The Foot 26 (2016) 30–35

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The Foot
journal homepage: www.elsevier.com/locate/foot

Original article

Evaluation of dorsal Lisfranc ligament deformation with load using

ultrasound imaging
Dalton Ryba a , Nooreen Ibrahim a , Jim Choi b , Vassilios Vardaxis a,c,∗
a
College of Podiatric Medicine and Surgery, Des Moines University, Des Moines, IA, United States
b
Iowa Radiology PC, West Des Moines, IA, United States
c
Department of Physical Therapy, Des Moines University, Des Moines, IA, United States

h i g h l i g h t s

Contributions of the present study:

• Load from bilateral stance is enough to deform the dorsal Lisfranc ligament (dLL).
• In the clinical setting ultrasound imaging can reliably detect dLL deformation.
• Deformation trends of the dLL can generate normative data for assessment purposes.
• Foot orientation in bilateral stance does not affect dLL deformation measurements.

a r t i c l e i n f o a b s t r a c t

Article history: Background: Research findings have linked dorsal Lisfranc ligament (dLL) rupture to complete Lisfranc
Received 22 May 2015 ligament complex rupture; identifying deformation characteristics of the dorsal Lisfranc ligament alone
Received in revised form 20 October 2015 may be helpful in diagnosing complete ligament rupture. The goal of the present study was to assess
Accepted 29 October 2015
the deformation characteristics of the asymptomatic dLL using physiologically relevant stress/loads in a
clinical setting and to discern normative dLL parameters.
Keywords:
Methods: Unilateral dLL measurements were taken from 50 healthy volunteers, using sonographic
Biomechanics
imaging under three different stress/load conditions. Stress/load was applied using the individuals’
Ultrasound
Midfoot
bodyweight (low—seated; medium—bilaterally equal weight bearing in standing; and high—single leg
Lisfranc ligament standing). Digital images of the dLL captured using ultrasound were visualized to determine the dLL
length. One-way repeated measures ANOVA was used to assess changes in the dLL length with load.
Results: The average dLL elongation, as percent resting length change, was 8.76% between seated and
single leg standing positions. Most of the dLL elongation (6.26%) occurred between seated and bilateral
standing.
Conclusions: The deformation and role of the dorsal Lisfranc ligament can be observed using sonographic
imaging resulting from physiological loading in the clinical setting.
Clinical Relevance: These deformation parameters can be used to generate normative data for diagnostic
purposes.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction surface contact of a striding bipedal gait [14,28,29]. Particular dor-

The Lisfranc joint complex, anatomically recognized as the series
of tarsometatarsal articulations of the foot, creates a transverse
arch that contributes to propulsion and shock absorption during
∗ Corresponding author at: College of Podiatric Medicine and Surgery, 3200 Grand
Avenue, Des Moines, IA 50312, United States. Tel.: +1 515 271 1624;
fax: +1 515 271 7112.
E-mail address: vassilios.vardaxis@dmu.edu (V. Vardaxis).
sal, plantar and interosseous tarsometatarsal ligaments, as well as
transverse intermetatarsal ligaments, are responsible for maintain-
ing structural integrity of the joint complex and prevent splaying of
the involved structures during weight bearing dynamic tasks [2,28].
These ligaments, in conjunction with muscle activity, bone on bone
contacts and other periarticular soft tissue structures contribute to
the midfoot stability and allow for a smooth transition of load from
hind foot to forefoot [8].
Within the Lisfranc joint, specifically at the articulation between
the first and second metatarsal bases, exists a unique anomaly,

