Overview



There are two types of flatfeet. Flexible flatfoot means that the foot has some arch, even if it only appears when the person flexes the feet or stands on the toes. This is a normal condition that is generally painless and does not require treatment. Stiff, inflexible, or painful flatfoot is an abnormal condition and may indicate a bone abnormality in the foot, a disease, or an injury. Flatfeet are a normal condition in infants and toddlers. This is partly the result of fatty deposits along the bottom of the foot that go away as the child grows. It is also because the ligaments in the foot have not fully developed. Flat-footedness in children is generally painless and does not interfere with walking or activity. In fact, as children learn to walk, the soft tissues in the foot tighten and form the arch. Most children develop arches by late childhood. When flatfeet continue into adulthood, most cases are considered normal. Incidence of flatfeet in the general population is unknown.

Causes

Family history, experts say fallen arches can run in families. Weak arch, the arch of the foot may be there when no weight is placed on it, for example, when the person is sitting. But as soon as they stand up the foot flattens (falls) onto the ground. Injury, arthritis, tibialis posterior (ruptured tendon), pregnancy, nervous system or muscle diseases, such as cerebral palsy, muscular dystrophy, or spina bifida. Tarsal Coalition, the bones of the foot fuse together in an unusual way, resulting in stiff and flat feet. Most commonly diagnosed during childhood. Diabetes. Age and wear and tear, years of using your feet to walk, run, and jump eventually may take its toll. One of the eventual consequences could be fallen arches. The posterior tibial tendon may become weakened after long-term wear a tear. The postario tibial tendon is the main support structure of the arch of our feet. The tendon can become inflamed (tendinitis) after overuse - sometimes it can even become torn. Once the tendon is damaged, the arch shape of the foot may flatten.

Symptoms

Flat feet don't usually cause problems, but they can put a strain on your muscles and ligaments (ligaments link two bones together at a joint). This may cause pain in your legs when you walk. If you have flat feet, you may experience pain in any of the following areas, the inside of your ankle, the arch of your foot, the outer side of your foot, the calf, the knee, hip or back. Some people with flat feet find that their weight is distributed unevenly, particularly if their foot rolls inwards too much (overpronates). If your foot overpronates, your shoes are likely to wear out quickly. Overpronation can also damage your ankle joint and Achilles tendon (the large tendon at the back of your ankle).

Diagnosis

Runners are often advised to get a gait analysis to determine what type of foot they have and so what kind of running shoe they require. This shouldn?t stop at runners. Anyone that plays sports could benefit from this assessment. Sports shoes such as football boots, astro trainers and squash trainers often have very poor arch support and so for the 60-80% of us who do overpronate or have flat feet they are left unsupported. A change of footwear or the insertion of arch support insoles or orthotics can make a massive difference to your risk of injury, to general aches and pains and even to your performance.

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Non Surgical Treatment

Flexible flat feet that are painless do not require treatment. If you have pain due to flexible flat feet, an orthotic (arch-supporting insert in the shoe) can bring relief. With the increased interest in running, many shoe stores carry shoes for normal feet and pronated feet. The shoes designed for pronated feet make long distance running easier and less tiring because they correct for the abnormality. Rigid or painful flat feet require evaluation by a health care provider. The treatment depends on the cause of the flat feet. For tarsal coalition, treatment starts with rest and possibly a cast. If this fails to improve the pain, surgery may be necessary. For problems with the posterior tibial tendon, treatment may start with rest, anti-inflammatory medications, and shoe inserts or ankle braces. In more advanced cases, surgery may be needed to clean or repair the tendon, or fuse some of the joints of the foot into a corrected position. Flat feet in older adults can be treated with pain relievers, orthotics, and sometimes surgery.

Surgical Treatment



Surgical procedures for flat feet vary depending on the root cause of the condition. Surgical correction to control pronation may include bone implants or Achilles tendon lengthening. Tendon transfer, which is a procedure to re-attach a tendon to another area of bone, may also be used to reduce pronation and improve foot function.

