CLINICALLY SPEAKING
Simultaneous Bilateral Stress Fractures in a Homemaker A Case Report and Literature Review Sohail Yousaf, MBBS, MRCS* Kapil Sugand, BSc, MBBS† Mushahid Raza, MBBS, MRCS, FCEM‡ Palanisamy Ramesh, FRCS(T&O)† Stress fractures commonly occur in athletes and military cadets due to repetitive stress on the bony cortex. Stress fractures of the tibia are commonly localized proximally and occur during aerobic weightbearing exercises. This is an unusual case of bilateral simultaneous distal tibial stress fracture in a young homemaker. (J Am Podiatr Med Assoc 104(5): 518-521, 2014)
Stress fractures commonly occur in the physically active and have been described particularly in athletes and military cadets.1,2 This is secondary to the repetitive stress on the bone, which results in weakening of the bony cortex.3 Stress fractures are more common in the proximal tibia due to groundreaction forces being distributed during aerobic weightbearing exercises such as running or marching.1-5 However, stress fractures of the distal tibia are relatively uncommon2,4-8 and are usually found in those who are physically active or regularly lift heavy objects, such as military personnel.2,5,9,10 This is a case report of bilateral distal tibial stress fractures in a young homemaker generally leading a sedentary lifestyle.
Case Report A 31-year old Croatian homemaker presented to her general practitioner (GP) with a 2-day history of bilateral shin pain. Her last physical activity was reported to be jogging for approximately 10 minutes 2 weeks prior to her presentation. There were no previous episodes of repetitive injury to her legs. Her past medical history was unremarkable with a *Department of Orthopedics, Frimley Park Hospital, Surrey, England. †Department of Orthopedics, Kingston Hospital, Surrey, England. ‡Department of Emergency Medicine, Frimley Park Hospital, Surrey, England. Corresponding author: Sohail Yousaf, MBBS, MRCS, Department of Orthopedics, Frimley Park Hospital, Portsmouth Road, Surrey, GU16 7UJ, United Kingdom. (E-mail: [email protected])
518
negative history of recreational drugs and smoking. She described herself as a social drinker and was living a sedentary lifestyle on a strict vegetarian diet. Her initial management was oral analgesics and she was advised to bear weight as able. The GP referred her to the orthopedic outpatient clinic at Frimley Park Hospital (Surrey, England) with the suspicion of ‘‘shin splints,’’ suggesting further investigations. On clinical examination 3 weeks later, she demonstrated an antalgic gait and partial weightbearing with minimal edema on the anterior aspect of the distal third of the tibia bilaterally (localized pain measured 4–6 cm superior to the medial malleoli). She was also tender on the anterior aspect in the region of the third of the tibial diaphyses. Her anteroposterior and lateral radiographs on the day of her clinic visit elicited stress reactions in the distal one third of the tibia bilaterally, suggesting bilateral stress fractures. The patient was provided with bilateral air cast boots, and touch weightbearing was recommended. A bone scintigraphy was performed along with biochemical and hematological tests to investigate any obvious reason for stress fractures. Her urea and electrolytes were found to be within normal range. Her adjusted calcium was 2.26 mmol/ L and phosphate 1.17 mmol/L. She had a vitamin D level of 60 nmol/L (normal 75–200), falling under mild insufficiency. The anteroposterior and lateral radiographs (Figs. 1 and 2) showed distal tibial fractures 3 weeks after presenting to her GP. Two weeks after first presenting to the orthopedic outpatient clinic, the
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
Figure 1. Lateral (left) and anteroposterior (right)
radiographs of the right leg showing a single incomplete and undisplaced oblique distal tibial stress fracture (red arrow) with overlying soft callous formation secondary to inflammation (hyperdense line). technetium-99m (Tc-99m) bone scan (Fig. 3) confirmed focal uptake in both tibial metaphyses. A dual energy X-ray absorptiometry (DEXA) scan (Fig. 4) elicited bone mineral density in her lumbar spine and hip within the osteopenic range with an average T-score of 1.6 and average Z60 score of 1.5. The usual recommendation for this type of stress fracture is immobilization in a nonweightbearing plaster cast; however, the patient was not prepared
Figure 3. Anterior (left) and posterior (right) Technetium-99m scans showing intense symmetrical increased activity related to the distal metaphyseal region of distal tibiae bilaterally. This would be in keeping with healing fractures demonstrated on the recent plain radiographs. Otherwise, there is normal even distribution of isotope in the bony skeleton with no evidence of further fractures.
