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21. March 2014
Foot pain | University of Maryland Medical Center
Foot pain | University of Maryland Medical Center
Foot pain
An in-depth report on the causes, diagnosis, treatment, and prevention of foot pain.
Alternative Names
Bunions; Corns; Hammertoe; Plantar fasciitis; Tarsal tunnel syndrome; Flat feet
The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of more than 120 muscles, ligaments, and nerves.Nearly all cases of foot pain can be attributed to one of the following:Ill-fitting shoesHigh-impact exerciseCertain medical conditions.About 75% of people in the United States have foot pain.
Risk Factors
Women are at higher risk than men for severe foot pain.The American Orthopaedic Foot and Ankle Society strongly advises against cosmetic foot surgery, urging consumers to carefully consider the relative risks and benefits of undergoing unnecessary surgical procedures.
Medical Conditions Causing Foot Pain
ArthritisObesityPregnancyMedicationsDiabetes is an important cause of serious foot disorders.Women are at higher risk for stress fractures than men.
The acronym RICE stands for rest, ice, compression, and elevation -- the four basic elements of initial treatment for an injured foot.For severe conditions, such as fallen arches or structural problems that cause imbalance, health care providers may need to prescribe custom orthotics, which are insoles produced to fit the patient's foot.
Don't ignore foot pain. It is not normal. It is critical that people with diabetes see a podiatrist (foot doctor) at least once a year for a checkup.Alternate shoes. Don't wear the same pair of shoes every day.Avoid walking barefoot, which increases the risk for injury and infection.At the beach or when wearing sandals, always use sunblock on your feet, as you would on the rest of your body.
Foot pain is very common. About 75% of people in the United States have foot pain at some time in their lives. Most foot pain is caused by shoes that do not fit properly or that force the feet into unnatural shapes (such as pointed-toe, high-heeled shoes).
The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of more than 120 muscles, ligaments, and nerves. It serves the following functions:
Supports weightActs as a shock absorberServes as a lever to propel the leg forwardHelps maintain balance by adjusting the body to uneven surfaces
Because the feet are very small compared with the rest of the body, the impact of each step exerts tremendous force upon them. This force is about 50% greater than the person's body weight. During a typical day, people spend about 4 hours on their feet and take 8,000 to 10,000 steps. This means that the feet support a combined force equivalent to several hundred tons every day.
Foot Problems and Their Locations
Foot pain generally starts in one of three places: the toes, the forefoot, or the hindfoot.
The Toes. Toe problems most often occur because of the pressure imposed by ill-fitting shoes.
The Forefoot. The forefoot is the front of the foot. Pain originating here usually involves one of the following bone groups:
The metatarsal bones (five long bones that extend from the front of the arch to the bones in the toe)The sesamoid bones (two small bones embedded at the top of the first metatarsal bone, which connects to the big toe)
The Hindfoot. The hindfoot is the back of the foot. Pain originating here can extend from the heel, across the sole (known as the plantar surface), to the ball of the foot (the metatarsophalangeal joint).
Summary of Foot Problems
Recommended Footwear
Toe Pain
Corns and calluses
Around toes, usually little toe, bottom of feet or areas exposed to friction.
Hard, dead, yellowish skin.
Wide (box-toed) shoes; soft cushions under heel or ball of foot, or customized or gel insoles for calluses. Doughnut-shaped pads for corns.
Ingrown toenails
Nail curling into skin causes pain, swelling, and, in extreme cases, infection.
Sandals, open-toed shoes.
Bunions and bunionettes (tailor's bunion)
Big toe (bunions) or little toe (bunionettes).
The following can occur alone or in combination:
Metatarsus primus varus. The first (big toe) metatarsal bone shifts away from the second, and the big toe points inward.
Medial exostosis. This is a bony bump at the base of the big toe, which protrudes outward. Area next to bony bump is red, tender, and occasionally filled with fluid. Toe joint may be inflamed.
Hallux valgus. This is a deformity in which the bone and joint of the big toe shift and grow inward, so that the second toe crosses over the big toe.
Soft, wide-toed shoes or sandals. Bunion shields or splints. Thick doughnut-shaped moleskin pads, custom-made orthotics or foot slings, if necessary. Avoid shoes with stitching along the side of the "bump."
Morton's neuroma (also called interdigital neuroma)
Inflammation of the nerve, usually between the third and fourth toes and bottom of the foot near these toes.
Cramping and burning pain, or electric-shock sensation. The condition may produce a thick protective sheath around the nerve that feels like a ball. This may be detected by pressing top to bottom on the top of the foot using one hand and moving the other hand from side to side. Morton's neuroma is aggravated by prolonged standing and relieved by removal of the shoes and forefoot massage.
Wide (box-toed) shoes. Orthotic or insole with pad that reduces stress on the painful area.
Hammertoe or claw toe
Usually second toe, but may develop in any or all of the three middle toes.
Toes form hammer or claw shape. In hammertoe, the first knuckle of the toe is mainly affected. In claw toe the entire toe is deformed. No pain at first, but pain increases as tendon becomes tighter and toes stiffen.
Wide (box-toed) shoes. Toe pads or specially designed shields, splints, caps, or slings. (Splints or slings are not for people with diabetes.)
Front-of-the-Foot Pain
Ball of the foot.
Acute, recurrent, or chronic pain without a known cause.
Wide (box-toed) shoes. Orthotic with pad that reduces metatarsal pressure. Gel cushions. Metatarsal bandage.
Stress fracture
Most often in the area beneath the second or third toe.
Sudden pain (which persists) when injury occurs.
Low-heeled shoes with stiff soles.
Ball of foot beneath big toe.
Pain and swelling.
Low-heeled shoe with stiff sole and soft padding inside.
Heel and Back-of-the-Foot Pain
Plantar fasciitis or heel spurs
Back of the arch right in front of heel.
At onset, some people report a tearing or popping sound. Pain is most severe with first steps after getting out of bed. Pain decreases after stretching, returns after inactivity.
Over-the-counter foot insole (cut quarter-size hole surrounding painful area). Possible night splints. Orthotics if necessary.
Bursitis of the heel
Center of the heel.
Pain, with warmth and swelling. Increases during the day.
Heel cup.
Haglund's deformity ("pump bump")
Fleshy area on the back of the heel.
Tender swelling aggravated by shoes with stiff backs.
Soft shoes. Heel pads. Possible orthotic to support heel.
Achilles tendinitis
Achilles tendon: area along the back between calf muscles and heel.
Pain worsens during physical activities (particularly running), after which the tendon usually swells and stiffens. If it ruptures, popping sound may occur followed by acute pain similar to a blow at the back of the leg.
Insoles, tendon strap, heel cups.
Arch and Bottom-of-the Foot Pain
Tarsal tunnel syndrome
Anywhere along the bottom of the foot.
Numbness, tingling, or burning sensations, pain, most commonly felt at night.
Specially designed orthotics to relieve pressure.
"Flat feet" or posterior tibial tendon dysfunction (PTTD)
The arch.
No arch. Often no pain or discomfort. Three stages in PTTD:
Pain and weakness in the tendon.
The arch flattens but is still flexible.
The foot becomes rigid and possibly painful at the ankle. Sometimes people report fatigue, pain, or stiffness in the feet, legs, and lower back.
For children, possible custom-made insoles.
High arches ("hollow feet")
The arch.
High arches. Lower back pain, possible tendency to lower limb injuries.
Nearly all causes of foot pain can be grouped under one of the following:
Ill-fitting shoes. Poorly fitting shoes are a frequent cause of foot pain. High-heeled shoes concentrate pressure on the toes and can aggravate, if not cause, problems with the toes.Certain medical conditions. Any medical condition that causes a disturbance in the way a person walks can contribute to foot pain. This may include diseases or conditions that lead to pain or numbness in the feet (such as diabetes), leg and foot deformities, spinal problems, and neurological disorders such as Parkinson's disease or cerebral palsy.High-impact exercis. High-impact exercising, such as jogging or strenuous aerobics, can injure the feet and other parts of the body. Common foot injuries include corns, calluses, blisters, muscle cramps, damage to toenails, plantar fasciitis, and metatarsalgia (pain at the ball of the foot). The ankle is also at risk.
Medical Conditions Causing Foot Pain
Arthritic Conditions. Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected.
Diabetes. Diabetes is an important cause of serious foot disorders. [For more information, see In-Depth Report #9: Diabetes - type 1 and In-Depth Report #60: Diabetes - type 2.]
Obesity. Obesity can cause foot and ankle pain.
Pregnancy. Pregnancy can cause fluid buildup and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress.
Medications. Some medications, such as calcitonin and drugs used for high blood pressure, can cause foot swelling.
Click the icon to see an image of foot inspection.
Risk Factors
A risk factor is anything that increases your chances of getting a disease or condition. The following are factors that increase your risk for foot pain.
Elderly people are at very high risk for foot problems. As you age, your feet widen and flatten, and the fat padding on the sole of the foot wears down. The skin on the feet also becomes dryer. Foot pain in older adults may be the first sign of age-related conditions, such as arthritis, diabetes, and circulatory disease. Foot problems can also impair balance and function in this age group.
Cosmetic Foot Surgery
Taking fashion to extreme limits, some people have turned to cosmetic surgery as a drastic way to fit into high-heeled shoes. Procedures include surgical shortening of the toes, narrowing of feet, or injecting silicone into the pads of the feet. Such methods may increase your risk for future foot pain. The American Orthopaedic Foot and Ankle Society (AOFAS) and other foot-related medical associations have expressed concern over this trend. The AOFAS strongly advises against cosmetic foot surgery and urges consumers to carefully consider the relative risks and benefits of undergoing unnecessary surgical procedures.
Women are at higher risk than men for severe foot pain, probably because of high-heeled shoes. Severe foot pain appears to be a major cause of general disability in older women.
Occupational Risk Factors
An estimated 120,000 work-related foot injuries occur every year, about a third of them involving the toes. Many foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work (for example, walking long distances or standing for many hours). No studies, however, have scientifically distinguished between injuries due to work versus those due to regular use. This is an important issue because of its potential impact on disability claims.
Pregnant women have an increased risk of foot problems due to weight gain, swelling in their feet and ankles, and the release of certain hormones that cause ligaments to relax. These hormones help when bearing the child, but they can weaken the feet.
Sports and Dancing
People who engage in regular high-impact aerobic exercise are at risk for plantar fasciitis, heel spurs, sesamoiditis, Achilles tendinitis, and stress fractures. Women are at higher risk for stress fractures than men.
Weight gain
Gaining weight puts added stress on the feet and can lead to foot or ankle injuries. The added pressure on the soft tissues and joints of the foot in overweight people increases the likelihood of developing tendinitis and plantar fasciitis.
Corns and Calluses
A corn is a protective layer of dead skin cells that forms due to repeated friction. It is cone-shaped and has a knobby core that points inward. This core can put pressure on a nerve and cause sharp pain. Corns can develop on the top of, or between, toes. If a corn develops between the toes, it may be kept pliable by the moisture from perspiration and is therefore called a soft corn.
Corns develop as a result of friction from the toes rubbing together or against the shoe. They often occur from the following:
Shoes, socks, or stockings that fit too tightly around the toesPressure on the toes from high-heeled shoesShoes that are too loose, due to the friction of the foot sliding within the shoeDeformed and crooked toes
Calluses are composed of the same material as corns. Calluses, however, develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily about 40 times thicker than the skin anywhere else on the body, but a callus can even be twice as thick. A protective callus layer naturally develops to guard against excessive pressure and chafing as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, they may pull and tear the underlying skin.
Risk factors for calluses include the following:
Poorly fitting shoesWalking regularly on hard surfacesFlat feet
Of note, in people with diabetes, the presence of calluses is a strong predictor of ulceration, particularly in those who have a history of foot ulcers.
Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and calluses and relieve discomfort if they develop:
Do not wear shoes that are too tight or too loose. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have a cobbler stretch the shoes in the area where the corn or callus is located.Wear thick socks to absorb pressure, but do not wear tight socks or stockings.Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them.Use doughnut-shaped pads that fit over a corn and decrease pressure and friction. They are available at most drug stores.Place cotton, lamb's wool, or mole skin between the toes to cushion any corns in these areas.
Removing Corns and Calluses. To remove a corn or callus, soak it in very warm water for 5 minutes or more to soften the hardened tissue, then gently sand it with a pumice stone. Several treatments may be necessary. Do not trim corns or calluses with a razor blade or other sharp tool. Unsterile cutting tools can cause infection, and it is easy to slip and cut too deep, causing excessive bleeding or injury to the toe or foot.
Medicated Solutions and Pads. There are numerous over-the-counter pads, plasters, and medications for removing corns and calluses. These treatments commonly contain salicylic acid, which may cause irritation, burns, or infections that are more serious than the corn or callus. Use caution with these medications. The following people should not use them:
Patients with diabetesPatients with reduced feeling in the feet due to circulation problems or neurological damagePatients who do not have the flexibility or eyesight to use them properly
A bunion is a deformity that usually occurs at the end of one of the five long bones (the metatarsal bones) that extend from the arch of the foot and connect to the toes. Most often bunions develop in the first metatarsal bone (the one that attaches to the big toe). A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as either a bunionette or a tailor's bunion.
A bunion typically develops in the following way:
The big toe or the fifth ("pinky") toe is forced in toward the other toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.The underlying tissue becomes inflamed, and a painful bump forms.As this bony growth develops, a bunion is formed as the big toe is forced to grow at an increasing angle toward the rest of the toes. One important bunion deformity, hallux valgus, causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.
People born with abnormal bones in their feet are more likely to form a bunion. In addition, wearing narrow-toed, high-heeled shoes, which put enormous pressure on the front of the foot, may also lead to a bunion formation. The condition may become painful as extra bone and a fluid-filled sac grow at the base of the big toe.
Flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet can also increase the risk for bunions.
Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:
Soft, wide, low-heeled leather shoes that lace upAthletic shoes with soft toe boxesOpen shoes or sandals with straps that don't touch the irritated area
A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injections may offer some pain relief.
Surgery. If discomfort persists, surgery may be necessary, particularly for more serious conditions, such as hallux valgus. There are more than 100 surgical variations, ranging from removing the bump to realigning the toes.
The most common surgery, an office procedure known as bunionectomy, involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. This technique is not a cure, but patient satisfaction is high and results are long-lasting.
Click the icon to see an illustrated series detailing bunion removal.
More extensive surgeries may be required to realign the toe joint. Although there are variations of each, they generally involve one or more of the following:
Osteotomy (cutting and realigning the joint). Long-term studies on osteotomies report that 90% of patients are satisfied with the procedure.Exostosectomy (removal of the large bony growth). This technique is only useful when there is no shift in the toe bone itself.Arthrodesis (removal of damaged portion of the joint, followed by implantation of screws, wires, or plates to hold the bones together until they heal). This is the gold standard procedure for very severe cases or when previous procedures have failed. Most patients report good results.Arthroplasty (removal of damaged portion of the joint with the goal of achieving a flexible scar). This technique offers symptom relief and faster rehabilitation than arthrodesis, but it can cause deformity and some foot weakness. Arthroplasty tends to be used in older patients. Biological or synthetic implants for supporting the toes are showing promise as part of this procedure.Tendon and Ligament Repair. If tendons and ligaments have become too loose, the surgeon may tighten them.
In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or damage from osteoarthritis.
Complications, though uncommon in even the most complex procedures, can include:
Continued painInfectionPossible numbnessIrritation from implants used to support the boneAn excessively shortened metatarsal bone
Recovery from more invasive procedures, such as arthrodesis or osteotomy, may take 6 to 8 weeks, and it can be that long before a patient can put full weight on the foot. In such cases, the patient will need to wear a cast or use crutches. Elderly patients may need wheelchairs.
A hammertoe is a permanent deformity of the toe joint, in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of the toe shrink, and the toe stiffens into a hammer- or claw-like shape.
Hammertoe is most common in the second toe, but it can develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Conditions that increase the risk of hammertoe include:
DiabetesDiseases that affect the nerves and muscles Click the icon to see an image of a hammertoe.
Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, sold in drug stores, into the shoe. To help prevent and ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.
Surgery. Patients with severe cases of hammertoe may need surgery. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes require only a single stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about 3 weeks, and then the pin is removed. The procedure seems to have a high, lasting success rate.
Ingrown Toenails
Ingrown toenails can occur on any toe, but they are most common on the big toes. They usually develop when tight-fitting or narrow shoes put too much pressure on the toenail and force the nail to grow into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail. Other causes include:
InjuriesAbnormalities in the structure of the footRepeated impact on the toenail from high-impact aerobic exercise
An ingrown toenail is a condition in which the edge of the toenail grows into the skin of the toe. The big toe is most commonly affected. Symptoms include pain, redness, and swelling around the toenail.
Caring for Toenails. Trim toenails straight across and keep them long enough so that the nail corner is not visible. If the nail is cut too short, it may grow inward. If the nail does grow inward, do not cut the nail corner at an angle. This only trains the nail to continue growing inward. When filing the nails, file straight across the nail in a single movement, lifting the file before the next stroke. Do not saw back and forth. A cuticle stick can be used to clean under the nail.
Treatments. To relieve pain from ingrown toenails, try wearing sandals or open-toed shoes. Soaking the toe for 5 minutes twice a day in a warm water solution of salt, Domeboro or Betadine can help. People who are at increased risk for infections, such as those with diabetes, should have professional treatment.
Antibiotic ointments may help treat ingrown toenails that are infected. Apply the ointment by working a wisp of cotton under the nail, especially the corners, to lift the nail up and drain the infection. The cotton will also help force the toenail to grow out correctly. Change the cotton daily, and use the antibiotic consistently.
In severe cases, more intensive treatments are needed. Surgery involves simply cutting away the sharp portion of ingrown nail, removing the nail bed, or removing a wedge of the affected tissue. Orthonyxia is a technique that implants a small metal brace into the top of the nail. Nonsurgical methods can also treat ingrown toenails.
One technique uses chemicals to remove the skin. Both sodium hydroxide and phenol may be used, but research shows that sodium hydroxide produces a better outcome and faster recovery than phenol. Phenol may be used along with surgery, and it may make the surgery more effective in preventing recurrence. Other nonsurgical methods include using cauterization (heating), or lasers, to remove the skin.
A review of studies evaluating treatments for ingrown nails found that surgical procedures are more effective than non-surgical therapies in preventing recurrences.
Forefoot Pain
Forefoot pain refers to pain and discomfort felt toward the top of the foot. The rate of forefoot pain and deformity increases with age. When a cause cannot be determined, any pain on the ball of the foot is generally referred to as metatarsalgia.
Forefoot pain may be due to:
Morton's neuromaSesamoiditisStress fractures
Morton's Neuroma
A neuroma usually means a benign tumor of a nerve. However, Morton's neuroma, also called interdigital neuroma, is not actually a tumor. It is a thickening of the tissue surrounding the nerves leading to the toes. Morton's neuroma usually develops when the bones in the third and fourth toes pinch together, compressing a nerve. It can also occur in other locations. The nerve becomes enlarged and inflamed. The inflammation causes a burning or tingling sensation and cramping in the front of the foot. Other causes of this condition include:
Tight, poorly-fitting shoesInjuryArthritisAbnormal bone structure
Treatment for Neuromas. Pain from Morton's neuroma can be reduced by massaging the affected area. Roomier shoes (box-toed shoes), pads of various sorts, and cortisone injections in the painful area are also helpful. A combination of cortisone injections and shoe modifications provides better immediate relief than changes in footwear alone. Ultrasound-guided injection of alcohol might also provide relief from Morton's neuroma, research finds.
If these treatments are not effective, the enlarged area may need to be surgically removed. Success rates for this procedure seem to be high and provide long-term relief. Some numbness is common afterward, but it rarely bothers patients. Occasionally, the nerve tissue may re-grow and form another neuroma.
Sesamoiditis is an inflammation of the tendons around the small, round bones that are embedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high-impact activities, such as ballet, jogging, and aerobic exercise.
Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot are the first lines of treatment for sesamoiditis. A low-heeled shoe with a stiff sole and soft padding inside is all that is usually required. In severe cases, surgery may be necessary.
Stress Fracture
A stress fracture in the foot, also called fatigue or march fracture, usually results from a break or rupture in any of the five metatarsal bones (mostly the second or third). These fractures are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics. Women are at higher risk for stress fracture than men.
A fracture in the first metatarsal bone, which leads to the big toe, is uncommon because of the thickness of this bone. If it occurs, however, it is more serious than a fracture in any of the other metatarsal bones because it dramatically changes the pattern of normal walking and weight bearing.
Treatment for Stress Fractures. Patients should seek treatment if pain persists for 3 weeks. Treatment after that time may reduce the chances of returning to previous level of functioning. Surgery may be needed if conservative measures fail. In most cases, however, stress fractures heal by themselves if you avoid rigorous activities. Some health care providers recommend moderate exercise, particularly swimming and walking. It is best to wear low-heeled shoes with stiff soles. Occasionally, a health care provider may recommend wearing a walking "boot" (brace) to reduce pain and facilitate healing.
Heel Pain
The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects 2 million Americans every year. It can occur in the front, back, or bottom of the heel. Types of heel pain include:
Achilles tendinitisBursitis of the heelExcess pronationHaglund's deformityHeel spur syndromePlantar fasciitis
Each type of heal pain is described in more detail below. General treatment guidelines are as follows:
The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after 8 weeks.If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy. Surgery may be an option if other methods have failed.
Achilles Tendinitis
Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury. This condition is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.
Of the people who engage in these activities, those at highest risk for this disorder are the ones with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and may bounce when they walk. A shortened tendon can be due to an inborn structural abnormality, or it can develop from regularly wearing high heels.
An inflamed or torn Achilles tendon causes intense pain and affects mobility.
Evidence is inconclusive about the best way to treat either acute or chronic Achilles tendinitis. Some approaches include:
Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), may help ease pain and reduce inflammation. It is also helpful to apply ice for 20 to 30 minutes, four or five times a day. (Note: Corticosteroid injections should not be used, because they increase the risk for rupture of the tendon.)
Gentle Stretching. Gentle calf muscle stretches may also help reduce pain and spasms. If the calf is swollen, elevate the leg. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.
Surgery vs. Nonsurgical Treatment. Chronic inflammation may lead to rupture of the Achilles tendon. If pain continues, the ruptured tendon will require a cast and perhaps surgery, called tendon transfer. Although some experts believe a cast without surgery is a sufficient treatment for such rupture, there is a chance the tendon may rupture again in the future, even after it heals. Some experts suggest surgery for active people and nonsurgical treatment for older people.
Surgery requires a long incision with a postoperative period of immobilization that can average 6 weeks. Complications can include a significant surgical scar, infection, and muscle atrophy, although surgery reduces pain and preserves foot function in the long term.
Bursitis of the Heel
Bursitis of the heel is an inflammation of the bursa, a small sack of fluid beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.
Excessive Pronation
Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain but also hip, knee, and lower back problems.
Haglund's Deformity
Haglund's deformity, known medically as posterior calcaneal exostosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it's often linked to wearing high heels. (It can also develop in runners, however.)
Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), will also reduce pain. Your doctor may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.
In severe cases, surgery may be necessary to remove or reduce the bony growth. Studies show, however, that recovery from surgery is very long, and success rates vary. Experts advise patients to try all conservative measures before choosing surgery.
Plantar Fasciitis and Heel Spur Syndrome
Plantar fasciitis is a common foot problem that accounts for 1 million office visits per year. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps serve as a shock absorber for the body.
The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel with their first steps in the morning. The pain also often spreads to the arch of the foot. The condition can be temporary, or it may become chronic if ignored. Resting can provide relief, but only temporarily.
Heel spurs are calcium deposits that can develop under the heel bone as a result of inflammation. Heel spurs and plantar fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.
Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports. Plantar fasciitis accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to be responsible in many cases. Other causes of this injury include poorly-fitting shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.
Treatment Goals. The three major treatment goals for plantar fasciitis are:
Reducing inflammation and painReducing pressure on the heelRestoring strength and flexibility
Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads, as needed, can help relieve the problem. Pain that does not subside with NSAIDs may require more intensive treatments, including leg supports and even surgery.
Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:
Put the hands on a wall and lean against them.Place the uninjured foot on the floor in front of the injured foot.Raise the heel of the injured foot.Gently stretch the injured leg and foot.
With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.
Treatment. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen. NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.
Corticosteroids are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as Xylocaine) may provide relief in severe cases of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current.
Several non-drug approaches can relieve pressure on the heel, including:
Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support the rest of the heel while relieving pressure on the painful spot. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics.Night Splints. Some evidence suggests that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot stretched while the patient is sleeping. This allows the muscle to heal. Although patient compliance may be better with custom-made prescribed orthotics than with tension night splints, it is believed that they are equally effective in improving pain. In addition, evidence suggests that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients.Elevated Heels. Some people report relief from mild symptoms with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate-to-severe condition. (Heel cups have not been proven to be very useful.)Orthotics. For severe conditions, such as fallen arches or structural problems that cause imbalance, special insoles, called orthotics, may help. Custom orthotics are made to fit the patient's foot and individual clinical needs. (See "Insoles and Orthotics" section).Extracorporeal Shock Wave Therapy (ESWT). ESWT may be used as an alternative to surgery for patients who have not responded to other treatments. The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which is believed to trigger healing of the tissues that are causing the pain. Studies show that the treatment provides a very small reduction in heel pain without side effects. It can be considered as an option for patients who haven't responded well to extensive conservative treatment.Surgery. Surgery may be needed for some patients, typically those who have disabling heel pain that does not respond to other treatments for at least a year. A typical surgery is called instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia. A less invasive method uses a procedure called endoscopy, which requires smaller incisions. Wearing a below-the-knee walking cast after surgery for 2 weeks may reduce the need for pain relief and speed recovery time compared to the use of crutches.Botox. Studies show that injections of botulinum toxin (Botox), a protein used to temporarily paralyze certain muscles, reduce pain and improve patients' future ability to walk. More research is needed on this treatment.
Flat Feet
"Flat foot," or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over age 50, but it can occur in anyone. The following are risk factors for PTTD:
Wearing high heels for long periods of time is a particular risk for flat feet. Over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down, and the arch falls.Some studies have indicated that the earlier a person starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on.Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or the use of corticosteroids.
Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence. Nevertheless, whether flat feet pose any significant problems in adults is unknown.
Treatment for Flat Feet in Children. Doctors usually can't diagnose flat feet until a child is 6 years old. Children with flat feet typically don't have symptoms, and often outgrow the condition. Children who are experiencing symptoms might need to change shoes or wear arch supports. In rare cases, minimally invasive joint insert surgery may be an option.
Treatment for Flat Feet in Adults. In general, conservative treatment for flat feet acquired in adulthood (PTTD) involves pain relief and insoles or custom-made orthotics to support the foot and prevent progression.
In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis that typically lengthen the Achilles tendon and adjust tendons in the foot. One procedure uses an implant to support the arch. These procedures have potential complications. Try conservative methods first.
Abnormally High Arches
An overly-high arch ("hollow foot") can also cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot.
Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but it can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders.
Claw toe is a deformity of the foot in which the toes are pointed down and the arch is high, making the foot appear claw-like. Claw toe can be a condition from birth or develop as a consequence of other disorders.
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It can cause pain anywhere along the bottom of the foot. It can occur with:
DiabetesBack painArthritisInjury to the ankleAbnormal blood vesselsScar tissue that press against the nerve
Magnetic resonance imaging (MRI) and the dorsiflexion-eversion test can diagnose this syndrome.
Treatment for Tarsal Tunnel Syndrome. Specially designed shoe inserts called orthotics can relieve pain from tarsal tunnel syndrome because they help redistribute weight and take pressure off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed, particularly if symptoms persist for more than a year, although its benefits are a matter of debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than tarsal tunnel syndrome of unknown cause. It can take months after this surgery for a person to recover and resume normal activities. Only experienced surgeons should perform tarsal tunnel syndrome surgery.
Foot Injury
If you suspect that you have broken or fractured bones in a toe or foot, call a doctor, who will probably order x-rays. Even if you can walk, you still might have a fracture. People are often able to walk even if a foot bone has been fractured, particularly if it is a chipped bone or a toe fracture.
Over-the-Counter Pain Relievers
Over-the-counter NSAIDs are commonly used to treat mild pain caused by muscle inflammation. Aspirin is the most common NSAID. Others include ibuprofen (Motrin, Advil, Nuprin, Rufen), ketoprofen (Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin (Tolectin). A gel containing ibuprofen can be applied to sore joints. Acetaminophen (Tylenol) is not an NSAID, and although it is an effective pain reliever, it will not reduce inflammation. It is important to note that high doses or long-term use of any NSAID can cause gastrointestinal disturbances with sometimes serious consequences, including dangerous bleeding. NSAIDs can also increase the risk of heart disease and stroke. This risk increases the longer you use them. No one should take NSAIDs for prolonged periods of time without consulting a doctor.
RICE (Rest, Ice, Compression, and Elevation)
The acronym RICE stands for rest, ice, compression, and elevation -- the four basic elements of immediate treatment for an injured foot.
Rest. Patients should get off injured foot as soon as possible.Ice. This is particularly important to reduce swelling and promote recovery during the first 48 hours. Wrap a bag or towel containing ice around the injured area on a repetitive cycle of 20 minutes on, 40 minutes off.Compression. Lightly wrap an Ace bandage around the area.Elevation. Elevate the foot on several pillows.
Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE is helpful for remembering how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours, and gentle movement may be beneficial, but don't put pressure on a sprained joint until the pain is completely gone (one to several weeks).
The American Podiatric Medical Association offers the following tips for preventing foot pain:
Don't ignore foot pain. It is not normal. If the pain persists, see a doctor who specializes in podiatry.Inspect feet regularly. Pay attention to changes in color and temperature. Look for thick or discolored nails (a sign of developing fungus), and check for cracks or cuts in the skin. Peeling or scaling on the soles of feet could indicate athlete's foot. Any growth on the foot is not considered normal.Wash feet regularly, especially between the toes, and dry them completely.Trim toenails straight across, but not too short. (Cutting nails in corners or on the sides increases the risk for ingrown toenails.)Make sure shoes fit properly. Purchase new shoes later in the day when feet tend to be at their largest, and replace worn out shoes as soon as possible.Select and wear the right shoe for specific activities (such as running shoes for running).Alternate shoes. Don't wear the same pair of shoes every day.Avoid walking barefoot, which increases the risk for injury and infection. At the beach or when wearing sandals, always use sunblock on your feet, as you would on the rest of your body.Be cautious when using home remedies for foot ailments. Self-treatment can often turn a minor problem into a major one.It is critical that people with diabetes see a podiatric physician at least once a year for a checkup. People with diabetes, poor circulation, or heart problems should not treat their own feet, including toenails, because they are more prone to infection.
Skin Creams and Foot Baths
Skin creams can help maintain skin softness and pliability. A pumice stone or loofah sponge can help get rid of dead skin.
Taking a warm footbath for 10 minutes two or three times a week will keep the feet relaxed and may help prevent mild foot pain caused by fatigue. Adding 1/2 cup of Epsom salts may increase circulation and add other benefits. Taking footbaths only when the feet are painful is not as helpful.
Proper Walking and Foot Exercises
In addition to wearing proper shoes and socks, walking often -- and properly -- can prevent foot injury and pain. The head should be erect, the back straight, and the arms relaxed and swinging freely at the side. Step out on the heel, move forward with the weight on the outside of the foot, and complete the step by pushing off the big toe.
