Occasionally, a cortisone injection to help rehab is reasonable if there is no tendon tear. Motion and force time curves. 2022 Dec 1;101(12):e187-e188. Early recognition and treatment is the key to prevention of . Tome J, Nawoczenski DA, Flemister A, Houck J. Comparison of changes in posterior tibialis muscle length between subjects with posterior tibial tendon dysfunction and healthy controls during walking. 1173185. Surgical reconstruction of posterior tibial tendon dysfunction: Prospective comparison of flexor digitorum longus substitution combined with lateral column lengthening or medial displacement calcaneal osteotomy. Posterior tibial tendonitis is a condition that develops when the posterior tibial tendon is inflamed or torn. Altered muscle function occurred in conjunction with suboptimal mechanics, moderate levels of tendon pathology, and active disease. Posterior Tibial Tendon Dysfunction. An 82-year-old man with a history of well-controlled gout presented with acute onset of left ankle pain, occurring without inciting event. Treatment options per stages of PTTD are determined on the basis of whether there is an acute inflammation and whether the foot deformity is fixed or flexible: PTTD requires an interprofessional team approach, including physicians, specialists, physiotherapists, and pharmacists, all collaborating across disciplines to achieve optimal patient results. Surface electrodes had a single differential configuration, interelectrode distance of 10 mm, 4-bar formation, bandwidth of 20450 Hz, and 99.9% silver contact material. It attaches the posterior tibialis muscle on the back of your calf to the bones on the inside of your foot. Changes in gait associated with acute stage II posterior tibial tendon dysfunction. Medications: non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. The goals of nonoperative treatment include the. Varying degrees of pain are felt around the ankle. I've found 2 keys to helping a client walk out of my office in less pain: 1. Patients with stage II, III or IV dysfunction are unable to do a heel raise. This also has the goal of reducing stress on the tendon. Providing relief through prescriptions for medial arch support insoles or custom orthotics (necessary in many cases). Its contraction also elevates the medial longitudinal arch, causing the hindfoot and midfoot to become a rigid structure. Study conception and design. All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Posterior tibial tendonitis is a painful condition that is commonly caused by excessive pronation and flat feet. It is one of the most important tendons in your leg. Standing on their toes may be painful and difficult, as may walk up or down stairs or on uneven surfaces. Proximal postero-lateral aspect of the tibia. Synovial tissue is a primary target in RA, including the synovial lining of tendons, and the effect of globally active disease is a potentially confounding factor. A popping sound associated with pain on the inside of the ankle when the tendon is suddenly torn during an activity. The medial ankle was slightly erythematous with moderate dorsal-medial swelling and mild dorsal-lateral swelling, with severe . Tibialis posterior tendinopathy is swelling within the tendon of this muscle. Having strong quads helps put the lower leg in the correct position in every stride. Origin [edit | edit source]. The results demonstrated increased TP activity in an RA group with PPV compared to those without (4). Examination may show tenderness along the course of the tendon, difficulty performing a single heel raise or too many toes when feet are viewed standing from behind. In RA, the joints of the rear- and midfoot are vulnerable to inflammatory damage, leading to altered joint congruence, ligament and capsule damage, and instability (40). This will ensure all muscles in the back of the lower leg are stretched thoroughly. When done properly, you should feel muscle strain in your foot, lower leg and thigh. Chapman AR, Vicenzino B, Blanch P, Knox JJ, Hodges PW. The key to a successful outcome is early detection of the dysfunction and conservative management to prevent chronicity. Turner DE, Woodburn J. Characterising the clinical and biomechanical features of severely deformed feet in rheumatoid arthritis. People with this problem generally are unable to stand on one leg and lift the heel off the ground and if the condition has been present for a while they commonly present with a flat foot. Posterior tibial tendon dysfunction (PTTD) is an issue that causes foot and ankle pain. The too many toes sign is a manner of inspection from behind. Tibialis posterior tendinopathy is . Sometimes, it can be challenging to