Prevention

Donning a first-rate pair of arch supports, therapeutic socks and proper footwear before heading out to enjoy hours of holiday fun is one option to consider. Your podiatrist can help you find just the right ones. Once you have them on, they?ll help ease the amount of pressure being put on your body and keep the blood flowing in the right direction. While you?re standing in line, consider doing a bit of exercise as well. We?re not talking about channeling your inner Jack LaLanne here. Otherwise, you might attract the attention of the mall security guards. Simple ankle rotations and walking in place may help to reduce edema and give your flat feet a bit of a break. If you happen to be in a shopping mall or center where foot massages are available, take advantage of them periodically. They are likely to make you feel better and it?s a great excuse to carve out a few quiet moments for yourself. If you can?t visit a professional, tuck a personal foot massager into your purse. That way, you can lightly massage your own feet during the car ride home. Lastly, there are certain foods and nutritional supplements available that may reduce edema caused by standing on flat feet for hours at a time. The list includes potassium rich foods like raisins, bananas, baby carrots, nuts and yogurt. So, you may want to pack a snack for those trips to the mall or hit the food court before you hit the stores.

After Care

Time off work depends on the type of work as well as the surgical procedures performed. . A patient will be required to be non-weight bearing in a cast or splint and use crutches for four to twelve weeks. Usually a patient can return to work in one to two weeks if they are able to work while seated. If a person's job requires standing and walking, return to work may take several weeks. Complete recovery may take six months to a full year. Complications can occur as with all surgeries, but are minimized by strictly following your surgeon's post-operative instructions. The main complications include infection, bone that is slow to heal or does not heal, progression or reoccurrence of deformity, a stiff foot, and the need for further surgery. Many of the above complications can be avoided by only putting weight on the operative foot when allowed by your surgeon.

Overview

Surgery to shorten the longer leg. This is less involved than lengthening the shorter leg. Shortening may be done in one of two ways. Closing the growth plate of the long leg 2-3 years before growth ends (around age 11-13), letting the short leg catch up. This procedure is called an epiphysiodesis. Taking some bone from the longer leg once growth is complete to even out leg lengths. Surgery to lengthen the shorter leg. This surgery is more involved than surgery to shorten a leg. During this surgery, cuts are made in the leg bone. An external metal frame and bar are attached to the leg bone. This frame and bar slowly pull on the leg bone, lengthening it. The frame and bar must be worn constantly for months to years. When the frame and bar are removed, a leg cast is required for several months. This surgery requires careful and continued follow-up with the surgeon to be sure that healing is going well.

Causes

Some limb-length differences are caused by actual anatomic differences from one side to the other (referred to as structural causes). The femur is longer (or shorter) or the cartilage between the femur and tibia is thicker (or thinner) on one side. There could be actual deformities in one femur or hip joint contributing to leg length differences from side to side. Even a small structural difference can amount to significant changes in the anatomy of the limb. A past history of leg fracture, developmental hip dysplasia, slipped capital femoral epiphysis (SCFE), short neck of the femur, or coxa vara can also lead to placement of the femoral head in the hip socket that is offset. The end-result can be a limb-length difference and early degenerative arthritis of the hip.

Symptoms

Faulty feet and ankle structure profoundly affect leg length and pelvic positioning. The most common asymmetrical foot position is the pronated foot. Sensory receptors embedded on the bottom of the foot alert the brain to the slightest weight shift. Since the brain is always trying to maintain pelvic balance, when presented with a long left leg, it attempts to adapt to the altered weight shift by dropping the left medial arch (shortening the long leg) and supinating the right arch to lengthen the short leg.1 Left unchecked, excessive foot pronation will internally rotate the left lower extremity, causing excessive strain to the lateral meniscus and medial collateral knee ligaments. Conversely, excessive supination tends to externally rotate the leg and thigh, creating opposite knee, hip and pelvic distortions.

Diagnosis

The doctor carefully examines the child. He or she checks to be sure the legs are actually different lengths. This is because problems with the hip (such as a loose joint) or back (scoliosis) can make the child appear to have one shorter leg, even though the legs are the same length. An X-ray of the child?s legs is taken. During the X-ray, a long ruler is put in the image so an accurate measurement of each leg bone can be taken. If an underlying cause of the discrepancy is suspected, tests are done to rule it out.

