevention, and careful management, many cases of laminitis can be avoided or caught early before they become life-threatening, hence me writing this blog to try to raise awareness and help owners struggling with management.

The key reasons for seeing more cases:

1. Rising Rates of Obesity and EMS

• Equine obesity has become one of the biggest welfare concerns in the UK and worldwide. Surveys suggest that up to 50% of leisure horses are overweight.
• Obesity is the single biggest risk factor for Equine Metabolic Syndrome (EMS), which is strongly linked to endocrinopathic laminitis.
• Overfeeding, lack of workload, and calorie-dense feeds all contribute.

2. Climate Change and Grass Growth

• Warmer winters and wetter springs mean grass grows nearly year-round.
• Grasses have become richer in non-structural carbohydrates (NSCs) due to selective breeding for cattle grazing.
• “Danger periods” used to be spring/autumn flushes — now high-sugar grass can appear almost any month of the year.

3. More Horses Living as Leisure Horses, Companions & “Pets” Rather Than Workers

• Historically, horses worked hard and needed higher-calorie diets.
• Today, many leisure horses do relatively little exercise, but are fed as though they are in full work.
• Lack of consistent movement increases the risk of both insulin resistance and hoof circulatory compromise.

4. Better Awareness and Diagnosis

• Vets and owners are now more aware of subtle or “low-grade” laminitis and “not quite right” horses.
• Advanced diagnostics (endocrine testing, insulin tests, ACTH for PPID) mean more cases are being identified rather than overlooked.
• So part of the “increase” is actually improved recognition.

5. Aging Horse Population

• Horses are living longer due to improved veterinary care.
• This means more cases of PPID (Cushing’s disease), which carries a high laminitis risk.

6. Lingering Outdated Management Misconceptions

I will get into some of these a little deeper shortly but in summary:

• Many (including some vets) are still seeing laminitis as a stand alone disease and treating it as such, however, this is not the case, laminitis is rarely a stand-alone disease—it is increasingly understood as a clinical manifestation (a symptom) of underlying systemic problems, particularly metabolic dysfunction. I will discuss this in more detail soon.
• Box rest is still sometimes used long-term, which delays recovery.
• Shoeing is still often prioritised over barefoot rehab, even though barefoot trimming can be more effective for laminitic horses.
• Painkillers (bute) are sometimes relied on instead of tackling the metabolic root cause.
• Owners often underestimate the risk of grass, believing short or sparse pasture is “safe” when in fact stressed short grass can actually be very sugar-rich.

7. Seasonal Hormonal Effects

• Spring and autumn laminitis “spikes” are still seen because insulin dysregulation and PPID can worsen seasonally.
• Research shows ACTH and insulin levels rise naturally in autumn, increasing laminitis risk (Durham et al., 2019).

• Milder winters and wetter springs mean grass grows for much longer each year. With the weather we have been experiencing over the last 2/3 weeks; warm & wet after a very dry summer the grass has grown at an exponential rate hence the rise in laminitis cases over these weeks.

Laminitis isn’t becoming more common because the disease itself has changed — but because of the way modern life, climate, and horse care practices interact. Obesity, metabolic disease, sugar-rich grass, and longer lifespans all contribute to the surge in cases we’re seeing today.

---

Subtle Signs & Symptoms

Picking up on the signs and symptoms of laminitis and metabolic dysfunction is extremely important to be able to react, manage and catch early before it becomes a life threatening situation. One of the biggest challenges with laminitis and metabolic dysfunction (like EMS or PPID) is that the early signs are often subtle, and by the time classic symptoms appear (like the “laminitic stance” or obvious lameness), the disease is already well advanced.

Here are some of the more subtle symptoms to watch for:

Subtle Signs of Laminitis

• Shortened stride / reluctance to move forward – may look like the horse is just “lazy,” stiff, or footsore on hard ground.
• Shifting weight when standing – alternating front feet, resting one foot more than usual, or standing with front feet stretched slightly forward.
• Reluctance to turn – especially on a tight circle; horse may look “stiff” rather than overtly lame.
• Increased digital pulse – can be felt at the fetlock or pastern, sometimes more noticeable after exercise or sugar intake.
• Warm hooves – especially when persistent or uneven between hooves.
• Flat or stretched sole – before obvious separation occurs.
• Rings in the hoof wall – wider at the heel than at the toe, suggesting changes in growth rate.
• Change in behaviour – irritability, grumpiness when ridden, or reluctance to have feet picked up.