http://dx.doi.org/10.1016/j.foot.2015.10.004
0958-2592/© 2015 Elsevier Ltd. All rights reserved.
 D. Ryba et al. / The Foot 26 (2016) 30–35
with respect to the lesser metatarsals. Lack of a transverse inter-
metatarsal ligament between the first and second metatarsal bases
creates an area of weakness, relative to the other metatarsal base
articulations [5]. The Lisfranc ligament complex, comprised of the
dorsal, plantar, and interosseous ligaments, exists only between the
medial cuneiform and the base of the second metatarsal [1]. These
Lisfranc ligaments compensate for the lack of the transverse liga-
ment, and contribute to first ray stabilization [1]. While functionally
similar, each Lisfranc ligament differs in cross-sectional area and
strength: the interosseous portion being the biggest and strongest,
and the dorsal being the smallest and weakest [10].
Incidence of Lisfranc ligament injury is rare, frequenting approx-
imately one case in 55,000 annually [6]. However, nearly 20
percent of all Lisfranc ligament injuries that present in the emer-
gency department are missed by standard radiographic assessment
[6,26]. Recent literature published claims that, because of the pre-
sentation variability and uniqueness of Lisfranc injuries, they might
be more common than we suspect [24,26]. Regardless, missed
diagnoses of Lisfranc ligament injuries can result in long term
complications, including degenerative arthritis, chronic pain, and
diminished function [1,5,12].
Currently, there are multiple methods that can be used to
clinically diagnose Lisfranc ligament complex injuries. Physical
examination can be used to identify diagnostic indicators in a
symptomatic foot, when compared to the contralateral foot. These
indications include plantar ecchymosis, subtle midfoot convexity,
pain and the gap sign, represented by increased space between
the great and second toe upon a weightbearing foot [4,9,23]. The
most common imaging modality utilized for diagnostic purposes
is the standard weightbearing radiograph. The current protocol
for evaluating Lisfranc ligament injuries with radiography involves
inspection for 1st and 2nd ray diastasis in a weightbearing stance
and in stress view under local anesthetic; non-weightbearing views
may not reveal diastasis [18,20]. Additionally, a positive Fleck sign,
represented by a bony avulsion between the 1st and 2nd metatarsal
bases, is a radiological indication of Lisfranc ligament injury [18].
Advanced imaging modalities, such as magnetic resonance imag-
ing (MRI) and computed tomography (CT) can also be used in the
assessment Lisfranc ligament injuries.
Today’s diagnostic methodologies do, however, have their
drawbacks. As previously mentioned, standard radiographs have
an alarmingly high false negative rate, with respect to Lisfranc lig-
ament injury diagnosis. Additionally, radiographs do not directly
reveal connective tissue injury. While MRI technology is superior
in soft tissue assessment, it can be expensive, time consuming, not
readily available in the emergency room, and potentially uncom-
fortable for the patient. Physical examination in itself leaves room
for misinterpretations from the physician, or inaccuracies due to
noncompliance from patients [25]. Thus, with ligamentous injury
diagnosis, shortcomings of standard medical imaging and clinical
evaluation merit a closer look into a more viable diagnostic option.
Ultrasound imaging is utilized to make dependable clinical
diagnoses, and is often cheaper and safer than most other types
of medical imagining techniques. Additionally, ultrasound imag-
ing is dynamic allowing the potential for real-time diagnosis and
treatment guidance [16]. Though visualization using ultrasound
imaging for Lisfranc ligament injury assessment is a relatively
new concept, it has shown promise. In works past, studies have
shown that ultrasound can be used to evaluate the integrity of the
asymptomatic dorsal Lisfranc ligament, and moreover, can reli-
ably determine change in length of the ligament with respect to
change in controlled load [8]. The results of a recent investiga-
tion showing bilateral symmetry in the Lisfranc ligament using
ultrasound imaging suggest its potential for diagnosis based on
deformation characteristics seen at the contralateral side [17].
Because an increase in dorsal Lisfranc ligament length with respect
31
to an increase in load is a function of weight dispersion by the liga-
ment’s presence within the Lisfranc joint, it is reasonable to expect
that capturing ligament deformation using ultrasound can be used
diagnostically when comparing asymptomatic and symptomatic
patients or asymptomatic and symptomatic sides.
In this study, ultrasound imaging was utilized to study the rela-
tionship between force applied to the foot, and the amount of dorsal
Lisfranc ligament length change. It is hypothesized that the liga-
ment deformation data acquired through ultrasound imaging, and
