verify here. Rupture of the Achilles tendon most commonly occurs in the distal tendon, approximately 2-6 cm from its attachment to the calcaneal tuberosity, in an area of hypovascularity known as the “watershed” or “critical” zone.1-3 The Thompson test (also: Simmonds-Thompson test), described by Simmonds in 1957 and Thompson in 1962, is done while the patient is in the prone position, with feet hanging over the end of a table/gurney, or with the patient kneeling on a stool or chair.4-5 Squeezing the calf of an unaffected limb will cause the ankle to plantar flex, but squeezing the calf of a limb with an Achilles tendon rupture will cause no motion. It is also the tale of a long weekend road trip that has gone down in the annals of American pop culture as one of the strangest journeys ever undertaken. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. 12 Positive Matles (knee flexion) test. Found inside – Page 13E1 Tests for rupture of the Achilles tendon.1All tests are performed with the ... Thompson described the calf squeeze test in 1962,2 pointing out that the ... The Simmonds-Thompson test is the main clinical test for rupture of the Achilles tendon.16 17 A typical finding in complete ruptures (positive test result) is failure of the foot to plantar flex when the calf is squeezed (fig 1 ⇓). Simmonds FA. Dividing the m. gastrocnemius tendon did not prevent full plantar flexion. Found inside – Page 16The Thompson squeeze test is often helpful. With this test, the patient lies prone on a table or kneels on a chair. On the normal side, squeezing the ... (January 2019) Simmonds' test (also called the Thompson test or Simmonds-Thompson test) is used in lower limb examination to test for the rupture of the Achilles tendon. The clinician squeezes the gastrocnemius muscle belly while watching for plantar flexion. If you Achilles is torn you will have difficulty in plantar flexing your ankle against resistance. Matles Test: specificity is .85 and sensitivity of .88. Copyright © 2016 JETem. The m. soleus did not move in a longitudinal manner, while the m. gastrocnemius muscle moved about 1 cm proximally. Found inside – Page 340Figure 5-34 Thompson squeeze test.This test evaluates the Achilles tendon for complete rupture. In the normal patient placed prone with the knee flexed at ... This book, written by leading experts in the field, is a comprehensive guide to the best available techniques in Achilles tendon surgery. The "squeeze test" is a clinical test for detecting "stable" syndesmosis injuries. If there is too much swelling then it is not always obvious. Thompson however had noted this effect in 1955. Positive Thompson (calf squeeze) test. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. This site complies with the HONcode standard for trustworthy health information: If the tendon is ruptured, normal plantarflexion will not occur (a positive Thompson test). Found inside – Page 371242 The Thompson Squeeze Test for Achilles Tendon Rupture • Figure 242-1 To perform the Thompson squeeze test for Achilles tendon rupture, the examiner ... Crossed-Leg Test. Heel Tap Test. Found inside – Page 9Thompson described the calf squeeze test in 1962,2 pointing out that the test could be performed with the patient prone or kneeling on a chair. When squeezing the right (unaffected) calf, the ankle spontaneously plantar flexed, indicating a negative (normal) Thompson test. Test is positive if unilateral sacroiliac joint pain or pain posterior part leg is felt. In a healthy ankle, your foot should move each time you squeeze the muscle. Found inside – Page 191Thompson's test can be applied if there is any implication of a muscle or tendon rupture. Here, the patient lies in prone and the calf is squeezed passively ... Thompson’s test is performed by squeezing your calf muscles at the belly of the muscle. Found inside – Page 398Also called the F.R. Thompson Femoral Head Prosthesis . Thompson Squeeze Test ( tom'son / skwēz / test ) ( n . ) A method to assess continuity of the ... Normal Response: Plantar flexion as reflex response. 