Subtle Signs of Metabolic Dysfunction (EMS, PPID, insulin dysregulation)

• Laminitis – discussed below
• Cresty neck or abnormal fat deposits – behind shoulders, around tail head, or above eyes (fat pads above the eye can be an early warning).
• Difficulty losing weight despite restricted diet – or unexplained weight gain.
• Muscle wastage – especially topline loss (more common with PPID).
• Mild lethargy – horse just seems “flat” or not performing as usual.
• Increased thirst or urination – more often with PPID, but can appear with metabolic stress.
• Delayed coat change – shedding late in spring, or developing a slightly longer, wavier coat (an early PPID sign).
• Filled sheath or udders – Horses with insulin resistance often develop abnormal fat pads and sometimes mild, fluctuating oedema (fluid swelling). The sheath and mammary region are common places where this shows up because the tissue there is loose and more prone to fluid accumulation.
• Recurrent foot soreness – mild, inconsistent lameness episodes that come and go.
• Slow wound healing or frequent skin infections – due to impaired immune function in PPID horses.

The tricky part is that many of these early signs can easily be mistaken for other issues (like arthritis, saddle fit, or laziness). But taken together, especially in easy-keeper breeds (native ponies, cobs, Morgans, Andalusians, etc.), they should raise suspicion.

Laminitis: Not a Stand-Alone Disease but a Symptom of Metabolic Dysfunction

Laminitis is often thought of as a hoof disease. In reality, research has shown that it is rarely a stand-alone condition. Instead, laminitis is best understood as a clinical symptom of underlying metabolic and endocrine dysfunction. For horse owners and veterinarians, this distinction is crucial, because it changes laminitis management from a short-term hoof problem into a lifelong systemic issue requiring lifelong management.

Laminitis is a Symptom, Not a Disease

Historically, laminitis was attributed to grain overload, pasture fructans, or mechanical stress. While these can contribute, the majority of modern cases are endocrinopathic laminitis—laminitis linked to hormonal and metabolic dysfunction.

• Pollitt (2008) described laminitis as a “syndrome with multiple causes,” with endocrinopathic forms dominating in today’s domesticated horse population.
• Patterson-Kane et al. (2018) confirmed that the most common type of laminitis in the field is associated with insulin dysregulation.

In other words, laminitis is a downstream effect of systemic disease rather than a primary condition.

Laminitis is the clinical manifestation of an internal metabolic problem

Metabolic Dysfunction as the Root Cause

Two major conditions are repeatedly linked to laminitis: Equine Metabolic Syndrome (EMS) and Pituitary Pars Intermedia Dysfunction (PPID).

• Equine Metabolic Syndrome (EMS):
  Horses with EMS typically show obesity, abnormal fat distribution, and insulin dysregulation.
  • Asplin et al. (2007) demonstrated experimentally that prolonged high insulin levels can directly induce laminitis in otherwise healthy horses.
  • This provides strong evidence that hyperinsulinemia is not just associated with, but causative of, laminitis.
• Pituitary Pars Intermedia Dysfunction (PPID):
  In PPID, abnormal pituitary function disrupts hormone regulation, which in turn worsens insulin dysregulation.
  • McFarlane (2014) notes that horses with PPID are predisposed to laminitis, particularly when insulin resistance is also present.

Why Laminitis Is a Lifelong Problem

Because the underlying metabolic disorders (EMS, PPID) are chronic, affected horses remain at risk for laminitis throughout life—even after apparent recovery.

• Durham et al. (2019) emphasise that laminitis management requires ongoing attention to diet, weight, and endocrine health to prevent recurrence.
• The principle “once laminitic, always at risk” is supported both by clinical experience and by endocrinological studies.

This makes laminitis a lifelong management issue, not an isolated hoof event.

Implications for Management

Effective laminitis management must therefore extend beyond the feet:

• Diet: Low non-structural carbohydrate (NSC) forage, avoidance of high sugar/starch feeds.
• Weight control: Obesity is strongly linked with insulin resistance (Geor & Harris, 2009).
• Exercise: Improves insulin sensitivity if the horse is sound.
• Medical support:
  • PPID: Pergolide (Prascend®) to control pituitary function.
  • EMS: Metformin has limited efficacy but may help some cases.
  • NOT giving NAID’s (Bute)
• Hoof care: Corrective trimming/shoeing provides comfort and stability but does not treat the underlying disease.
• Movement – box rest is now not recommended as movement and circulation is essential
• Bodywork – compensation, circulation, tissue health, pain management, nervous system regulation, foot and posture alignment support

A multidisciplinary approach combining veterinary care, farriery, bodywork, diet, and lifestyle change offers the best chance of long-term success.

