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Archive for February, 2019

ICB Lower limb biomechanics

Sesamoiditis is painful inflammation of the sesamoid apparatus, which is located in the forefoot under the 1st MTPJ. It is not a particularly common condition and can be at times difficult to diagnose and treat. Generally it is accepted that the sesamoids perform two principal functions:

1. Absorbing impact forces in the fore-foot during walking through a series of attachments to other structures in the forefoot.

2. Acting as a fulcrum to provide the flexor tendons with a mechanical advantage as they pull the hallux down against the ground during gait.

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The hallux (big toe) has two phalanges and two joints (interphalangeal joints), together with two small sesamoid bones (the medial and lateral sesamoid bones).

The sesamoids are implanted or embedded in the flexor hallucis brevis tendon which exerts pressure from the big toe against the ground and aids in the act of walking during the toe-off phase of gait. The sesamoids not only have to endure the pressure of body, weight and gravity, but also the constrictive pressure of the flexor hallucis brevis tendon.

There are generally five categories of sesamoid apparatus type injuries:

A. Sesamoiditis is a general description of the condition which is given to inflammation of the sesamoids but actually relates more specifically to tendonitis of the flexor halluces longus1.

B.  Stress fractures of the sesamoid usually occurring as an impact injury.

C. Acute sesamoid fracture most commonly an evulsion fracture.

D. Osteochondritic dissecans or avascular necrosis. A feature in which the blood supply to the sesamoid bone is interrupted in which bone death can result.

E. Chondromalacia of the sesamoid resulting from continual synovitis of the 1st MTPJ in which fibrosis develops leading to freezing of the sesamoids1 and apparatus.

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Sesamoiditis is the most common and is characterised by pain at the first metatarsal sesamoid commonly occurring in combination with a plantar flexed 1st metatarsal. This condition may present as often as in 4% of overuse type foot injuries (Dennis and McKinney, 1990).

Sesamoiditis typically affects physically active young people and is more common in sporting people who require to balance on the ball of the foot (such as ballet dancers, basket ballers, netballers, cricket players and soccer players) – as they attempt to stop and change direction by pivoting or putting pressure on the forefoot area and the 1st MTPJ.

Sesamoiditis Pain

The condition causes pain under the 1st MTPJ and commonly affects the medial (inner) side of the joint. The pain may be constant, or it may occur with or be aggravated by, movement of the big toe joint. It may also be accompanied by swelling (oedema) throughout the plantar aspect (bottom) of the forefoot.

It is reputed that the forefoot bears approximately one half the body’s weight and balances pressure on the ball of the foot. Sesamoiditis has been also linked as a possible uncommon cause to Metatarsalgia2.

It is generally accepted that the sesamoids perform two principal functions:

1. Absorbing impact forces in the forefoot during walking through a series of attachments to other structures in the forefoot.

2. Acting as a fulcrum to provide the flexor tendons with a mechanical advantage as they pull the hallux down against the ground during gait.

Patients who suffer from Sesamoiditis often exhibit a fixed or mobile plantar flexed 1st metatarsal which maintains the 1st MTPJ on impact. The lesser metatarsals absorb the impact in the gait cycle, however, if the 1st MTPJ is rigid and the sesamoid take the full impact during toe off. Repetitive chronic pressure and tension on the forefoot will cause the surrounding tissues to become irritated and inflamed. In some cases the sesamoids may bifurcate and in severe cases necrosis may occur.

The practitioners should check the patient for a Plantar flexed 1st using the common test in which the movement of the joint should be 5mm dorsiflexion, and 5mm plantar flexion or a total range of approx 10mm.

This test will identify if there is a limitation in the joint’s range of motion due to a fixed osseous condition.

How to perform this test:

1.With the patient in the supine position, maintain the foot in the neutral position, using ICB Anterior Alignment Method.

2. Grip the lesser metatarsals, line the thumbs up and the range of movement should be 5mm up and 5mm down.
Step 2

Pronation will displace the sesamoids laterally causing trauma to the sesamoid apparatus. This can change the patient’s gait as they try to compensate and may cause other upper body compensatory effects, including hip pain.