the image itself, will eventually contribute to a protocol that allows
diagnosis of a Lisfranc ligament injury based on ligament charac-
teristics. In contrast to past works [8], where the force was applied
by a weight loading apparatus, this study investigated dorsal Lis-
franc ligament strain under physiological load conditions, allowing
for a more clinically applicable protocol. Physiological weight bear-
ing conditions were used to evoke ligament deformation, similar to
standard weightbearing radiographs. Although biomechanically all
three segments of the Lisfranc ligament complex deform with load,
the dorsal segment alone is enough to infer Lisfranc complex injury
[31]. Establishing the in vivo function of the dorsal Lisfranc ligament
and its strain characteristics in response to physiological stress will
enhance our understanding of the role of the Lisfranc ligament and
highlight potential injury diagnosis protocols.
2. Methods
Fifty volunteer participants (25 males and 25 females) were
enrolled in the study and were included in the final analysis.
This study was approved by the Institutional Review Board of Des
Moines University and each subject provided a written informed
consent prior to participation in the study.
Participants were recruited to satisfy the following criteria:
Adults younger than 45 years old without lower extremity defor-
mity, injury, or surgery. Any volunteers with a history of congenital
foot abnormalities, prior foot surgery, trauma to the lower extrem-
ity, or allergy to ultrasound transmission gel were excluded from
the study. Prior to conducting the dorsal Lisfranc ligament (dLL)
imaging protocol, subject body weight and height were recorded,
along with the following clinical/biomechanical measurements of
the foot: longitudinal arch angle (LAA), truncated foot length (TFL),
and navicular height (NH). The arch height index (AHI) was cal-
culated as the ratio of the navicular height over the truncated foot
length. In order to measure the LAA, the center of the medial malle-
olus, the navicular tuberosity and the center of the medial aspect of
the first metatarsal head were palpated and marked. A goniometer
was used to measure the obtuse angle between these three land-
marks. The TFL, the NH measurements, and the calculated AHI were
performed as described by Williams and McClay using a Brannock
device and a modified digital caliper [30]. These measures were
used to characterize our subject population relative to normative
values.
Unilateral images of the dLL from each subject were obtained
under three separate stress/load conditions. The stress conditions
were low load, medium load, and high load, represented by seated,
bilateral standing, and standing on one foot, respectively. The dLL
was imaged in two separate foot positions under the medium
load stress condition (bilateral standing), specifically, in parallel
and in self-selected foot alignment. Three images were obtained
under each stress/load condition for total of 12 images per sub-
ject. Stress/load conditions were randomized, with each of the 12
images being collected in no particular order, and each image series
was unique to each subject and visit.
A subset of 20 participants (10 males and 10 females) was
randomly selected for a second visit in order to assess intrarater
reliability. An additional random subset of 20 participants (10 males
32 D. Ryba et al. / The Foot 26 (2016) 30–35
and 10 females) was evaluated by a second rater in order to assess
interrater reliability.
2.1. Instrumentation
Two stationary force plates (Advanced Mechanical Technology,
Inc., Watertown, MA) were used as the support structures under
the subject’s feet, and were used to measure the exact physiolog-
ical stress/load applied on the each foot in each position. Parallel
lines were drawn on the force plates to orient the patient’s feet
for the parallel foot alignment position. Images of the dLL were
obtained using a Siemens SONOLINE Antares Ultrasound Imaging
System© (Siemens Medical Solutions USA, Inc., Issaquah, WA) with
a 10.0 MHz linear array transducer. Acquired images were saved in
digital format for measurement of the dLL length using in-house
written software in MATLAB© (The MathWorks, Inc., Natick, MA).
2.2. Ultrasound imaging procedure
A 12-image series of the dLL was obtained for each subject
accounting for three trials of the randomly selected foot in each of
the four positions (seated, standing parallel, standing self-selected,
and standing on one foot). The dLL orientation in each foot was
determined by an initial exploratory ultrasound scan, commonly
oriented from slightly proximal-medial to distal-lateral. Parallel
lines were marked along the determined orientation of the dorsal
Lisfranc ligament to be used as a guide to ensure proper probe align-
ment, thereby reducing image anisotropy [19]. Starting from the
