Treatment Information, Events, News & Articles
Treatment Information: How to Know If It Is Time to Get That Bunion Fixed…..
Bunion is the name given to a prominent bump on the inside of the foot at the base of the great toe. The medical term is hallux abductovalgus. Bunions tend to increase in size and severity as time goes on, and they can become painful for a variety of reasons such as soft tissue irritation (bursitis) related to rubbing on tight fitting shoes, inflammation of the joint capsule (synovitis), or from arthritis of the great toe joint from moving in a position for which it was not designed.
Bunions occur in approximately 1 in 4 adults and as age increases, so does the incidence of bunions. Women develop bunions more than men, and bunions can occur in small children to elderly patients. They often run in families but certainly don’t have to.
It’s important to know that not all bunions require surgery. Initial conservative treatment is usually helpful and is directed at reducing pressure and inflammation over the painful bony prominence. This is accomplished with wider shoes and padding. For inflammation, the RICE protocol (Rest, Ice, Compression, and Elevation), anti-inflammatories, and perhaps a cortisone injection if warranted are usually quite effective during the early phases of bunion development. Other popular treatments such as bunion splints and toe spacers that hold the great toe in a corrected position yield mixed results. They may help the toe feel better but do nothing to keep the toe in the corrected position when not wearing the device. Orthotics are specialized shoe inserts that are intended to address the forces in the foot that lead to the formation of bunions in the first place. They can slow down or halt the progression of bunions, but unfortunately will not cause a bunion disappear once developed.
So when should one consider having a bunion surgically corrected? No two bunions are created equally and there are many factors that come into play when attempting to answer this question.
I’ve seen patients with severe bunion deformities (think big toe crossing under the second toe) that had no pain. Conversely, I’ve seen patients with relatively mild degrees of deformity that couldn’t wear shoes because the pain was so severe. There are many reasons that this may be the case and further workup usually reveals the answer as to why. The degree of deformity is almost always less important than one’s ability to walk without pain and function at a high level regardless of how bad a bunion may appear. I always ask a few questions when helping patients decide if a bunion surgery is best for them, such as “Do you have difficulty wearing shoes without pain? Even wide shoes? Is the pain keeping you from doing things you would otherwise be doing (i.e. exercise, hiking, work, etc.)? Have the symptoms failed to resolve or substantially improve with first trying conservative measures? Has the deformity significantly worsened over a short period of time (less than a year)?” If the answer to these questions is “yes”, then we usually further discuss what surgical options may result in long-term pain relief in addition to appropriate expectations following bunion surgery.
When discussing bunion surgery with your doctor, there are many things to consider. There are many different surgical procedures to fix bunions and if you see 5 different doctors, you may very well get 5 different opinions on which procedures work best. Procedure selection and rational comes down to individual patient factors, severity of deformity, apex of the deformity, surgeon preference, and a patient’s given expectations following a surgery. For instance, I may choose very different procedures based on postoperative expectations for a 25 year old athlete versus an 87 great grandmother even though they may have a similar deformity.
Recovery can vary significantly depending on which procedures are performed. A bunionectomy surgery could be a simple procedure (shaving a painful bump) to a quite complex surgery (fusing multiple unstable joints with plates and screws), and that’s the difference between being weight bearing and back into normal shoes in 2 weeks versus 2 months of being non-weight bearing on crutches. Your average bunionectomy surgery (~70% of cases) will consist of 6 weeks of weight bearing in a protective cast boot before transitioning back into normal shoes; however, high impact activities such as running and jumping may need to be put off for an additional 1-2 months. Recovery is a gradual process and people heal at different rates.
In some instances, bunions can come back even after surgery. This doesn’t happen very often, but it certainly is a possibility and something of which all patients should be aware and consider prior to surgery. One can re-develop a bunion for the same reasons that they developed the bunion in the first place, although surgical correction is usually enough to counteract the body’s desire to want to re-develop a bunion. For instance, hyper-mobility and excessive pronation (over collapse of the arch) are common predisposing factors that can lead to bunion formation in certain patients. A beautiful surgical correction can be obtained, but if hyper-mobility is not addressed (or is greater than the surgical correction) then these patients are much more likely to have a recurrence. Hyper-mobility is managed with appropriate procedure selection and/or orthotics in most cases. Other factors that increase the chance of recurrence are a rounded metatarsal head (as opposed to more of a square shape), early onset of bunion deformity (childhood), family history, returning to inappropriate shoes, and adherence to postoperative protocol.
