Treatment Options for Turf Toe: A Systematic Review.

Turf toe is hyperextension injury of the plantar plate at the first metatarsophalangeal joint. Etiologies have often included sports/activities with excessive forefoot axial loading and/or violent pivotal movements. The purpose of the systematic review was to systematically review and present an overview for the current evidence-based treatment options of turf toe. Both authors systematically reviewed the PubMed and EMBASE databases from inception to April 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The level of evidence and quality of evidence were assessed by using the Level of Evidence for Primary Research Question of the Journal of Bone and Joint Surgery, and the quality of evidence was assessed with use of the Newcastle-Ottawa scale. Data were collected and categorized into: case reports and case series. Eight studies (16 turf toes) met the aforementioned criteria and were included. Five case reports and 3 case series reported various treatment options for turf toe. Specifically, 3 studies reported solely conservative treatment (n = 5), 1 study reported solely surgical treatment (n = 1), and 4 studies involved patients in conservative and/or surgical treatments (n = 10). All studies were of level of clinical evidence 4 and quality of clinical evidence score 2 (poor quality). Conservative treatment included closed reduction and immobilization, and surgical treatment included plantar plate tenodesis. Restricted dorsiflexion was the most common complication reported. Turf toe is an underreported injury with no evidence-based treatment guideline to date. Future studies of higher level and quality of evidence with a specific classification system (Jahss or Anderson) consistently reported are warranted for the development of an optimal guideline to determine the most appropriate treatment for each specific severity in injury.

Surgical Repair of Complete Plantar Fascia Ruptures in High-Demand Power Athletes: An Alternative Treatment Option.

Surgical repair of complete plantar fascia ruptures has not yet been reported in the literature. Operative technique and outcome are described in 2 gymnasts with heavy plyometric demands who received surgical repair compared with 3 athletes treated nonoperatively. Biomechanics and clinical implications are discussed. In the last 8 years, we have seen 5 high-demand athletes with total rupture of the plantar fascia. This is a retrospective clinical evaluation 1.5 to 8 years postinjury of all 5 patients using dynamic ultrasound, Foot Function Index, sports-specific questions, Foot Posture Index, and foot length. The operated gymnasts returned to the same level of performance within 12 months. None of the conservatively treated athletes returned to preinjury plyometric sports levels but reached a foot load capacity of distance running with the injured foot as limiting factor. Ultrasound with simultaneous dorsiflexion of the toes showed a normal fascia in the operated patients, but a slack fascia that tightened up only at terminal toe dorsiflexion in the conservatively treated group. According to the Foot Function Index, the operated patients reported no complaints, whereas the nonoperative group had clinical relevant impairments in activities of daily life. The Foot Posture Index in all nonoperated patients showed a relative shift toward pronation with increased foot length compared with the noninjured foot. The operated patients showed no difference in foot length but minimal shift into supination with a slightly altered arch contour. Surgical repair of plantar fascia ruptures is technically feasible to restore normal foot load capability with return to high-demand plyometric sports within 12 months.

Utilization of Fluorescence Microangiography in Pediatric Acute Compartment Syndrome: A Case Report.

Acute compartment syndrome is a critical condition, most commonly arising as the result of high-energy trauma, fracture, and crush injury. Early diagnosis and treatment are imperative to avoid permanent functional damage to the affected extremity. Although isolated pedal compartment syndrome is well studied in adults, in the pediatric population, it has been seldom reported. Pediatric patients pose a unique challenge when diagnosing compartment syndrome. Their inability to appropriately verbalize symptoms and participate in physical examinations often causes a delay in diagnosis. We present the case of a 5-year-old female who developed compartment syndrome of her left foot 26 hours after sustaining an isolated crush injury to the distal forefoot. Her treatment included emergent fasciotomy in combination with 20 hyperbaric oxygen therapy treatments. The progression of her acute digital ischemia was monitored by using serial fluorescence microangiography studies performed at 17 hours, 7 days, and 3 weeks postinjury. Throughout these serial studies, improvement in hypofluorescence was noted involving the dorsolateral midfoot, as well as digits 3, 4, and 5, which correlated with physical examination. The patient went on to uneventfully autoamputate the distal aspects of digits 4 and 5 within 4 months of injury. At the 12-month follow-up visit, she denied any pain, sensory deficits, or functional disability and had returned to all preinjury activities. Our case study demonstrates the use of serial microangiography to monitor progression of acute ischemia associated with acute pediatric compartment syndrome and discusses prognostic capabilities.

Radiographic Value of the Lisfranc Diastasis in a Standardized Population.