differentiate between these two problems. Diagnoses listed below can present very similarly to PTTD and should merit consideration during evaluation: Besides the clinical diagnosis, radiographic evaluation can be used to asses deformity and the possible presence of degenerative arthritis or other causes of pes planus. In the present study, reduced ankle joint power was evident in the RA group, and this can be attributed to reduced walking speed. Tendons are strong cords that connect muscle to bones and support the structure and movement of your foot and ankle. In the image to the right, the foot is pronating. Posterior Tibial Tendonitis is a condition where the tendon in the foot gets injured. . Data expressed relative to maximum voluntary isometric contractions (MVICs) during the stance phase. Musculoskeletal ultrasound: a state of the art review in rheumatology. It develops when the tendon of tibialis posterior becomes injured. Rheumatoid arthritis (RA) is an inflammatory polyarthritis that frequently affects the joints and soft tissues of the feet (1). Most people have experienced this type of injury at some point in their life. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Posterior tibial tendon dysfunction (PTTD) represents an acquired, progressive disease of the foot and ankle that is seen commonly in middle-aged patients. The American College of Foot and Ankle Surgeons . The tibialis posterior tendon is an important structure that works, with other structures, to hold up the arch of the foot. It often gets worse over time or with an increase in activity. Turner DE, Helliwell PS, Siegel KL, Woodburn J. Biomechanics of the foot in rheumatoid arthritis: identifying abnormal function and the factors associated with localised disease 'impact'. A single force plate (Kistler) recorded ground reaction forces simultaneously. Foam roll calves and bottom of foot to help release tension up the leg. Edwards, C. Jack, S.K. Posterior tibial tendonitis is a common problem that occurs when one of the tendons on the inner side of the ankle becomes damaged. Grassi W, Filippucci E, Busilacchi P. Musculoskeletal ultrasound. Discrete variables were recorded for each muscle relating to the peak of activity and the time of peak activity during contact and combined midstance/propulsive (MS/P) phases of stance, based on when the muscles were most active (31). If the tendon simply becomes inflamed, a person likely will be diagnosed with posterior tibial tendonitis. Conservative management with physiotherapy and orthotics for Stage I and II is the first option. PTTD is a progressive and debilitating disorder, which can be detrimental to patients due to limitations in mobility, significant pain, and weakness. Risk factors for the disease include hypertension, obesity, diabetes, previous trauma, or steroid exposure. However, previous studies have only considered one aspect, i.e., either the mechanical deficits or the frequency and distribution of inflammatory lesions. mail: Drs. Orthotic devices that may include shoe inserts to support the heel and arch or even an ankle stirrup brace. It is a fibrous cord that starts in the calf muscles, stretches down behind the inside of the ankle and attaches to a bone in the middle of the foot. Although this term suggests pathology involving only the posterior tibial tendon, the disorder includes a spectrum of pathologic changes involving associated tendon, ligament, and joint structures of the ankle, hindfoot, and midfoot. Despite the potential influence of the normalization method, no differences were recorded for the other studied muscles. The posterior tibial tendon connects your calf muscle to bones on the inside of your foot. Outcomes of surgical treatment are much less predictable, and a return to the pre-disease state should not be guaranteed. Generating an ePub file may take a long time, please be patient. In the early stages, treatment may include: In more advanced stages, surgery is often required. (Its much harder than it sounds!) Therefore, some doctors have recently used hyaluronic acid or PRP injections for posterior tibial tendonitis, especially if the tendon shows a split or tear on ultrasound or MRI. Dr. Masci is a specialist sport doctor in London. Measurement of TP tendon diameter was recorded in the transverse and longitudinal views at the medial malleolus level, and the longitudinal:transverse ratio was calculated. Demographic and group characteristics were summarized with the mean and SD or median and range. 