Foot

The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons that allow for flexibility as well as dynamic and static support. The foot has 3 primary arches and multiple ligaments that are essential to its structure. The arches are important in absorbing weight during standing, walking, and running and the ability to adapt to uneven terrain during locomotion.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Bones and Joints

Bones of the foot

The 26 bones of the foot are divided into 3 groups: tarsals, metatarsals, and phalanges.

  • Tarsal bones (7):
    • Calcaneus: 
      • Largest and strongest
      • Acts as a lever for the strong muscles of the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, specifically the muscles of the posterior compartment
      • Articulates with the talus at the superior portion, forming the subtalar joint
      • Articulates with the cuboid anteriorly
    • Talus: 
      • 2nd largest tarsal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones
      • The majority of the talar surface is covered with articular cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage
      • No tendons or muscles insert to or originate from the talus.
      • Articulates with the tibia, fibula, navicular, and calcaneus bones
    • Cuboid:
      • Anterior to the calcaneus, on the lateral side of the foot
      • Articulates with the calcaneus, lateral cuneiform, 4th–5th metatarsals, and occasionally the navicular
    • Navicular: 
      • Anterior to the talus on the medial aspect of the foot
      • Articulates with the talus, medial, middle, and lateral cuneiforms, and occasionally with the cuboid
    • Cuneiforms (3):
      • Medial, middle (intermediate), and lateral
      • Configuration creates a keystone effect that contributes to the stability of the foot
  • Metatarsal bones (5): 
    • The bases articulate with the tarsal bones proximally:
      • 1st–3rd metatarsals articulate with the cuneiforms
      • 3rd–5th metatarsals articulate with the cuboid
    • The distal heads articulate with the proximal phalanges.
    • The 1st metatarsal is the shortest and strongest. 
    • The 2nd metatarsal is the longest.
  • Phalanges (14): 
    • Small bones of the digits
    • Each toe has 3 phalanges: proximal, middle, and distal
      • The exception is the hallux, which has only a proximal and a distal phalanx.
      • A common variant is a fused middle and distal phalange of the 5th digit.
  • Other bones of the foot:
    • Sesamoid bones:
      • 2 sesamoid bones are usually present at the plantar area of the 1st metatarsal phalangeal joint, within the tendon of the flexor hallucis brevis.
      • Increase the mechanical advantage of the 1st digit
    • Common accessory ossicles or accessory bones of the foot:
      • Os trigonum: found at the posterior aspect of the talus
      • Os navicular (accessory navicular): medial aspect of the navicular
      • Os peroneum: accessory bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones within the peroneus longus tendon
      • Bipartite sesamoid: Sesamoids of the 1st digit fail to ossify, resulting in a fibrous union.

Mnemonic

From superior to inferior and from medial to lateral in a right foot: Talus, Calcaneus, Navicular, Medial cuneiform, Intermediate or middle cuneiform, Lateral cuneiform, Cuboid

  • The Cab in New Mexico Is a Land Cruiser
  • The Cub Needs MILC

Joints of the foot

The joints of the foot, from proximal to distal, include the following articulations.

Subtalar or talocalcaneal joint: 

  • Type: synovial joint or plane synovial joint
  • Composed of 3 alternating convex–concave areas on each of the talus and calcaneus bones
  • Supporting ligaments:
    • Anterior, posterior, lateral, and medial talocalcaneal ligaments 
    • Interosseous talocalcaneal ligament (the strongest of this joint, lies within the sinus tarsi or tunnel between the talus and calcaneus)
  • Function:
    • Inversion and eversion of the foot
    • Minimal amount of dorsiflexion

Transverse tarsal or midtarsal joint: 