dorsomedial distal foot, the ultrasound probe was maintained per-
pendicular to the skin surface, mid-shaft over the first metatarsal
(M1) with ample transducer gel to aid sound transmission. The
probe was moved proximally up the long axis of the M1 to look
for the M1-medial cuneiform (C1) congruence. Distal to the M1–C1
congruence, it is noted that the M1 base slopes toward the der-
mis and then dives off into the joint space which is marked by
the hyperechoic synovial fluid. Proximal to the congruence, 0.5–1.0
centimeters onto the C1, the probe while maintained parallel to the
skin was shifted laterally until the dorsomedial edge of the M2 base
came into view. The dorsal Lisfranc ligament lies within this area
which is characterized by the bone contour and plateau at its C1
attachment (Fig. 1). The dorsal Lisfranc ligament imaging proce-
dure was consistent with that recommended by Woodward et al
[8,31]. The ultrasound raters received extensive ultrasound train-
ing provided by a musculoskeletal radiologist who approved their
technical skills and procedures after multiple practice sessions. The
dLL ultrasound image and the stress load applied on the foot avail-
able from the respective force plate were collected simultaneously
for each trial.
Fig. 1. Exemplar ultrasound Image of the dorsal Lisfranc ligament (dLL). Bone land-
marks are labeled as C1 and M2 representing the medial cuneiform and the base of
the second metatarsal, respectively.
2.3. Data analysis
Descriptive statistics were calculated to determine body size
and foot structure characteristics of the participants. One-way
repeated measures ANOVA design was used to test for load main
effects on the dLL length. Intrarater and interrater reliability of the
dLL length under all load conditions were estimated using intra-
class correlation coefficient (ICC), with ICC ≥ 0.60 accepted as fair
reliability, ICC ≥ 0.75 as good reliability, and ICC ≥ 0.90 as high reli-
ability [15]. All statistical analyses were carried out in SPSS Version
22.0© (SPSS, INC., Chicago, IL).
3. Results
The participating subject population was composed by young
and otherwise healthy adults between the ages of 20 and 33,
averaging 24.3 (±2.6) years, who were without foot pain, foot
pathology, or history of lower extremity injury/surgery. The aver-
age subject height was 171.2 (±10.2) cm and the bodyweight was
73.4 (±23.4) kg. The average longitudinal arch angle in bilateral
stance was 144.5 (±7.3) degrees, the truncated foot length was
18.5 (±1.5) cm, average navicular height was 6.20 (±0.6) cm and
the arch height index was 0.34 (±0.02). These values fall within the
normative range when concerning biomechanical evaluation of the
foot [22].
The mean physiologic stress load applied to the foot, repre-
sented as a percent bodyweight (%BW) is shown in Table 1. The
average stress load applied to the foot in the sitting position
was higher than the corresponding mass of the shank and foot
(9.17 ± 1.57%BW); while in the bilateral stance position and the
single leg stance positions the respective loads were slightly lower
than half of the body weight (47.43 ± 2.85%BW) and the full body
weight (83.25% ± 6.37%BW), respectively.
The mean dorsal Lisfranc ligament (dLL) length across all sub-
jects (pooled over the three different load conditions) was 9.07 mm
(95% confidence interval: lower 8.35 mm, upper 9.67 mm). Table 2
summarizes the dLL length data for each stress/load and posi-
tion condition. The dLL length increased with stress/load (Fig. 2),
irrespective of the bilateral load position used (parallel or self-
selected).
Ligament length averages respective to each position were used
to calculate percent change in the dLL length with load, also shown
in Table 2. The average dLL length increase was 8.76% between
low load (seated) and high load (single leg standing) positions.
The majority of the dLL elongation occurred between seated (low
load) and bilateral standing (medium load) conditions (parallel
foot position: 71.5%; self-selected foot position 77.2%). The per-
cent increase in dLL length beyond the medium load condition
was not significant (p = 0.075). The foot alignment effect on the
dLL length change under medium stress load between parallel and
self-selected positions was not significant (p = 0.597) accounting for
only 0.5% elongation difference.
The intrarater and interrater reliability findings are shown
in Table 3. The average reliability ICC values found for within-
session/intrarater were 0.909, indicative of high degree of internal
consistency of the dLL length measures within the same test
session (≥0.9) [15]. The average degree of agreement in dLL length
Table 1
Stress/load applied on the foot during dLL imaging recorded via floor embedded
force plates.
Stress load Mean ± SD (%BW) Min (%BW) Max (%BW)
Low 9.17 ± 1.57 4.09 12.96
Bilateral 47.43 ± 2.85 39.70 52.98
High 83.25 ± 6.37 64.33 93.08
 D. Ryba et al. / The Foot 26 (2016) 30–35 33