Introduction. Injury to the Lisfranc's joint, in particular to the second metatarsal-medial cuneiform (second MMC) joint, can be difficult to evaluate, especially in subtle Lisfranc injuries. The purpose of this study was to determine the value of the Lisfranc joint width (diastasis) of the adult foot in a standardized population thereby establishing a potential reference range when investigating this area for potential injury. Methods. The 2nd MMC joint in 50 men and 50 women was evaluated. Individuals with a history of foot/ankle pain, previous foot/ankle operation or fracture, or a history of systemic disease were excluded from the study. Bilateral weightbearing digital anterior-posterior and lateral radiographs were taken using a standardized method. Results. The mean 2nd MMC diastasis in 200 feet was 5.6 mm (95% CI 5.39-5.81). In the female population, the mean 2nd MMC diastasis was 5.8 mm (95% CI 5.51-6.09) as compared with 5.6 mm (95% CI 5.31-5.89) in males. The mean distance between the fifth metatarsal base and first cuneiform in the entire study population was 16.3 mm (95% CI 15.57-17.03). Conclusion. This study helps define baseline measurements of the Lisfranc joint for the general population, which can provide a standard measurement against which suspected foot injuries can be compared.Level of Evidence: Level IV.

Tarsometatarsal joint complex injuries: A study of injury pattern in complete homolateral lesions.

INTRODUCTION: Tarsometatarsal joint complex (TMC) is the anatomical structure of midfoot composed by metatarsals, tarsometatarsal (TMT) joints, cuneiforms, cuboid and navicular. TMC lesion are rare but critical since they cause severe disability if misdiagnosed. The knowledge of anatomic pattern of the lesion and biomechanics of the midfoot is the key for a successful diagnosis and treatment. The aim of this study was to review a consecutive series of TMC injuries analyzing preoperative radiograph and CT scan to accurately define the pattern of ligament and bone injuries. MATERIAL AND METHODS: We reviewed a series of 24 complete TMC injuries with homolateral dorsolateral dislocation. The total TMT joints involved were 120. We observed if the lesions were pure ligamentous or fracture-dislocation detecting the extent and the location of fractures. Twenty-nine lesions (24%) were pure dislocations and they were mainly localized in the first and fifth ray. The fracture-dislocations were 91 (76%) and 25 were fractures of the proximal row (cuneiforms and cuboid), 39 of the distal row (metatarsals), 27 of both the distal and proximal row. RESULTS: Proximal fracture had a homogeneous distribution and they were more frequently simple than comminuted. Comminuted fractures were more frequent in the cuboid. In the proximal row, majority of partial articular fractures were localized in the dorsal side. Fracture-dislocations of the distal row were more frequent in the second metatarsal base (100%) and the partial articular fractures were always placed in the plantar side. In TMC injuries fracture-dislocations are more frequent than pure dislocations. Pure dislocations occur more often in the marginal rays that are characterized by weaker ligaments and larger mobility. The second ray, where there is the more stable joint of TMC, was never dislocated with a pure ligamentous lesion. CONCLUSIONS: We suppose that plantar avulsion from the distal row and dorsal compression fracture of the proximal row is consistent with a direct force applied to the forefoot and direct dorsolaterally. The direction of the forces may explain why some fractures occur in the distal row, some in the proximal and some in both rows. The thickness of plantar ligaments may explain the frequency of plantar bone fragment avulsion.

Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome.

BACKGROUND: Forefoot fractures account for 6% to 10% of fractures in children, and although the majority heals with supportive treatment, complications may lead to pain and disability. No previous study in children has evaluated complication risk in the emergency department based on initial assessment characteristics. STUDY OBJECTIVES: The study aim was to identify the radiological and clinical variables that increase the complication rate of pediatric forefoot fractures. This may help emergency physicians refer patients who require more thorough follow-up or surgical intervention. METHODS: We evaluated 497 forefoot fractures on initial presentation to a pediatric emergency department at the Children's Hospital at London Health Science Centre over a 6-year period. We collected variables such as degree of angulation, displacement, number of concurrent fractures, and demographic data such as age and sex. We then determined the variables associated with complications by reviewing each patient's chart. RESULTS: Overall, there was a 6.4% complication rate. Analysis identified sex as an important predictor of complications. Females, although representing approximately one third of the sample, represented nearly two thirds of the cases with complicated outcomes (P = 0.001; odds ratio [OR], 4.67). Increased number of fractures was also significant (P = 0.01; OR, 2.41) as was increasing age (P = 0.01; OR, 1.17) and patients who chose to return to the emergency department (P < 0.05; OR, 5.282). Lateral angulation/displacement and anteroposterior angulation/displacement were not associated with increased complications. CONCLUSION: Identifying features, such as female sex, increasing age, multiple fractures, and return to emergency departments for repeat visits, may help guide the emergency physician on whom to refer for specialized care.

