Tibial (Medial) Sesamoiditis

Tibial sesamoiditis—or medial sesamoiditis—is an inflammation of the small, round bones (sesamoids) located beneath the first metatarsal head on the inner (medial) side of the foot. These sesamoid bones act as pulleys for the flexor tendons of the big toe, helping to absorb and distribute the weight during walking, running, and jumping. When these sesamoids become irritated or inflamed, patients experience sharp pain under the ball of the foot, especially during push‑off in gait. Sesamoiditis can progress from a mild, overuse injury to a chronic, degenerative condition if left untreated.

Tibial (medial) sesamoiditis is inflammation of the small sesamoid bone located under the big toe at the first metatarsophalangeal joint. This tiny, pea‑shaped bone helps bear weight and acts like a pulley for the flexor hallucis brevis tendon, aiding toe movement and push‑off during walking or running. When repetitive stress or biomechanical overload irritates its covering tissues, pain and swelling develop beneath the inner side of the big toe, making activities like walking, jumping, or standing painful OrthoInfoMDPI.

This condition most often affects athletes, dancers, or individuals engaging in repetitive forefoot loading. The pain typically starts gradually, worsening over weeks to months. In advanced cases, chronic inflammation may lead to degenerative changes of the sesamoid bones themselves, sometimes called sesamoid osteonecrosis or turf toe‑associated sesamoiditis. Early recognition and management are crucial to prevent long‑term complications such as sesamoid fracture, joint stiffness, or permanent bone damage.

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Types of Tibial Sesamoiditis

1. Acute Overuse Sesamoiditis
   Occurs when a sudden increase in foot stress—such as ramping up running mileage or new dance routines—overloads the sesamoids, causing inflammation in the tendon pulley system.

2. Chronic Degenerative Sesamoiditis
   Develops over months to years, marked by progressive wear of the sesamoid bones and surrounding cartilage, often leading to osteoarthritis of the sesamoid groove.

3. Traumatic Sesamoiditis
   Results from a direct blow or forced hyperextension of the big toe—common in sports injuries—leading to bruising and inflammation of the sesamoid complex.

4. Ischemic (Osteonecrotic) Sesamoiditis
   In rare cases, poor blood supply to the sesamoid bones causes bone death (osteonecrosis), leading to chronic pain and potential bone collapse.

5. Sesamoiditis Associated with Biomechanical Abnormalities
   Arises in people with foot deformities—such as hallux valgus (bunions), high arches, or flat feet—that alter pressure distribution under the first metatarsal head.

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Causes of Tibial Sesamoiditis

1. Repetitive Forefoot Loading
   Continuous high‑impact activities—like running, dancing, or court sports—stress the sesamoid region, triggering inflammation over time.

2. Sudden Increase in Activity
   A rapid jump in exercise intensity or duration without gradual conditioning overloads the sesamoid bones faster than they can adapt.

3. Improper Footwear
   Shoes with poor cushioning, lack of arch support, or rigid soles fail to absorb shock, transmitting excessive force to the sesamoids.

4. Biomechanical Foot Deformities
   Conditions such as hallux valgus thrust the big toe medially, increasing pressure on the tibial sesamoid during stance and push‑off.

5. High‑Arched (Cavus) Feet
   Cavus feet concentrate body weight on the forefoot rather than distributing it evenly, straining the sesamoid bones.

6. Flat Feet (Pes Planus)
   Fallen arches can cause hyperpronation, altering gait mechanics and overloading the medial sesamoid area.

7. Tight Calf Muscles or Achilles Tendon
   Limited ankle dorsiflexion forces more motion through the big toe joint, increasing sesamoid stress.

8. Obesity
   Excess body weight amplifies ground‑reaction forces on the forefoot, compounding sesamoid stress with each step.

9. Rheumatoid Arthritis
   Autoimmune inflammation in the joints can extend to the sesamoid complex, causing pain and swelling.

10. Gout
    Uric acid crystal deposition in the first metatarsophalangeal region can mimic or exacerbate sesamoiditis.

11. Osteoarthritis
    Wear‑and‑tear degeneration of the first metatarsal joint often involves the sesamoids, leading to chronic inflammation.