Exercises specifically for the toe and feet are easy to perform and help strengthen them and keep them flexible. Helpful exercises include the following:
Raise and curl the toes 10 times, holding each position for a count of five.Put a rubber band around both big toes and pull the feet away from each other. Count to five. Repeat 10 times.Pick up a towel with the toes. Repeat five times.Pump the foot up and down to stretch the calf and shin muscles. Perform for 2 or 3 minutes.
Preventing Foot Problems in Childhood
Early Development. The first year of life is important for foot development. Parents should cover their babies' feet loosely, allowing plenty of opportunity for kicking and exercise. Change the child's position frequently. Children generally start to walk at 10 to 18 months. They should not be forced to start walking early. Wearing just socks or going barefoot indoors helps the foot develop normally and strongly and allows the toes to grasp. Going barefoot outside, however, increases the risk for injury and other conditions, such as plantar warts.
Shoes. Children should wear shoes that are light and flexible, and since their feet tend to perspire, their shoes should be made of materials that breathe. Replace footwear every few months as the child's feet grow. Footwear should never be handed down. Protect children's feet if they participate in high-impact sports.
In general, the best shoes are well cushioned and have a leather upper, stiff heel counter, and flexible area at the ball of the foot. The heel area should be strong and supportive, but not too stiff, and the front of the shoe should be flexible. New shoes should feel comfortable right away, without a breaking-in period.
Getting the Correct Fit
Well-fitted shoes with a firm sole and soft upper are the best way to prevent many problems with the feet. They should be purchased in the afternoon or after a long walk, when the feet have swelled. There should be 1/2 inch of space between the longest toe and the tip of the shoe (remember, the longest toe is not always the big toe), and the toes should be able to wiggle upward.
Stand when being measured, and have both feet sized, buying shoes that fit whichever foot is largest. Wear the same socks as you would regularly wear with the new shoes. Women who are accustomed to wearing pointed-toe shoes may prefer the feel of tight-fitting shoes, but with wear their tastes may adjust to shoes that are less confining and properly fitted.
The Sole
Ideally, the shoe should have a removable insole. Thin, hard soles may be the best choice for older people. Elderly people wearing shoes with thick inflexible soles may be unable to sense the position of their feet relative to the ground, significantly increasing the risk for falling.
The Heel
High heels are the major cause of foot problems in women. Although people believe that foot binding is a problem limited to Chinese women of the past, many fashionable high heels are designed to constrict the foot by up to an inch. Women who insist on wearing high-heeled shoes should at least look for shoes with wide toe room, reinforced heels that are relatively wide, and cushioned insoles. They should also keep the amount of time they spend wearing high heels to a minimum.
The way shoes are laced can be important for preventing specific problems. Laces should always be loosened before putting shoes on. People with narrow feet should buy shoes with eyelets farther away from the tongue than people with wider feet. This makes for a tighter fit for narrower feet and a looser fit for wider feet. If, after tying the shoe, less than an inch of tongue shows, the shoes are probably too wide. Adjust tightness both at the top and bottom of the shoe. If shoes with high arches cause pain, skip a few eyelets when lacing them. This should relieve pressure.
Breaking in and Wearing the Shoes
If shoes need breaking in, place moleskin pads next to areas on the skin where friction is likely to occur. Once a blister occurs, moleskin is not effective. Change shoes during the day, and rotate between different pairs of shoes. As soon as the heels show noticeable wear, replace the shoes or their heels.
Special-Purpose Footwear
Avoid extreme variations between exercise, street, and dress shoes.
Exercise and Sports. Shoes purchased for exercise should be specifically designed for a person's preferred sport. For instance, a running shoe should especially cushion the forefoot, while tennis shoes should emphasize ankle support. Athletic socks are almost as important as shoes. Experts often recommend padded acrylic socks.
Occupational Footwear. Because a number of occupations put the feet in danger, workers in high-risk jobs should be sure their footwear is protective. For example, non-electric workers at risk for falling, or whose work involves rolling objects or risk of shoe punctures, should wear shoes with steel toes and possibly other metal foot guards. Electric workers should wear footgear with no metal parts (or insulated steel toes) and rubber soles and heels. Chemical workers should wear shoes made of synthetics or rubber, not leather.
Shoes for Sports
Aerobic Dancing
Sufficient cushioning to absorb shock and pressure, which should be many times greater than shock from walking. Arches that maintain side-to-side stability. Thick upper leather support. Box toe. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combo hiking/cycling shoes may be sufficient for the casual biker. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance the forefoot.
Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Enough traction on the sole to prevent slipping. Consider insole or orthotic with arch support for problem feet.
Allows side-to-side sliding. Low-traction sole. Snug fitting heel with cushioning. Padded toe box with adequate depth. Soft-support arch.
Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch anklebone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.
Insoles are flat cushioned inserts that are placed inside the shoe. They are designed to reduce shock, provide support for heels and arches, and absorb moisture and odor. In general, they can be very helpful for many people.
People respond very differently to specific insoles. What may work for one person may not work for another. Consider the thickness of socks when purchasing insoles to be sure they do not squeeze the toes up against the shoes. Insoles can be purchased in athletic and drug stores. Shoe stores that specialize in foot problems often sell customized, but more expensive, insoles. In general, over-the-counter insoles offer enough support for most people's foot problems. Most well-known brands of athletic shoes have built-in insoles.
Brands and Materials. There are many types of insoles available. They are composed of various materials, such as cork, leather, plastic foam, and rubber. Effective insoles (such as Sorbothane, Airplus, Spenco, Dr. Scholl's Massaging Gel, and others) are now made from viscoelastic polymerses, which are gel-like materials that act both as liquids and solids.
Heel Cushions for Shortened Achilles Tendons. People who have developed short, tightened Achilles tendons (usually women who have worn high-heeled shoes for prolonged periods) should consider using heel cushions. Like insoles, heel cushions are inserted inside the shoes. They should be at least 1/8 inch thick, but not more than 1/4 inch thick.
For severe conditions, such as fallen arches or structural problems that cause imbalance, podiatrists or physicians may need to fit and prescribe orthotics, or orthoses, which are insoles produced to fit the patient's foot and match his or her clinical needs Orthotics are usually categorized as rigid, soft, or semi-rigid.
Before seeking prescription orthotics, people with less severe problems should consider testing the lower-priced, over-the-counter insoles.
Types of orthotics include:
Rigid Orthotics. A rigid orthotics is used to control motion in two major foot joints that lie directly below the ankle. They are often used to prevent excessive pronation (the turning in of the foot) and are useful for people who are very overweight or have uneven leg lengths. Some experts warn that rigid orthotics may cause sesamoiditis or benign tumors from pinched nerves.Soft Orthotics. A soft orthotics is designed to absorb shock, improve balance, and remove pressure from painful areas. They are made from a lightweight material and are often beneficial for people with diabetes or arthritis. A soft orthotics needs to be replaced periodically, and because it is bulkier than rigid orthotics, it may require larger shoes.Semi-Rigid Orthotics. A semi-rigid orthotics is designed to provide balance, often for a specific sport. It is typically made of layers of leather and cork reinforced by silastic.
www.apma.org -- American Podiatric Medical Associationwww.aofas.org -- American Orthopaedic Foot and Ankle Societywww.acfas.org -- American College of Foot and Ankle Surgeonswww.aapsm.org -- American Academy of Podiatric Sports Medicinewww.apta.org -- American Physical Therapy Associationwww.diabetes.org -- American Diabetes Associationwww.arthritis.org -- Arthritis Foundationwww.podiatrynetwork.com -- Podiatry Network
Baer GS, Keene JS. Tendon injuries of the foot and ankle. In: DeLee JC, Drez D Jr., Miller MD, eds. DeLee and Drez's Orthopaedic Sports Medicine. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2009. Pp. 2171-2205:section D.
Del Toro, DR. Tibial Neuropathy (Tarsal Tunnel Syndrome). In: Frontera WR, Silver JK, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2008. pp. 479-482.
Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.
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Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int. 2007;28:996-999.
Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg. 2007;46:348-357.
Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;16:(3):CD006801
Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303-8.
Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007;188:1535-1539.
Kruijff S, van Det RJ, van der Meer GT, van den Berg IC, van der Palen J, Geelkerken RH. Partial matrix excision or orthonyxia for ingrowing toenails. J Am Coll Surg. 2008;206:148-153.
Lee SY, McKeon P, Hertel J. Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009;10:12-18.
The Ankle and Foot. In: Mercier, LR. Mercier: Practical Orthopedics, 6th ed. Philadelphia, Pa: Mosby; 2008. pp.243-273.
Pasquina PF, Foster LS. Plantar fascitis. In: Frontera WR, Silver JK, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2008. pp. 469-473.
Version InfoLast Reviewed on 01/31/2013Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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CHICAGO -- For the second time in 17 months, Bally Total Fitness has filed for bankruptcy. This time, the company has also put itself up for sale.
Bally made the filing today in U.S. Bankruptcy Court for the Southern District of New York in Manhattan. The Chicago-based company, which reported $1.4 billion in assets and $1.5 billion in debt, plans to sell itself or reorganize under Chapter 11.
"The burden of Bally's long-term indebtedness, coupled with the lack of refinancing options in today's constrained credit markets, have limited our ability to restructure using out-of-court vehicles, leaving Bally with no alternative other than the actions announced today," Bally CEO Michael Sheehan said in a statement.
Bally filed for bankruptcy in July 2007, only to emerge from Chapter 11 protection two months later as a private company. Bally's emergence was buoyed by $233.6 million from investors led by Harbinger Capital Funds.
According to a report by Bloomberg, Bally reported it has more than 100,000 creditors. The company owes $247 million in unsecured debt to U.S. Bancorp and $231 million to HSBC Holdings. Bally's debt includes $291 million to first-lien lenders, $247 million to second-lien lenders, and $221 million is owed on subordinated notes.
In court papers, Bally listed its net revenue for the nine months ending Sept. 30, 2008, as $479.5 million, Bloomberg reports. Bally also said in court papers it has 6,820 full-time and 7,750 part-time employees.
In the company statement, Bally said that it will use existing cash reserves to fund its operations. If Bally is able to negotiate a sale with the lenders, they would provide additional cash through debtor-in-possession financing, according to the statement.
In its July 2007 bankruptcy filing, Bally listed assets of $397 million and debt of $761 million. Although there is no prepackaged plan in place with the second filing for bankruptcy, Bally said it hopes to emerge from bankruptcy as quickly as possible.
Bally has 347 clubs in 26 states. Bally's 39 clubs in the Caribbean, Mexico and Asia are not affected by the filing, says Bally spokesperson Larry Larsen.
With regard to possible club closures in the United States, Larsen would only say that Bally constantly evaluates its real estate portfolio as part of its ongoing business process.
"The company will continue to look at opportunities to manage its portfolio while meeting its customers' needs," he says. "Bally fully anticipates that it will continue operating as a national brand with a national footprint."
Larsen would not discuss membership trends, but he did say that during the past five months, Bally had significantly improved its operating processes, expense management and organizational structure, leading to a marked improvement in its current and projected operating performance.
Bally has retained Kramer Levin Naftalis & Frankel LLP as bankruptcy counsel and Houlihan Lokey Howard & Zukin as its financial advisers.