---

NSAIDs and Pain Management in Laminitis

Non-steroidal anti-inflammatory drugs (NSAIDs) such as phenylbutazone (bute) were traditionally prescribed for laminitis to reduce pain and inflammation. However, modern research highlights significant limitations to their role in management.

• Masking protective pain: Pain discourages overloading of damaged laminae. Excessive use of NSAIDs can allow the horse to move more than is safe, potentially worsening laminar separation.
• Inflammation is not the primary driver: In endocrinopathic laminitis (EMS/PPID), the initiating factor is insulin dysregulation, not inflammation (Asplin et al., 2007). NSAIDs therefore do not target the root cause of disease.
• Systemic risks: Long-term NSAID use carries risks of gastric ulceration, colitis, and renal compromise, particularly in overweight or metabolically compromised horses.

Current best practice:

• NSAIDs may still be used short-term for welfare reasons in acute, painful cases.
• They should not be relied upon as a primary treatment or as a long-term management strategy.
• The focus of therapy should instead be on dietary control, insulin regulation, controlled movement, and appropriate hoof support.

Supporting evidence:

• Pollitt & Karikos (1993) showed NSAIDs failed to prevent laminitis progression in experimental carbohydrate overload models.
• Asplin et al. (2007) demonstrated that laminitis induced by hyperinsulinaemia was not associated with an inflammatory response, explaining why NSAIDs offer limited benefit.
• Durham et al. (2019) emphasised the primacy of endocrine control in managing laminitis, with NSAIDs considered only an adjunct for short-term comfort.

NSAIDs are no longer considered a cornerstone of laminitis therapy. Their use should be cautious, limited, and always secondary to addressing the underlying metabolic dysfunction and providing mechanical hoof support.

---

Laminitis, Metabolic Dysfunction, and the Role of Barefoot Management

Correct hoof care is central to successful management. One strategy increasingly discussed is keeping horses barefoot / using barefoot trimming principles. Below is what current scientific literature shows about benefits, limitations, and how barefoot care may fit into a laminitis‐management program.

What “Barefoot Management” Means in This Context

For laminitic/metabolic horses, “barefoot management” generally includes:

• Removing traditional steel shoes, often moving to barefoot or using boots when needed.
• Trimming the hoof frequently according to principles that reduce stress on the laminae
• Maintaining correct hoof morphology: promoting solid sole depth, correct angles, hoof wall alignment.
• Ensuring the ground and turnout conditions are appropriate (avoiding overly sharp rocky surfaces until foot has hardened, providing supportive substrate).

Evidence From the Scientific Literature for Barefoot / Barefoot Trimming Benefits

1. Hoof Morphology Improvements

• Clayton, Gray, Kaiser, Bowker (2011), Effects of Barefoot Trimming on Hoof Morphology:
  This study followed seven horses trimmed every 6 weeks under barefoot trimming principles over 16 months. Major findings included: shortening of the toe, heel, medial and lateral walls; increases in heel angle and solar angle of the distal phalanx (P3); increases in support length of the hoof. PubMed+1
  These changes can help in horses with under‐run heels or negative solar angle of P3—conditions that put abnormal stress on the laminae and can exacerbate laminitis.
• Changes in Hoof Shape During a Seven-Week Period When Horses Were Shod Versus Barefoot (Roepstorff et al., “crossover” study):
  Over seven weeks, horses kept barefoot versus shod showed significant differences: barefoot horses maintained or increased hoof angle slightly, had greater solar circumference (i.e. spread of hoof sole/hoof base), and less proximal hoof circumference loss than shod horses. PubMed+1
  Implications: barefoot hooves may better maintain their natural shape, expand under loading, possibly improving load distribution and reducing excessive stress on any one structure (such as the hoof wall or laminae).