Non Surgical Treatment

The treatment of LLD depends primarily on the diagnosed cause, the age of the patient, and the severity of the discrepancy. Non-operative treatment is usually the first step in management and, in many cases, LLD is mild or is predicted to lessen in the future, based on growth rate estimates in the two legs. In such cases, no treatment may be necessary or can be delayed until a later stage of physical maturity that allows for clearer prognostic approximation. For LLD of 2cm to 2.5cm, treatment may be as simple as insertion of a heel lift or other shoe insert that evens out leg lengths, so to speak. For more severe cases, heel lifts can affect patient comfort when walking, decrease ankle stability, and greatly increase the risk of sprains. For infants with congenital shortening of the limb, a prosthetic ? often a custom-fit splint made of polypropylene ? may be successful in treating more severe LLD without surgery. In many instances, however, a surgical operation is the best treatment for LLD.



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Surgical Treatment

Your child will be given general anesthetic. We cut the bone and insert metal pins above and below the cut. A metal frame is attached to the pins to support the leg. Over weeks and months, the metal device is adjusted to gradually pull the bone apart to create space between the ends of the bones. New bone forms to fill in the space, extending the length of the bone. Once the lengthening process is completed and the bones have healed, your child will require one more short operation to remove the lengthening device. We will see your child regularly to monitor the leg and adjust the metal lengthening device. We may also refer your child to a physical therapist to ensure that he or she stays mobile and has full range of motion in the leg. Typically, it takes a month of healing for every centimeter that the leg is lengthened.

Overview



Heel pain is usually felt either under the heel or just behind it. Heel pain has a prevalence of 3.6%. US studies estimate that 7% of older adults report tenderness under the heel. Plantar fasciitis is estimated to account for 8% of all running-related injuries. There are 26 bones in the human foot, of which the heel is the largest. Pain typically comes on gradually, with no injury to the affected area. It is often triggered by wearing a flat shoe. In most cases the pain is under the foot, towards the front of the heel. The majority of patients recover with conservative treatments within months. Home care such as rest, ice, proper-fitting footwear and foot supports are often enough to ease heel pain. To prevent heel pain, it's recommended to reduce the stress on that part of the body.

Causes

There are several causes of heel pain. By far the most common cause in adults is a condition commonly known as plantar fasciitis. Other names occasionally used for the same condition are heel spurs, and policeman?s heel. Plantar means bottom of the foot, and fascia is the fibrous tissues that helps tether the heel bone (calcaneus) to the heads of the metatarsal bones found at the base of your toes The meaning of ?itis? is inflammation. However, inflammation does not have a large part to play in the pathology, it is more degenerative (wear & tear) so the preferred title is plantar fasciosis or plantar aponeurotic fasciosis. For simplicity sake, we will refer to this common cause of heel pain as plantar fasciitis in this manual.

Symptoms

The most common complaint is pain and stiffness in the bottom of the heel. Heel pain may be sharp or dull, and it may develop slowly over time or suddenly after intense activity. The pain is typically worse in the morning, when taking your first steps of the day. After standing or sitting for a while. When climbing stairs.

Diagnosis

The diagnosis of plantar fasciitis is generally made during the history and physical examination. There are several conditions that can cause heel pain, and plantar fasciitis must be distinguished from these conditions. Pain can be referred to the heel and foot from other areas of the body such as the low back, hip, knee, and/or ankle. Special tests to challenge these areas are performed to help confirm the problem is truly coming from the plantar fascia. An X-ray may be ordered to rule out a stress fracture of the heel bone and to see if a bone spur is present that is large enough to cause problems. Other helpful imaging studies include bone scans, MRI, and ultrasound. Ultrasonographic exam may be favored as it is quick, less expensive, and does not expose you to radiation. Laboratory investigation may be necessary in some cases to rule out a systemic illness causing the heel pain, such as rheumatoid arthritis, Reiter's syndrome, or ankylosing spondylitis. These are diseases that affect the entire body but may show up at first as pain in the heel.