  • Type:
    • The talocalcaneonavicular joint is a modified ball-and-socket joint.
    • The calcaneocuboid joint is a modified saddle-type joint.
  • Components:
    • Talocalcaneonavicular joint: 
      • Head of the talus
      • Concavity formed by the posterior area of the navicular and anterior area of the calcaneus 
    • Calcaneocuboid joint: 
      • Distal surface of the calcaneus 
      • Proximal area of the cuboid
  • Supporting ligaments:
    • Talocalcaneonavicular joint: articular capsule, dorsal talonavicular ligament, and plantar calcaneonavicular ligament
    • Calcaneocuboid joint: bifurcate (Y-shaped) ligament superiorly, long plantar ligament inferiorly, and short plantar ligament
  • Function:
    • Talocalcaneonavicular joint performs inversion and eversion of the foot
    • Calcaneocuboid joint performs gliding and rotational movements between the calcaneus and cuboid

Tarsometatarsal or Lisfranc joints: 

  • Type: arthrodial joints
  • Components: 
    • 1st–3rd metatarsals articulate with the cuneiforms
    • 3rd–5th metatarsals articulate with the cuboid
  • Supporting ligaments: 
    • Dorsal and plantar tarsometatarsal ligaments
    • Interosseous cuneometatarsal ligaments
      • The strongest of these is the Lisfranc ligament, which extends from the 2nd metatarsal to the lateral aspect of medial cuneiform.
  • Function: 
    • Minimal gliding movement
    • Primarily stability

Metatarsophalangeal joints:

  • Type: condyloid joints
  • Components: articulations between the metatarsal heads and the base of the proximal phalanges of the digits
  • Supporting ligaments: 
    • A capsule encloses each joint.
    • Medial and lateral collateral ligaments 
    • Plantar ligament 
  • Function:
    • Flexion and extension
    • Abduction and adduction
    • Circumduction

Plantar Arches and Ligaments

The foot has 3 primary arches and multiple supporting ligaments.

Plantar arches

The plantar arches function to distribute and absorb the body weight, provide the foot with elasticity and resilience during locomotion, adapt to uneven surfaces, and protect the neurovasculature on the plantar surface.

  • Medial longitudinal arch:
    • Formed by the calcaneus, talus, navicular, cuneiforms, and 1st–3rd metatarsals
    • Generally the highest arch of the foot
    • Supported by the intrinsic muscles of the foot
  • Lateral longitudinal arch:
    • Formed by the calcaneus, cuboid, and 4th–5th metatarsals
  • Transverse arch:
    • Formed by the cuboid, cuneiforms, and bases of the 1st–4th metatarsal bones
    • Forms the medial to lateral midfoot curvature
Medial view of the foot

Medial view of the foot featuring the arches of the foot

Image by Lecturio.

Plantar ligaments

The plantar ligaments are essential in the maintenance of the functional integrity of the arches on the sole of the foot.

  • Long plantar ligament: 
    • Longest and strongest ligament in the body
    • Supports the longitudinal arches
    • Connects the calcaneus and the cuboid bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones/base of 5th metatarsal
    • Converts the cuboid groove into a canal for the fibularis longus tendon
  • Short plantar ligament: 
    • Deep to the long plantar ligament
  • Plantar calcaneonavicular ligament:
    • Also known as the spring ligament
    • Runs from the sustentaculum tali to the plantar surface of the navicular bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones
  •  Other ligaments that contribute to the structural integrity of the arches:
    • Plantar cuneonavicular ligament 
    • Plantar intercuneiform ligaments 
    • Plantar cuboideonavicular ligament
    • Plantar cuneocuboid ligaments
Plantar view of the foot

Plantar view of the foot featuring the numerous plantar ligaments

Image by Lecturio.

Plantar fascia or plantar aponeurosis

  • Thick band of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue that supports the bony arches of the foot
  • Extends from the calcaneal tuberosity to the proximal phalanges
  • Divides the foot into lateral, medial, and central compartments through septa of the plantar aponeurosis
Plantar fascia or aponeurosis

Plantar fascia or aponeurosis:
Note how the deep fascia is continuous with the plantar fascia, which is thickened centrally as the toughened plantar aponeurosis. The aponeurosis has bands and intermuscular septa that divide the sole of the foot into 3 compartments: medial, lateral, and central.