A Supinated foot will often display a plantar flexed 1st as compensation to assist in lowering the 1st MTPJ to the ground and thereby enabling toe off.

Patients who suffer from Sesamoiditis may exhibit a fixed or mobile plantar flexed 1st metatarsal 3 which maintains the 1st MTPJ in a plantar flexed position on impact. The lesser metatarsals are able to absorb the impact in the gait cycle, however, the 1st MTPJ is rigid and the sesamoid take the full impact during toe off.

Repetitive chronic pressure and tension on the forefoot will cause the surrounding tissues to become irritated and inflamed. In some cases the sesamoids may bifurcate and in severe cases necrosis may occur.

Treatment

Initial treatment for sesamoiditis is usually non-invasive and includes orthotic therapy to treat the plantar flexed 1st. Generally a deflection will need to be incorporated into the orthotic to remove or reduce the pressure from this area.

ICB Orthotics

The Plantar flexed 1st Ray (metatarsal) deflection is cut around the 1st MTPJ and then the edges are heated and smoothed to taper the edge of the orthotic, and avoid irritation (see opposite). The orthotic itself has some in-built forefoot support under the 2nd to 5th to support this area similar to a 2-5 bar.

Treatment is generally non-surgical, however, if conservative measures fail, surgical intervention by way of removal or pinning of the sesamoids may be undertaken.

Modifying the patients’ shoes is not overly effective as each pair would need to be modified. The easier approach a heat mouldable orthotic incorporating a Plantar flexed 1st ray deflection modification which can be moved and transferred from shoe to shoe with relative ease.

In addition, the big toe may be bound with strapping tape (or athletic strapping) to immobilise the joint as much as possible and allow healing to take place.

Acupuncture can be used to reduce inflammation and anti inflammatory drugs can be taken to reduce swelling.

If a full length orthotic is required a ‘relief trench’ can be placed into the orthotic using a dremel hand grinder to allow the 1st MTPJ to plantar flex without restriction.

Full Length Orthotic with deflective trench

Differential Diagnosis:

• Stress fracture of the sesamoid bone

• Avulsion fracture or sprain of the proximal pole of the sesamoid

• Sprain of the distal pole

• Sprain of a bipartite sesamoid

• Arthrosis of the sesamoid metatarsal articulation. Arthrosis pain is often felt during the day and emphasises during joint movement efforts

• Pre-radiographic osteonecrosis of the sesamoids

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References
1 Neal’s Disorders of the foot 8th edition 2002 p318
2. Merriman’s Assessment of the Lower Limb 3rd Edition. Churchill Livingstone. p331
General REFERENCES
Michaud T.C. (1993) Foot Orthoses and Other Forms of Conservative Foot Care. Williams and Wilkins, Baltimore, pp.93-105.
Root M.L., Orien W.P. and Weed J.H., (1971) Clinical Biomechanics: Normal and Abnormal Function of the Foot. Clinical Biomechanics Corp, Los Angeles, Chapter 10.

ICB Lower limb biomechanics

Severs Condition (Calcaneal Apohphysitis) is an inflammation of the growth plate of the bone at the back of the heel (apophysitis of the calcaneus) and occurs during a child’s adolescent years, usually affecting children who are physically active. The point where the inflammation of Severs condition appears is usually localised to the posterior and plantar side of the heel over the calcaneal apophysis – where the Achilles tendon attaches to the back of the calcaneus.
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Often young children experience pain in one or both heels whilst engaging in general activities such as running, jumping, or sports such as netball, basketball, football and soccer. Symptoms of Severs Condition include extreme pain when the child places their heel on the ground. This pain is alleviated when the child runs or walks on their toes (i.e. activities that do not exert weight and pressure on the heels). This is because strain is reduced on the epiphyseal plate as the heel is raised off the ground.

The calcaneus takes on a slightly supinated position thus reducing tension on the attachment.

Often full immobilisation is recommended to treat this condition, however, there is no need to plaster the foot or for the child to stop playing sport during the course treatment. That is, unless X-rays show evidence of a fracture in the heel growth plate or epiphyseal plate. (see Fig:1) If a fracture is evident, sporting activities should cease for approximately 6 weeks to allow healing.
X-ray Severs Condition

This condition usually affects children, between the ages of 8 to 13 years. Severs condition is more common in boys than in girls, and it is uncertain why this appears to be the case. Micheli and Ireland reported on 85 patients, 64% of whom were male1 in their research – however, they did not provide definitive reasons for the skew towards young males.