[EFFECTIVENESS OF REPAIRING OR RECONSTRUCTING DEFECTS OF FOREFOOT].

METHODS: Between February 2006 and February 2013, 57 patients with defects of the forefoot were treated. There were 41 males and 16 females with an average age of 38.9 years (range, 19-68 years). The disease causes included motor vehicles crush injury in 28 cases, crashing injury in 17 cases, and machine extrusion injury in 12 cases. The left side was involved in 25 cases and the right side in 32 cases, with a mean disease duration of 4.7 hours (range, 0.5-75.0 hours). Defect located at the 1st metatarsus in 9 cases, at the 5th metatarsus in 8 cases, at the 1st and the 2nd metatarsus in 16 cases, at the 4th and 5th metatarsus in 11 cases, at multiple metatarsus and the forefoot in 13 cases. The bone defect ranged from 2.5 cm x 1.9 cm x 1.4 cm to 13.3 cm x 11.2 cm x 2.7 cm. The soft tissue defect ranged from 12.4 cm x 6.3 cm to 27.2 cm x 18.7 cm. The iliac bone or vascularized iliac bone or vascularized fibula bone was used to rebuild the arch of the foot, and free flap was used to repair defects of the forefoot. The donor site was sutured directly or covered with skin graft. RESULTS: Venous crisis and partial necrosis occurred in 3 and 2 flaps respectively, which healed after symptomatic treatment. The other flaps and grafted skins survived, and wounds healed primarily. Fifty-one cases were followed up 1.5-2.5 years (mean, 2.1 years). The appearance was excellent and the feeling of the flap recovered at different levels. The two-point discrimination was 8.4-19.8 mm (mean, 13.7 mm) at 1.5 years after operation. According to upper extremity functional evaluation standard by hand surgery branch of Chinese Medical Association, sensation recovered to 52 in 6 cases, to 53 in 18 cases, and to 54 in 27 cases. The patients began to walk with weight loading at 2-6 months after operation (mean, 3.9 months). The bone healing time was 3-6 months (mean, 4.2 months). Based on American Orthopaedic Foot and Ankle Society (AOFAS) standards, the results were excellent in 19 cases, good in 24 cases, fair in 7 case, and poor in 1 case, and the excellent and good rate was 84.3%. CONCLUSION: It is a good solution to treat defects of the forefoot to use iliac bone or vascularized iliac bone or vascularized fibula bone for rebuilding the arch of the foot and use free flap for repairing defect.

Midfoot and Forefoot Injuries.

Sports injuries of the midfoot and forefoot encompass a spectrum of osseous and soft tissue trauma. Magnetic resonance imaging serves as a primary or important supplementary diagnostic modality in evaluation of various injuries, most important of which include Lisfranc complex injury, stress fractures, and injury to the first metatarsophalangeal joint, aka "turf toe." Current technical advances in magnetic resonance and improved knowledge of regional anatomy enable thorough evaluation of the complex anatomic structures of the foot and facilitate accurate diagnosis in the setting of trauma.

MR Imaging Evaluation of the Lisfranc Ligament in Cadaveric Feet and Patients With Acute to Chronic Lisfranc Injury.

BACKGROUND: Magnetic resonance (MR) imaging is known to be useful to demonstrate Lisfranc ligament injury. There are few studies that report differences in MR imaging findings of acute or chronic Lisfranc ligament injuries. We applied oblique MR imaging planes parallel to the Lisfranc ligament for better visualization of the entire course of the ligament and assessed the detailed MR imaging appearances of the Lisfranc ligament in cadavers and patients with presumed Lisfranc injuries. METHODS: Twelve preserved cadaveric feet were examined using a small-diameter surface coil. Long axis, oblique sagittal, and oblique short axis cross sections parallel to the Lisfranc ligament, dorsal ligament, and plantar ligament were obtained. Twenty-six MR examinations from 23 patients with suspected Lisfranc joint injuries were evaluated. RESULTS: In the cadaveric study, the Lisfranc ligament was satisfactorily visible along its entire course in a single slice on long axis and oblique sagittal MR images. The dorsal ligament and the plantar ligament were visible separately from the Lisfranc ligament in oblique sagittal and oblique short axis planes. In the patient study, 11 MR examinations led to diagnoses of complete tears of the Lisfranc ligament that were acute injuries (3-21 days after trauma) mostly associated with disruption of the dorsal and plantar ligaments. Nine studies led to diagnoses of incomplete tears of the Lisfranc ligament that were chronic injuries (2-14 months after trauma). Recovery of the continuity of the disrupted ligament was observed in 3 patients. CONCLUSION: MR imaging demonstrated the integrity of the ligaments and was useful for diagnosing an acute Lisfranc injury. Fibrous healing of the torn ligament was observed in a chronic injury.