Image by Lecturio.

Muscles of the Dorsum of the Foot

Aside from the tendons of the extrinsic muscles from the anterior compartment of the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg (extensor hallucis longus, extensor digitorum, tibialis anterior, and peroneus tertius), which pass under the extensor retinaculum, only 2 intrinsic muscles exist on the dorsum of the foot: 

  • Extensor digitorum brevis
  • Extensor hallucis brevis

Muscles of the Sole of the Foot

The intrinsic muscles of the plantar surface, or sole, of the foot both originate and insert within the foot. These muscles produce the fine movements of the digits and support the arches of the foot during standing, walking, and running. Commonly, the plantar muscles of the foot are organized into 4 layers, from superficial to deep: 

  • 1st layer:
    • Abductor hallucis
    • Flexor digitorum brevis
    • Abductor digiti minimi
  • 2nd layer: 
    • Quadratus plantae
    • Lumbricals
  • 3rd layer: 
    • Flexor hallucis brevis
    • Adductor hallucis
    • Flexor digiti minimi brevis
  • 4th layer: 
    • Plantar (3) interossei
    • Dorsal (4) interossei
Table: Most superficial muscle layer of the foot
Muscle Origin Insertion Innervation Function
Abductor hallucis Tuberosity of calcaneus and plantar aponeurosis Base of proximal phalanx of the hallux Medial plantar nerve (S3) Abducts and flexes the 1st digit
Flexor digitorum brevis Middle phalanges of digits 2–5 Flexes digits 2–5
Abductor digiti minimi Base of proximal phalanx of digit 5 Lateral plantar nerve (S3) Abducts and flexes digit 5
Most superficial layer of the muscles of the sole of the foot

Most superficial layer of the muscles of the sole of the foot

Image by Lecturio.
Table: 2nd most superficial muscle layer of the foot
Muscle Origin Insertion Innervation Function
Quadratus plantae Medial and lateral aspect of the calcaneus Lateral margin of the tendons of the flexor digitorum longus (FDL) Lateral plantar nerve (S1–S3) Assist flexion of digits 2–5 with the FDL
Lumbricals Tendons of the flexor digitorum longus Medial aspects of digits 2–5
  • Medial (medial plantar nerve, S3)
  • Lateral (lateral plantar nerve, S3)
  • Flexes the proximal phalanges
  • Extends the middle and distal phalanges of digits 2–5
2nd most superficial layer of the muscles of the sole of the foot

2nd most superficial layer of the muscles of the sole of the foot

Image by Lecturio.
Table: 3rd most superficial muscle layer of the foot
Muscle Origin Insertion Innervation Function
Flexor hallucis brevis Cuboid and lateral cuneiform Base of the proximal phalanx of the 1st digit Medial plantar nerve (S3) Flexes the proximal phalanx of the 1st digit
Adductor hallucis
  • Oblique head: 2nd–4th metatarsals
  • Transverse head: metatarsophalangeal joints of digits 3–5
Lateral plantar nerve (deep branch, S3) Adducts the 1st digit
Flexor digiti minimi brevis Base of the 5th metatarsal Base of the proximal phalanx of the 5th digit Lateral plantar nerve (superficial, S3) Flexes the proximal phalanx of the 5th digit
Third-most superficial layer of the muscles of the sole of the foot

3rd most superficial layer of the muscles of the sole of the foot

Image by Lecturio.
Table: Deepest muscle layer of the foot
Muscle Origin Insertion Innervation Function
Plantar interossei Medial surface of the 3rd–5th metatarsals Medial surface of the proximal phalanx of digits 3–5 Lateral plantar nerve (S3) Adducts digits 3–5 and flexes metatarsophalangeal joints
Dorsal interossei Adjacent surfaces of the 1st–5th metatarsals
  • 1st: medial surface of the proximal phalanx of the 2nd digit
  • 2nd-4th: lateral surface of the proximal phalanx of digits 2–4
Abducts digits 2–4 and flexes metatarsophalangeal joints
Deepest layer of the muscles of the sole of the foot

Deepest layer of the muscles of the sole of the foot

Image by Lecturio.