12. Sesamoid Fracture
    A small crack in the sesamoid bone can present as sesamoiditis, with sharp pain on weight bearing.

13. Bone Cysts or Tumors
    Rarely, benign bone lesions within the sesamoid create focal weakness and pain under stress.

14. Infection (Osteomyelitis)
    Though uncommon, bacterial infection of the sesamoid bone or surrounding tissues leads to inflammation and systemic symptoms.

15. Iatrogenic Causes
    Foot surgeries or steroid injections near the first metatarsal head can inadvertently injure the sesamoid region, precipitating inflammation.

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Symptoms of Tibial Sesamoiditis

1. Localized Pain Under the Big Toe
   Sharp or aching pain felt directly beneath the first metatarsal head, especially on the medial side where the tibial sesamoid lies.

2. Worsening Pain with Push‑Off
   Activities involving toe‑off—such as running, jumping, or climbing stairs—intensify symptoms.

3. Swelling and Tenderness
   The area around the sesamoid bones may appear swollen, red, and painful to touch.

4. Pain When Wearing Certain Shoes
   High heels or stiff soles that alter foot mechanics can aggravate sesamoid pain.

5. Difficulty Bearing Weight
   Patients often limp or shift weight off the forefoot to avoid pain during stance.

6. Stiffness of the First MTP Joint
   Limited range of motion in the big toe joint due to inflammation of the sesamoid pulley.

7. Callus Formation Under the Sesamoid
   Chronic loading may cause thickened skin or callus under the affected area.

8. Pain Relief at Rest
   In early stages, symptoms often diminish with rest and worsen again when activity resumes.

9. Possible Bruising
   In traumatic or fracture‑related cases, bruising around the sesamoid region may occur.

10. Radiating Discomfort
    Occasionally, patients describe pain extending into the ball of the foot or along the big toe.

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Diagnostic Tests for Tibial Sesamoiditis

Physical Examination Tests

1. Inspection and Gait Analysis
   The clinician observes foot posture, arch height, and walking pattern to identify pronation, supination, or unequal pressure distribution.

2. Palpation of the Medial Sesamoid
   Direct pressure applied under the first metatarsal head elicits tenderness over the inflamed sesamoid bone.

3. Range of Motion Assessment
   Passive and active dorsiflexion and plantarflexion of the big toe joint are measured to detect stiffness or pain at end‑range.

4. Weight‑Bearing Assessment
   Standing on tip‑toes or performing a single‑leg toe rise replicates push‑off stress, reproducing sesamoid pain.

Manual Testing Maneuvers

5. Sesamoid Squeeze (Axial Loading) Test
   The examiner compresses the sesamoid complex by pushing the big toe axially toward the tibia, provoking pain if sesamoiditis is present.

6. Grind Test of the First MTP Joint
   With the joint in slight dorsiflexion, the clinician rotates the big toe back and forth; pain suggests intra‑articular involvement including the sesamoids.

7. Tinel’s Sign Over the Medial Sesamoid
   Light tapping over the medial sesamoid elicits tingling or electric‑shock sensations if nerve irritation accompanies the inflammation.

8. Plantar Pressure Loading Test
   Manual compression of the forefoot while the patient bears weight identifies focal discomfort under the medial sesamoid.

Laboratory and Pathological Tests

9. Complete Blood Count (CBC)
   Evaluates for systemic infection or inflammatory markers that might accompany osteomyelitis or autoimmune disease.

10. Erythrocyte Sedimentation Rate (ESR)
    A nonspecific marker elevated in chronic inflammation, useful in distinguishing sesamoiditis from simple overuse pain.

11. C‑Reactive Protein (CRP)
    More sensitive than ESR, CRP levels rise quickly with acute inflammation or infection affecting the sesamoid bones.

12. Serum Uric Acid
    High levels indicate gout, which can deposit urate crystals around the first MTP and mimic sesamoiditis symptoms.

Electrodiagnostic Studies

13. Nerve Conduction Study (NCS) of the Tibial Nerve
    Determines whether tibial or digital nerve compression contributes to medial forefoot pain.

14. Electromyography (EMG) of Intrinsic Foot Muscles
    Assesses muscle function around the sesamoid complex, ruling out neuropathy as a pain source.

