This condition presents with pain at the back of the ankle, base of the calf muscle, inflammation of the tendon and or tendon sheath. Often worse on rising in the morning and walking up hills or running.
Treatment may involve Shock wave therapy, various stretching, footwear changes, orthotics, please consult Podocare Podiatrist for further diagnosis and treatment.
This is a degeneration of the fibers of the Achilles tendon directly at its insertion into the heel bone. It may be associated with inflammation of a (retrocalcaneal) bursa or tendon sheath in the same area.
What are the symptoms?
Most patients report the gradual onset of pain and swelling at the Achilles tendon insertion into the back of the heel bone without specific injury. At first, the pain is noted after activity alone, but becomes more constant over time. The pain is made worse by jumping or running and especially with sports requiring short bursts of these activities. There is tenderness directly over the back of the heel bone and often there is a bone prominence at this area. Positioning the ankle above a 90 degree position is limited by pain.
What causes insertional Achilles tendinitis?
The cause is primarily a degeneration of the tendon. The average patient is in their 40s. Conditions associated with increased risk include psoriasis and Reiter’s syndrome, spondyloarthropathy, gout, familial hyperlipidemia, sarcoidosis and diffuse idiopathic skeletal hyperostosis as well as the use of medications such as steroids and fluoroquinolone antibiotics.
What Is an Ankle Sprain?
An ankle sprain is an injury to one or more ligaments in the ankle, usually on the outside of the ankle. Ligaments are bands of tissue – like rubber bands – that connect one bone to another and bind the joints together. In the ankle joint, ligaments provide stability by limiting side-to-side movement.
Some ankle sprains are much worse than others. The severity of an ankle sprain depends on whether the ligament is stretched, partially torn, or completely torn, as well as on the number of ligaments involved. Ankle sprains are not the same as strains, which affect muscles rather than ligaments.
Sprained ankles often result from a fall, a sudden twist, or a blow that forces the ankle joint out of its normal position. Ankle sprains commonly occur while participating in sports, wearing inappropriate shoes, or walking or running on an uneven surface.
Sometimes ankle sprains occur because of a person is born with weak ankles. Previous ankle or foot injuries can also weaken the ankle and lead to sprains.
The symptoms of ankle sprains may include:
- Pain or soreness
- Difficulty walking
- Stiffness in the joint
The two most common types of arthritis that affect the foot are Osteoarthritis and Rheumatoid arthritis.
Osteoarthritis is degeneration of the joint usually involving swelling of the affected joint. It can affect single or multiple joints. There is often associated pain and weakness. This is basically the wear and tear disease; the swelling is partly soft tissue and synovial fluid and partly bone as the joint tries to remodel and repair itself. The disease can manifest itself in any joint of the foot.
Rheumatoid Arthritis is a systemic auto immune disease affecting all connective tissue particularly but not limited to joints. There is pain swelling and muscle weakness of multiple joints often with nodular involvement. Bony changes often lead to misalignment and even partial dislocation of joints. In the foot the first joint to be seen in is usually the great toe often over riding or under riding the lesser toes as the disease progresses, it can lead to sever corns and even ulcers.
Both diseases respond well to anti inflammatory drugs at the onset rheumatoid patients often require immunosuppressive drugs as the disease progresses. From a Podiatry perspective treatments aim at pain reduction by treating corns’ ulcers, use of insoles and orthotics is often indicated to redistribute pressure away from joints.
Athlete’s foot is a skin infection caused by fungus. A fungal infection may occur on any part of the body; on the foot it is called athlete’s foot, or tinea pedis. Fungus commonly attacks the feet because it thrives in a dark, moist, warm environment such as a shoe.
Fungal infections are more common in warm weather when feet tend to sweat more. Fungus thrives in damp areas such as swimming pools, showers, and locker rooms. Athletes commonly have sweaty feet and use the facilities where fungus is commonly found, thus the term “athlete’s foot.”
Athlete’s foot usually produces itchy, dry, scaling skin. It is commonly seen on the soles of the feet and in between the toes. In advanced cases, inflammation, cracks, and blisters may form; an infection caused by bacteria can also result. The fungus can spread to other areas of the body, including toenails.