to use cast immobilization and opted to follow an alternative regime that included partial weightbearing until pain free with air cast boots. She discarded the air cast boots after 2 weeks and continued with her activities of daily living with less discomfort. A dietician introduced her to a varied diet with added treatment of active vitamin D3 (calcitriol) as her calcium was within the normal range. Three months later, at the follow-up in the orthopedic outpatient clinic, she remained asymptomatic in terms of pain and was independently mobile. Repeat laboratory investigations showed normal vitamin D levels and her repeat radiographs demonstrated fracture healing. The patient was subsequently discharged from outpatient care and her GP was informed of the outcomes. Hence, no repeat Tc-99 or DEXA scans were warranted.
Discussion
Figure 2. Lateral (left) and anteroposterior (right)
radiographs of left leg showing a single incomplete and undisplaced oblique distal tibial stress fracture (red arrow).
Stress fractures commonly occur with repetitive mechanical loading over a long period. This equates to a higher number of fractures in the proximal tibia; however, the incidence of symptomatic bilateral distal tibial stress fractures has rarely been reported.2,4-8 Singer and Maudsley5 commented that stress fractures in the distal tibia occur at the site where the ratio of cancellous to
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
519
Figure 4. Bone densitometry dual energy X-ray absorptiometry (DEXA) report.
cortical bone was greatest known as a ‘‘critical point.’’ They defined the critical point in the tibia as 1.5 to 2.5 inches superior to the apex of the medial malleolus. Risk factors associated with stress fractures in the tibia include female gender5,11; repetitive activity such as running, marching, and heavy lifting2,5,9,10,12,13; and systemic diseases causing weakening of the bony cortex including inflammatory arthritides,14-16 osteoporosis,17 and defects in the mechanism of bone mineralization such as low serum levels of vitamin 25(OH)D.11,12,18 Other predisposing factors include a short or narrow tibia with a low area moment of inertia and significant external rotation of the hip8 as well as heavy smoking.19 The remarkable feature was that she sustained bilateral simultaneous fractures despite any significant history of repetitive trauma. Due to the poor bone cortical instability secondary to osteopenia, the mechanical loading exerted over a short period of time was a significant factor for her stress fractures. Her initial symptomatic presentation of bilateral shin tenderness at her GP should have warranted an early radiograph and biochemical investigations. Yet, it is notably uncommon for GPs in the UK to request radiography for such presentations and usually refer patients to orthopedic outpatient clinics, which was done in this case. If patients are symptomatic with no plain radiological abnormality identified, they should be followed-up with an outpatient Tc-99m bone scan, which is highly sensitive in detecting fractures by typically showing poor uptake at fracture site. The Tc-99 scan in our patient revealed extensive uptake likely attributable to an underlying mechanism of
520
poor bone mineral density or a response to bone remodeling (Fig. 3).20,21 With regards to bone mineralization, the importance of vitamin D in the prevention of rickets in children and osteomalacia in adults is well recognized.22 Our patient’s unvaried vegetarian dietary preference and vitamin D insufficiency had overall been a major contributor to her stress fractures. Vitamin D deficiency may occur due to eating disorders or metabolic derangements. In recent studies, a correlation has been found between vitamin D insufficiency and the occurrence of stress fractures in athletes.18,23,24 It has also been documented that additional supplementation of vitamin D reduces the incidence of stress fractures in physically active females.25 However as of yet, no large-scale studies have investigated a possible correlation between vitamin D insufficiency and stress fractures in those who live a definable sedentary lifestyle. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. MARTIN AD, MCCULLOCH RG: Bone dynamics: stress, strain and fracture. J Sports Sci 5: 155, 1987. 2. SCIBERRAS N, TAYLOR C, TRIMBLE K: Bilateral distal tibial stress fractures in a military recruit. BMJ Case Rep May 30, 2012. Published online; doi:10.1136/bcr.01. 2012.5563. 3. FITZGERALD RH, KAUFFER H, MALKANI AL (EDS): ‘‘Overuse Injuries Including Stress, Fractures, Exertional Compartment Syndrome,’’ in Orthopaedics, p 1557, Mosby Elsevier, UK, 2002. 4. ZLATKIN MB, BJORKENGREN A, SARTORIS D, ET AL: Stress fractures of the distal tibia and calcaneus subsequent to
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
5.