15. Somatosensory Evoked Potentials (SEPs)
    Measures nerve signal transmission from the foot to the spinal cord, identifying sensory pathway compromise.

16. H‑Reflex Test
    A specific reflex study of the tibial nerve that can reveal subtle nerve entrapment contributing to sesamoid discomfort.

Imaging Studies

17. Plain Radiography (X‑Ray) with Sesamoid View
    Standard weight‑bearing AP, lateral, and axial (tangential) views visualize sesamoid alignment, fractures, and arthritic changes.

18. Magnetic Resonance Imaging (MRI)
    Provides detailed soft‑tissue resolution to detect bone marrow edema, sesamoid stress reactions, and tendon involvement.

19. Computed Tomography (CT) Scan
    Offers high‑resolution bone detail to confirm hairline fractures, bone cysts, or osteonecrosis of the sesamoid.

20. Musculoskeletal Ultrasound
    Dynamic imaging of the sesamoid tendons and surrounding bursae that can identify fluid collections, tendon tears, and guided injection sites.

Non‑Pharmacological Treatments

Exercise Therapies

1. Big Toe Stretch
   Gently extend the big toe upward using the other hand until you feel a mild pull along the bottom of the toe. Hold for 20 seconds and repeat three times. This loosens tight tissues around the sesamoid, improves range of motion, and reduces pressure by rebalancing forces across the joint MDPI.

2. Intrinsic Foot Muscle Strengthening
   Pick up small objects (like marbles) with your toes for 2–3 minutes daily. Strengthening these tiny muscles improves foot stability, distributing weight more evenly and lessening direct load on the sesamoid bone MDPI.

3. Calf Raises
   Stand on both feet and slowly rise onto tiptoes, then lower back down in a controlled fashion. Perform 3 sets of 10. Strong calves reduce the compensatory strain on the forefoot during walking, easing sesamoid stress MDPI.

4. Toe Flexor Resistance
   Place a resistance band around the tip of the big toe and hold the band with your hand, then push the toe downward against the band’s tension. Hold for five seconds and repeat 10 times. This builds tendon strength, stabilizing the semimobile sesamoid region MDPI.

5. Ankle Alphabet
   Sit with your leg extended and trace the alphabet in the air with your big toe. Perform the exercise twice per session. This dynamic stretch promotes joint lubrication and optimal alignment to reduce friction around the sesamoid MDPI.

6. Aquatic Walking
   Walking in a shallow pool reduces body weight on the foot by up to 90%, allowing gentle movement without aggravating pain while promoting circulation and healing MDPI.

7. Stationary Biking
   Low‑resistance cycling keeps the foot in a neutral position, promoting blood flow and maintaining joint mobility without high-impact stress on the sesamoid MDPI.

8. Balance Board Training
   Standing on a wobble board for 1–2 minutes challenges proprioception, improving foot muscle coordination and reducing uneven pressure on the medial sesamoid MDPI.

9. Foot Rolling
   Gently roll a frozen water bottle under the arch and ball of the foot for 1–2 minutes. The cold combined with gentle massage reduces inflammation and eases tender tissues over the sesamoid OrthoInfo.

10. Metatarsal Pad Application
    Placing a small pad just behind the sesamoid shifts pressure away from the inflamed bone. The pad redistributes forces under the foot, providing relief during weight‑bearing OrthoInfo.

Mind‑Body Therapies

11. Progressive Muscle Relaxation
    Systematically tensing and relaxing foot and calf muscles for 10 minutes reduces overall tension and may lower pain perception by calming the nervous system MDPI.

12. Guided Imagery
    Visualizing soothing images (like walking on soft sand) for 10 minutes can distract from pain and improve coping, altering pain processing pathways in the brain MDPI.

13. Mindfulness Meditation
    Focusing attention on breath and bodily sensations for 5–10 minutes daily fosters non‑judgmental awareness, which can decrease pain intensity by reducing stress‑related muscle tension MDPI.

14. Deep Breathing Exercises
    Slow abdominal breathing for 5 minutes activates the parasympathetic system, reducing inflammation‑promoting stress hormones and easing pain MDPI.

15. Yoga for Foot Health
    Gentle yoga poses like downward dog and calf stretches improve flexibility and blood flow to the foot, aiding healing and decreasing tension around the sesamoid MDPI.