Non Surgical Treatment

Treatment of plantar fasciitis is usually performed in stages according to the duration and degree of pain. Treatment may take many months if the condition has been longstanding. Treatment usually begins with anti-inflammatory medication, shoe modification, temporary limitation of activities, weight loss and heel cord stretching. Also, night splints are often helpful to stretch the plantar fascia. An arch support (orthotic) may also be helpful, especially if you have a flat foot. If the problem continues, the tender area occasionally may be injected with cortisone and a local anesthetic. For a difficult, chronic problem, a period of casting may be used to improve this condition. Surgical treatment is rarely needed. If performed, it aims to partially release the plantar fascia and stimulate healing of the chronic inflammation. Removal of a heel spur, if it is large, may also be done at the time of surgery.

Surgical Treatment

If treatment hasn't worked and you still have painful symptoms after a year, your GP may refer you to either an orthopaedic surgeon, a surgeon who specialises in surgery that involves bones, muscles and joints or a podiatric surgeon, a podiatrist who specialises in foot surgery. Surgery is sometimes recommended for professional athletes and other sportspeople whose heel pain is adversely affecting their career. Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms. Surgery can be performed either as open surgery, where the section of the plantar fascia is released by making a cut into your heel or endoscopic or minimal incision surgery - where a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia. Endoscopic or minimal incision surgery has a quicker recovery time, so you will be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery. A disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery. Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in your foot. As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare). You should discuss the advantages and disadvantages of both techniques with your surgical team.

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Prevention



It is not always possible to prevent heel pain, but there are measures you can take to help avoid further episodes. Being overweight can place excess pressure and strain on your feet, particularly on your heels. This increases the risk of damaging your feet and heels. If you are overweight, losing weight and maintaining a healthy weight by combining regular exercise with a healthy, balanced diet can be beneficial for your feet. You can calculate your body mass index (BMI) to find out whether you are a healthy weight for your height and build. To work out your BMI, divide your weight in kilograms by your height in metres squared. A BMI of less than 18.5 means that you are underweight, 18.5-24.9 means that your weight is healthy, 25-29 means that you are overweight, 30-40 means that you are obese, over 40 means that you are morbidly obese. You can also use the BMI healthy weight calculator to work out your BMI.

Overview

Neuromuscular. Muscle imbalance causing different pull on pelvis (anterior superior Ilium or posterior inferior ilium). Muscle tightness/shortness especially piriformis (which lead to an external rotation of the femur thus shortening of the leg) and QL (raising ipsilateral iliac crest). Genu recurvatum, valgus, varus. Asymmetrical fallen arches or over pronation. Polio, Cerebral palsy. Trauma. Fracture. Injury epiphyseal plate. Iatrogenic (such as hip or knee surgery). Idiopathic. Hip disorder (such Legg-Perthes-Calve? or Slipped capital femoral epiphysis). Advanced degenerative changes.

Causes

There are many causes of leg length discrepancy. Structural inequality is due to interference of normal bone growth of the lower extremity, which can occur from trauma or infection in a child. Functional inequality has many causes, including Poliomyelitis or other paralytic deformities can retard bone growth in children. Contracture of the Iliotibial band. Scoliosis or curvature of the spine. Fixed pelvic obliquity. Abduction or flexion contraction of the hip. Flexion contractures or other deformities of the knee. Foot deformities.

Symptoms

Children whose limbs vary in length often experience difficulty using their arms or legs. They might have difficulty walking or using both arms to engage in everyday activities.

Diagnosis

Leg length discrepancy may be diagnosed during infancy or later in childhood, depending on the cause. Conditions such as hemihypertrophy or hemiatrophy are often diagnosed following standard newborn or infant examinations by a pediatrician, or anatomical asymmetries may be noticed by a child's parents. For young children with hemihypertophy as the cause of their LLD, it is important that they receive an abdominal ultrasound of the kidneys to insure that Wilm's tumor, which can lead to hypertrophy in the leg on the same side, is not present. In older children, LLD is frequently first suspected due to the emergence of a progressive limp, warranting a referral to a pediatric orthopaedic surgeon. The standard workup for LLD is a thorough physical examination, including a series of measurements of the different portions of the lower extremities with the child in various positions, such as sitting and standing. The orthopaedic surgeon will observe the child while walking and performing other simple movements or tasks, such as stepping onto a block. In addition, a number of x-rays of the legs will be taken, so as to make a definitive diagnosis and to assist with identification of the possible etiology (cause) of LLD. Orthopaedic surgeons will compare x-rays of the two legs to the child's age, so as to assess his/her skeletal age and to obtain a baseline for the possibility of excessive growth rate as a cause. A growth chart, which compares leg length to skeletal age, is a simple but essential tool used over time to track the progress of the condition, both before and after treatment. Occasionally, a CT scan or MRI is required to further investigate suspected causes or to get more sophisticated radiological pictures of bone or soft tissue.