6.
7. 8.
9.
10.
11.
12.
13. 14. 15.
acute fractures of the tibia and fibula. AJR Am J Roentgenol 149: 329, 1987. SINGER M, MAUDSLEY RH: Fatigue fractures of the lower tibia; a report of five cases. J Bone Joint Surg Br 36-B: 647, 1954. BRUDVIG TJ, GUDGER TD, OBERMEYER L: Stress fractures in 295 trainees: a one-year study of the incidence as related to age, sex and race. Mil Med 148: 666, 1983. ROEBUCK JD, FINGER DR, IRVIN TL: Evaluation of suspected stress fractures. Orthopedics 24: 771, 2001. SPEED CA, FORDHAM JN, CUNNINGHAM JL: Simultaneous bilateral tibial stress fractures in a 15-year-old milkmana case report. Br J Rheumatol 35: 905, 1996. SOBCZYK K, MOC´KO K, SONECKI L, ET AL: Bilateral stress fracture of distal fibula and tibia: case report. Ortop Traumatol Rehabil 10: 183, 2008. RUOHOLA JP, KIURU MJ, PIHLAJAMA¨KI HK: Fatigue bone injuries causing anterior lower leg pain. Clin Orthop Relat Res 444: 216, 2006. MATTILA VM, NIVA M, KIURU M, ET AL: Risk factors for bone stress injuries: a follow-up study of 102,515 personyears. Med Sci Sports Exerc 39: 1061, 2007. CHATZIPAPAS CN, DROSOS GI, KAZAKOS KI, ET AL: Stress fractures in military men and bone quality related factors. Int J Sports Med 29: 922, 2008. JENSEN A, DAHL S: Stress fracture of the distal tibia and fibula through heavy lifting. Am J Ind Med 47: 181, 2005. PEASE CT: Insufficiency fractures of the distal tibia. Br J Rheumatol 33: 1056, 1994. MA¨ENPA¨A¨ H, LEHTO MU, BELT EA: Stress fractures of the
16.
17. 18.
19.
20. 21. 22. 23. 24.
25.
ankle and forefoot in patients with inflammatory arthritides. Foot Ankle Int 23: 833, 2002. ELKAYAM O, PARAN D, FLUSSER G ET AL: Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics. Clin Exp Rheumatol 18: 369, 2000. MIYAKOSHI N, SATO K, MURAI H ET AL: Insufficiency fractures of the distal tibiae. J Orthop Sci 5: 71, 2000. VAN DEMARK RE 3RD, ALLARD B, VAN DEMARK RE JR: Nonunion of a distal tibial stress fracture associated with vitamin D deficiency: a case report. S D Med 63: 87, 2010. MPOFU S, MOOTS RJ, THOMPSON RN: Bilateral distal fibular and tibial stress fractures associated with heavy smoking. Ann Rheum Dis 62: 273, 2003. BLANK S: Transverse tibial stress fractures: a special problem. Am J Sports Med 15: 597, 1987. MULLIGAN ME, SHANLEY DJ: Supramalleolar fatigue fractures of the tibia. Skeletal Radiol 25: 325, 1996. DEVAS M: Stress Fractures, Churchill Livingstone, Edinburgh, 1975. LARSON-MEYER DE, WILLIS KS: Vitamin D and athletes. Curr Sports Med Rep 9: 220, 2010. PE´REZ-LO´PEZ FR: Vitamin D and its implications for musculoskeletal health in women: an update. Maturitas 58: 117, 2007. LAPPE J, CULLEN D, HAYNATZKI G, ET AL: Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res 23: 741, 2008.