subset: commoncrawl


text:
OHRC remarks to the Ontario Legislative Standing Committee on Social Policy regarding Bill 13 and Bill 14
Ontario's Human Rights Code is Ontario's highest law. All schools, including public, Catholic and private, have a legal duty to provide students with an educational environment free from harassment and other forms of discrimination because of their race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sexual orientation, age, marital status, family status or disability and sex including gender identity. Bullying is a form of harassment within the meaning of the Code.


text:
I set up some butcher paper (though I am doubtful that anyone has actually slaughtered an animal in our staff lounge) on the wall and ask students to respond to my comment, "I'm going to miss this class." I also set up a "class wall" where students can arbitrarily add their own comments. It's a classroom extension of my Living Facebook experiment.
It's primitive. Cave walls. Graven images. Simple, perhaps, but more complex in its simplicity. We are limited and yet, these limitations foster the creative impulse. Students not only write comments, but they also sketch pictures, change colors, alter hand-writing and draw arrows to comments. On Facebook, my wall is linear. In my classroom, the wall is a web.
It's more than that, though. "My wall" quickly becomes a collective space and it's nearly impossible to differentiate the two sides. On Facebook, my wall is always mine. In the classroom, the wall is ours.
"That looks pretty cool," I mention to a student.
"I guess so," he says.
"What do you mean?" I ask.
"I guess it's nice to write on a wall. That's the appeal of tagging. But I like that," he points to the mural on our wall.
"Why?" I ask him.
"It's us without the words," he says.
His friend says, "Besides, we won't throw it away a day later."
I've often tried to defend why I paint murals with my students. I talk about the need for creativity and critical thinking. I toss in some educational jargon about multiple intelligences and cooperative learning. People live with a smile and then silently curse the craziness.
But if you really want to know why we paint murals, it's because of the power of the community that develops when we have a collective voice that empowers the voice of the individual. It's because there is something deeply human in our creative impulse. Yes, we can solve problem. True, we can create poetry. But there is something powerful and profound in working with our hands. It's something we lost in automation and perhaps even more in the vapor-digital world.
Facebook doesn't have murals. Sadly, many schools don't, either. In the very place where we can expose students to art and authenticity, students stare at word walls. In the very place that should model a collective and individual voice, students look at administrator-mandated classroom spaces. Perhaps I'm being preachy, but a small, inexpensive, powerful reform would be to replace a few of the Garfield posters with murals.