Non Surgical Treatment

Treatment depends on the amount and cause of the leg length discrepancy as well as the age of your child. Typically, if the difference is less than 2 cm we don?t recommend immediate treatment. We may recommend that your child wear a heel lift in one shoe to make walking and running more comfortable. If the leg length discrepancy is more significant, your doctor may recommend surgery to shorten or lengthen a leg. The procedure used most often to shorten a leg is called epiphysiodesis.



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Surgical Treatment

Epiphysiodesis is a surgical option designed to slow down the growth of the long leg over a period of months to years. It is only used in growing children. The operation involves a general anaesthetic. Small incisions are made around the knee near the growth plates of the thigh bone and the shin bone. The growth plates are prevented from growing by the use of small screws and plates (?8 - plates?). The screws are buried beneath the skin and are not visible. Stitches are buried beneath the skin and do not need to be removed. The child is normally in hospital for 2-3 days. The child can weight bear immediately and return back to normal activity within a few weeks. Long term follow up is required to monitor the effects of the surgery. The timing of the surgery is based on the amount of growth predicted for the child. Therefore, this procedure can under- and over-correct the difference in leg length. Occasionally the screws have to be removed to allow growth to continue. This procedure can be used on one half of the growth plate to correct deformity in a limb e.g. knock-knees or bow legs. This is known as hemiepiphysiodesis.

Overview

A neuroma develops when a nerve is compressed, injured or pinched, causing swelling and pain. A neuroma in the area between the third and fourth toes, or between the second and third toes, is known as a Morton?s neuroma. Morton?s neuroma causes sharp, burning pain and numbness in the toes and foot. You may feel like you?ve stepped on a tiny hot coal and can?t get rid of it. At the same time, you?ll have the disconcerting experience of not being able to feel your toes. Sometimes the nerve tissue becomes so thickened you can feel or see a lump.

Causes

Unfortunately, the cause of Morton?s Neuroma remains unknown to researchers. It is likely that a variety of factors may play a role in the development of this condition, including the presence of chronic pain conditions like fibromyalgia. Factors that may contribute to the development of Morton?s Neuroma include Wearing improperly fitting shoes can cause pressure on your foot, leading to swelling around the toe nerves. High heels are of particular concern as they cause a large amount of weight to be shifted to the ball of the foot. Repetitive activities like jogging, walking, and aerobics can also place a lot of pressure on the feet. This could lead to Morton?s Neuroma. Having a previous foot or muscle injury may cause you to hold your foot in a poor position when walking, contributing to nerve inflammation. Some people are just born with poorly shaped feet. People with extremely low arches or "flat feet" may suffer from Morton?s Neuroma more than others.

Symptoms

Patients with neuroma may develop pain on the bottom of the forefoot, most commonly under the 3rd and 4th toes, though any toe may be affected. The pain may be dull and mild or severe and sharp. The toes may feel ?numb? as times, especially the area between the 3rd and 4th toes. A classic complaint is that patients feel as if they are ?walking on a stone or pebble? and/or ?feel as if the sock is rolled up in the shoe.? Pain is often worse when walking barefoot.

Diagnosis

Your health care provider can usually diagnose this problem by examining your foot. A foot x-ray may be done to rule out bone problems. MRI or high-resolution ultrasound can successfully diagnose Morton's neuroma. Nerve testing (electromyography) cannot diagnose Morton's neuroma, but may be used to rule out conditions that cause similar symptoms. Blood tests may be done to check for inflammation-related conditions, including certain forms of arthritis.