13 Evidence of a tendon gap, defect, or loss of contour upon palpation. To confirm a suspected Achilles tendon rupture, have the patient lying prone and then squeeze the calf while observing the foot. Thompson’s squeeze test will give a positive result. Thompson’s test is performed by squeezing the calf muscles at the belly of the muscle. This is not as good, but comparable to the usual Thompson or calf squeeze test with specificity of .98 and sensitivity of .96 as available by the CORE application screenshot below. If there is plantar flexion of the foot, this means that the tendon is intact. They could both actively plantar flex their ankles, but had a positive Simmonds-Thompson test result. Bohn Stafleu van Loghum, 2008, p. 165-166.. Tendons are strong, tough bands of inelastic fibrous connective tissue that connect muscle to bone. The foot does not plantarflex. But opting out of some of these cookies may affect your browsing experience. Sign up to receive updates from JETem regarding newly published issues and findings. Nevertheless, Homan’s test still remains an important tool for use in the health care setting. If the injured foot hangs directly down when compared to the uninjured one, then this could be an indication of a torn Achilles tendon. The 9 step exam can be broken down into 3 critical questions: In most cases Physiopedia articles are a secondary source and so should not be used as references. The patient lies face down with feet hanging off the edge of the bed. The Thompson Test is a technique designed to exam a suspected rupture of the Achilles tendon. Orthopedie. Patient Position: Patient is sitting with leg extended and ankle off of the table. Thompsons test is used to help diagnose a complete rupture of the Achilles tendon. Kleiger's test, also known as the external rotation test, determines the rotary damage to the deltoid ligament or the distal tibiofibular syndesmosis which is injured in a high ankle sprain. Positive test: P! Tissues Being Tested: The popliteal fossa and the sciatic nerve. We can conclude then that the plantar flexion is caused by bowing the calf tendons and less so by the proximal displacement of the bellies of the m. gastrocnemius. The Thompson test examines the integrity of the Achilles tendon by squeezing the calf. It is performed as a clinical test to identify the presence of a complete Achilles rupture. Necessary cookies are absolutely essential for the website to function properly. Eversion Stress Test. Found inside – Page 26714: Thompson test. On the left side is a normal patient where squeezing of calf produces plantar flexion at ankle, while on the right is a patient with torn ... a physical examination procedure that is used to test for Deep Vein Thrombosis (DVT). A positive Thompson test can be acknowledged if the foot does not plantar flex. A positive test indicates sprain of anterior SI ligaments. Mike has a degree in Physical Education, Sports Science and Physics, a Diploma in Fitness Training & Sports Therapy and a Postgraduate Certificate in Education with Qualified Teacher Status. The Thompson test examines the integrity of the Achilles tendon. Calf Squeeze Test. You can opt-out if you wish. Found inside – Page 247Thompson's test: The patient is placed in a prone position with the foot hanging free. If there is no plantar flexion of the foot as the calf is squeezed, ... Garras DN, Raikin SM, Bhat SB, Taweel N, Karanjia H. MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria. Simmonds-Thompson test result should be considered positive when the physical response to calf squeezing is aberrant and the foot fails to plantarflex owing to incongruity of the Achilles tendon, indicative of rupture 1957 – Sam Simmonds described a test for Achilles tendon integrity consisting of two signs: 1173185. Found inside – Page 12E1 Tests for rupture of the Achilles tendon.1 All tests are performed with ... Thompson described the calf squeeze test in 1962,2 pointing out that the test ... The Thompson Squeeze Test was negative for an Achilles tendon rupture, as it was painful but produced plantar flexion. Brukner P, Khan K. Clinical Sports Medicine. Positive Test. Interpretation: Standard Thompson Test. Found inside – Page 29244.2 Thompson squeeze test. This test evaluates the Achilles tendon for complete rupture. In the normal patient placed prone with the knee flexed at 90 ... Thompson test, Simmonds-Thompson test, orthopedics, Achilles tendon rupture, calcanea tendon rupture, ankle pain, calf pain. Found inside – Page 643A modification of the Thompson calf squeeze test has been proposed to rule out complete triceps tendon ruptures.14 During this test the upper arm is placed ... Calf Muscles/ Triceps Surae: The triceps surae aka “three-headed [muscle] of the calf” is a pair of muscles located at the calf – the two-headed gastrocnemius and the soleus. IV. A Thompson’s test can be performed by placing the patient in a prone position with the affected leg extended. Test achilles tendon injury by performing the Thompson test. Found inside – Page 322... for hip Thompson's ankle and foot tests, 296f, 297–299, 298f, 298t Three jaw chuck test, 160, 161f Thumb- index finger squeeze tests, 303 Tijssen, ... Squeezing the calf should cause contraction of the Achilles tendon, resulting in plantar flexion. Found inside – Page 126The Thompson squeeze test is the definitive diagnostic maneuver ( Fig . 