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
521
Simultaneous Bilateral Stress Fractures in a Homemaker A Case Report and Literature Review Sohail Yousaf, MBBS, MRCS* Kapil Sugand, BSc, MBBS† Mushahid Raza, MBBS, MRCS, FCEM‡ Palanisamy Ramesh, FRCS(T&O)† Stress fractures commonly occur in athletes and military cadets due to repetitive stress on the bony cortex. Stress fractures of the tibia are commonly localized proximally and occur during aerobic weightbearing exercises. This is an unusual case of bilateral simultaneous distal tibial stress fracture in a young homemaker. (J Am Podiatr Med Assoc 104(5): 518-521, 2014)
Stress fractures commonly occur in the physically active and have been described particularly in athletes and military cadets.1,2 This is secondary to the repetitive stress on the bone, which results in weakening of the bony cortex.3 Stress fractures are more common in the proximal tibia due to groundreaction forces being distributed during aerobic weightbearing exercises such as running or marching.1-5 However, stress fractures of the distal tibia are relatively uncommon2,4-8 and are usually found in those who are physically active or regularly lift heavy objects, such as military personnel.2,5,9,10 This is a case report of bilateral distal tibial stress fractures in a young homemaker generally leading a sedentary lifestyle.
Case Report A 31-year old Croatian homemaker presented to her general practitioner (GP) with a 2-day history of bilateral shin pain. Her last physical activity was reported to be jogging for approximately 10 minutes 2 weeks prior to her presentation. There were no previous episodes of repetitive injury to her legs. Her past medical history was unremarkable with a *Department of Orthopedics, Frimley Park Hospital, Surrey, England. †Department of Orthopedics, Kingston Hospital, Surrey, England. ‡Department of Emergency Medicine, Frimley Park Hospital, Surrey, England. Corresponding author: Sohail Yousaf, MBBS, MRCS, Department of Orthopedics, Frimley Park Hospital, Portsmouth Road, Surrey, GU16 7UJ, United Kingdom. (E-mail: [email protected])
518
negative history of recreational drugs and smoking. She described herself as a social drinker and was living a sedentary lifestyle on a strict vegetarian diet. Her initial management was oral analgesics and she was advised to bear weight as able. The GP referred her to the orthopedic outpatient clinic at Frimley Park Hospital (Surrey, England) with the suspicion of ‘‘shin splints,’’ suggesting further investigations. On clinical examination 3 weeks later, she demonstrated an antalgic gait and partial weightbearing with minimal edema on the anterior aspect of the distal third of the tibia bilaterally (localized pain measured 4–6 cm superior to the medial malleoli). She was also tender on the anterior aspect in the region of the third of the tibial diaphyses. Her anteroposterior and lateral radiographs on the day of her clinic visit elicited stress reactions in the distal one third of the tibia bilaterally, suggesting bilateral stress fractures. The patient was provided with bilateral air cast boots, and touch weightbearing was recommended. A bone scintigraphy was performed along with biochemical and hematological tests to investigate any obvious reason for stress fractures. Her urea and electrolytes were found to be within normal range. Her adjusted calcium was 2.26 mmol/ L and phosphate 1.17 mmol/L. She had a vitamin D level of 60 nmol/L (normal 75–200), falling under mild insufficiency. The anteroposterior and lateral radiographs (Figs. 1 and 2) showed distal tibial fractures 3 weeks after presenting to her GP. Two weeks after first presenting to the orthopedic outpatient clinic, the
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
Figure 1. Lateral (left) and anteroposterior (right)
radiographs of the right leg showing a single incomplete and undisplaced oblique distal tibial stress fracture (red arrow) with overlying soft callous formation secondary to inflammation (hyperdense line). technetium-99m (Tc-99m) bone scan (Fig. 3) confirmed focal uptake in both tibial metaphyses. A dual energy X-ray absorptiometry (DEXA) scan (Fig. 4) elicited bone mineral density in her lumbar spine and hip within the osteopenic range with an average T-score of 1.6 and average Z60 score of 1.5. The usual recommendation for this type of stress fracture is immobilization in a nonweightbearing plaster cast; however, the patient was not prepared
Figure 3. Anterior (left) and posterior (right) Technetium-99m scans showing intense symmetrical increased activity related to the distal metaphyseal region of distal tibiae bilaterally. This would be in keeping with healing fractures demonstrated on the recent plain radiographs. Otherwise, there is normal even distribution of isotope in the bony skeleton with no evidence of further fractures.