Deciding to proceed with an elective foot surgery, no matter how major or minor, is a process. It is worth discussing with friends, family, your employer, and your foot and ankle surgeon before committing to anything. There is unfortunately a lot of misinformation out there and speaking with a specialist will help you sort through the facts, develop accurate expectations, and make an informed decision. Having appropriate expectations will play a large role in determining your satisfaction with your results after bunion surgery. With careful preoperative planning and discussion, bunion surgery yields predictable results and a high rate of patient satisfaction.
Article Treatment Information: Ankle Stabilization Procedures
Recurrent ankle sprains, pain, and chronic instability are conditions we treat on a regular basis. There are many treatment options as these conditions are quite common and the degree of instability can vary widely. When conservative measures have failed, surgery can provide relief for the vast majority of patients.
A variety of procedures have been utilized to address ankle instability. Historically, direct repair of the ligament (sewing the ligament back together) resulted in reasonable outcomes but was certainly not without its drawbacks. Old injuries often meant that there was little remaining ligament or substantial soft tissue to sew back together. This made tensioning and a robust repair problematic. Re-injury and tearing of the repair was extremely common.
The advancement of bone anchors was a great step forward in terms of repairing ankle instability. A bone anchor is an implant used to secure soft tissues back to bone. These anchors are usually constructed of metal, bio-absorbable materials, or other advanced medical grade plastics. They’re typically screwed or press-fit into drill holes and provide excellent security/strength in good bone. Attached to the anchor are strong sutures which are utilized to secure the torn ligament back to the face of the bone. The development of quality bone anchors has resulted in significant improvement and patient outcomes and made for a simpler more reproducible procedure. Unfortunately, re-injury and tearing of the repairs remained extremely common especially if the soft tissues were compromised. Unfortunately with chronic injuries, this is often the case.
Tendon transfers and grafts have also been utilized to reconstruct ligaments with some success. These procedures usually resulted in more a substantial and robust repair that were difficult to re-injure. The downside was more extensive surgery and harvesting of what would be an otherwise healthy, functional tendon and transferring it to provide ligamentous support where needed. This was often well-tolerated but certainly less than ideal.
More recently, a new anchor system called an “internal brace” has been utilized to address many of the shortcomings of the above procedures (the internal brace is a product made by Arthrex, a company with which we have no affiliation). This technique is utilized in conjunction with one of the above procedures as augmentation. The main problem with less invasive techniques has always been re-injury and compromise of the repair. The internal brace is placed on top of the repair as reinforcement. This utilizes a strong fiber tape placed over the repaired ligament that is secured on either end directly to the talus and fibula bones to bolster the ligament repair and serve as a backup. Another way to look at it is the primary ligament repair provides dynamic stability where the internal brace is more of a static construct which serves as a secondary backup if the primary repair were to loosen or become torn. This greatly lessens the detrimental impact of weak soft tissues with regard to the overall structural integrity of the repaired ligaments. In our experience this has been a nice adjunctive procedure and has improved outcomes, particularly over the long-term.
Article: Cycling Part 3 – Do orthotics have a place in cycling shoes?
Foot beds and orthotics are a great way to really improve the performance of any cycling shoe. Our feet are designed for walking/running, adapting to uneven terrain, absorbing shock, and providing propulsion. Needless to say, our feet have not evolved around cycling. Fortunately, cycling footwear and insoles have evolved around our feet.
When the foot lands, it pronates (think arch collapse, forefoot splays out) to absorb shock. Some pronation is a good thing. This is the result of the foot reacting to the ground and the position of the lower leg and hind foot. As weight is progressively applied, the tibia internally rotates and weight is transferred from the hind foot to the midfoot. The foot becomes a “loose bag of bones” at this point. It absorbs impact and conforms to uneven surfaces. Too much or too little pronation is a bad thing.
On the opposite end of the spectrum is supination. During normal walking, supination occurs when weight is shifted from the midfoot to the forefoot. This occurs as the foot switches from deceleration (shock absorption) to acceleration (progression towards toe off). The tibia externally rotates and the foot goes from that “loose bag of bones” to a rigid lever. This allows for efficient propulsion and keeps power generated by the legs from being robbed by the foot when explosiveness is needed.