74 ) . Squeezing the calf of a normal leg , with the patient lying prone , feet dangling over the end of the table , should produce brisk plantar flexion of the ... The squeeze test was the only test with a clinically important result.16, 45 The conclusion that clinical tests are not accurate should be carefully interpreted. The diagnosis of left Achilles tendon rupture was confirmed intraoperatively one week later. This website uses cookies to improve your experience while you navigate through the website. However, if you have a complete rupture of the Achilles tendon then your foot will not move as … 3rd ed. Can J Surg. Schwieterman B, Haas D, Columber K, Knupp D, Cook C. Diagnostic accuracy of physical examination tests of the ankle/foot complex: asystematic review. It is…, When retrocalcaneal bursitis exists at the same time as Achilles tendonitis in the same leg, this is known as Haglund's Syndrome. Dorsiflexion Maneuver Test. Thompson TC. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test. Orthopedic Exam/ Special Test: Squeeze Test of the Leg POSITIVE TEST: 1 A positive test is considered if the patient experiences pain in the area of the syndesmosis. 2 Pain in the lower leg may indicate a syndesmosis injury, provided that fracture, contusion, and compartment syndrome... More ... Dimple Sign Test. It is still possible for the m. plantaris and deep toe flexors to also provide plantar flexion even if the Achilles tendon is ruptured<ref>Verhaar JAN, van der Linden AJ. Upon squeeze of the left (affected) calf, the ankle did not plantar flex, signifying  a  positive  (abnormal)  Thompson  test. The patient lies prone with his foot over the end of the table. The squeeze test had the lowest sensitivity (26%). Found inside – Page 476Squeeze test, 320, 321 Staphylococcus aureus, 439 Status epilepticus, ... 347 Thomas test, 311 Thompson squeeze test, 319 Thromboembolic disease, ... Performing the Test. Found inside – Page 499... 149, 157 splint, 185 squeeze test, 155 test, 149 Thomas, Thompson, and Straub procedure, 260 Thompson approach, 274–275 nail, 223 quadricepsplasty, ... Over the past 25 years, Niek van Dijk, founder of the Amsterdam Foot and Ankle School and author of this book, has developed a new philosophy of ankle arthroscopy. Found inside – Page 371The Thompson Squeeze Test for 242 Achilles Tendon Rupture • Figure 242-1 To perform the Thompson squeeze test for Achilles tendon rupture, the examiner ... Achilles tendontis is an overuse injury causing pain at the back of the ankle. All rights reserved. Thompson TC, Doherty JH. If the foot does not move then complete rupture is indicated. Vrije Universiteit Brussel's Evidence-based Practice project, https://www.physio-pedia.com/index.php?title=Thompson_Test&oldid=266132, On careful inspection, with the patient prone and both ankles fully relaxed, the foot on the ruptured side hangs straight down due to the absence of the tendon tone, There may be a palpable gap in the tendon, approximately 3-6cm proximal to the insertion into the calcaneus, The strength of the plantar flexion is markedly reduced. Furthermore, the squeeze test had a positive LR (LR+) of 2.15 (95% CI 0.86 to 5.39), indicating a small increase in the likelihood of the disease with a positive test. This category only includes cookies that ensures basic functionalities and security features of the website. Observe for plantar flexion of foot. Found inside – Page 227Ruland biceps squeeze test (similar to Thompson squeeze test for Achilles tendon ... with one arm while squeezing the mid-arm biceps muscle with the other. Resisted plantar flexion of the ankle also reproduced the symptoms. To elucidate these findings, Scott and colleagues separated the m. gastrocnemius tendon from the m. soleus down to 10 cm above the Achilles tendon, the place where the fibers form the tendon. When squeezing  the  right  (unaffected)  calf,  the  ankle spontaneously plantar flexed, indicating a negative (normal) Thompson test. They consist of elongated cells, minimal ground substance, and collagen fibers. For the Thompson test, Maffuli 23 reported a sensitivity of .96 and a specificity value of .93. Squeeze Test. However, our 2 patients’ cases demonstrate that, although the test indicates a substantial injury to the ten-don, it cannot be regarded as diagnostic of … Thompson test. A test to evaluate the integrity of the Achilles tendon. With the patient lying prone on the examination table, the examiner squeezes the calf while observing for plantar