Avoiding walking barefoot combined with good foot hygiene can help reduce the spread of the fungus. Feet should be washed every day with soap and water and thoroughly dried, including between the toes. Feet should be kept as dry as possible. If your feet sweat a lot, you may need to change your socks during the day. Anti-fungal powders, sprays, and/or creams are often utilized to treat athlete’s foot. Your foot and ankle surgeon will recommend the best treatment for you.
Even though bunions are a common foot deformity, there are misconceptions about them. Many people may unnecessarily suffer the pain of bunions for years before seeking treatment.
What is a Bunion?
A bunion (also referred to as hallux valgus or hallux abducto valgus) is often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. The big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment – producing the bunion’s “bump.”
Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which becomes increasingly prominent. Symptoms usually appear at later stages, although some people never have symptoms.
Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion.
Although wearing shoes that crowd the toes won’t actually cause bunions, it sometimes makes the deformity get progressively worse. Symptoms may therefore appear sooner.
Symptoms, which occur at the site of the bunion, may include:
- Pain or soreness
- Inflammation and redness
- A burning sensation
- Possible numbness
Symptoms occur most often when wearing shoes that crowd the toes, such as shoes with a tight toe box or high heels. This may explain why women are more likely to have symptoms than men. In addition, spending long periods of time on your feet can aggravate the symptoms of bunions.
A Bursa is a small sack filled with synovial fluid usually there to protect a structure, for example there is a bursa between the Achilles tendon and the heel bone to prevent the tendon rubbing on the bone. There are two types of Bursa, anatomical (the ones we are born with and adventitious the type we develop to protect a certain area. Bursitis is inflammation of a Bursa.
Thickening of skin often but not limited to the underside of the foot (plantar surface) usually due to increased pressure or friction in that area often exacerbated by dryness. Can be painful and in severe cases usually associated with diabetes can result in ulceration.
Treatment involves sharp debridement (cutting off the callous), this is a painless procedure. The use of emollients is also beneficial. Please consult your podiatrist
A concentration of callous or hard skin over a bony prominence the area can be acutely painful and inflamed and if neglected, may even ulcerate. Treatment involves enucleating the corn (cutting it out) this is a painless procedure. Then reducing the pressure which originally caused it, by altering footwear or deflective padding or simple insoles. If this condition is problematic please see your Podiatrist
Inflammation of the capsule of the joint usually associated with acute trauma (sports injury or over use) the area becomes hot swollen and painful.
Capsulitis of the Second Toe
What is Capsulitis of the Second Toe?
Ligaments surrounding the joint at the base of the second toe form a “capsule,” which helps the joint to function properly. Capsulitis is a condition in which these ligaments have become inflamed.
Although capsulitis can also occur in the joints of the third or fourth toes, it most commonly affects the second toe. This inflammation causes considerable discomfort and, if left untreated, can eventually lead to a weakening of surrounding ligaments that can cause dislocation of the toe. Capsulitis—also referred to as predislocation syndrome—is a common condition that can occur at any age.
It is generally believed that capsulitis of the second toe is a result of abnormal foot mechanics, where the ball of the foot beneath the toe joint takes an excessive amount of weight-bearing pressure.
Certain conditions or characteristics can make a person prone to experiencing excessive pressure on the ball of the foot. These most commonly include a severe bunion deformity, a second toe longer than the big toe, an arch that is structurally unstable, and a tight calf muscle.
Because capsulitis of the second toe is a progressive disorder and usually worsens if left untreated, early recognition and treatment are important. In the earlier stages—the best time to seek treatment—the symptoms may include:
- Pain, particularly on the ball of the foot. It can feel like there’s a marble in the shoe or a sock is bunched up
- Swelling in the area of pain, including the base of the toe
- Difficulty wearing shoes
- Pain when walking barefoot
In more advanced stages, the supportive ligaments weaken leading to failure of the joint to stabilize the toe. The unstable toe drifts toward the big toe and eventually crosses over and lies on top of the big toe—resulting in “crossover toe,” the end stage of capsulitis. The symptoms of crossover toe are the same as those experienced during the earlier stages. Although the crossing over of the toe usually occurs over a period of time, it can appear more quickly if caused by injury or overuse.