Pronation-supination is a continuum. Some people fall more on one end or the other. In cycling, there is much less need for pronation than there is with walking or running. What would be considered a normal amount of pronation with these activities would be considered excessive for cycling resulting in inefficient power transfer to the bike under the same conditions.
Orthotics control the position of the foot and cause it to function in a more supinated position when intended. This is useful for sports like skiing and cycling. There are really two options when it comes to orthotic – custom and prefabricated over-the-counter (OTC) devices.
OTC orthotics will mostly benefit casual riders with a relatively neutral foot type. Not all OTC orthotics are created equal, however. Look for devices with an aggressive rigid arch. If you can take the foot bed, place it on the counter top, and completely compress the arch with your thumb, it’s no good. You standing on it, is no contest and it is nothing more than a squishy pad, robbing you of energy transfer. My favorite OTC orthotic is Superfeet (no affiliation) although there are other decent ones out there (Powersteps, Sole, etc).
There are many times when a one size fits all approach simply won’t do. Custom orthotics are preferred when treating pathology to the lower extremity, when there is a presence of more significant deformity (excessive pronation/supination for instance), or for serious cyclists who really want their setup dialed in.
Article: Cycling Part 2 – Cycling shoe fit tips
Many cyclists think little of spending $400 on the latest pair of carbon racing cycling shoes. Much less thought is given to the foot beds that come in the shoes or aftermarket inserts/orthotics. The ultimate goal is a comfortable, well-fitting setup, light weight, and efficient transfer of power from the lower extremity to the crank arms.
Poorly fitting shoes, regardless of price point, will result in compression and friction injuries – think blisters, numbness, pain under the ball of the foot, etc. Every brand uses different lasts and will therefore accommodate different foot types. If you have a wide foot type, lean toward Specialized, Northwave, Mavic, or Spiuk. Narrow feet? Try Sidi, Italian shoes, or consider shoes with a Boa closure system. These are not absolutes however, as some of these companies make both wide and narrow models. There is no substitute for trying on shoes in person. You could buy a top-of-the-line shoe but will be miserable if it is poor fitting.
Cycling shoes, especially road shoes, should fit snuggly. More snug than a pair of street shoes. This is where things get tricky and the small details have a profound impact on comfort. Some guidelines to follow when selecting shoes:
- Do not buy shoes where the longest toes are pressed or touching the end of the shoe, unless you do not value your toenails. Ideally 3-5mm past the end of your longest toes when standing and bearing weight.
- Very few cycling shoes have appropriate arch support despite marketing (this is easily remedied with aftermarket insoles/orthotics). Try on shoes with the insoles you plan to use in them. This dramatically changes fit. Make sure to remove the factory insole first.
- If you have to really crank down the closure system (laces, ratchet, boa, etc.) for the shoe to feel secure, it is probably a poor fit.
- Heels should never slip and you should never feel uncomfortable pressure while walking.
- Width – not too much, not too little. Too narrow results in hot spots, pain under the ball of the foot, and nerve compression injuries; too wide results in inefficient transfer of power. I would err on the side of too wide rather than too narrow. You can always add a shim to take up space, but there is usually little you can do to add space where there is none.
Article: Cycling: Foot and Ankle Injuries
We live in a community where cycling is an integral part of the culture. Consequently, I treat a lot of injuries related to cycling – both mountain biking and road biking.
Ensuring proper bike fit is a good place to start in terms of treating and preventing chronic cycling injuries. When standing over the top tube of a road bike, there should be 1-2 inches of space between the rider’s crotch and the top tube. Mountain bikes will have quite a bit more space to accommodate for different riding styles and frame geometries. Saddle position is also of significant importance. On a road bike: Place the crank arms at the 6 and 12 o’clock position, the bottom of the 6 o’clock foot should be parallel to the floor and the knee just flexed when sitting on the seat. On a mountain bike, this would be an appropriate position for a fully extended dropper seat post. Regarding fore and aft seat position: With the crank arms placed in the 3 and 9 o’clock position, a plumb line off the patella should pass through the center of the pedal axle for the forward foot. Mountain bikers should slide the seat back about an inch to improve traction on steep climbs and confidence on steeper descents.