Non Surgical Treatment

It can be helpful to perform deep stripping massage techniques along the length of the tibial nerve and the medial and lateral plantar nerves. After properly mobilizing these tissues, moving the foot and toes through a full range of motion to make sure the nerve can move freely will also be helpful. Foot pain like that occurring in Morton's neuroma, can become a debilitating and painful condition. And while massage can be helpful for this condition, it is also clear that improperly applied massage can aggravate it and make it worse. Consequently it is crucial that we use good clinical reasoning and appropriate evaluation methods to most effectively help these clients.

Surgical Treatment

For severe or persistent pain, you may need surgery to remove the neuroma. Once the nerve is gone, you permanently lose feeling in the affected area. One alternative to surgery is to undergo neurolysis injections. These use chemical agents to block pain signals. Another alternative is to take a prescription pain reliever that alleviates nerve pain.

There are actually not one but two different types of leg length discrepancies, congenital and acquired. Congenital implies you are born with it. One leg is structurally shorter in comparison to the other. Through developmental stages of aging, the brain picks up on the gait pattern and recognizes some variation. The human body typically adapts by dipping one shoulder to the "short" side. A difference of less than a quarter inch is not grossly excessive, demand Shoe Lifts to compensate and usually doesn't have a serious effect over a lifetime.



Leg length inequality goes largely undiagnosed on a daily basis, yet this condition is easily fixed, and can eradicate quite a few instances of lower back pain.

Treatment for leg length inequality usually involves Shoe Lifts. These are typically affordable, in most cases priced at under twenty dollars, compared to a custom orthotic of $200 and up. Differences over a quarter inch can take their toll on the spine and should probably be compensated for with a heel lift. In some cases, the shortage can be so extreme that it requires a full lift to both the heel and sole of the shoe.

Chronic back pain is easily the most prevalent health problem impacting men and women today. Over 80 million people have problems with back pain at some point in their life. It is a problem which costs businesses millions of dollars year after year on account of time lost and production. Fresh and improved treatment solutions are always sought after in the hope of lowering economic influence this condition causes.



People from all corners of the world suffer the pain of foot ache as a result of leg length discrepancy. In a lot of these cases Shoe Lifts are usually of very useful. The lifts are capable of easing any discomfort and pain in the feet. Shoe Lifts are recommended by numerous professional orthopaedic doctors.

So that you can support the human body in a healthy and balanced fashion, your feet have a vital part to play. In spite of that, it is often the most neglected region in the body. Some people have flat-feet which means there may be unequal force placed on the feet. This will cause other areas of the body such as knees, ankles and backs to be impacted too. Shoe Lifts make sure that correct posture and balance are restored.

There are two different types of leg length discrepancies, congenital and acquired. Congenital indicates that you are born with it. One leg is structurally shorter in comparison to the other. Through developmental periods of aging, the human brain picks up on the step pattern and identifies some variation. The body usually adapts by dipping one shoulder to the "short" side. A difference of less than a quarter inch is not really excessive, require Shoe Lifts to compensate and mostly does not have a serious effect over a lifetime.



Leg length inequality goes mainly undiagnosed on a daily basis, yet this condition is very easily corrected, and can reduce many incidents of back discomfort.

Therapy for leg length inequality commonly consists of Shoe Lifts. Many are cost-effective, ordinarily costing less than twenty dollars, compared to a custom orthotic of $200 or even more. Differences over a quarter inch can take their toll on the spine and should probably be compensated for with a heel lift. In some cases, the shortage can be so extreme that it requires a full lift to both the heel and sole of the shoe.

Back pain is the most common ailment impacting people today. Around 80 million men and women are afflicted by back pain at some point in their life. It is a problem that costs employers huge amounts of money annually due to time lost and productivity. Innovative and superior treatment methods are always sought after in the hope of decreasing the economical influence this issue causes.



People from all corners of the earth suffer the pain of foot ache as a result of leg length discrepancy. In these situations Shoe Lifts can be of immense help. The lifts are capable of relieving any pain in the feet. Shoe Lifts are recommended by countless professional orthopaedic practitioners".

To be able to support the human body in a healthy and balanced fashion, feet have a very important part to play. Despite that, it can be the most neglected zone of the body. Some people have flat-feet which means there is unequal force exerted on the feet. This will cause other parts of the body like knees, ankles and backs to be impacted too. Shoe Lifts make sure that correct posture and balance are restored.