There are many potential causes of “cracked heels.” Dry skin (xerosis) is common and can get worse with wearing open-back shoes, increased weight, or increased friction from the back of shoes. Dry cracking skin can also be a subtle sign of more significant problems, such as diabetes or loss of nerve function (autonomic neuropathy).
Heels should be kept well moisturized with a cream to help reduce the cracking. If an open sore is noted, make an appointment Podiatrist for evaluation and treatment.
Is increase in circulating blood sugar levels, there are two types of Diabetes, Type I and Type II. Type I often known as juvenile diabetes, onset is in childhood and young adults and occurs when the pancreas fails to produce insulin which is the hormone which processes sugar resulting in increased sugar circulating in the blood stream. Type II diabetes, often known as mature onset diabetes, as the name suggests usually happens later in life. Although the pancreas continues to produce insulin the body develops a resistance to it and therefore is unable to metabolize sugar. Although both diseases are controlled differently, Type I requiring injections of insulin and Type II may be controlled by reducing sugar intake (diet) or drugs which help the body to use insulin better. Ultimately the disease causes the same problems to the body, especially if uncontrolled or poorly controlled. There is damage to small blood vessels particularly in feet, hands, eyes, kidneys and heart and damage to nerves. Manifestations in the in the foot are largely three fold, poor circulation, nerve damage and poor healing following injury. Diabetics represent the largest group of lower limb amputees. Complications with the foot due to the manifestations of diabetes can, if not treated promptly can lead to ulceration gangrene.
Foot wise treatment involves assessment of circulation and nerves, education on diabetic foot care, treatment of any presenting issues (nails, callous, corns, ulceration and skin infections). It important to have feet assessed by a podiatrist at least annually, from this assessment it can then be decided whether further regular treatment is required or simply an annual check up.
Diabetic Foot Care Guidelines
Diabetes can be dangerous to your feet – even a small cut can produce serious consequences. Diabetes may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, you may not notice a foreign object in your shoe. As a result you could develop a blister or a sore. This could lead to an infection or a non-healing wound that could put you at risk for an amputation.
To avoid serious foot problems that could result in losing a toe, foot, or leg, follow these guidelines.
Inspect your feet daily. Check for cuts, blisters, redness, swelling, or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
Wash your feet in lukewarm (not hot!) water. Keep your feet clean by washing them daily. Use only lukewarm water – the temperature you would use on a newborn baby.
Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting, and carefully dry between the toes.
Moisturize your feet – but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But DON’T moisturize between the toes – that could encourage a fungal infection.
Cut nails carefully. Cut them straight across and file the edges. Don’t cut nails too short, as this could lead to ingrown toe nails. If you have concerns about your nails, consult your doctor.
Never treat corns or calluses yourself. No “bathroom surgery” or medicated pads. Visit your podiatrist for appropriate treatment.
Wear clean, dry socks. Change them daily.
Avoid the wrong type of socks. Avoid tight elastic bands (they reduce circulation). Don’t wear thick or bulky socks (they can fit poorly and irritate the skin).
Wear socks to bed. If your feet get cold at night, wear socks. NEVER use a heating pad or hot water bottle.
Shake out your shoes and feel the inside before wearing. Remember, your feet may not be able to feel a pebble or other foreign object, so always inspect your shoes before putting them on.
Keep your feet warm and dry. Don’t let your feet get wet in snow or rain. Wear warm socks and shoes in winter.
Never walk barefoot. Not even at home! Always wear shoes or slippers. You could step on something and get a scratch or cut.
Take care of your diabetes. Keep your blood sugar levels under control.
Don’t smoke. Smoking restricts blood flow in your feet.
Get periodic foot exams. Seeing your foot and ankle surgeon on a regular basis can help prevent the foot complications of diabetes.
Diabetic Peripheral Neuropathy
What is Diabetic Peripheral Neuropathy?
Diabetic neuropathy is nerve damage caused by diabetes. When it affects the arms, hands, legs and feet it is known as diabetic peripheral neuropathy. Diabetic peripheral neuropathy is different from peripheral arterial disease (poor circulation), which affects the blood vessels rather than the nerves.