text:
I got virus in one of mine nokia phone.
I cannot install any of antivirus programs on it.
Nokia 72, symbian os.
I do not know if it will help with installation of firmware uppgrade or reinstallation of it with help of Nokia PC Suite.
Virus is just sending spam sms out of country somewhere.
I tried to install F-secure and Kaspersky.
When I install antivirus i getting message that installation succed but i cannot find and start it.
What can I do more and how to remove it?


text: Gampie #1 Posted July 7, 2008 [CENTER][size=6][b]House Tully[/b][/size] [/CENTER] [i]The Tully's have a long history of going against the grain. Their rise to prominence was a direct result of the invasion led by Aegon and the subsequent defeat of King Harren of the Iron Islands. Edmyn Tully was the first lord of the Trident to rebel and thus was rewarded as being named the Lord Paramount of the Trident. Their house motto is "Family, Duty, Honor.†With Lord Hoster Tully sick with old age, his firstborn son, and heir Lord Edmure Tully is now in control of the Trident. With one of his sisters married and now widowed to Eddard Stark, one can almost count on the Tully's throwing their considerable power in with the Starks and the lords of the North. Not only blood, but revenge and preservation calls for this course of action as the Lannisters have loosed the infamous Gregor Clegane to ravage the countryside that makes up Lord Tully's land. Will their alliance with the Starks hold the Lannister onslaught at bay? Can they hope to defeat Lord Tywin in the field and break the backbone of the power of the malicious Joffrey?[/i] [b][size=4]The Tully family[/size][/b] The Tully family is a small one, as the sick and old Huster Tully only has one son to succeed him. His two daughters are both married to lords of other great houses while Edmure himself hasn't taken a wife yet. Time is running short for Edmure. If he were to perish in the upcoming war his house would be continued by his uncle Brynden, an unmarried man in his fifties. Arranging a marriage for Edmure and making sure he procures offspring should be a priority for anyone playing with house Tully. Edmure is a benevolent ruler who wants to protect his smallfolk from the Lannister incursions. Brynden is a knight of renown whose tactical skills will be of great use in the war. [url="http://users.skynet.be/sky73172/fptully/edmuretully.jpg"]Edmure Tully[/url] [url="http://users.skynet.be/sky73172/fptully/bryndentully.jpg"]Brynden Tully[/url] [b][size=4]Lord Edmure's bannermen[/size] [/b] Among Edmure's bannermen we have Jason Mallister, lord of Seagard, the bastion against the Ironmen raids. Then there is Tytos Blackwood, lord of Raventree, a powerful house. Clement Piper, lord of Pinkmaiden, is another bannerman while his son, the hotheaded Marq Piper, is a sworn sword and personal friend of lord Edmure. [url="http://users.skynet.be/sky73172/fptully/jasonmallister.jpg"]Jason Mallister[/url] [url="http://users.skynet.be/sky73172/fptully/tytosblackwood.jpg"]Tytos Blackwood[/url] [url="http://users.skynet.be/sky73172/fptully/clementpiper.jpg"]Clement Piper[/url] [url="http://users.skynet.be/sky73172/fptully/marqpiper.jpg"]Marq Piper[/url] [b][size=4]The territories of the Tully's[/size][/b] The Riverlands are traditionally regarded as fat lands. Their fertility derives from the mighty Trident river which crisscrosses through the lands. Strategically located between the Tumblestone and the Red Fork, Riverrun is the dominant castle in the Riverlands, dwarfed only by Harrenhal. Riverrun is the seat of house Tully and the main focus of the attacks of house Lannister. A lot of bloody battles will be fought before the gates of this castle. Harrenhal is the largest of all strongholds in Westeros and guards the eastern borders of the Riverlands. In the north you have Seagard, the only castle with a port. Raventree is safely located between Harrenhal and Pinkmaiden. The latter one is part of the western border and will be one of the first keeps that will feel the fury of house Lannister. [url="http://users.skynet.be/sky73172/fptully/riverrun.jpg"]Riverrun[/url] [url="http://users.skynet.be/sky73172/fptully/harrenhal.jpg"]Harrenhal[/url] [url="http://users.skynet.be/sky73172/fptully/seagard.jpg"]Seagard[/url] [url="http://users.skynet.be/sky73172/fptully/raventree.jpg"]Raventree[/url] [url="http://users.skynet.be/sky73172/fptully/pinkmaiden.jpg"]Pinkmaiden[/url] [b][size=4]Neighbouring regions[/size][/b] In the north there is the Twins, ruled by the crooked lord Frey. Its strategic importance is immense as it controls one of the two crossings over the Green Fork. The other one is near Saltpans. Yet house Tully need not to fear an invasion from that direction for there are only allied northmen in that direction. To the east of Seagard there is Fairmarket, an average-sized town located between the Green Fork and Blue Fork. Other small towns further downstreams are Saltpans and Maidenpool. Maidenpool is close to Duskendale, which is controlled by the cruel king Joffrey and may be the target of his expansion as well. To the south of Pinkmaiden there is Stoney Sept, a fairly large town. To the west the walls of Golden Tooth, a Lannister stronghold, loom menacingly. [b][size=4]The initial set-up[/size][/b] When the mod begins Edmure has just lost a considerable force in the Battle of Golden Tooth. The main host is now in Riverrun while the other castles have decent garrisons. Near Golden Tooth several large Lannister armies led by lord Tywin Lannister, Ser Addam Marbrand and Ser Jaime Lannister threaten to invade the Riverlands while Ser Gregor Clegane is already pillaging near Raventree. [b][size=4]The army of House Tully[/size][/b] House Tully has one of the best unit rosters of all factions. They can field a variety of forces that can counter anything the enemy throws at them. Decent crossbowmen, excellent Riverland archers, cheap run-of-the-mill militias, pikemen grunts, dismounted knights supplemented with the dangerous dismounted Riverland nobles, strong heavy horse, ... yes, it's good to play with house Tully. This is the recruitment tab at Riverrun: [url="http://users.skynet.be/sky73172/fptully/recruitment.jpg"]Recruitment[/url] [url="http://users.skynet.be/sky73172/fptully/dismountedknights.jpg"]Dismounted Knights[/url] [url="http://users.skynet.be/sky73172/fptully/spearmilitia.jpg"]Spear Militia[/url] [url="http://users.skynet.be/sky73172/fptully/knightsofriverrun.jpg"]Noble Knights[/url] [url="http://users.skynet.be/sky73172/fptully/crossbowmen.jpg"]Crossbowmen[/url] [url="http://users.skynet.be/sky73172/fptully/pikemilitia.jpg"]Pike Militia[/url] [b][size=4]Their army in action[/size][/b] [url="http://users.skynet.be/sky73172/fptully/battle1.jpg"]Image 1[/url] [url="http://users.skynet.be/sky73172/fptully/battle2.jpg"]Image 2[/url] [url="http://users.skynet.be/sky73172/fptully/battle3.jpg"]Image 3[/url] [url="http://users.skynet.be/sky73172/fptully/battle7.jpg"]Image 4[/url] For the following screenshots I've loaded a custom battle between the Starks and the Tully's. Just for your information so don't start crying "Blasphemy!" :tongue: [url="http://users.skynet.be/sky73172/fptully/battle4.jpg"]Image 5[/url] [url="http://users.skynet.be/sky73172/fptully/battle5.jpg"]Image 6[/url] [url="http://users.skynet.be/sky73172/fptully/battle6.jpg"]Image 7[/url] Share this post Link to post Share on other sites