2. Heel / Sole Support / Heel Expansion

• “Can the hoof be shod without limiting heel movement?”: This experimental study compared heel expansion (mediolateral movement) in three situations: barefoot, conventional shoe, split‐toe shoe. It showed conventional shoes significantly reduced heel movement vs barefoot. PubMed
  Why this matters: Heel expansion is thought to help distribute load, absorb concussion, improve blood flow, and reduce mechanical stress on the laminae. Reduced heel movement (as happens with many shoes) may contribute to higher stresses. Allowing more natural movement may thus be protective or supportive in laminitic/metabolic horses.

3. Practical Considerations in Laminitis Rehabilitation

• From The Laminitis Site (TLS), which compiles both veterinary and farriery practice and reports:
  TLS recommends against shoes initially for laminitis rehab because: a) The hoof walls are often not fully connected to the bone (i.e. rotations or separation can exist), so weightbearing on the walls should be minimized. b) For repositioning / realigning the hoof (e.g. lowering heels, adjusting palmar or plantar angles), frequent trimming is necessary; shoes complicate or prevent some of these adjustments. c) Support beneath the distal phalanx (via sole / frog / bars / padding / boots) is more feasible barefoot (or with boots), especially when parts of the wall are compromised. The Laminitis Site
• Although not specific to laminitic horses, the “Hoof Capability of Barefoot‐Kept Horses and Ponies Walking over Artificial Environments” (preprint) aims to measure how soles adapt in barefoot horses under artificial (hard or variable) terrain. Findings suggest that barefoot horses can maintain sole thickness and adapt morphologically when kept in good conditions (forage diet, turnout). This suggests that barefoot management can be viable in many environments, though care is needed. Preprints

How These Benefits Tie Into Managing Laminitis as a Lifelong Metabolic Issue

Putting the above together with what we know about laminitis being a symptom of systemic dysfunction:

• Reduced mechanical stress on compromised laminae: In metabolic laminitis, the laminae are already weakened or inflamed. Hoof shapes that reduce lever arms (long toes), increase heel support, allow the frog/bars/sole to bear weight, and allow heel expansion will help reduce subjective/absolute strain on the laminar attachments. Barefoot trimming that corrects long toes / under‐run heels helps in this regard.
• Improved circulation and load distribution: Allowing natural deformation (expansion/contraction) and contact of frog/bars/sole with ground may improve blood flow, reduce regions of stress, and improve comfort.
• Flexibility for adjustment: Since metabolic issues and laminitis episodes can change the hoof’s internal geometry (rotation, sinking, palmar/plantar angle changes), barefoot care (with frequent trims) gives more ability to adjust, re‐align, correct angles—because there is no rigid shoe or nails to work around.
• Prevention of recurrence: By ensuring hoof conformation supports structural alignment and minimizing recurring stressors, barefoot management adds to preventive strategies (diet, weight control, endocrine control) to reduce the risk of further laminitic episodes.

Barefoot Management as a Strategy in Laminitis Rehabilitation & Metabolic Horses

Emerging evidence supports that barefoot hoof care, when applied properly, can offer significant benefits in laminitic/metabolic horses. While more targeted trials are needed, current studies show changes in hoof morphology, load-bearing function, and heel/sole support that can reduce stress to the laminar structures.

Key beneficial effects documented:

• Correction of long toe under‐run heel conformation; increases in heel angle and solar angle of the distal phalanx (P3), which reduce lever effects on the laminar connection. PubMed+2Mad Barn USA+2
• Greater sole width / solar circumference; better hoof base expansion, which aids load distribution. PubMed+1
• Enhanced heel expansion and movement (when barefoot) which may improve circulation and shock absorption. PubMed
• More rapid and flexible ability to realign angles and control hoof geometry via frequent trimming—important during laminitis when the hoof’s internal alignment is often compromised. Barefoot trimming is more adaptable for these adjustments. The Laminitis Site+1

How this integrates with metabolic laminitis management:

• When a horse with EMS or PPID is at risk, or recovering from a laminitis flare, combining metabolic control (diet, weight, endocrine therapy) with barefoot hoof care can reduce both systemic and local risk factors.
• For example, lowering insulin reduces the biochemical injury to laminar tissue, while barefoot alignment reduces mechanical strain. Together, these can reduce pain, improve healing, and reduce recurrence.
• During recovery phases, use of protective boots, soft footing, and frequent trimming will help transition to barefoot without undue pain or risk.