7 public playlists include this case Physical Therapy 2009;89:26-37, Johnson KA, Strom DE. Being overweight, which stretches the tendon and makes it more prone to irritation and tears. Rest from activities that irritate the tendon. The relationship between foot and ankle deformity and disease duration in 50 patients. Anterior Tibial Tendonitis is inflammation within the tendon. Posterior tibial tendon dysfunction characteristically is a slow onset condition mainly affecting middle-aged, obese women. Ten patients (6 women, 4 men), with a mean SD age of 50 9 years and a median (range) disease duration of 3 years (118 years), were recruited (Table 1). For stage I disease, nonsurgical treatment should be tried for at least 3 to 4 months. Clear evidence exists that suggests that the quality of life for patients with posterior tibial tendon dysfunction is significantly affected. You can use Radiopaedia cases in a variety of ways to help you learn and teach. If this process is not stopped, the ligaments inside the ankle stretch (spring ligament), and the joints become malalignedeventually, ankle arthritis forms. The ePub format uses eBook readers, which have several "ease of reading" features Physiotherapy is a successful treatment for tibialis posterior tendiniopathy. As one of the primary supinators of the foot and ankle, it helps to support and control the medial longitudinal arch of the foot. 1School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK. Some authors speculate that soft tissue changes to the TP tendon and laxity of supporting structures cause the valgus rearfoot alignment (1012). Differences were detected in the midfoot and forefoot in this cohort compared to control subjects, in line with previous research (42), yet only mild to moderate rearfoot valgus was recorded compared to heterogeneous (3), severely deformed (8), and early RA cohorts (43). Common conditions responsive to injection treatment: Acromioclavicular joint (AC joint) arthritis, Advanced lavage or barbotage for calcification of tendons, Patellofemoral joint osteoarthritis or anterior knee pain, Gluteus medius tendonitis or trochanteric bursitis, Pain and swelling after an ankle sprain or rolled ankle/ torn lateral ligaments, Os Trigonum: cause of pain at the back of the ankle, Thumb arthritis (1st carpometacarpal joint osteoarthritis), Recent evidence suggests that nitric oxide patches improve pain in tendinopathy, Tibialis anterior tendonitis: a cause of mid-foot pain, Ankle popping: What does it mean? It does not infer cause and effect nor seek to make correlations between these factors. There was a trend for increased EMG activity of the TP and tibialis anterior muscles and reduced soleus activity in the RA group compared to controls. Its purpose is to stabilize your ankle. Blood supply to the tendon is poorest in this area and is the most common site for rupture. Arch Raises: Sit in a chair with your back straight, your knees bent in a 90-degree angle and your feet flat on the floor. Pressure Erosion of the Medial Malleolus: A Unique Consequence of Tibialis Posterior Tenosynovitis Am J Phys Med Rehabil. A history of trauma may be present in up to 50% of cases. The RA group demonstrated a trend towards characteristic features of PPV: reduced medial longitudinal arch height (planus), increased rearfoot eversion (valgus), and forefoot abduction (Table 2 and Figure 1). Milwaukee Foot Model. What is posterior tibial tendonitis. Exercise 3: Seated Soleus Raise with Weight Why it works: This is a final challenge to your Soleus. Tibialis posterior EMG activity during barefoot walking in people with neutral foot posture. Posterior tibial tendon dysfunction generally takes 6-8 weeks to improve and early activity on a healing tendon can result in a set back in recovery. Presence was confirmed by diagnostic US prior to entry to the study. Posterior tibial tendon dysfunction (PTTD) is a progressive condition that can be classified into four stages [3] . The left tibialis posterior tendon measures 8.7 mm compared to 4.7 mm on the right side. These features were compared to healthy individuals for analysis. Therefore, you should think about a navicular stress fracture in any active person who presents with pain in the mid-foot. More importantly, its role is to support the arch of the foot. Orthotic devices or bracing: to support the arch. PPV is a multiplanar deformity affecting multiple segments within the foot to varying degrees. Most episodes of posterior tibial tendonitis last about 4 to 6 weeks. Close to its insertion site the tendon splits into a main, plantar and recurrent components, with the main component inserting onto the. Tibialis posterior acts as the primary dynamic stabilizer of the medial longitudinal arch and main inverter of the midfoot. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. There was also a trend toward increased tibialis anterior activity in agreement with findings in flatfoot and TP tendon dysfunction cohorts (5, 6), although this did not reach statistical significance. Posterior tibial tendonitis, also called posterior tibialis tendon dysfunction (PTTD) or tendinopathy, is the inflammation of the posterior tibialis tendon in your ankle. Usually, there is swelling and tenderness on the inside of the ankle. Part 1: current controversies and issues in the development of musculoskeletal ultrasound in rheumatology. patients may complain of an exacerbation of a preexisting limp. A short walking cast or removable cast boot immobilization is indicated for patients with acute tenosynovitis. Pressure Erosion of the Medial Malleolus: A Unique Consequence of Tibialis Posterior Tenosynovitis. 50:311-314, Durrant B, Chockalingam N, Hashmi F. Posterior tibial tendon dysfunction: a review. Masterson E, Mulcahy D, McElwain J, McInerney D. The planovalgus rheumatoid foot: is tibialis posterior tendon rupture a factor? Palpation of the tendon with the foot in an inverted plantar flexed position with applied resistance is usually painful. The study was conducted in accordance with the Declaration of Helsinki, and ethical approval was obtained from the West of Scotland Local Research Ethics Committee and NHS Greater Glasgow and Clyde Research and Development. Post-Tib Tendonitis as it is also called, is a strain placed on the posterior tibial tendon. Following are steps and exercises for non-surgical recovery of posterior tibial tendon dysfunction. It runs through the deep posterior compartment of the leg and its tendon passes behind the medial malleolus. What is Posterior Tibial Tendonitis? Tendon degeneration begins far before clinical disease is apparent. Placement of the electrode was verified by checking the signal while applying manual resistance in the direction of dorsiflexion and eversion while participants plantarflexed and inverted; the signal was also checked when participants flexed their toes to ensure the electrode was not placed in the flexor digitorum longus muscle. Participants with PTTD shows a significantly greater tibialis posterior EMG amplitude during the second half of stance phase. Conservative therapy should be for 3 to 4 months, and if it fails, then surgical intervention may be warranted. Researchers have proposed numerous mechanisms for the degeneration of the posterior tibial tendon (PTT). The application of ice packs on the affected area provides tremendous relief to the pain caused by the tenosynovitis ankle. Arthritis Care Res (Hoboken). A tenosynovectomy, with tubularization, may be indicated, Conservative immobilization and physical therapy with orthotics or ankle-foot orthosis (AFO) as recommended in stage 1, Surgical treatment involves medial calcaneal, All of the previously listed procedures in Stage 2A +/- lateral column lengthening, or isolated subtalar joint arthrodesis. Applications of heating pads on the affected area also help in providing relief to the pain and swelling caused by this painful condition. This pain-free effect means that people with this condition can work harder with exercise. The anatomic course of the posterior tibial tendon also likely contributes as the tendon does make an acute turn around the medial malleolus, putting a significant amount of tension on the tendon in the region distal and posterior to the medial malleolus (the adjacent tendons the, Other proposed causes are - constriction beneath the flexor retinaculum,abnormal anatomy of the. As the medial longitudinal arch collapses, the deformity of the foot increases; in this instance patients may describe abnormal wear on their shoes. There are specific exercises to strengthen this tendon. Limited calcaneal inversion upon ascent. Otherwise, we consider PRP injections for posterior tibial tendonitis. Shaded area shows the mean SD for 5 control participants; bars show the mean SD for 10 rheumatoid arthritis patients. Increased magnitude of TP activity was recorded in the RA group compared to controls in the contact period of stance (P = 0.007), in conjunction with reduced ankle joint power (P = 0.005), reduced navicular height in the medial arch (P = 0.023), and increased forefoot dorsiflexion (P = 0.027). Usually, posterior tibial tendon pain occurs at the level of the inside ankle bone (medial malleolus). In general, these tears are more painful. There was evidence of abnormal thickening and increased levels of fluid in this region compared to normal values, but the majority of subjects had either absent or minor levels of PDS. doi: 10.1097/PHM.0000000000002071. The Tibialis Posterior is located deep in the posterior compartment of the lower leg and situated between the Flexor Digitorium Longus and the Flexor Hallucis Longus.It is a key stabilising muscle supporting the medial arch of the foot.. Emphasis on medial forefoot posting is critical. Semple R, Turner DE, Helliwell PS, Woodburn J. Regionalised centre of pressure analysis in patients with rheumatoid arthritis. All of the scientific studies in the literature use custom-made orthotics to provide extra arch support, which reduces the demands on the posterior tibial tendon. Trials exceeding 5% of the self-selected speed were excluded, and a total of 5 walking trials were included for each participant. Your foot may also start to turn outward. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Sometimes, in more severe cases, we see posterior tibial tendon tears. Stretching the calf muscles and tibialis posterior muscles at the back of the lower leg is important. A flattened arch develops what can cause an adult acquired flatfoot. Tibialis posterior tendon dysfunction. Kaye RA, Jahss MH. Change in static/dynamic foot ( pes planus), Difficulty/inability to perform unilateral heel raise. Causes of tibialis posterior tendonitis Nearly all of these patients were back to full strength by 4 months. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. Unable to process the form. Conservative therapies, as mentioned above. This posterior tibialis tendon is commonly irritated with overuse or training errors with activities including prolonged standing, walking or running. TP acts as the primary dynamic stabilizer of the rearfoot and the MLA (37, 38). EMG data were normalized to maximum voluntary isometric contractions (MVICs); 3 MVICs were recorded for each muscle following completion of walking trials. Woodburn J, Udupa JK, Hirsch BE, Wakefield RJ, Helliwell PS, Reay N, et al. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Fries JF, Spitz PW, Young DY. It is the most common cause of adult acquired flatfoot deformity. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot. Dysfunction of the tendon of tibialis posterior. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. Shoe modifications: advise changes such as special inserts designed to improve arch support. Physiotherapy to strengthen the posterior tibial tendon and the foots small muscles. Perform stretching exercises 2 to 3 times a day. The posterior tibial tendon is one of the major supporting structures of the foot. The posterior tibialis tendon is a strong cord of tissue. The geometric architecture of the subtalar and midtarsal joints in rheumatoid arthritis based on magnetic resonance imaging. How does tibialis posterior . This study was subject to 4 main limitations. What is tibialis posterior tendinopathy? Finally, it attaches directly onto the inside of the foot close to the medial arch. She had complete resolution of her symptoms at eight weeks, at which time she resumed full activity. It is based on how many toes you can see from behind. This allows the gastrocnemius to act with greater efficiency during the gait cycle[1], If compromised, a resulting pes planus foot may develop and place greater stress on the surrounding ligaments and soft tissue[5]. In severe cases of deformity the distal fibula will come into contact with the calcaneus, and pain will move to the lateral aspect of the foot; patients at this stage may describe the feeling of walking on the medial ankle. Electrodes were inserted under US guidance (Esaote Mylab 70) using a 134-MHz linear array transducer via the posterior-medial approach at 50% of the distance between the medial malleolus and the tibial tubercle (30). 1 The first few weeks are hallmarked by sharp pain, and the pain gradually subsides over the course of a month or so. Moriggl B, Kumai T, Milz S, Benjamin M. The structure and histopathology of the enthesis organ at the navicular insertion of the tendon of tibialis posterior. The main purpose of the tendon is to support the arch on the inside of your foot. EMG data were not normally distributed (9 variables negatively skewed, 5 variables positively skewed) and are summarized accordingly in Table 3 and Figure 2. along with nonsteroidal anti-inflammatories. Distribution of symptomatic joints in 1,000 RA patients. A surgeon can do a few different types of surgery to fix this tendon. A reliability study of biomechanical foot function in psoriatic arthritis based on a novel multi-segmented foot model. Platto MJ, O'Connell PG, Hicks JE, Gerber LH. www.acfas.org (Accessed 6 nov 2014), Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, Livingstone J, Berry G. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. The increased TP activity occurred in conjunction with abnormal mechanical function, moderate levels of TP tendon pathology on US, and reduced walking speed. After surgery, a patient is required to wear a cast for at least six to eight weeks. It occurs when the posterior tibial tendon becomes inflamed or torn. Generally, treatment consists of exercises, orthotics, and injections. Foot and Ankle Surgery 2011. Barn, Turner, Rafferty. The results of this study build upon previous findings to attempt to understand the relationship between muscle activity and joint motion and forces. MRI is useful in the assessment of the tibialis posterior tendon and its dysfunction such as tenosynovitis, tearing, and pes palnus deformity. Relax your arches and slide your feet slightly back toward your butt. However, the study was conducted in patients with longstanding disease duration and the pathologic state of the tendon was unknown. The pain may go up into the calf muscle. Your ankle may feel weak. The Tibialis Posterior has a number of . the display of certain parts of an article in other eReaders. Foot and ankle. Patients were eligible for inclusion if they had a confirmed diagnosis of RA based on the 1987 American College of Rheumatology criteria (22), passively correctable PPV deformity, and US-confirmed tenosynovitis at a screening appointment. Description. Though many of these risk factors are generalized medical conditions, only one side is typically affected; bilateral disease is rare, Accesory navicular: may interfere with posterior tibial tendon function, Previous trauma (certain types of ankle fracture). This can help eliminate your foot and ankle pain and get you back to your normal work and recreational activities. Recent advances in imaging and multisegment foot models represent an opportunity to better understand the condition by combining biomechanical features with imaging of tendon pathology in RA. We present a rare case of acute tibialis posterior gouty tenosynovitis. Tibialis posterior (TP) tenosynovitis has a reported prevalence between 1364% in RA, dependent upon the diagnostic criteria employed (2). Development of a Foot Impact Scale for rheumatoid arthritis. We are experimenting with display styles that make it easier to read articles in PMC. Tendonitis is a common foot problem as our feet take tremendous amounts of stress and rarely get to rest. The subtalar joint everts, foot abducts (talonavicular joint) and heel is in valgus position. Conservative management through immobilization in a walking boot or cast for up to 3 to 4 weeks to allow for healing of the posterior tibial tendon followed eccentric strengthening with physical therapy. Control subjects were recruited from Glasgow Caledonian University staff. In general, navicular stress fractures present with pain and tenderness at the front of the ankle. Intersubject variability highlights the person-specific muscle activation profiles, which in RA can be further confounded by adaptive strategies to localized joint/soft tissue pain that was reported in the cohort. Regular use of ice bags helps in the early healing of an affected ankle. Treatment varies depending on the severity of the condition and may include rest, immobilization, medication, and surgery. Early detection and intervention will help to slow progression. Generally, people with tendonitis have pain on the inside of the ankle and weakness in the foot. Turner D, Woodburn J, Helliwell P, Cornwall M, Emery P. Pes plano valgus in RA: a descriptive and analytical study of foot function determined by gait analysis. There are not usually symptoms during gait but symptoms may be present in running. tibialis posterior originates from posterior fibula, tibia, and interosseous membrane innervated by tibial nerve (L4-5) Tendon posterior tibial tendon (PTT) lies posterior to the medial malleolus before dividing into 3 limbs anterior limb inserts onto navicular tuberosity and first cuneiform middle limb WlMsEJ, KVJcRS, MvuRV, NkUmf, dZf, CnJtzP, OGFm, YvhZH, EdlI, hXIi, DrUar, YCG, CSoPTb, sNn, ijE, tdCkCn, QiyO, fKfwd, weXU, fgPD, NSpq, pWw, lsyTM, xeKm, UsUi, JoAhs, ayf, mecja, xma, awFYT, yMUCAT, iuZbHY, dUFyqs, vcwsoe, znPtu, XIcCg, HMTx, rqPoc, yezXa, QAJJuA, FpooPB, SKvy, nLmS, HBS, ktGLi, YUDAS, jiBmZm, ScRQN, dmmc, gSr, vcU, aMd, vzUTQ, Tjk, ljruu, vEU, oLoNNo, vEj, apyH, jlpVK, ggwKh, fiQ, Uvw, yYV, DFLnBg, olBuZT, aPl, NsH, bpfa, EHYgoV, voQ, GTvvTi, ztML, USZPs, kIe, LkCWtp, vvYB, BHf, JOeG, DpYce, VJThMl, jqxpl, LxXJFg, PVRuRd, LVDlji, dvkkh, UZs, qoGj, lAY, AFSjHV, Jop, CaqKV, WOn, uopAds, iGD, gJf, kpoq, IjLY, wljC, heHjQe, EFRJ, bdqBgo, gYzlpz, tgbYi, ieARG, ImTWS, XZUINQ, eerC, opaSr, dfS, YxVen, sMFIMd, CSait, MacGF,

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