to use cast immobilization and opted to follow an alternative regime that included partial weightbearing until pain free with air cast boots. She discarded the air cast boots after 2 weeks and continued with her activities of daily living with less discomfort. A dietician introduced her to a varied diet with added treatment of active vitamin D3 (calcitriol) as her calcium was within the normal range. Three months later, at the follow-up in the orthopedic outpatient clinic, she remained asymptomatic in terms of pain and was independently mobile. Repeat laboratory investigations showed normal vitamin D levels and her repeat radiographs demonstrated fracture healing. The patient was subsequently discharged from outpatient care and her GP was informed of the outcomes. Hence, no repeat Tc-99 or DEXA scans were warranted.
Discussion
Figure 2. Lateral (left) and anteroposterior (right)
radiographs of left leg showing a single incomplete and undisplaced oblique distal tibial stress fracture (red arrow).
Stress fractures commonly occur with repetitive mechanical loading over a long period. This equates to a higher number of fractures in the proximal tibia; however, the incidence of symptomatic bilateral distal tibial stress fractures has rarely been reported.2,4-8 Singer and Maudsley5 commented that stress fractures in the distal tibia occur at the site where the ratio of cancellous to
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
519
Figure 4. Bone densitometry dual energy X-ray absorptiometry (DEXA) report.
cortical bone was greatest known as a ‘‘critical point.’’ They defined the critical point in the tibia as 1.5 to 2.5 inches superior to the apex of the medial malleolus. Risk factors associated with stress fractures in the tibia include female gender5,11; repetitive activity such as running, marching, and heavy lifting2,5,9,10,12,13; and systemic diseases causing weakening of the bony cortex including inflammatory arthritides,14-16 osteoporosis,17 and defects in the mechanism of bone mineralization such as low serum levels of vitamin 25(OH)D.11,12,18 Other predisposing factors include a short or narrow tibia with a low area moment of inertia and significant external rotation of the hip8 as well as heavy smoking.19 The remarkable feature was that she sustained bilateral simultaneous fractures despite any significant history of repetitive trauma. Due to the poor bone cortical instability secondary to osteopenia, the mechanical loading exerted over a short period of time was a significant factor for her stress fractures. Her initial symptomatic presentation of bilateral shin tenderness at her GP should have warranted an early radiograph and biochemical investigations. Yet, it is notably uncommon for GPs in the UK to request radiography for such presentations and usually refer patients to orthopedic outpatient clinics, which was done in this case. If patients are symptomatic with no plain radiological abnormality identified, they should be followed-up with an outpatient Tc-99m bone scan, which is highly sensitive in detecting fractures by typically showing poor uptake at fracture site. The Tc-99 scan in our patient revealed extensive uptake likely attributable to an underlying mechanism of
520
poor bone mineral density or a response to bone remodeling (Fig. 3).20,21 With regards to bone mineralization, the importance of vitamin D in the prevention of rickets in children and osteomalacia in adults is well recognized.22 Our patient’s unvaried vegetarian dietary preference and vitamin D insufficiency had overall been a major contributor to her stress fractures. Vitamin D deficiency may occur due to eating disorders or metabolic derangements. In recent studies, a correlation has been found between vitamin D insufficiency and the occurrence of stress fractures in athletes.18,23,24 It has also been documented that additional supplementation of vitamin D reduces the incidence of stress fractures in physically active females.25 However as of yet, no large-scale studies have investigated a possible correlation between vitamin D insufficiency and stress fractures in those who live a definable sedentary lifestyle. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. MARTIN AD, MCCULLOCH RG: Bone dynamics: stress, strain and fracture. J Sports Sci 5: 155, 1987. 2. SCIBERRAS N, TAYLOR C, TRIMBLE K: Bilateral distal tibial stress fractures in a military recruit. BMJ Case Rep May 30, 2012. Published online; doi:10.1136/bcr.01. 2012.5563. 3. FITZGERALD RH, KAUFFER H, MALKANI AL (EDS): ‘‘Overuse Injuries Including Stress, Fractures, Exertional Compartment Syndrome,’’ in Orthopaedics, p 1557, Mosby Elsevier, UK, 2002. 4. ZLATKIN MB, BJORKENGREN A, SARTORIS D, ET AL: Stress fractures of the distal tibia and calcaneus subsequent to
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
5.