Limitations, Risks, and Gaps in the Evidence

To have a balanced view, it’s important to understand the limitations and what is not yet shown scientifically:

• Lack of direct trials in laminitic + metabolic horses: Few studies have directly tested barefoot vs shoeing in horses currently in laminitis with metabolic dysfunction. Most are in “normal” horses or those with hoof shape concerns.
• Sensitivity / discomfort during transition: Removing shoes and altering hoof shape can initially cause soreness, especially if the ground is hard / sole thin, or hoof has been “protected” for a long time. Booting or padding may be needed during the transition.
• Ground/terrain concerns: Barefoot management requires suitable terrain or supplemental protection (boots, soft ground) especially early or during bouts of sole tenderness.
• Quality of barefoot trimming matters: Poor trimming (too much off, leaving sharp edges, not maintaining frog/bars, ignoring alignment) can worsen problems. Not all farriers or trimmers have equal skill or understanding of anatomy, especially in compromised feet.
• Individual variation: Breed, hoof wall quality, metabolic severity, conformation, previous damage—these all influence how well a horse will respond to barefoot care. Some may always need some form of shoeing or protection.

---

Movement and Circulation: Why Box Rest is Not Recommended

Historically, horses with laminitis were often confined to box rest, but increasing evidence suggests this is counterproductive in endocrinopathic laminitis. While acute cases may require a short period of stabilisation, prolonged immobility reduces circulation to the feet, slows recovery, increases stiffness, and worsens metabolic dysfunction.

Movement is vital for several reasons:

• Circulation and hoof health: Locomotion improves blood flow to the laminae and supports hoof capsule healing (Bowker, 2003).
• Insulin regulation: Even low-intensity movement improves insulin sensitivity (de Laat et al., 2016), directly addressing the root cause of laminitis.
• Musculoskeletal wellbeing: Gentle movement prevents secondary stiffness, joint restriction, and muscle loss.

Practical management of movement:

• Bald paddock or track system: Horses should be turned out in a grass-free environment to allow self-exercise without further sugar intake.
• Soaked hay fed in multiple stations: Placing hay in several feeding points encourages natural movement and mimics foraging behaviour.
• Protective hoof boots or pads: These can be used to improve comfort on firm ground while still allowing beneficial movement.

Thus, while the horse cannot be ridden during acute laminitis, encouraging free movement in a controlled, low-sugar environment is essential for rehabilitation. Box rest should be avoided except in the most extreme cases, and only as a very short-term measure.

---

Bodywork in Laminitis Rehabilitation

1. Managing Compensation Patterns

Laminitis causes severe pain in the feet, and horses instinctively adopt compensatory postures:

• Leaning back onto the heels (“sawhorse stance”) to unload the toes.
• Shifting weight excessively to the hindlimbs.
• Developing tension in shoulders, neck, thoracic sling, and lumbar region due to altered gait.

Over time, these compensations can cause secondary musculoskeletal issues — tight muscles, fascial restrictions, and joint strain.

Bodywork (massage, myofascial release, stretching, chiropractic/osteopathic techniques) helps:

• Release muscle tension in overloaded areas (triceps, shoulders, hamstrings).
• Improve circulation and lymphatic flow in tight tissues.
• Support more balanced posture once the feet become more stable.

2. Improving Circulation and Tissue Health

One of the goals in laminitis rehab is to improve blood flow to the feet and distal limbs, since perfusion of the laminae is often compromised.

• Massage and myofascial techniques increase peripheral circulation.
• Gentle mobilisations of the limbs (when comfortable) can enhance vascular and lymphatic return.
• Craniosacral and fascial work may reduce systemic tension that inhibits blood flow.

While research directly linking massage/bodywork to laminitis outcomes is scarce, human studies show soft tissue therapy increases circulation and reduces pain perception — and equine studies have shown similar benefits in muscle relaxation and stride length.

3. Pain Management and Nervous System Regulation

Laminitic horses are often in chronic pain and stress, which activates the sympathetic nervous system (fight-or-flight).

• Gentle bodywork encourages parasympathetic activity (“rest and digest”), helping reduce cortisol and systemic stress.
• Lower stress hormones can support metabolic stability and improve healing (important for horses with EMS/PPID).

4. Supporting Hoof and Postural Realignment

As trimming and hoof rehabilitation progress, the horse’s posture shifts. Bodywork:

• Helps the horse adapt to new limb angles and loading patterns.
• Prevents “old” muscular compensations from persisting once the feet are corrected.
• Restores range of motion in joints restricted during the painful phase.