Clipless pedals that allow some degree of float are much preferred as opposed to rigid/fixed pedal systems. Cleat position is something that I will modify frequently to address certain types of pathologies. A good place to start is with the cleat centered under the widest part of the foot. I will often post the cleat at an angle to accommodate for various lower extremity deformities such as excessive pronation or supination.
Cycling shoes, especially road cycling shoes, tend to be quite snug and rigid. It is the rigidity and tightness that allows for efficient transfer of power from the lower extremity to the crank arms. Unfortunately, this can have the unintended consequence of lower extremity and foot pain. Pain under the ball of the foot or metatarsalgia and neuromas are frequently exacerbated under these conditions. Shoe modifications such as wedging, padding, and orthotics are usually quite effective at treating these conditions with cycling shoes, as long as there is adequate width.
Below is an algorithm that a lot of cyclists may find as a useful starting point for addressing different types of lower extremity injuries and pain:
- Achilles tendinitis – move the cleat back on the shoe so that the ball of the foot is more forward on the pedal, raise saddle height, address a limb length discrepancy with appropriate shim, decrease resistance and increase cadence.
- Patellar/quadriceps/patellofemoral tendinitis – raise saddle height and slide saddle back, decrease resistance and increase cadence.
- Plantar fasciitis – raise saddle height, remove the cleat back towards the heel, address a limb length discrepancy with appropriate shim.
- Tight hamstrings – ensure appropriate cleat position, move saddle forward, lower the saddle.
- IT band syndrome – position cleat with slight external rotation, move saddle forward, lower saddle.
-Dr. Douglas Goforth
Treatment Information: Ankle arthroscopy
If you have done any kind of sport in your life, chances are you have suffered an ankle sprain or fracture. Ankle sprains and fractures often result in damage to structures contained within the ankle joint. Primarily this affects bone, cartilage, and the soft tissue lining of the joint call the synovium. When surgery is selected, this requires either an open or percutaneous approach to repair damage within the joint. Ankle arthroscopy, however, allows a minimally invasive percutaneous advantage to open techniques.
Did you know that 90% of ankle sprains involve damage to the anterior talofibular ligament which is integrated into the ankle joint capsule? Now you do! And when the ligament tears, so does the capsule. This results in inflammatory tissue and scar tissue along the lining of the joint, synovitis. It is the synovitis which is responsible for a lot of the pain associated with ankle injuries as it is the joint capsule which contains the majority of nerve endings. These nerve endings are also responsible for proprioception which was discussed in last month’s blog posting.
Moreover, approximately 30% of significant ankle sprains will also involve damage to cartilage and bone within the joint. When this happens it is called an osteochondral lesion or OCD. Some of these will spontaneously resolve on their own while others will result in chronic ankle pain, long after the soft tissues have healed. Sometimes these chip fractures can result in a loose body in the ankle joint which can cause freezing, popping, or clicking. Left untreated, OCDs will result in progressive damage and progression to worsening bone-on-bone arthritis in the ankle joint.
The good news is that these conditions are all easily treatable with ankle arthroscopy. Ankle arthroscopy is a minimally invasive technique which utilizes a fiberoptic scope held in one hand and a small instrument in the other hand. The camera and the instruments are inserted into the joint through two tiny incisions, usually on the front of the ankle. This approach allows for easy removal of loose bodies, treatment of osteochondral lesions, and removal of inflamed synovium and scar tissue within the joint.
This is typically done as an outpatient procedure. The actual scope portion of the procedure usually takes anywhere from 15 minutes to an hour. After the surgery patients return home and are usually permitted to bear weight with the use of a protective cast boot. Most folks are able to work out of the cast boot after 3-6 weeks depending on which procedures were performed. This allows for early range of motion, PT, and consequently a much quicker return to activity than older more invasive procedures such as the ankle arthrotomy procedure (long incisions to access the ankle joint, longer surgery time). Recovery times are rapid and postoperative patient satisfaction scores are quite high with arthroscopy, especially when compared to older techniques.
If you’d like more information on the ankle arthroscopy, please call us at Balanced Rock Foot and Ankle today! 858-2530
Article: Ankle Instability / Proprioception
When an ankle becomes injured, stability is compromised. This happens for several reasons. First, damage to tendons, ligaments, and bones can have a direct impact on structural stability. Secondly, damage to nerves around the ankle can have just as profound of an impact. It is this injury that is unfortunately commonly ignored. Even with good conservative or surgical treatment, ignoring this component may result in a suboptimal outcome.