Educational Self‑Management

16. Activity Modification Training
    Learning to pace and prioritize low‑impact activities prevents overload. Keeping a diary of painful movements helps identify and avoid triggers, promoting gradual recovery MDPI.

17. Orthotic Education
    Teaching proper use and fitting of custom insoles ensures they effectively offload the sesamoid region, maintaining foot alignment and reducing recurrence OrthoInfo.

18. Footwear Selection Guidance
    Instruction on choosing supportive, low‑heeled shoes with wide toe boxes prevents cramping of the big toe and distributes pressure away from the sesamoid OrthoInfo.

19. Self‑Monitoring of Pain Signals
    Using a simple pain scale to track daily symptoms aids in adjusting activities and therapies before pain worsens, empowering the patient in their recovery MDPI.

20. Cooling‑Warmth Education
    Understanding when to apply ice (first 48 hours post‑injury) versus warmth (for chronic stiffness) helps modulate inflammation and maintain tissue flexibility MDPI.

Evidence‑Based Drugs

1. Ibuprofen (Advil, Motrin)
   A non‑selective NSAID that reduces inflammation and pain. Typical adult dosage is 200–400 mg every 6–8 hours with food. Side effects may include stomach upset, increased bleeding risk, and rare kidney stress OrthoInfohingehealth.

2. Naproxen (Aleve)
   An NSAID dosed at 250–500 mg twice daily. It inhibits COX‑1 and COX‑2 enzymes, lowering prostaglandin levels to relieve pain. Side effects mirror ibuprofen, including gastrointestinal irritation and fluid retention hingehealth.

3. Celecoxib (Celebrex)
   A COX‑2 selective inhibitor taken at 100–200 mg once or twice daily. It targets pain mediators while sparing stomach‑protective COX‑1, lowering GI bleed risk. Potential risks include cardiovascular events and kidney effects hingehealth.

4. Aspirin
   Low‑dose (325–650 mg every 4–6 hours) for acute pain. It irreversibly inhibits COX enzymes, reducing inflammation. Use cautiously due to bleeding risk and potential for gastric ulcers Concord Orthopaedics.

5. Acetaminophen (Tylenol)
   Analgesic dosed at 500–1000 mg every 4–6 hours (max 3000 mg/day). It works centrally to block pain signals but lacks anti‑inflammatory action. Side effects include rare liver toxicity at high doses hingehealth.

6. Diclofenac Gel (Voltaren)
   Topical NSAID applied to the painful area 3–4 times daily. It delivers local COX inhibition with minimal systemic exposure, reducing GI side effects. Side effects are limited to local skin irritation Concord Orthopaedics.

7. Indomethacin
   Potent NSAID at 25 mg two to three times daily. Effective for inflammation control but has higher risk of headache, dizziness, and GI upset than other NSAIDs Concord Orthopaedics.

8. Ketoprofen (Orudis)
   NSAID available as oral 50 mg every 6–8 hours or topical patch once daily. Blocks prostaglandin synthesis, decreasing pain. Watch for sun sensitivity and local irritation with topical use Concord Orthopaedics.

9. Triamcinolone Acetonide Injection
   A corticosteroid injection of 40 mg into the medial sesamoid sheath under ultrasound guidance. It halts inflammation for 4–6 weeks. Risks include tendon weakening and local fat atrophy PMC.

10. Lidocaine Plus Steroid Injection
    Mixing 1 mL of 1% lidocaine with 40 mg triamcinolone provides immediate pain relief from lidocaine and long‑term anti‑inflammatory action from steroid. Frequency up to three injections at three‑week intervals PMC.

Dietary Molecular Supplements

1. Glucosamine Sulfate
   1500 mg daily orally. Serves as a building block for joint cartilage, may reduce inflammation by modulating cytokines. Evidence is mixed but may help patients intolerant to NSAIDs Mayo ClinicPMC.

2. Chondroitin Sulfate
   800–1200 mg daily. Attracts water into cartilage, improving shock absorption. It may inhibit enzymes that break down cartilage, easing foot inflammation PMC.