In one prospective study of injuries among players aged 9-19 years in football academies, 2% of overall football injuries were due to Sever’s Condition; the peak for incidence was in the under-11 age group2. In a study of 85 children, the condition was bilateral in 61%.3

General research opinion agrees that between the ages of 8 and 13 years, children’s bones are still in the growth stage and the growth plates on the skeletal structure have not yet become fused and ossified, which normally occurs by around the age of 17 years4. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragility of the calcified cartilage.

The combination of growth and poor foot function and mechanics, can cause inflammation and pain at the point where the
tendo-Achilles inserts onto the calcaneus.
Severs Condition

Excessive pronation is a major contributing factor when combined together with the child’s growth spurt pattern.

In very severe cases, the growth plate can detach from the calcaneus. Fractures or micro fractures can completely detach the growth plate, pulling it out of position possibly resulting in osteochondritis dissecans.

Neal’s Disorders of the Foot states that, “Repetitive contractions of the muscles of the posterior compartment (gastrocnemius and soleus) may predispose to micro-fractures at the calcaneal epiphyseal plate5.”

Severs Condition Squeeze test

Assessment Techniques

Sever’s condition can be diagnosed based on the child’s medical history and presenting symptoms. A simple and effective test is the calcaneal “squeeze test” which will identify localised pain symptoms and then this will need to be combined with other tests to confirm the diagnosis. Once the squeeze test has been performed practitioners will need to assess for:

* Decreased ankle dorsiflexion.* Abnormal hind foot motion (eg.excessive pronation or supination).* Tight calf muscles* Excessive weight-bearing activities e.g running which will cause deformation of the rearfoot.

Madden and Mellion (1996) noted an means of assessment could be to require the patient to stand on their tip toes, raising and lowering, and gauge whether there was an exacerbation of symptoms6.
Childrens Orthotics
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Treatment

Orthotic therapy is an excellent treatment regime7 as it realigns the biomechanical structure whilst controlling excessive pronation of the rearfoot.

Stabilising the calcaneus and its growth plate by restricting or limiting excessive pronation can prevent long-term injury and discomfort.

The use of bilateral heel lift of approximately 4mm is recommended in combination with orthotics for short term relief. Removal of the heel lifts, after an initial 2 week acute pain period is recommended, however if additional support and control is required sports strapping using a low dye taping technique can be useful.

ICB Heel Lifts

Deep tissue massage of the calf muscle (in combination with orthotic therapy), is also a successful mode of treatment. Stretching the calf muscles is however not recommended whilst inflammation is still present, as this may cause further tearing at the attachment. Stretching and deep tissue massage may be in part, prophylactic in the maintenance of the condition.

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REFERENCES
1 Leri JP; Heel Pain in a Young Adolescent Baseball Player. (2004) Journal Chiropractic Medicine. Spring: 3(2):66-8.
2 Price RJ, Hawkins RD, Hulse MA, et al; The Football Association Medical Research Programme: An Audit of Injuries in Academy Youth Football. Br J Sports Med. 2004 Aug;38(4):466-71.
3 Micheli LJ, Ireland ML; Prevention and Management of Calcaneal Apophysitis in Children: An Overuse Syndrome. Journal Paediatric Orthopaedics. 1987 Jan-Feb;7(1):34-8.
4 Noffsinger MA, (Feb 2012) Sever Disease, Medscape
5 Neal’s Disorders of the Foot 8th Edition p113
6 Neal’s Disorders of the Foot 8th Edition p114
7 The American College of Foot & Ankle Orthopedics & Medicine, Prescription Custom Foot Orthoses – Practice Guidelines, December 2006

ICB Lower limb biomechanics

Back pain is a complex one as it can be categorised into a variety of locations Upper, Middle, and Low Back Pain, and can range in intensity from mild to severe (chronic). Sciatica for instance, can cause pain in the lower back and the legs, where-as low back strain can affect L1 –L5 region of the spine. Excessive pronation can also cause lower lumbar pain due to its affect of rotating the pelvis anteriorly. A short video on Back pain is below.