Another name for this is “proprioception.” Proprioception literally means “sense of self.” It is what allows us to walk down a flight of stairs in the dark with confidence. It is why cats always land on all four legs, and why we automatically know just how high to lift our legs to clear obstacles in our path. These are seemingly automatic and happen without thinking about it.
There are nerve endings in the body with receptors, specifically designed for proprioceptive feedback. These receptors and nerves trigger an automatic response through the lower levels of our central nervous system. Additional information from the vestibular system is processed in the brain and feedback is sent to our muscles. This is all done without even thinking about it; in the absence of cognition.
The ankle joint capsule has the highest density of proprioceptive nerve endings in the whole body. With an ankle sprain or fracture; or even just a period of prolonged immobilization, these nerve endings become compromised. When ankle ligaments tear, so does the joint capsule. This results in direct injury to these nerve endings and receptors. The result is decreased confidence in the affected ankle and an inability to trust it, even after the musculoskeletal injury heals.
The good news is that balance and proprioceptive training has been shown to be effective at restoring function and preventing reinjury. Physical therapy exercises specifically address this and should always be part of the patient’s rehabilitation plan following an ankle injury. This can often be done self-guided or under the supervision of the physical therapist.
These exercises are relatively simple and easy to do, well, at least with some practice. Early motion after an ankle injury or surgery entails drawing the entire alphabet with one’s big toe. Once weight bearing activity is permitted, I will often have patients attempt to stand on one foot for a minute. Once this is mastered, then they are asked to progressively increase the difficulty. Sometimes this is done by having them close their eyes, or doing an activity like brushing their teeth, all while standing on one foot. The difficulty can also be increased by standing on a BAPS board or pillow.
Remember, ankle instability or failure to thrive after an old injury is not considered normal. There are many options to help improve pain and function in addition to proprioceptive exercises.
Article: Ankle Pain
Hi! I’m Dr. Goforth and this is my first blog at Balanced Rock Foot and Ankle.
I’d like to share some insights regarding chronic ankle injuries and pain. The ankle joint functions very differently from other joints of the body and has unique anatomy. It therefore plays by a different set of rules and responds to treatments differently.
Joints like the knee are designed to glide a bit and have a large surface area to absorb the body’s high impact forces. The ankle, on the other hand, is shaped like a mortise and has about a third of the surface area of the knee. The ankle won’t tolerate significant sliding motion and prefers tight tolerances and great stability.
Ankle cartilage is also much tougher but thinner than cartilage of the knee. Cartilage of the knee has lower compression strength. This is because the forces that ankle cartilage must endure greatly exceed that of the knee per unit of surface area. When this cartilage of any joint wears out or becomes damaged, the result is arthritis. The most common causes of this type of damage varies from joint to joint. While knee arthritis is frequently the result of wear and tear, ankle arthritis is almost always the result of an old injury.
Commonly, a bad ankle sprain or fracture that failed to heal properly results in altered function of the ankle joint sufficient to cause arthritis. Instability is not compatible with the tight tolerances that the ankle requires to stay healthy. The result is accelerated wearing of the cartilage and progressive pain. This usually occurs over a number of years following the injury but can begin at the time of injury as well.
Immediately after an acute ankle injury, good care can often prevent the need for more invasive treatments at a later date. When an injury fails to heal properly, chronic instability can occur. At this stage, periodic bracing and physical therapy are often adequate, however surgery becomes a consideration and may be discussed. Restoration and tightening of the torn ligaments combined with arthroscopy result in good outcomes for active patients. The goal is to permanently restore ankle function/stability and to halt the predictable progression to ankle arthritis.
In later stages, isolated pockets of arthritis (called osteochondral) lesions are treated with the microfracture procedure or cartilage grafting. The worst ankles are surgically fused or replaced.
Feel free to contact us at 970-858-2530 for more detailed discussion, evaluation, or questions.
Article: Heel Pain – Part 3
For this last series on heel pain, I will be discussing some of the more rare causes of heel pain. Although these etiologies are not as common, it is important that are not overlooked by a treating physician as a possible cause.