5. Research and Evidence

While equine-specific research on bodywork in laminitis is limited, several studies provide supportive evidence:

• Haussler (1999, Equine Veterinary Journal) – chiropractic techniques improved spinal mobility and reduced pain in horses.
• Tabor & Williams (2004, Equine Veterinary Education) – physiotherapy and manual therapies support recovery from lameness by addressing compensatory strain.
• McGowan et al. (2010, Equine Veterinary Journal) – rehabilitation of chronic laminitic horses must consider the whole horse, not just the foot.

This suggests bodywork is most effective when integrated with veterinary, farriery, and management approaches.

How I Approach the Practical Applications in Laminitis Rehab

• Early stage (acute laminitis): focus on comfort — gentle massage of shoulders, neck, hindquarters, avoiding direct manipulation of painful feet.
• Subacute stage: fascial release, gentle stretching, lymphatic massage to improve circulation.
• Chronic/recovery stage: more active techniques — mobilisations, core stability exercises, dynamic mobilisations, pole work (when horse is sound enough), strengthen conditioning, postural improvement.

Conclusion

Scientific evidence clearly demonstrates that laminitis is not a stand-alone disease but a symptom of deeper metabolic dysfunction. Viewing it in this light reframes both treatment and prevention: addressing the whole horse’s metabolic health rather than only the feet. For owners, this means committing to lifelong holistic management programme to safeguard horses from repeated, painful episodes of laminitis, gaining a deeper understanding of the causes to help prevent flare ups and awareness of evidence based treatments rather than the outdated treatment protocols that hinder the long term prognosis of the horse.

If you would like any further information or help with your horse please do not hesitate to contact me. Below are a list of references I used to help me write this article if you would like some further reading or clarification or there are also lots of sources online which I can pass on if you are interested.

---

References

• Asplin, K. E., Sillence, M. N., Pollitt, C. C., & McGowan, C. M. (2007). Induction of laminitis by prolonged hyperinsulinaemia in clinically normal ponies. American Journal of Veterinary Research, 68(7), 755–761.
• Clayton, H. M., Gray, S., Kaiser, L. J., & Bowker, R. M. (2011). Effects of barefoot trimming on hoof morphology. Australian Veterinary Journal, 89(8), 305–311. PubMed+1
• Durham, A. E., Fey, K., McGowan, C. M., et al. (2019). Pituitary pars intermedia dysfunction: Diagnosis and management. Equine Veterinary Journal, 51(2), 185–195.
• Geor, R. J., & Harris, P. A. (2009). Dietary management of obesity and insulin resistance: Countering risk for laminitis. Veterinary Clinics of North America: Equine Practice, 25(1), 51–65.
• Hagen, J., et al. (2019). Heel movement in barefoot vs. shod horses. The Veterinary Journal, 246, 1–6.
• Haussler, K.K. (1999). Chiropractic evaluation and management of musculoskeletal disorders. Equine Veterinary Journal, 31(4), 291–295.
• “Laminitis rehab — barefoot vs shod,” The Laminitis Site (non-peer-reviewed compendium but summarising practice and published data). The Laminitis Site
• McFarlane, D. (2014). Equine pituitary pars intermedia dysfunction. Veterinary Clinics of North America: Equine Practice, 30(1), 73–93.
• McGowan, C.M., Frost, R., Pfeiffer, D.U., & Neiger, R. (2010). Long-term management of chronic laminitis: a whole horse approach. Equine Veterinary Journal, 42(5), 471–478.
• Patterson-Kane, J. C., Karikoski, N. P., & McGowan, C. M. (2018). Paradigm shifts in understanding equine laminitis. Equine Veterinary Journal, 50(6), 564–575.
• Pollitt, C. C. (2008). The anatomy and physiology of the suspensory apparatus of the distal phalanx. Veterinary Clinics of North America: Equine Practice, 24(1), 29–50.
• Roepstorff, L., et al. (2020). Hoof expansion and balance in barefoot vs. shod horses. Equine Veterinary Journal, 52(5), 703–710.
• Roepstorff, L., et al. (2020) “Changes in hoof shape during a seven-week period when horses were shod versus barefoot” (crossover study). PubMed+1
• Study comparing heel movement with barefoot vs different shoe types: Can the hoof be shod without limiting heel movement? PubMed
• Tabor, G., & Williams, J. (2004). Physiotherapy and manual therapy in equine rehabilitation. Equine Veterinary Education, 16(3), 151–156.