Three different groups of nerves can be affected by diabetic neuropathy:
- Sensory nerves, which enable people to feel pain, temperature, and other sensations
- Motor nerves, which control the muscles and give them their strength and tone
- Autonomic nerves, which allow the body to perform certain involuntary functions, such as sweating.
Diabetic peripheral neuropathy doesn’t emerge overnight. Instead, it usually develops slowly and worsens over time. Some patients have this condition long before they are diagnosed with diabetes. Having diabetes for several years may increase the likelihood of having diabetic neuropathy.
The loss of sensation and other problems associated with nerve damage make a patient prone to developing skin ulcers (open sores) that can become infected and may not heal. This serious complication of diabetes can lead to loss of a foot, a leg, or even a life.
The nerve damage that characterizes diabetic peripheral neuropathy is more common in patients with poorly managed diabetes. However, even diabetic patients who have excellent blood sugar (glucose) control can develop diabetic neuropathy. There are several theories as to why this occurs, including the possibilities that high blood glucose or constricted blood vessels produce damage to the nerves.
As diabetic peripheral neuropathy progresses, various nerves are affected. These damaged nerves can cause problems that encourage development of ulcers. For example:
- Because of numbness, a patient may not realize that he or she has stepped on a small object and cut the skin.
- Cracked skin caused by autonomic neuropathy, combined with sensory neuropathy’s numbness and problems associated with motor neuropathy can lead to developing a sore.
For autonomic neuropathy:
- Dry feet
- Cracked skin
.Inspect your feet every day. If you notice any cuts, redness, blisters, or swelling, see your right away. This can prevent problems from becoming worse.
- Visit your podiatrist on a regular basis for an examination to help prevent the foot complications of diabetes.
Fungal infections are very common in feet and tend to be either in the nails which appears as thickened discoloured and crumbly, or in the skin on the top or bottom of the foot where it can look dry or broken or between the toes when it will look white and may cause the skin to split. There is often an accompanying malodour.
Treatment should aim to treat the cause, which is often moisture and perspiration, while also treating the infection with the appropriate drugs. For further treatment please consult your podiatrist
Fungal nail infection can affect one or all your nails. An infection with nail fungus may begin as a a discoloration spot under the tip of your fingernail or toenail. As the nail fungus spreads deeper into your nail, it may cause your nail to discolor, thicken and develop crumbling edges which can be unsightly and potentially painful problem.
An fungal nail infection may be difficult to treat, and it may recur. However variety of treatment is available which the podiatrist will advice and treat to help clear up nail fungus.
Is acute joint inflammation caused by a build up of uric acid crystals in the joint. The condition can be so painful that even the bed sheets touching the foot can be too much for some patients.
Initial treatment is aimed at reducing pain anti inflammatory drugs and Laser has proven very effective at settling down the initial pain. In the long term diet and or medication can prevent further out breaks.
This is a general term used to describe pain in one or both heels; there may be a number of different causes. Probably the most common cause of heel pain is plantar fasciitis
Treatment, the most important thing here is correct diagnosis, after that appropriate treatment which may include shock wave therapy
Heel fissures, also known as cracked heels can be a simple cosmetic problem and a nuisance, but can also lead to serious medical problems. Heel fissures occur when the skin on the bottom, outer edge of the heel becomes hard, dry and flaky, sometimes causing deep splits that can be painful or even bleed.
Is a common condition in which nail has dug in to the side of the soft flesh of the toes and as a result has cause swelling and inflammation with possible infection. An ingrown toenail usually affects your big toe however lesser toenails can also be affected
Treatment would involve taking out the spike of nail, pending on severity. It may need minor surgery under local anaesthetic. the Podiatrist will advice you on this.
Many people will have one leg longer than the other often this is why we have one foot larger than the other. Usually the larger foot corresponds to the longer leg where the longer leg has to push down more on the foot causing the arch to lower (pronate) and elongating the foot. Limb length discrepancy may be caused by scoliosis in the back, tilting of the hip, or from one leg being genuinely longer than the other. Often people will go through life with one leg longer than the other and have no problems at all. But symptoms include any problem that is present on one foot and not the other, and can be as diverse as corns and callous, plantar fasciitis, knee problems, bunions, capsulitus, heel pain, metatarsalgia, and even tendonitis.