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Treating this pain requires that we determine wherever possible, the origin of the disorder whether from the muscles, nerves, bones, joints or other structures in the spine.

It is reported that low back pain causes 40% of missed days of work in the United States1, and is reputed to be the single leading cause of disability worldwide2.

The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, all of which are capable of producing pain. Therefore in this newsletter we just want to focus on basic back pain associated with structural leg length abnormality and how to treat these problems by incorporating orthotics and other modalities.

Leg length can, we believe, be categorised into two basic areas:

 1. Structural – a difference in the long bone measurement of the leg and,

 2. Functional – arising from a variety of causes which affect the biomechanics of the body.

When a patient presents with back pain a determination of the underlying factors needs to be undertaken. Always start with the basics, and complete a full biomechanical assessment, which includes long bone measurement and a comparison of the amount of pronation/eversion and supination/ inversion at the foundation. The first thing to look for is whether the patient is presenting with bilateral or unilateral pronation. If it is UNILATERAL, establish if the patient has:

a. suffered a trauma in which one plantar fascia may have ruptured or elongated and consequently, created a functional short leg or if there is idiopathic ulilateral excessive pronation or supination present.

b. assess if tibial torsion with hip compensation is present : such as tight psoas which will rotate the pelvis anteriorly, or tight piriformis ITB’s and Gluteals, as a compensation for internal tibial torsion to correct the pigeon toed position. Both these compensations could either, rotate the pelvis (anterior) forward or (posterior) backward creating functional leg length problems in the gait cycle.

Cat Scan

If the patient has a long leg compensation in which the long leg drops down or pronates to level the pelvis, establish the structural length and this can be verified using a CT scanogram (see Figure 1) for leg length or the normal x-ray film to check the leg length.

The longer leg will be predisposed to hip joint wear and tear. Therefore if a patient is asymmetrical, inform them about the consequences of not treating the condition. Some practitioners say the body will compensate for the difference so why bother with a heel lift to raise and level the pelvis? However, even everyday objects that are asymmetrical such as tables and chairs become unstable over time, how much more our bodies?

It has been said that 3-4mm can upset the biomechanical structures of the body.

If the patient is suffering from hip compensations they will need to be either referred to the appropriate Allied Health Practitioner for stretching and strengthening exercises to correct the anomaly. At the same time prescribe orthotics to realign and correct the biomechanics. A combination of orthotic therapy and muscle stretching and strengthening will give the best treatment results.

If there is no apparent structural leg length the use of orthotics to realign the foundation will be required and a combination of other modalities will be needed to address both skeletal and soft tissue imbalances and compensations.

When the patient presents with a structural deformity either due to a recent trauma or a long term biomechanical related anomaly, the use of a heel lift or raise on the structural short leg will be required.
ICB Heel Lift for ICB Orthotics

It is recommend that the practitioner applies ½ the leg length discrepancy measurement, in the heel lift. Then this amount can be gradually increased, this will limit initial discomfort and quicken patient compliance. In the case of treating a short leg due to trauma/ accident injury the entire amount can be applied, within the first 6 months, as long as the rehabilitation has ceased and the body has not started to use soft tissues to compensate for the leg length deficiency. Contraindication in these instances would be any fusing of the spine as this may cause the patient to be in more pain.

If you are prescribing orthotics and have NOT MEASURED structural leg length, the orthotic will invariably remove the any normal body compensation of the ‘long leg pronation’. If excessive long leg excessive pronation compensation is removed it will create a jamming in the long leg acetabulum at the hip, create problems with the SI joint and contribute to the development of a scoliosis, as stated in Blake & Ferguson, 1992.

Placing a heel lift in the shoe of the short leg without using orthotic devices is not recommended, as this will create a leg length problem on the raised leg side, because the longer structural leg will continue to pronate due to ligament laxity. The use of one orthotic is never recommended as the foundation needs to be balanced, and the necessary biomechanical corrective additions attached to the orthotic.