Traumatic Forefoot Reconstructions With Free Perforator Flaps.

The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used.

[The anatomy and clinical application of reverse saphenous nerve neurocutaneous flaps for reparing skin defects of forefoot].

OBJECTIVE: To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects of forefoot. METHODS: In the anatomic study, 50 cadaveric feet were injected with red latex and the anastomosis, distribution and external diameters of medialtarsal artery, medial anterior malleolus artery, medial plantar artery, the superficial branch of the medial basal hallucal artery and saphenousnerve nutritional vessels were observed. Based on anatomic research results, we designed the reverse saphenous nerve neurocutaneous flaps for repairing skin defects of forefoot. RESULTS: The blood supply of reverse saphenous nerve neurocutaneous flaps were based on the vasoganglion, which consist of arterial arch at the superior border of abductor hallucis and arterial network on the surface of abductor hallucis around the saphenous nerve and medial pedis flap. From Oct. 2006 to Oct. 2011, the reverse saphenous nerve neurocutaneous flaps were used to repair skin defects of forefoot in 11 cases. The flap size ranged from 2.5 cm x 3.5 cm to 7.5 cm x 8.5 cm. The wounds at donor site were covered with full-thickness skin graft. All flaps survived completely with no ulcer at the donor site. 11 cases were followed up for 6 to 18 months( mean, 10 months). The skin color and texture were satisfactory. The patients could walk very well. CONCLUSIONS: It is reliable to repair the skin defects of forefoot with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity. This flap should be considered as a preferential way to reconstruct skin defects of forefoot.

[Acute sports injuries and chronic overuse stress damage to the forefoot and midfoot]. / Akute Sportverletzungen und chronische Überlastungsschäden an Vor- und Mittelfuß.

Sports injuries of the foot can occur as sequelae of acute trauma or chronic overuse. Besides clinical examination, imaging plays a major role in the detection of structural abnormalities and the differential diagnostics. This article reviews the most important sports-related soft tissue and bone pathologies of the forefoot and midfoot together with their typical findings on radiography, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI).

Distally Based Abductor Hallucis Adipomuscular Flap for Forefoot Plantar Reconstruction.

Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps. The authors successfully used the distally based adipomuscular abductor hallucis flap for the treatment of 7 patients with soft tissue defect on the plantar forefoot after diabetic ulcer (n = 2), excision of melanoma at the medial forefoot (n = 3), and posttraumatic defects of the plantar forefoot (n = 2). The size of the defects ranged from 6 to 36 cm. All defects were covered successfully without major complications. The distally based adipomuscular flap from the abductor hallucis muscle provides a reliable coverage for small and moderate defects of the plantar and medial forefoot. This flap is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise.

Reconstruction of weightbearing forefoot defects with digital artery flaps.

Reconstruction of a defect of the weightbearing forefoot region remains a challenging problem owing to the limited alternatives available. The digital artery flap can be used for coverage of defects in the weightbearing forefoot. The present study reports our results using a digital artery flap for reconstruction of soft tissue defects of the weightbearing forefoot in 8 patients. The mean patient age was 35 ± 11.3 years. The etiology of the soft tissue defects included 4 (50%) traumatic events, 2 (25%) dysfunctional scars, and 2 (25%) neuropathic ulcerations. The mean postoperative follow-up duration was 22 ± 11.1 months (range 12 months to 4 years). All 8 flaps survived successfully. The complications included 1 case of delayed healing of a neuropathic ulceration. The digital artery flap is a good alternative for soft tissue defects of the weightbearing forefoot. The surgical techniques for harvesting the flaps are easy to manage.

Staged treatment of high energy midfoot fracture dislocations.

BACKGROUND: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. METHODS: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. RESULTS: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. CONCLUSION: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Plantar loading during jumping while wearing a rigid carbon graphite footplate.