Once again diagnosis is critical here and appropriate treatment which can include heel raise padding, strapping, orthotics .
This is a catch all term for pain in the fore foot (front of the foot just behind the toes) and again there may be one of many causes, Morton’s neuronal, capsulitis, stress fracture and even corn or callous.
Treatment, again diagnosis is all important, then appropriate treatment which may include, laser, padding, strapping, orthotics and or change of footwear.
Pain in the fore foot often between the 3rd and 4th metatarsals but may be between the 2nd and 3rd or even the 4th and 5th. The pain radiates forward into the toes and may also be accompanied by numbness and tingling. It is exacerbated by tight foot ware or exercise. It is caused by the nerve being squeezed between the metatarsal heads and getting thickened.
Pain in the heel usually worse on rising in the morning, and improves once the patient “gets going” but can be exacerbated by exercise and is often worse towards the end of the day. This condition is also known as Heel spur, as it was originally thought that the heel spurs which are often seen on x-ray with this condition were the cause of the problem. It is now known that the spur it’s self is not the cause of the problem but rather a symptom of the problem, as surgical removal of spurs rarely improves symptoms. The underlying problem here is inflammation where the plantar fascia attaches to the heel bone caused by increased pull on the plantar fascia. Increased pull may come from sudden increase in activity, over use or change in footwear.
Treatment is aimed at reducing the pull on the plantar fascia and may include stretches, strapping, changing footwear, and orthotics and in difficult cases night splints are very effective. For a more indepth Treatment plan and diagnosis see your Podiatrist
What is the Plantar Fibroma?
A plantar fibroma is a fibrous knot (nodule) in the arch of the foot. It is embedded within the plantar fascia, a band of tissue that extends from the heel to the toes on the bottom of the foot. A plantar fibroma can develop in one or both feet, is benign (non-malignant), and usually will not go away or get smaller without treatment. Definitive causes for this condition have not been clearly identified.
Signs and Symptoms
The characteristic sign of a plantar fibroma is a noticeable lump in the arch that feels firm to the touch. This mass can remain the same size or get larger over time, or additional fibromas may develop.
People who have a plantar fibroma may or may not have pain. When pain does occur, it is often caused by shoes pushing against the lump in the arch, although it can also arise when walking or standing barefoot.
For a more in-depth Treatment plan and diagnosis see your Podocare Podiatrist
Heel pain associated with activity, this condition affects children and young adults between the ages of about 10-18 years old who are very active in sports. It may affect one or both heels and will be exacerbated by exercise particularly activities that involve running or jumping. The disease usually occurs at about the same time the individual is going through a growth spurt. What is really occurring here is as the bone in the leg grows there is increased pull on the Achilles tendon. As this is attached to the back and under side of the heel it pulls the bone away from the still maturing growth plate causing avascular necrosis and pain. Although the disease is self limiting and the child will eventually grow out of it when they reach maturity it can be very painful and prevent the individual being able to lead a normal active life.
Inflammation of the tendon, this usually results in pain and often swelling. Tendonitis can affect any of the tendons of the foot and may be caused by sports injuries, over use or poor bony alignment.
Treatment will involve resting the area, icing, and shock wave therapy, in the longer term orthotics may be of use to treat the underlying biomechanical problem.
Ulcers in the foot can be roughly categorised into the following, arterial, venous and neuropathic. Arterial ulcers are due to poor arterial blood supply, this is occurs when the oxygenated blood that is pumped from the heart fails to reach the foot in sufficient quantity to repair a wound or give the skin sufficient nutrition for the skin to be viable. This is caused by hardening and narrowing of the arteries and is often seen in diabetes and peripheral vascular disease (PVD), sometimes also known as peripheral artery disease (PAD). Venous ulceration occurs when the veins (the vessels which take the blood back up to the heart) do not work as well, (varicose veins); ulceration often occurs around the inside of the ankle. Neuropathic ulceration occurs when there is loss of feeling or sensitivity in the foot, damage occurs and is not noticed by the patient leading to ulceration as they continue to walk on the foot. Neuropathic ulceration is common with diabetes. Ulceration occurs when a wound fails to heal or there sufficient pressure on a part of the foot to cause the skin to break down and ulcerate.