3. Methylsulfonylmethane (MSM)
   1000–2000 mg daily. Provides sulfur for collagen and joint tissues, potentially reducing pain through anti‑inflammatory effects Verywell Health.

4. Curcumin (Turmeric Extract)
   500 mg twice daily with black pepper extract for absorption. Inhibits NF‑κB and prostaglandin synthesis, offering strong antioxidant and anti‑inflammatory benefits Health.

5. Omega‑3 Fatty Acids
   1000 mg EPA/DHA combined daily. Compete with arachidonic acid, reducing pro‑inflammatory mediator production. Supports overall joint health and reduces foot pain tohealthyfeet.com.

6. Type II Collagen Peptides
   40 mg daily. Stimulate the body’s production of native collagen in cartilage, supporting structural integrity and joint lubrication Verywell Health.

7. Vitamin D₃
   1000–2000 IU daily. Essential for bone mineralization and modulating immune responses, which can help control inflammation around the sesamoid Verywell Health.

8. Vitamin C
   500 mg daily. Cofactor for collagen synthesis, aiding repair of connective tissues around the sesamoid Verywell Health.

9. Manganese
   2.3 mg daily. Cofactor for enzymes that form cartilage matrix, supporting joint structure and function Verywell Health.

10. Bromelain
    500 mg twice daily. Pineapple enzyme complex with anti‑inflammatory proteolytic action that may reduce swelling in the foot Health.

Regenerative and Stem Cell Therapies

1. Platelet‑Rich Plasma (PRP)
   3–5 mL of autologous PRP injected under ultrasound. Platelets release growth factors that stimulate tissue repair and reduce inflammation, speeding healing of sesamoiditis ScienceDirect.

2. Bone Marrow Aspirate Concentrate (BMAC)
   10–30 mL aspirated from the patient’s iliac crest and injected into the sesamoid region. Rich in mesenchymal stem cells that differentiate into bone and tendon cells, promoting regeneration ScienceDirect.

3. Adipose‑Derived MSC Injection
   Stromal vascular fraction isolated from fat tissue (50–100 million cells) and injected into the inflamed sesamoid sheath. These MSCs secrete anti‑inflammatory cytokines and growth factors for tissue repair Dr. Dennis Lox Stem Cell Therapy.

4. Umbilical Cord‑Derived MSCs
   10–20 million allogeneic MSCs injected under guidance. These young stem cells have strong immunomodulatory and regenerative potential to rebuild damaged tissue around the sesamoid .

5. Autologous Exosome Therapy
   Exosomes isolated from the patient’s blood or BMAC (1–2 mL) injected locally. Exosomes carry growth factors and miRNAs that orchestrate healing without the cells themselves Dr. Dennis Lox Stem Cell Therapy.

6. Hyaluronic Acid Combined with MSCs
   2 mL of HA mixed with 1–2 million MSCs to provide a scaffold plus regenerative cells. HA lubricates the joint and supports cell survival and differentiation tohealthyfeet.com.

Surgical Options

1. Open Tibial Sesamoidectomy
   Under local or regional anesthesia, the inflamed sesamoid bone is excised via a small incision. This directly removes the pain source and allows tendon reattachment for continued function Annals of Joint.

2. Minimally Invasive Sesamoidectomy
   Percutaneous removal of the tibial sesamoid using tiny incisions and specialized instruments. Benefits include faster healing, less scarring, and reduced infection risk Annals of Joint.

3. First Metatarsal Decompression Osteotomy
   A wedge of bone is removed or realigned in the first metatarsal to shift pressure off the sesamoid. This preserves the sesamoid bone and improves biomechanics for long‑term relief PubMed.

4. Weil Osteotomy
   Distal metatarsal shortening osteotomy reduces forefoot load. By shortening and shifting the metatarsal head, pressure under the sesamoid is relieved, reducing pain and improving function iskinstitute.com.

5. Debridement and Tendon Repair
   In cases with tendon involvement, surgeons debride inflamed tissue around the sesamoid and repair flexor hallucis brevis attachments. This restores normal tendon mechanics and alleviates pain Annals of Joint.

Prevention Strategies

• Wear shoes with wide toe boxes and low heels to avoid crowding and pressure on the sesamoid OrthoInfo.

• Use custom orthotic insoles with sesamoid pads to offload pressure.