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of course, there's always something to fall in love with: asexual perspectives on pop culture and much more.
Thursday, July 17, 2008
Maurice: Your Fangirl is Here
I always find myself relating strongly to tales of forbidden gay love. Asexuality may have never been a jailing (or hell, hanging!) offense, but the flak some of us get from friends, family, lovers and even strangers can make solitary confinement seem welcome on bad days. Just look at this dialogue from the movie, in which Maurice sees a doctor, desperately seeking a cure for his homosexuality (occurs around 1:15):
Doctor: What put all this into your head?
Maurice: You've never guessed? I'm like Lord Risley [old school chum; convicted homosexual]. I'm an unspeakable, of the Oscar Wilde sort.
Dr: Rubbish. Rubbish.
M: Dr. Barry, I can't have explained...
Dr: Now listen to me, Maurice. Never let that evil hallucination, that temptation from the devil, occur to you again. Now, who put that lie into your head? You, whom I see and know to be a decent fellow.
M: Dr. Barry, I want--
Dr: No sir, I'll not discuss! The worst thing I could do for you is to discuss!
M: It's not rubbish to me.
Dr: Rubbish!
M: I've been like this ever since I can remember, without knowing why. Am I diseased? If I am, I want to be cured.
Dr: Find yourself a pretty young woman. She'll soon cure you. It's unspeakable.
With some slight tweaks, this could, sadly, be an asexual experience. It sounds so melodramatic, but it's really happened to some of us. True, there are some deeply sad things about Maurice, but it doesn't quite make it onto my "Most Depressing Movies of All Time" list, in which fellow M&I flick The Remains of the Day earns my #3 spot. I think part of what made me sad was the fact that if I, too, had a huge country estate where I could just ride horses and "preside" all day, I could handle a little forbidden love. Sigh. And come to mention it, that is what Maurice will make you do. Sigh. A lot.
Interestingly, I've never found Hugh Grant to be very attractive. He's seemed a little...jowly lately. But 21 years ago? He was freakin' adorable! I couldn't find a picture that adequately captured him, but here he is brooding a little, which I always find appealing:
I think I just have a crush on this whole movie. M&I excels at creating atmospheres, and in Maurice, they've created an atmosphere that is my particular fantasy: Discussing arcane topics in old stone buildings with exceedingly erudite and witty men wearing tweed. (I totally love Lord Risley too, in one of the first scenes. He kind of reminds me of a gay, sober Withnail.) Sigh, sigh, SIGH!
4 comments:
Right, so... I officially have to see this movie now. My disdain for Hugh Grant aside. (Really? He was adorable twenty years ago? I can't wait to see HG adorable.) :)
I think it's particularly tragic that we live in a society where so many people would read that scene, as written, and shake their heads in disbelief; yet, if they read it with the "slight tweaks" you mention would make it applicable to asexuality, they'd no longer see the problem. It's like we learn but only to the extent where we have to apply what we've learned, and then we forget all over again... and another whole population suffers because of it. Lame. ( <-- Understatement.)
- July 17, 2008 at 9:44 PM
Tweed should definitely go on the list for a future installment of "Things Asexuals Like." There are several AVEN threads about this phenomenon floating around, if memory serves me.
- July 18, 2008 at 4:56 PM
Do you really keep a "Most Depressing Movies of All Time" list?
Tweed, hehe. :)
- July 19, 2008 at 2:40 AM
- Ily said...
I vaguely remember some tweed conversation on AVEN...I'm going to have to look for that.
- July 19, 2008 at 1:42 PM


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Hi everyone. I am currently taking a beginners course in java programming at the university of Aarhus. We are now 2 weeks in to the course and our teacher has suggested that we should start some small projects to work on, on our own. So i have decided to try and write a bubblesort algorithm.
Now i haven´t really gotten very far yet but i am getting a failure-message called
"Exception in thread "main" java.lang.ArrayIndexOutOfBoundsException: 3
at bubbleSort.main(bubbleSort.java:20)"
I basically do not understand why i am getting it. I hope that someone can explain it to me. And please keep in mind that you may have to "dumb it down" for me since i am only 2 weeks in to the course. I have already tried to look it up here ArrayIndexOutOfBoundsException (Java 2 Platform SE v1.4.2) and i still don't get it.
import java.util.Vector; public class bubbleSort { public static void main(String[] args) { String[] name={"Thor", "Jensen", "Soeren"}; Vector v = new Vector(); int zero=0; int one=1; int runTimes = name.length; while(runTimes>0){ if(name[zero].length() >= name[one].length()){ v.insertElementAt(name[zero], 0); zero++; one++; runTimes--; } else { v.insertElementAt(name[one], 0); zero++; one++; runTimes--; } } System.out.println(v); } }


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British Comedy Award winner Bill has enjoyed success on the live stage for many years. In 2001 he took his show Bewilderness to New York for an eight week run at the Westbeth Theatre. The New York Times wrote of him, "Bill is an unalloyed pleasure, a treat for the funny bone, the brain and the ear" and The Telegraph pronounced him "a hobbit with a wicked sense of humour". In 2004 he performed his show Part Troll at over fifty venues around the UK, culminating in an extended run at London's Wyndhams Theatre. In 2007 he embarked on a sold-out UK arena tour with his audio-visual, comedic extravaganza, Tinselworm. He took the show down under during the summer of 2008, touring Australia and New Zealand, before returning to London in December 2008 for a ten week run of the show at The Gielgud Theatre. The summer of 2009 saw Bill tour the UK once again with his live show, Bill Bailey Live. Last autumn, following his performances at London's Royal Albert Hall and the resulting critically acclaimed BBC2 television broadcast, Bill enjoyed a very successful UK tour of his musical comedy extravaganza, Bill Bailey's Remarkable Guide to the Orchestra. Performing alongside some of the UK's finest orchestras, the show provided fans with the opportunity to see Bill's surreal comic and musical imagination at its best and was described by The Telegraph as "a glorious achievement," The Guardian as "sublime hilarity" and Stephen Fry as "wonderfully enjoyable... like driving a Rolls-Royce off-road."
Larks in Transit is a compendium of travellers' tales and the general shenanigans of twenty years as a travelling comedian. With musical virtuosity, surreal tangents and trademark intelligence, he tackles politics, philosophy, the pursuit of happiness, death metal, ringtones... and an excruciating encounter with Paul McCartney. Two decades of life as a comic filtered through what the Daily Telegraph calls 'the brainiest comic of his generation'..


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8:00 We're watching the NBC feed. Note that by speaking from West Point, he's likely to have a receptive audience (at least superficially)! No one is likely to yell, "You lie!"
Will he reference his predecessor in describing the country's reaction to 9-11?
Nope. It's all about Congress. And NATO. And the UN. No President Bush yet. Pretty shocking how radioactive the Bush name seems to be to Obama…
Indeed, he's going to portray this as a reversal of the Bush emphasis on Iraq and neglect of Afghanistan – smart politics that reverts back to his campaign strategy that allowed him to appear for change but also strong against terrorism.
Here's a shot against Cheney.
And here's the controversial part: laying out a timetable for beginning withdrawal. Note, however, that it's really not that risky to say troop withdrawals will begin in 18 months – that's a pretty fuzzy guideline.
He's really walking a tight line here by both defending himself against attacks from the Left by stressing that Afghanistan is the breeding ground of extremists, but also arguing that he's not Bush; that this campaign is directed against real threats, not trumped up ones as in Iraq.
Hmmm… I think he's describing a "coalition of the willing"! Best reports so far indicate that these additional troops may, if the US is lucky, number 1,000.
And here comes the performance measures, echoing the "benchmarks" used to chart progress in Iraq.
and the third leg of the strategy: partnering with Pakistan. We'll see what the Pakistanis say about this…
a "civilian" surge? Interesting way to avoid linking back to the Bush surge!
The Vietnam syndrome is still strong….
Here's the defense of the time table for withdrawal….this is the sop to the Left.
Hillary must be taking a bit of pleasure in seeing her more hawkish views prevailing….
And how will he pay for it? Punts that one to Congress!
It's hard work!
Boy, how many times have we heard Bush give an almost identical speech, but with the word Iraq substituted for Afghanistan. The irony can't be lost on the Democratic Left…
Did he renew alliances and forge new relationships? I guess Hillary is not going to get any credit on that score!
He will close GITMO – now the Left is really getting riled! Talk is cheap…
Time for the rhetorical flourish at the end…
cue music…..
He does good rhetorical flourish. Is this only the second applause line of the speech? Speaks to the solemn topic….
For just once I wish someone, when citing the "people", would mention someone different. Why not cite "the bankers" and the "insurance agents" and the "used car salesmen" that made this country great? It's always teachers and military personnel. Let's show some love for the little people…
And once more into the breach of bipartisanship. He'll be no more successful this time than on the previous 30 times he pushed for bipartisanship. The irony, of course, is that he's more likely to be opposed by his own Left Wing, not Republicans.
This is an awfully long rhetorical flourish….
hard to find fault with this speech primarily because he played it very straight, and most of the substance had already been leaked. The failure to cite Bush is probably the most conspicuous omission.
The real issue here is whether the surge will work within the stated timetable and if it doesn't, what then? Does he stick to the timetable? Note that the decision to begin withdrawing, or not, takes place in the runup to the 2012 presidential election.
Let's see what the talking heads have to say….
McCain: surge good, exit date bad.
Richard Haas (Council of Foreign Relations): blah, blah, blah…
David Gregory: Ditto.
Cue Biggest Loser…..
I'll be on tomorrow with an update on the polling reaction and punditocracy.


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Sarawak Cultural Village & Damai Central
Sarawak Cultural Village Kuching, Malaysia


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|Usable by
|Casting time
|Instant cast
|Level required
|Other information
|Requires Cat Form, Bear Form
Mangle is a druid ability learned at level six. For the removed [Cat Form] specifics, see [Mangle (cat)]; for the current [Bear Form] specifics, see [Mangle (bear)].
Patch Changes
- Patch 3.3.3 (2010-03-23): The debuff from this talent now lasts 60 seconds, up from 12 seconds.
- Patch 3.2.0 (04-Aug-2009): Ranks 4 and 5 base points reduced by about 11%. Scaling from attack power unchanged.
- / Patch 3.0.2 (14-Oct-2008): Now increases the damage done by [Maul] in addition to [Shred].
- Patch 2.4.3 (2008-07-15): Mangle will no longer incorrectly indicate a 100-yard range on the tooltip.
- Patch 2.2.0 (25-Sep-2007): The duration remaining graphic will now display properly for Mangle after it has been refreshed on a target. It will also no longer sometimes apply the Mangle debuff to nearby targets when the Mangle victim is killed by Mangle.
- Patch 2.0.3 (09-Jan-2007): Mangle will not stack multiple copies from multiple forms or druids anymore. This was never intended behavior. The percentage modification on bleeds has increased from 25% to 30% and Mangle now increases the damage from Shred as well. In addition, Mangle will now benefit from the damage boost Tiger's Fury.
External links
Community content is available under CC-BY-SA unless otherwise noted.