Where back pain and SI joint pain is concerned it is recommend that leg length discrepancy is assessed and treated.

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Treatment
Measure and confirm structural or functional leg length discrepancy. Use a method you are comfortable with.
Medial Malleoli symmetry

• Orthotics to treat ‘long leg pronation’, together with a heel raise being added for the short leg.

• Raise the short leg in stages – if the discrepancy is a large, start with half the amount of measured discrepancy.

• Often a multi-disciplinary approach such as adjustments to ‘free’ the pelvis, stretching tight muscles is beneficial. Check the head of femur is sitting correctly in the acetabulum, in combination with orthotic therapy will deliver the best results for the patient.

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REFERENCES:

1. Manchikanti, L; Singh, V; Datta, S; Cohen, SP; Hirsch, JA; American Socie-ty of Interventional Pain, Physicians (Jul–Aug 2009). “Comprehensive review of epidemiology, scope, and impact of spinal pain.”. Pain physician 12 (4): E35–70. PMID 19668291.
2. Institute for Health Metrics and Evaluation. “2010 Global Burden of Disease Study”
3. Gary Fryer 2005 : Factors affecting the intra-examiner and inter-examiner reliability of palpation for supine medial malleoli asymmetry.
General REFERENCES:
Blake, R.L. and Ferguson H (1992) ‘Limb Length Discrepancies’ Merriman, LM and Tollafield, DR (1995) ‘Assessment of the Lower Limb’
Blake RL, Ferguson, H (1992) Limb Length Discrepancies. Journal of the American Podiatric Medical Association 1: 33-38.
Blustein SM, D’Amico JC (1985) Limb Length Discrepancy –identification,Clinical Significance and Management. Journal of the American Podiatric Medical Association 75(4): 200-206.

ICB Lower limb biomechanics

Shin splints or Tibial Fasciitis1 (TF) is a descriptive term for pain in the soft tissue apparatus of the tibia, medial pain being the most common and is referred to by American Academy of Orthopaedic Surgeons as Medial tibial stress syndrome (MTSS) being described by the academy as “pain along the inner edge of the shin-bone (tibia).”


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Shin splints are a common injury affecting athletes and others who engage in running sports or other forms of physical activity. Characterised by general pain in the lower region of the leg: between knee and ankle.

Recent reports suggest that it comprises 13% to 17% of all running-related injuries 2,3 .

Often patients experience shin splints after being told by their General Practitioner to start walking as a means of healthy cardiovascular exercise.

Shin splints are classified as an over-use syndrome due to fatigue failure at the deep fascial attachment sites of the tibia, excessive supination or excessive pronation is often an underlying causative factor. Excessive supination and the association of forefoot valgus has been linked to the lateral shin splints, whereas excessive pronation is more often at tributed and associated with medial shin splints.

At mid stance, with the foot excessively pronated and the tibia internally rotated, the tibialis posterior muscle and tendon is placed under tension at its attachment to the tibia and the interosseous membrane. Repetitive stress initially produces tendonitis. The tibialis anterior and tibialis posterior muscle is partly responsible for inverting the foot and ankle in respect to the midline of the body and assisting in plantarflexion of the foot. Another function is that it helps to maintain the arch of the foot and is particularly active during weight-bearing activity such as walking and running.

When training it is NOT advised that one should train through the ‘pain barrier’ of the initial shin splint type injury, as the chronic traction may produce periostitis. (Bruhner & Khan, 1993; Lorimer et al, 1997).

Pain in the shin can be separated into 3 areas:

1. Medial shin pain
2. Lateral shin pain
3. Anterior shin pain

Medial Shin Pain: usually occurs when the patient engages in prolonged walking or running uphill. The patient will feel the pain along the tibialis posterior muscle and tendon. Sometimes it can be experienced close to the inferior medial collateral ligament attachment, all the way down to the navicular area.

The Tibialis Posterior tendon may slip over the medial malleolar due to tight Tibialis Posterior tendon, this action can be attributable to a weak retinaculum. Repetitive STJ pronation, causes the Tibialis Posterior tendon to elongate as the foot collapses medially, hence causing medial shin pain. Constant elongation may contribute to the development a tears and scaring in the muscle belly, and a pulling away from the tibia, causing inflammation and pain.