6.
7. 8.
9.
10.
11.
12.
13. 14. 15.
acute fractures of the tibia and fibula. AJR Am J Roentgenol 149: 329, 1987. SINGER M, MAUDSLEY RH: Fatigue fractures of the lower tibia; a report of five cases. J Bone Joint Surg Br 36-B: 647, 1954. BRUDVIG TJ, GUDGER TD, OBERMEYER L: Stress fractures in 295 trainees: a one-year study of the incidence as related to age, sex and race. Mil Med 148: 666, 1983. ROEBUCK JD, FINGER DR, IRVIN TL: Evaluation of suspected stress fractures. Orthopedics 24: 771, 2001. SPEED CA, FORDHAM JN, CUNNINGHAM JL: Simultaneous bilateral tibial stress fractures in a 15-year-old milkmana case report. Br J Rheumatol 35: 905, 1996. SOBCZYK K, MOC´KO K, SONECKI L, ET AL: Bilateral stress fracture of distal fibula and tibia: case report. Ortop Traumatol Rehabil 10: 183, 2008. RUOHOLA JP, KIURU MJ, PIHLAJAMA¨KI HK: Fatigue bone injuries causing anterior lower leg pain. Clin Orthop Relat Res 444: 216, 2006. MATTILA VM, NIVA M, KIURU M, ET AL: Risk factors for bone stress injuries: a follow-up study of 102,515 personyears. Med Sci Sports Exerc 39: 1061, 2007. CHATZIPAPAS CN, DROSOS GI, KAZAKOS KI, ET AL: Stress fractures in military men and bone quality related factors. Int J Sports Med 29: 922, 2008. JENSEN A, DAHL S: Stress fracture of the distal tibia and fibula through heavy lifting. Am J Ind Med 47: 181, 2005. PEASE CT: Insufficiency fractures of the distal tibia. Br J Rheumatol 33: 1056, 1994. MA¨ENPA¨A¨ H, LEHTO MU, BELT EA: Stress fractures of the
16.
17. 18.
19.
20. 21. 22. 23. 24.
25.
ankle and forefoot in patients with inflammatory arthritides. Foot Ankle Int 23: 833, 2002. ELKAYAM O, PARAN D, FLUSSER G ET AL: Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics. Clin Exp Rheumatol 18: 369, 2000. MIYAKOSHI N, SATO K, MURAI H ET AL: Insufficiency fractures of the distal tibiae. J Orthop Sci 5: 71, 2000. VAN DEMARK RE 3RD, ALLARD B, VAN DEMARK RE JR: Nonunion of a distal tibial stress fracture associated with vitamin D deficiency: a case report. S D Med 63: 87, 2010. MPOFU S, MOOTS RJ, THOMPSON RN: Bilateral distal fibular and tibial stress fractures associated with heavy smoking. Ann Rheum Dis 62: 273, 2003. BLANK S: Transverse tibial stress fractures: a special problem. Am J Sports Med 15: 597, 1987. MULLIGAN ME, SHANLEY DJ: Supramalleolar fatigue fractures of the tibia. Skeletal Radiol 25: 325, 1996. DEVAS M: Stress Fractures, Churchill Livingstone, Edinburgh, 1975. LARSON-MEYER DE, WILLIS KS: Vitamin D and athletes. Curr Sports Med Rep 9: 220, 2010. PE´REZ-LO´PEZ FR: Vitamin D and its implications for musculoskeletal health in women: an update. Maturitas 58: 117, 2007. LAPPE J, CULLEN D, HAYNATZKI G, ET AL: Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res 23: 741, 2008.
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
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