Fifth metatarsal stress fractures are common in sports and often result in delayed and non-union. The purpose of this study was to examine the effect of a rigid carbon graphite footplate (CGF) on plantar loading during take-off and landing from a jump. Nineteen recreational male athletes with no history of lower extremity injury in the past 6 months and no foot or ankle surgery in the past 3 years participated in this study. Subjects completed 7 jumping tasks while wearing a standard running shoe and then the shoe plus the CGF while plantar loading data was recorded. A series of paired t-tests were used to examine differences between the two footwear conditions independently for both takeoff and landing (a = 0.05). The contact area in the medial midfoot (p < .001) and forefoot (p = .010) statistically decreased when wearing the CGFP. The force­time integral was significantly greater when wearing the CGFP in the middle (p < .001) and lateral forefoot (p = .019). Maximum force was significantly greater beneath the middle (p < .001) and lateral forefoot (p < .001) when wearing the CGFP, while it was decreased beneath the medial midfoot (p < .001). During landing, the contact area beneath the medial (p = .017) and lateral midfoot (p = .004) were significantly decreased when wearing the CGFP. The force­ time integral was significantly decrease beneath the medial midfoot (p < .001) when wearing the CGFP. The maximum force was significantly greater beneath the medial (p = .047) and middle forefoot (p = .001) when the subject was wearing the CGFP. The maximum force beneath the medial midfoot (p < .001) was significantly reduced when wearing the carbon graphite footplate. The results of the study indicate that the CGF is ineffective at reducing plantar loading during jumping and landing.

Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa.

BACKGROUND: We questioned whether different forms of Achilles tendon overuse injuries can be differentiated by retrocalcaneal bursa pressure measurement. METHODS: Retrocalcaneal bursa pressure was determined by using invasive pressure measurement in patients suffering from retrocalcaneal bursitis (n=13) or Achilles tendinopathy (n=15), respectively. Standardized measurements were taken with the subject lying prone. Initially, the foot and ankle was in a spontaneous, unsupported position. Then passive dorsiflexion was induced by an increasing pressure which was applied in five defined steps against the plantar forefoot. FINDINGS: Mean pressures found in unloaded position were 30.5 (SD 28.9) mmHg in retrocalcaneal bursitis and -9.9 (SD 17.2) mmHg in Achilles tendinopathy (p<0.001). A stepwise increase in passive ankle dorsiflexion was associated with increasing pressure values in both groups. The differences were p=0.009 to 0.035 when dorsiflexion was initiated with 10, 20, 30, and 40N, respectively. Dorsiflexion induced by 50N load resulted in a mean pressure of 113.7 (SD 124.9) mmHg for retrocalcaneal bursitis and 32.5 (SD 48.9) mmHg for Achilles tendinopathy (p=0,051). INTERPRETATION: Higher retrocalcaneal bursa pressure values were found in patients suffering from chronic retrocalcaneal bursitis. This result supports the hypothesis that retrocalcaneal bursa hypertension leads to an impingement lesion of the corresponding anterior Achilles tendon.

Advances in forefoot trauma.

Forefoot traumas, particularly involving the metatarsals, are commonly occurring injuries. There have been several advances in management of these injuries. These advances include updates in operative technique, internal fixation options, plating constructs, and external fixation. In addition, the advances of soft tissue management have improved outcomes. This article outlines these injuries and provides an update on techniques, principles, and understanding of managing forefoot trauma.

Barefoot running: biomechanics and implications for running injuries.

Despite the technological developments in modern running footwear, up to 79% of runners today get injured in a given year. As we evolved barefoot, examining this mode of running is insightful. Barefoot running encourages a forefoot strike pattern that is associated with a reduction in impact loading and stride length. Studies have shown a reduction in injuries to shod forefoot strikers as compared with rearfoot strikers. In addition to a forefoot strike pattern, barefoot running also affords the runner increased sensory feedback from the foot-ground contact, as well as increased energy storage in the arch. Minimal footwear is being used to mimic barefoot running, but it is not clear whether it truly does. The purpose of this article is to review current and past research on shod and barefoot/minimal footwear running and their implications for running injuries. Clearly more research is needed, and areas for future study are suggested.

Surgical reconstruction of severe forefoot derangement in a patient with traumatically acquired contralateral limb-length discrepancy: a case report.

Limb-length discrepancy is a very common condition. A severe debilitating forefoot deformity resulting from a post-traumatic limb length discrepancy is quite rare. This case study discusses the surgical reconstruction of a forefoot deformity of a 64-year-old male following a post-traumatic limb-length discrepancy from a motor vehicle accident that caused compensatory biomechanical changes in the unaffected lower extremity. These changes resulted in a severe hallux abducto valgus deformity with subluxated metatarsophalangeal joints of the second and third digits, leaving the patient with a severe symptomatic forefoot deformity that closely mimics the radiographic appearance of a rheumatoid forefoot. The forefoot deformity was corrected using the Mckeever and Hoffman procedures with Kirschner-wire fixation. Seven months following the corrective procedures, the patient was able to obtain an asymptomatic plantigrade foot and can now wear regular footwear.