Osteoid osteoma is a benign tumor of the heel bone that often causes heel pain at night. The pain can be significant and is oftentimes alleviated by taking aspirin. The tumor tends to be less than 1.5 cm in size. The pain associated with this tumor is often described as a continuous, deep, aching, and intense pain with varying quality and severity. It is typically localized to the site of the lesion. Pain is usually worse at night (in 95% of patients) and diminishes by morning. Some patients may have an exertional component and it may also affect the patient’s gait.
Stress fracture is another possible cause of heel pain. This is a fracture, often a hairline fracture, that is caused by overuse. Our bodies are continually building up tissue and breaking it down. If the breakdown process exceeds the repair, then stress fractures can occur. Stress fractures are more likely to occur when bone is weakened, as in osteoporosis or osteopenia, and can often manifest with the patient starting a new exercise regimen.
Infections of the heel bone can occur due to direct trauma such as puncture wounds or spread from nearby wounds. Infections in other parts of the body such as dental infections, can spread through the blood stream to the heel bone and cause heel pain or an abscess within the heel.
Heel pain is less common in children than adults and the causes are usually different. The most common cause of heel pain in the approximately 9 to 14 year old age group is calcaneal apophysitis or Sever’s disease. This was discussed in a previous blog which you can reference for further information.
Baxter’s nerve is another name for the inferior calcaneal nerve, which is a nerve branch that runs beneath the heel bone. Entrapment of this nerve branch is a potential cause of heel pain. Baxter’s neuritis or Baxter’s nerve entrapment may cause heel pain which can be confused with plantar fasciitis. There are some differences in the type of symptoms each causes and this can be determined by a qualified foot and ankle specialist. Treatment options for Baxter’s neuritis include injections and mechanical control; but, ultimately this may require a surgical nerve release of the nerve or neurolysis.
Retro calcaneal heel pain (pain at the back of the heel) is the result of a tight or contracted Achilles tendon. The ankle joint allows the foot to move up and down (dorsiflexion and plantarflexion). The foot needs to be able to move up on the leg by about 15 degrees in order to allow normal gait. Upward motion of the foot on the leg is called dorsiflexion. Lack of adequate dorsiflexion can be caused by functional, neurological and congenital problems and can indicate a systemic or musculoskeletal disease in some cases. Treatment can involve physical therapy, bracing, or mechanical control. In some cases, a surgical lengthening of the gastrocnemius or the Achilles tendon may be required.
I hope you have found this series on Heel Pain informative. Remember heel pain is not normal. Any heel pain lasting more than a week should be appropriately evaluated to rule out many of the more severe causes of heel pain. If you are living with heel pain call Dr. Griffiths at 970-858-2530 to discuss a treatment plan to get you back to your active lifestyle.
Article: Heel Pain – Part 2
In part two of this series we will continue our discussion on the different causes of heel pain. We will focus on some different systemic problems that can manifest in part with heel pain. Not all individuals with one of these systemic conditions will develop heel pain, however it is important to consider these problems as a potential cause.
The systemic problems we will first look at are a group of arthritic conditions known as HLA-B27 Arthritis. This group includes conditions such as ankylosing spondylitis, psoriatic arthritis and Reiter’s syndrome. This can be a bit confusing for the lay person who probably associates arthritis with a joint and there is no joint at the location of plantar heel pain. However, these conditions can manifest with a large plantar heel spur, with inflammation surrounding this at the insertion or attachment of the plantar fascia ligament. This inflammation and spurring can be the cause of significant plantar heel pain. A simple blood test in combination with a skilled physical examination can help determine whether or not one of these problems may be the cause of heel pain.
Rheumatoid arthritis is a form of arthritis due to antibodies formed against the individual’s own tissues, most commonly tissues in joints. Once again, the more common manifestations of this arthritic condition involve joints, however it is a fairly common cause of heel pain.
Gout is a metabolic disease in which the body collects too much of a waste product called uric acid. Uric acid levels can be raised because the body makes too much uric acid or because it has difficulty excreting it. Gouty tophus materials can be deposited into the tissues and can affect the plantar fascia or the Achille’s tendon at the attachment to the heel bone causing heel pain.
In all of these cases, treatment of the underlying systemic condition is paramount in controlling the symptoms. Conservative options such as orthotics and injections may alleviate the pain in a majority of patients. In some cases, surgery may be required to address some of the local changes in the tissues.