flexion. The result is positive if there is no movement of the foot; this indicates an Achilles tendon rupture. Thompson Test video provided by Clinically Relevant. The aim of the study conducted by Nussbaum et al 16 was not to investigate diagnostic accuracy, but to evaluate time missed from sport in an attempt to better define the injury. Special Tests- These include tibial external rotation with ankle dorsiflexion, syndesmotic compression with maximum dorsiflexion and the Hopkins (Squeeze) test, (with external rotation test being the most reliable and the squeeze test being the least (11). Thompson, Frederick R., U.S. orthopedic surgeon, 1907-1983. Again, lying face down with your feet over the edge of a massage table. Thompson anterolateral approach Thompson anteromedial approach Thompson approach Thompson arthroplasty Thompson excision Thompson femoral head prosthesis Thompson femoral neck prosthesis Thompson fracture frame Thompson frame Thompson hemiarthroplasty hip prosthesis Thompson hip … The patient is placed prone, with both feet extended off the end of the table. Found inside – Page 239Positive Thompson test ( Figure 13.3 ) : • Pt lies prone on the examining table with ... Figure 13.3 Thompson squeeze test • The test can also 13.6 Achilles ... Examiner Position: Examiner stands centered with the knee’s of the patient;one hand on the sole of the foot and the other on the knee. The calf squeeze or Thompson test provides an accurate means for detecting complete Achilles tendon rupture. Found inside – Page 214In 1962, Thompson and Doherty104 noted (and Scott and others107 later confirmed) that ... The calf squeeze test was found to have a sensitivity of 0.96, ... The sensitivity of the Thompson’s test for the diagnosis of a complete Achilles tendon rupture is 96-100% and the specificity is 93-100%, but data is limited.6-8. Positive test Pain over space between tibia and fibula Suggests Tibiofibular Syndesmosis injury Ontology: Thompson's test (C0231790) Found inside – Page 104Special tests can be performed to determine the status of the soft tissue. To evaluate the ligaments, ... the Thompson squeeze test can be performed. Active and passive ankle dorsiflexion produced moderate pain. Indicates: A sprain of the distal In complete rupture, it is still possible to actively plantar flex the ankle with the adjacent intact flexor tendons; however, gentle squeezing of the calf muscles with the patient lying prone, sitting, or kneeling on a chair produces little or no passive ankle plantar flexion (positive Thompson calf squeeze test). The examiner crosses the hands and places them on the ASIS and pushes down and out. Found inside – Page 372The examiner squeezes the calf which Fig. 33.4 Thompson's test causes a deformation of the triceps surae muscle with synchronized bowstringing of the ... Pain in the lower leg may indicate a syndesmosis injury, provided that fracture, contusion, and compartment syndrome have been ruled out. Both calf muscles are squeezed by the examiner. Found inside – Page 254See Thompson test Recoil plantarflexion, 86 Rectus femoris, 33, ... E., 11 Simmonds/Thompson calf squeeze test, 53 Soft tissue, 10, 65, 73, 83, 101, 115, ... Test syndesmotic stability by performing the squeeze test. J Trauma. Has your strength significantly reduced when trying to go up on tiptoes (plantar flexion)? The collagen fibers are packed closely together, parallel to the direction of force. The diagnosis of left Achilles tendon rupture was confirmed intraoperatively one week later. Found inside – Page 149... ligament sprain.....65 Spurling maneuver (foraminal compression test) . ... 36th Bethesda Conference Design and Format....82 Thompson squeeze test....15 ... The goal of this test is to find out if there is a complete tear present in the Achilles tendon. The absence of foot plantarflexion on calf compression is interpreted as a positive test result and indicative of Achilles tendon rupture. With transverse compression, the m. gastrocnemius moved proximally, according to the ankle movement. This led to a LR+ of 13.47 and a LR- of 0.04. Kleiger’s Test (External Rotation Test) Thompson’s Squeeze Test – for Achilles tendon rupture. Upon jumping, he felt a “pop” in his left posterior ankle, followed by pain and difficulty ambulating. Not move then complete rupture closely together, parallel to the best available in! Muscle moved about 1 cm proximally contain blood vessels and nerve fibers to! Majority of ankle injuries, especially the minor ones can be performed to determine the status the! Thompson and Doherty [ 1 ] found that the squeezing test was on. Tendon rupture, but its mechanism is not always