Alternatively, the intrinsic muscles of the plantar surface, or sole, of the foot can be divided into 3 groups, using the medial, lateral and central compartments of the foot.  These compartments are formed by the deep fascia or plantar aponeurosis.

  • Lateral plantar muscles act on the 5th toe: 
    • Abductor digiti minimi
    • Flexor digiti minimi brevis
    • Opponens digiti minimi ( variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables)
  • Central plantar muscles act on the 2nd–5th digits
    • Flexor digitorum brevis
    • Quadratus plantae
    • Lumbrical muscles
    • Dorsal and plantar interossei muscles
  • Medial plantar muscles act on the hallux
    • Abductor hallucis
    • Flexor hallucis brevis
    • Adductor hallucis

Neurovasculature

Innervation

Primarily from branches of the tibial nerve and the deep fibular nerve.

Innervation of the plantar surface:

The tibial nerve branches into the medial and lateral plantar nerves at the ankle within the tarsal tunnel.

  • Medial plantar nerve:
    • Courses posterior to the medial malleolus and deep to the abductor hallucis muscle
    • Motor function: 
      • 1st lumbrical 
      • Abductor hallucis
      • Flexor hallucis brevis 
      • Flexor digitorum brevis
    • Sensory function:
      • Anterior ⅔ of the medial sole
      • Medial 3½ digits, including the nail beds
  • Lateral plantar nerve:
    • Runs deep to the abductor hallucis muscle and between the flexor digitorum brevis and quadratus plantae muscles
    • Motor function:
      • Lumbricals (2–4)
      • Dorsal and plantar interossei 
      • Abductor digiti minimi
      • Quadratus plantae
      • Adductor hallucis
      • Flexor digiti minimi brevis
    • Sensory function:
      • ⅔ of the lateral sole
      • Lateral 1½ digits

Innervation of the dorsal surface:

  • Superficial fibular or peroneal nerve:
    • Originates from the common fibular nerve
    • Supplies the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of the dorsum of the foot, excluding digits 1, 2, and 5
  • Deep fibular or peroneal nerve:
    • Sensory innervation to the 1st web space (1st and 2nd digits)
    • Motor innervation to the extensor digitorum brevis and extensor hallucis brevis
  • Saphenous nerve:
    • Originates from the femoral nerve
    • Supplies the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of the medial side of the ankle joint and foot
    • Supplies the distal aspect of the 1st metatarsal
  • Sural nerve:
    • Lateral dorsal cutaneous
    • Lateral calcaneal
Innervation of the dorsal and plantar portions of the foot

Innervation of the dorsal and plantar portions of the foot

Image by Lecturio.

Blood supply

Posterior tibial artery:

  • Origin: 
    • The most proximal posterior tibial artery 
    • The largest terminal branch of the popliteal artery
    • Enters the foot by passing behind the medial malleolus of the tibia, where it provides branches to the ankle joint
    • The terminal branches are the lateral and medial plantar arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.
  • Location:
    • Palpated posterior to the medial malleolus 
    • Courses through the tarsal tunnel behind the medial malleolus.
  • Function:
    • Supplies the posterior compartment of the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg via the tarsal tunnel
    • Supplies the entire plantar surface of the foot via the medial plantar and lateral plantar arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries:
      • Medial plantar artery: supplies medial aspect of the 1st metatarsal and the 1st digit
      • Lateral plantar artery: supplies the majority of the sole of the foot and gives rise to the deep plantar arch
Posterior tibial artery

Oblique view of the plantar aspect of the foot showing the branches of the posterior tibial artery

Image by Lecturio.