Differential Diagnosis: Compartment Syndrome and stress of the tibia.

Treatment for Medial Shin Pain

• R.I.C.E technique
• Deep tissue massage therapy – to break down adhesions.
• Orthotic therapy to control the excessive pronation.
• Low dye strapping to mimic orthotic and give additional support (short-term treatment only).

Lateral Shin Pain: the patient may feel this pain when undertaking excessive running and walking activities and is mainly experienced when walking or running downhill. The biomechanical aspects of the foot may be a high forefoot valgus or fixed plantarflexed 1st ray, both of which may cause a supinatory effect.

In gait, contraction of the anterior tibialis muscle raises the toes and dorsiflexes the foot. The main functions of the anterior tibialis during athletic activities are dorsiflexion through concentric contraction, and slowing the reverse movement, plantarflexion, through eccentric contraction.

Weakness of the anterior tibialis, particularly in eccentric contractions (lengthening contraction), can cause cumulative damage to the muscle and surrounding connective tissue.

Strength of the posterior muscles of the lower leg is an-other factor implicated in both anterior shin splints and posterior shin splints. Though it is less common in the case of anterior shin splints, a lack of support from the calf muscles may contribute to shin splint pain. (see Fig. 1).

In addition to this, if the foot exhibits a forefoot valgus, the foot in gait seeks to reach the ground and it does this by encouraging the foot into supination, hence tearing the peroneal muscles and causing inflammation and tenderness to touch, and difficulty walking. See Figure : 2

Differential Diagnosis: Compartment Syndrome and stress of the tibia.

Treatment for Lateral Shin Pain

• R.I.C.E.
• Strapping with a valgus wedge added for short term relief.
• Orthotic therapy (and the addition of lateral wedging ) to control the supination.

• Add a 1st ray cut-away to the orthotic if the patient has a plantarflexed first ray (see Figure 3).

Anterior Shin Pain: the patient normally feels the pain after running or walking and is mainly associated with uphill and downhill walking and running.

Biomechanically, it is related to supination at heel strike and then pronation at the mid stance to toe off stage.

During the gait cycle the Tibialis Anterior muscle acts as an inverter of the foot to allow for ground clearance at late swing phase. If there is a forefoot valgus of <10˚ (less than) the foot will supinate at heel strike and the ground reaction force on the lateral side will then propel the foot into pronation at mid stance of gait to toe off. In this circumstance the Tibialis Anterior will elongate and cause tearing to occur at the muscle belly especially on the lateral tibial crest and cause adhesions.

In short, during swing phase the tibialis anterior contracts causing the foot to invert and dorsiflex. At lateral foot strike the ground reaction forces propel the foot into pronation in early midstance to late midstance, causing a sudden pull of the tibialis anterior. This firstly causes a shortening of the tibialis anterior, then a sudden lengthen-ing of the tibialis anterior from midstance to the toe-off stage.

Differential Diagnosis: Compartment Syndrome and stress of the tibia.

Treatment for Anterior Shin Pain

• R.I.C.E. technique.
• Deep tissue massage at the Tibialis Anterior and along the lateral tibial crest.
• Suction cup therapy
• Acupuncture on the adhesion to help break down scaring.
• Orthotic therapy – not only to control pronation, but also the supination at heel strike and the a forefoot lateral wedge to treat the Forefoot Valgus if apparent.

References
1 Steven I Subutnick. (1999) Sports Medicine of the Lower Extremity p277
2 Clement D., Taunton J., Smart G. (1981). “A survey of overuse running injuries”. The Physi-cian and Sports Medicine 9, 47–58.
3 Cox J. S., Lenz H. W. (1984). Women midshipmen in sports. American Journal of Sports Medicine, 12(3), 241 – 243.
General References:
BRUNKER, P., & KHAN, K. (1993) Clinical Sports Medicine, Sydney: McGraw-Hill Book Com-pany
LORIMER, D., FRENCH, GWEN, & WEST, S. (1997) Neales Common Foot Disorders: Diagno-sis and Management, 5th Edition, Melbourne: Churchill Livingstone

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