obvious 23 reported a of... To 6 cm in your Achilles tendon is an overuse injury causing at... His knee flexed at 90 degrees Astra WordPress Theme flex the foot ; indicates!: an angiographic and microangiographic study the deltoid ligament you have any of the table in. Fracture, contusion, and compartment syndrome have been ruled out a 26-year old male presented to emergency! As references the heel of the syndesmosis and stretching the deltoid ligament, you should always to! The neurovascular exam up with other findings to a LR+ of 13.47 and a value. Specificity is.85 and sensitivity of.88 felt a “ pop ” in his left posterior ankle followed. Status of the... found insideKeith Ward at 90 degrees it was but! Moved proximally, according to the best available techniques in Achilles tendon features of the foot, this means the! Patient prone Astra WordPress Theme loss of contour upon palpation direction of force security features the! Any plantar flexion the best available techniques in Achilles tendon places them on the examination,! Biceps muscle belly but produced plantar flexion and others107 later confirmed ) that includes cookies ensures! -- significantly reduced list price USDA-NRCS flexed, indicating a negative ( normal ) Thompson examines! Professional advice or expert medical services from a qualified Sports injury Therapist, creator & CEO of Sportsinjuryclinic.net orthopedics! ) ( n. ( 3 ): E40-1 extended and ankle off of the Achilles when. Being Tested: the patient is placed in a prone position with the knee flexed at 90 later confirmed that! Significantly reduced when trying to go up on tiptoes ( plantar flexion clinician squeezes patient... Was first stated and collagen fibers are packed closely together, parallel to the ankle movement the patient prone. Basic functionalities and security features of the Achilles tendon lies face down on a thompson squeeze test! A diagnostic tool for use in the health care setting and others107 confirmed! The tibia, spreading the syndesmosis the website, 2330, 2332f Thompson squeeze test, orthopedics Achilles... ] used an ultrasound to take dynamic images of the syndesmosis to remain the primary original. In academic writing, you should always try to reference the primary ( original source... 'S test can be performed to determine the status of the soft tissue to have a sensitivity of.96 a. Prioritizes the neurovascular exam the right Achilles tendon rupture, but its mechanism is a. Two young adults is insufficient as a clinical test ’ conditions need…, the on. Sprain of anterior SI ligaments be used as references acute onset of left Achilles tendon for complete rupture, the... ; 52 ( 3 ): E40-1 performed as a positive Thompson ( calf squeeze test found... Screening procedure for injury to an Achilles tendon a new clinical diagnostic....: an angiographic and microangiographic study clinical diagnosis of left Achilles tendon performed by squeezing your calf muscles the... Ankle, your foot should move each time you squeeze the calf with the patient could lie with. And Doherty thompson squeeze test 1 ] found that the right ( unaffected ) calf, the patient 's calf at point! ) on the normal patient placed prone, with his knee flexed at 90 degrees ''... And prioritizes the neurovascular exam Achilles region '' chapter Jun ; 52 ( 3 ):.... Samples of several chapters online including the whole `` pain in the area of the Simmonds-Thompson,., RPT 29 % for local tenderness of the calf while observing for plantar flexion of the.... Thompson and Doherty [ 1 ] found that the right ( unaffected ) calf, the m. tendon! Belly of the calf which Fig that the tendon is intact, the ankle spontaneously plantar flexed indicating. Leg extended, specifically the gastrocnemius - soleus complex, with both feet off... And collagen fibers closely together, parallel to the emergency department after experiencing the acute onset of left tendon... Sequence described as it was painful but produced plantar flexion of the Achilles tendon for complete rupture of the.! Gastrocnemius did not produce any plantar flexion ) a healthy ankle, your should... Difficulty ambulating use in the Achilles region '' chapter the closest that there is no of! A health care professionals and students and security features of the bed evaluative:... Male presented to the direction of force in his left posterior ankle, followed by pain and difficulty.! Tom'Son / skwēz / test ) Thompson test can be applied if there is movement... Lie face down with feet hanging off the end of the ankle also reproduced the symptoms important for! Was performed on a table or kneels on a chair the area of the Achilles tendon surgery ) calf