Anterior tibial artery:

  • Origin:
    • A terminal branch of the popliteal artery
    • Passes in front of the ankle joint and becomes the dorsalis pedis artery in the foot
    • Reaches the 1st intermetatarsal space and branches into:
      • Lateral tarsal artery → arcuate artery
      • 1st dorsal metatarsal artery  
      • Forms an anastomosis with the lateral plantar artery → deep plantar arch
  • Location:
    • Lateral to the extensor hallucis longus tendon
    • Medial to the extensor digitorum longus and deep peroneal nerve
    • Pulse is palpated between the extensor hallucis longus and the extensor digitorum longus tendons on the dorsum of the foot.
  • Function:
    • Supplies the tarsal bones 
    • Supplies the dorsal aspect of the metatarsals
Anterior tibial artery

Anterior view of the dorsal foot demonstrating the anterior tibial artery to the dorsalis pedis artery and its branches

Image by Lecturio.

Venous drainage

Venous drainage of the foot begins with the digital veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins, which run proximally to form both a deep plantar venous arch and a dorsal venous arch. These veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins drain into the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg via the anterior and posterior tibial veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins and the peroneal vein.

Clinical Relevance

Foot deformities Foot deformities Foot deformities in children include congenital or acquired malformations of the feet. Two common examples are talipes equinovarus, commonly known as clubfoot, and metatarsus adductus, also called metatarsus varus. Foot Deformities

  • Bunion: hallux valgus deformity that presents as pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain at the medial aspect of the 1st metatarsal phalangeal joint as well as associated deformity.
  • Hammer toe: common flexion deformity of the proximal interphalangeal joints of the 2nd–4th digits. Hammer toe is caused by shoe wear, trauma, rheumatologic disorders, and neurologic conditions. Initial treatment includes shoe modification, padding, orthotics, and surgical intervention to correct the deformity if medical management fails.
  • Lisfranc injury: fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures/dislocation of the tarsal–metatarsal articulations at the junction of the midfoot and forefoot. This injury commonly occurs when there is indirect loading on a plantar-flexed foot or with a crush injury. The Lisfranc ligament, which is found between the medial cuneiform and the base of the 2nd metatarsal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, is disrupted. This type of injury commonly needs a CT scan for detection, as it may be missed with an x-ray. A Lisfranc injury may lead to chronic injury.
  • Pes cavus: excessively arched foot or “claw foot.” Pes cavus is usually caused by neurologic disorders, resulting in plantar hyperflexion of the 1st metatarsal. 
  • Pes planus: Also known as “flat foot,” pes planus is due to a collapse of the longitudinal arches, especially the medial longitudinal arch. Pes planus can be a common congenital nonpathologic condition, or it can develop in adults (adult-acquired flatfoot deformity).
  • Plantar metatarsophalangeal sprain or turf toe: sprain or disruption of the plantar stabilizers of the 1st metatarsal phalangeal joint.
  • Plantar fasciitis: common degenerative condition of the proximal plantar fascia. Presentation is with heel pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with the 1st step in the morning or with prolonged standing.
  • Tarsal coalitions: union of ≥ 2 tarsal bones. Tarsal coalitions occur most commonly between the talus and calcaneus or the navicular and calcaneus and are usually asymptomatic until adolescence.

References

  1. Drake, R.L., Vogl, A.W., Mitchell, A.W.M. (2014). Gray’s Anatomy for Students, 3rd ed. Churchill Livingstone.
  2. Netter, F. H. (2006). Atlas of Human Anatomy. Saunders/Elsevier.
  3. Standring, S., Gray, H. (2016). Gray’s Anatomy: The Anatomical Basis of Clinical Practice.
  4. Ficke, J., Byerly, D.W. Anatomy, Bony Pelvis and Lower Limb, Foot. StatPearls. Retrieved December 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK546698/

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