Verruca or plantar warts as they are sometimes known occur when the skin is infected by the verruca virus, human papiloma virus (HPV). Often but not exclusively seen in children verruca’s can be but are not always painful. On the top (dorsum) of the foot they may stick up and look warty in appearance, where as in the bottom of the foot they get pushed into the foot and develop callous over them. Please consult your Podocare Podiatrist for further Treatment and diagnosis
Treatment include Swift, verrutop & cryotherapy & variety of different strength of acid
It takes nearly 18 years for a child’s foot to mature fully. During this time, you should make the effort to ensure that your child’s shoes are the proper size so that proper growth can occur.
In the first 10 years, your child’s foot will grow a total of about 6-inches. The greatest changes will occur in the first 3 years of life.
Your child’s feet are subjected to enormous stress not typically experienced by the average adult foot. In fact, the stress on a child’s foot can be 3 times the stress experienced by adult feet. Our shoes are designed with padded footbeds to absorb this stress.
The cause of this is due to variety of reasons from trauma, ill-fitting footwear, fungal infection, skin disorder, corns
The treatment would involve in the initial stage of diagnosing the actual cause then treatment plan seeing your podiatrist who will advice you on what the cause is and treat it
What Is a Tailor’s Bunion?
Tailor’s bunion, also called a bunionette, is a prominence of the fifth metatarsal bone at the base of the little toe. The metatarsals are the five long bones of the foot. The prominence that characterizes a tailor’s bunion occurs at the metatarsal “head,” located at the far end of the bone where it meets the toe. Tailor’s bunions are not as common as bunions, which occur on the inside of the foot, but they are similar in symptoms and causes.
Why is it called a tailor’s bunion? The deformity received its name centuries ago, when tailors sat cross-legged all day with the outside edge of their feet rubbing on the ground. This constant rubbing led to a painful bump at the base of the little toe.
Often a tailor’s bunion is caused by an inherited faulty mechanical structure of the foot. In these cases, changes occur in the foot’s bony framework, resulting in the development of an enlargement. The fifth metatarsal bone starts to protrude outward, while the little toe moves inward. This shift creates a bump on the outside of the foot that becomes irritated whenever a shoe press against it.
Sometimes a tailor’s bunion is actually a bony spur (an outgrowth of bone) on the side of the fifth metatarsal head.
Regardless of the cause, the symptoms of a tailor’s bunion are usually aggravated by wearing shoes that are too narrow in the toe, producing constant rubbing and pressure.
What Is Hallux Rigidus?
Hallux rigidus is a disorder of the joint located at the base of the big toe. It causes pain and stiffness in the joint, and with time it gets increasingly harder to bend the toe. ‘Hallux” refers to the big toe, while “rigidus” indicates
that the toe is rigid and cannot move. Hallux rigidus is actually a form of degenerative arthritis.
This disorder can be very troubling and even disabling, since we use the big toe whenever we walk, stoop down, climb up, or even stand. Many patients confuse hallux rigidus with a bunion, which affects the same joint, but they are very different conditions requiring different treatment.
Because hallux rigidus is a progressive condition, the toe’s motion decreases as time goes on. In its earlier stage, when motion of the big toe is only somewhat limited, the condition is called “hallux limitus.” But as the problem advances, the toe’s range of motion gradually decreases until it potentially reaches the end stage of “rigidus,” in which the big toe becomes stiff, or what is sometimes called a “frozen joint.”
Early signs and symptoms include:
- Pain and stiffness in the big toe during use (walking, standing, bending, etc.)
- Pain and stiffness aggravated by cold, damp weather
- Difficulty with certain activities (running, squatting)
- Swelling and inflammation around the joint
As the disorder gets more serious, additional symptoms may develop, including:
- Pain, even during rest
- Difficulty wearing shoes because bone spurs (overgrowths) develop
- Dull pain in the hip, knee, or lower back due to changes in the way you walk
- Limping (in severe cases)
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