• Gradually increase activity intensity to allow tissues to adapt.

• Maintain healthy body weight to reduce forefoot load.

• Perform regular foot and calf stretching to keep tissues flexible.

• Cross‑train with low‑impact exercises like swimming or cycling.

• Avoid barefoot walking on hard surfaces.

• Change worn‑out shoes every 300–500 miles of walking or running.

• Incorporate foot‑strengthening exercises into your routine.

• Schedule periodic podiatry checkups if you’re an athlete or have high foot stress MDPI.

When to See a Doctor

Seek professional evaluation if you experience severe pain under the sesamoid that lasts more than four weeks despite home care, if you have difficulty bearing weight, visible swelling or redness, numbness in the toe, or if you develop fever alongside foot pain, as these signs may indicate fracture or infection Mayo ClinicOrthoInfo.

What to Do and What to Avoid

1. Do rest and apply ice packs (wrapped in cloth) for 15–20 minutes every 2–3 hours during flare‑ups.

2. Do wear supportive, cushioned shoes or a walking boot as instructed.

3. Do perform gentle stretching and strengthening as pain allows.

4. Do use NSAIDs short‑term under guidance for pain relief.

5. Do monitor your pain on a daily log to adjust activities.

6. Avoid high‑impact activities such as running on hard surfaces.

7. Avoid high heels or narrow shoes that squeeze the toes.

8. Avoid prolonged standing or toe‑walking without breaks.

9. Avoid self‑injecting medications or using heat during acute inflammation.

10. Avoid ignoring persistent pain that interferes with daily life londonorthopaedicsurgery.co.uk.

Frequently Asked Questions

1. What causes tibial sesamoiditis?
   Overuse, repetitive stress, and biomechanical imbalances—such as flat feet or a high‑arched foot—often overload the tibial sesamoid, leading to inflammation OrthoInfo.

2. How is tibial sesamoiditis diagnosed?
   Diagnosis is based on clinical examination—tenderness under the inner big toe—and may be confirmed with X‑rays or MRI to rule out fracture or degeneration PMC.

3. Can rest alone heal sesamoiditis?
   Rest helps but often needs to be combined with offloading measures (orthotics), targeted exercises, and possibly medications for full recovery MDPI.

4. Is custom orthotic therapy effective?
   Yes, orthotics with a sesamoid pad redistribute pressure away from the bone, often providing significant pain relief OrthoInfo.

5. How long does recovery take?
   Most cases improve within 6–8 weeks of consistent conservative treatment; stubborn cases may require injections or surgery MDPI.

6. Are corticosteroid injections safe?
   When guided by ultrasound and limited to three injections, they are generally safe but carry small risks of tendon weakening or fat pad atrophy PMC.

7. Can I return to sports?
   With a structured rehabilitation plan—including strength training and gradual load increase—many athletes return to full activity within 2–3 months MDPI.

8. Do supplements like glucosamine help?
   Glucosamine and chondroitin show mixed but often mild benefits for joint comfort, especially in patients who cannot tolerate NSAIDs Mayo ClinicPMC.

9. What are the risks of sesamoidectomy?
   Risks include altered toe mechanics, stiffness, or incomplete pain relief, but most experience good outcomes when indications are appropriate Annals of Joint.

10. Is PRP therapy worth it?
    PRP can accelerate healing in chronic cases, but evidence is still emerging, and multiple sessions may be needed ScienceDirect.

11. Can barefoot running cause sesamoiditis?
    Yes, insufficient cushioning and sudden load increase in barefoot running can strain the sesamoid region MDPI.

12. How do I maintain foot health long‑term?
    Rotate activities, replace shoes promptly, perform regular foot exercises, and listen to pain signals to prevent recurrence MDPI.

13. When is surgery indicated?
    Surgery is considered after 3–6 months of failed conservative care with persistent debilitating pain MDPI.

14. Will sesamoiditis recur?
    Without preventive strategies—footwear, orthotics, exercises—recurrence is possible, so ongoing management is key MDPI.

15. Can weight loss help?
    Reducing excess body weight decreases forefoot load and may alleviate or prevent sesamoiditis Mayo Clinic.

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Last Updated: July 20, 2025.

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