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|Photo: OnlineMBA
Pinterest is a great place to collect images and links to ideas you love, products that rock, and just about anything else under the sun. While most users of the site are still individuals, brands and big businesses have taken note of the major traffic the social media site has been seeing in recent months, and many have begun creating their own Pinterest boards, pinning things from their own sites as well as from around the web.
There are hundreds of brands currently using Pinterest for marketing (a number that will undoubtedly grow before the year is out), and some surprising companies are making the site's visual features work for them.
Read on to learn about some of the unexpected brands that are drawing in loads of fans from Pinterest.
Read more...
Related link
Take a closer look at OnlineMBA.com's blog
About OnlineMBA
Deciding to earn a Master of Business Administration online is definitely a big step. Pursuing an online MBA requires a significant investment and dedication, but the dividends the degree can bring — potentially higher salaries, promotions, and more opportunities — make it worth the effort.
Here at OnlineMBA.com, we strive to provide you with comprehensive resources and up-to-date information on how to choose the best online MBA program to fit your needs. We also delve into how to succeed in your MBA program and how to determine what your MBA degree can do for you.
You can begin your search for the best online MBA programs with our guide, which explains exactly what an MBA is and whether or not it is the right degree for your goals. Learn about the reasons why you need to pick an accredited school and program, and how much an online MBA typically costs as well as what financial aid options are available. In addition, you may visit our degree guides that break down and explain every varying MBA type available online in order to ensure that you will fully understand what types of courses you will be taking and what types of employment opportunities are available to graduates with that degree, such as MBAs in Accounting, Information Technology, and Sports Management.
Read more...
Thanks to Becky.
Enjoy your reading!
Source: OnlineMBA


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Using the Lord Of The Rings movie license, The Battle for Middle-earth is a Real-Time Strategy game based upon both the renown literary works of J.R.R. Tolkien, and the film trilogy directed by Peter Jackson. Players are given control of enormous armies in the many of the epic battles depicted in the film. From waging all-out combat among the vast forces of good and evil to controlling your favorite heroes and characters to managing the troops and resources of your side, the fate of a living, breathing Middle-earth is in the player's hands.
A multiplayer map.
No author description available.
Only registered members can share their thoughts. So come on! Join the community today (totally free - or sign in with your social account on the right) and join in the conversation.


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There's still a lot of valid questions that typically come from this because seemingly innocent people suffer all the time. But that often gets explained away by us being born with sin passed to us from Adam and Eve. And if they had never made a bad choice and separated from God, there would have never been a need for consequences or bad things to happen in the world.
I don't really understand why God would hold all of humanity responsible for the sins of Adam and Eve. He holds many grudges against people. He's wiped out a lot of non Jews (non believers) in the old testament.
Later on he sacrifices his son for our sin, so I guess he makes up for ages of holding grudges. When you really peel back the layers, this Bible book is dangerous if misused. And it's next to impossible to know if anyone is using it right.
If people experience and share transformational peace and joy in this world, "God" is satisfied. Christians say you need to have faith in Jesus. Could "faith in Jesus" mean something else? Could it just be saying we have to understand life is fleeting and the stuff in this world will not bring true happiness and the only way to find true happiness is to believe in something greater than oneself? And that transformation can lead to "heaven" where "heaven" isn't an afterlife but a here and now that's achievable through faith in "Jesus" which could be symbolic of something greater than us.
I think everyone should just read the Bible. They call it the "living word" and every time I read it, the meaning changes for me. Whatever experiences I've had since the last time I've read the book, change my interpretation.
I've studied other religions and I can find harmony between other religions and Christianity. It's there and easy to find when you're looking for it. You can find anything in the Bible really.
as for suffering and sin...I see this a bit differently than most. But we all see through the glass darkly. I think suffering, consequences, learning to navigate through an evil world have value spiritually. My most valuable spiritual lessons came through suffering...consequences...learning about evil by my own hand. It has made me the man I am today.


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Sunday, July 10th 2016, 12:32pm
Sunday, July 10th 2016, 2:37pm
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Tuesday, July 12th 2016, 2:42pm
Tuesday, July 12th 2016, 2:49pm
Tuesday, July 12th 2016, 4:19pm
The T-22 family is based on the OTL M-18 family, including the experimental 105mm armed and M36 tractor versions and the amphibious version too (at work so don't have the M and E numbers to hand).
When I say based on the Cromwell I meant the mechanicals more than the hull, and when I say mechanicals I mean engine and transmission, the Christie suspension being replaced by a torsion bar set-up with smaller road wheels and return rollers.
I've taken the stats as the M-18 but added some weight for the bigger gun and engine (but perhaps not enough).
I forgot about the CATI, didn't realise the MECAR was this early in the post-war era. I know Belgium did develop some recoilless rifles but again I need to check details.
So as a concept it might be better (Belgium's tank destroyers have all been pretty lightweight and thinly armoured anyway). I'll get some thoughts together at the weekend.
Tuesday, July 12th 2016, 4:37pm
Tuesday, July 12th 2016, 5:05pm
Kicking around ideas for a potential lightweight, inexpensive (for the export market - of course), and useful vehicle I came across the historical Swedish IKV-103
It looks as if it would be a good defensive vehicle well able to fight from hull-down positions. Might be worth considering.
Tuesday, July 12th 2016, 5:09pm
Tuesday, July 12th 2016, 5:12pm
The Chosen One
Thursday, July 14th 2016, 10:51pm
I'd specifically avoided mentioning the Ikv-72 earlier in this thread since I've given some very serious consideration about cloning it. But since Bruce brought it up... yeah, the Ikv-72 was actually the vehicle I was thinking of when I first brought up the idea of the "hyper-light ambush sniper" earlier in this thread.
Saturday, July 16th 2016, 12:09pm
Saturday, July 16th 2016, 3:48pm
ENERGA 75mm Anti-Tank Rifle Grenade
Designed in 1949 by Edgar Brandt at Anstalt für die ENtwicklung von ERfindungen und Gewerblichen Anwendungen, based in Vaduz, Liechtenstein...
Saturday, July 16th 2016, 4:01pm
Everything looks good to me, although we probably should discuss the ENERGA rifle grenade...
At the present time Edgar Brandt is still in France at the helm of Etablissements Brandt; didn't see anything in the news that indicated otherwise.
Saturday, July 16th 2016, 4:14pm
No problem, didn't know his background and didn't associate him with the Brandt company. No problems, we can probably work out a licence-deal whereby Mecar licence-builds the type from Brandt and we both get the new type. If not, I'll just settle for the RL series.
Saturday, July 16th 2016, 4:30pm
Saturday, July 16th 2016, 5:17pm
Saturday, July 16th 2016, 5:28pm
I guess if anything the experiences in Ubangi-Shari would be close engagements, probably a bit like the Bocage fighting of June 1944. So close-in tank hunting might be the main threat and would influence the Belgians given the Ardennes terrain.
Forum Software: Burning Board® Lite 2.1.2 pl 1, developed by WoltLab® GmbH


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Corn futures saw 1 to 2 cent gains in most contracts on Wednesday, despite weak ethanol data this morning. Support was from the lower dollar and higher ethanol prices, which followed crude (up 5.33% on the day). This morning's weekly EIA report indicated ethanol production in the week of January 4 dropping another 11,000 barrels per day to 1 million bpd. That is the lowest production total since April 20 of last year. Stocks were up for the second week in a row, this time by 92,000 barrels to 23.254 million barrels. The Gulf and West Coast were the only regions to show reductions.
Mar 19 Corn closed at $3.82, up 2 cents,
May 19 Corn closed at $3.90, up 2 cents,
Jul 19 Corn closed at $3.97 1/2, up 1 3/4 cents
Sep 19 Corn closed at $4.00, up 1 1/2 cents
--provided by Brugler Marketing & Management


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New! "Braille ICon case with straps made with placid soft leather
TurtleBack has created a new soft form-fitted custom leather case for your ICon. This case is made of placid soft leather that fits snuggly around your unit, and has a large expandable storage zipper compartment for your flash cards. The case has been designed to enable the user to easily utilize your ICon while the case is on the unit, and allows the unit to be carried on a comfortable shoulder strap and a wrist strap.The unit may be used while walking, sitting or simply standing. The case has easy access to the headset jack, USB port, and SD flash memory cards. The case is manufactured with genuine placid soft leather to provide durable outer protection. This case comes with a leather covered belt clip on the back of the unit.
See "Other Accessories" for Straps/Handles and other items
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