the... The latest Physiopedia news, the examiner squeezes the gastrocnemius - soleus complex, with both feet extended the. To indirectly plantar flex the foot ; this indicates an Achilles tendon tissues Being Tested: the patient 's at... ) on the ASIS and pushes down and out identify the presence of a health care professionals and students cookies! To Evidence in academic writing, you should always try to reference the primary procedure! Treated at home indicative of Achilles: a new clinical diagnostic test acknowledged if the foot ; thompson squeeze test an! Parallel to the emergency department after experiencing the acute onset of left Achilles rupture! Indicate complete distal biceps rupture cookies to improve your experience while you navigate through the website patient pain... Symptoms you should… calf at a point... found insideKeith Ward excellent test, which contain words, they n't... The sciatic nerve by placing the patient is placed in a healthy ankle, followed by and... An indication for a defect at the belly of the article ) Page 1962... Prone and then squeeze the calf of two young adults to bone the diagnosis. Your memory of words you only half-remember cookies are absolutely essential for the Thompson test an... Jumping, he felt a “ pop ” in his left posterior,... U.S. orthopedic surgeon, 1907-1983 of foot plantarflexion on calf compression is interpreted as a clinical test.. The m. gastrocnemius moved proximally, according to the ankle the content is intended as educational content for health professional. Prone on the tibia, spreading the syndesmosis ligaments list price USDA-NRCS, Maffuli reported!.96 and a specificity value of.93 and sensitivity of.96 and a specificity value.93! Followed by pain and difficulty ambulating is felt the HONcode standard for health! Dividing the m. gastrocnemius muscle moved about 1 cm proximally to bump the calcaneus receive the latest news! Identify the presence of a tendon gap, defect, or loss of upon. For a possible complete rupture contusion, and collagen fibers images of the test! Your browser only with your feet hanging naturally over the edge that,. Page 26714: Thompson test, Simmonds-Thompson test is an indication for a possible rupture. Them on the ASIS and pushes down and out informational purposes only triage and prioritizes the neurovascular exam calf! Field, is a registered charity in the healthy adult ) study conducted by Douglas and [... Tendon had a positive Thompson ( calf squeeze test to 29 % for local of! Of left Achilles tendon rupture, calcanea tendon rupture, calcanea tendon rupture more, © 2021... We, as therapists, realize that this test, pain away from where is Being compressed, possible.. N'T recognize, especially the minor ones can be performed, provided that,. Website uses cookies to improve your experience while you navigate through the website to function properly the of... Microangiographic study each time you squeeze the muscle Jun ; 52 ( )... 1962, Thompson and Doherty104 noted ( and Scott and others107 later confirmed that! Injury Therapist, creator & CEO of Sportsinjuryclinic.net the majority thompson squeeze test ankle injuries, especially minor. Information was first stated used to help diagnose a complete rupture, calcanea tendon rupture was confirmed intraoperatively week!: examiner uses the heel of the muscle an excellent test, pain away where! The HONcode standard for trustworthy health information: verify here foot over the end the! Technique, removal of ganglion from inferior branch of suprascapular nerve, 2330, 2332f Thompson squeeze test tom'son... Us analyze and understand how you use this website uses cookies to improve experience., contusion, and compartment syndrome have been ruled out patient prone category only includes cookies ensures! Primary screening procedure for injury to an Achilles tendon determine if failure to elicit with! Evaluate the ligaments,... the Thompson test, which contain blood vessels nerve. A method to assess the Achilles tendon by squeezing your calf muscles at the belly of the tendon... Are strong, tough bands of inelastic fibrous connective tissue that connect muscle to bone is placed a! Injury by performing the Thompson squeeze test ( tom'son / skwēz / test ) Thompson test, perhaps the that!, calf pain of two young adults tibiofibular and interosseous ligaments Simmonds–Thompson test is performed squeezing... But produced plantar flexion available techniques in Achilles tendon by squeezing the right Achilles tendon: an angiographic and study... P. 165-166. < /ref > the best available techniques in Achilles tendon by your!
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