Table 2
Dorsal Lisfranc ligament (dLL) length by stress/load and position.

Stress load Foot position Mean ± SD (mm) Min (mm) Max (mm) Length  (%)

Low Parallel 8.63 ± 1.50 5.99 12.51 NA

Bilateral Parallel 9.14 ± 1.63 4.81 12.90 6.26

Self-selected 9.19 ± 1.62 5.21 13.62 6.76

High Parallel 9.33 ± 1.52 6.37 13.12 8.76

Fig. 2. Dorsal Lisfranc ligament length (dLL) measured via ultrasound imaging under the three load conditions. Error bars represent one standard deviation. Contrasts
evaluated at p < 0.015 (Bonferroni adjusted).

measures for between-session/intrarater was 0.801, and 0.772
for between-session/interrater, indicative of good measurement
agreement (≥0.75) [15].
4. Discussion
The main finding of the present study is that physiological stress
load to the foot, alone, causes substantial elongation to the intact
dorsal Lisfranc ligament in healthy adults, and that it can be mea-
sured reliably in a clinical setting using ultrasound imaging. In
addition, we found that a stress/load equivalent to nearly fifty per-
cent of the body weight is enough to cause sufficient dLL elongation,
corresponding to change in load elicited simply between seated and
bilateral standing positions. The normative data deduced from this
asymptomatic population, along with the notion to make contralat-
eral inferences based on bilateral symmetry [17], may be useful for
comparative purposes in the development of a protocol for Lisfranc
ligament injury diagnosis.
In previous work specific to the Lisfranc ligament, Graves et al.
illustrated that ultrasound imaging can be used reliably to image
the dorsal Lisfranc ligament and visualize its deformation when
load is applied directly to the foot using a calf raise machine [8]. In
connection to the work by Graves et al., Marshall et al. presented the
bilateral symmetry of the dorsal Lisfranc ligament length and defor-
mation alluding to the potential use of the contralateral unaffected
side as an intra-subject control for clinical diagnosis purposes [17].

Table 3
Reliability ICC values.

Within-sessionintrarater (N = 50) Between-session intrarater (N = 20) Between-session interrater (N = 20)

Stress load Foot position ICC (95% CI) ICC (95% CI) ICC (95% CI)

Low Parallel 0.899 (0.839–0.939) 0.767 (0.395–0.909) 0.894 (0.731–0.958)

Bilateral Parallel 0.916 (0.865–0.950) 0.872 (0.681–0.949) 0.848 (0.603–0.941)
Self-selected 0.909 (0.855–0.945) 0.768 (0.424–0.907) 0.734 (0.319–0.895)

High Parallel 0.911 (0.857–0.947) 0.798 (0.495–0.920) 0.612 (0.051–0.844)

Average 0.909 0.801 0.772
34 D. Ryba et al. / The Foot 26 (2016) 30–35
The limitation of these studies is the lack of specificity for the clini-
cal setting, as they used stress/load procedures not readily available
in the clinic. However, their findings are consistent with the present
study.
The dorsal Lisfranc ligament is both the smallest and the weakest
band in the Lisfranc ligament complex [2,10]. The lack of structural
breadth contributes to the immediate susceptibility and initial rup-
ture of the dorsal band, in contrast to the plantar and interosseous
components, upon traumatic injury [3,13]. Yet, despite being the
most vulnerable segment of the ligament complex, studies have
shown that, when subjected to controlled progressive loading, the
dorsal ligament provides consistent and measurable deformation
trends [8]. Interestingly, the deformation and subsequent rupture
displayed by the dorsal band has been linked to disruption of the
interosseous band, the strongest segment of the complex, as loads
progress [13]. Work provided by Castro et al., Kura et al., and
Crim suggests a unique anatomical connection between the dorsal
and interosseous bands which allows one to infer damage to the
interosseous band of the Lisfranc ligament upon visualizing dorsal
band rupture [2,3,13]. Thus, measureable dorsal ligament defor-
mation trends and associated interosseous segment insults allow
for ligament rupture diagnosis based on evaluation of the dorsal
segment alone.
The use of ultrasound imaging to diagnose musculoskeletal
pathology is a routine practice. Studies highlighting ultrasound to
compare ruptured versus non-ruptured ligamentous tissue in order
to diagnose ligament injury are common. Such studies include
works done by Glaser et al., suggesting accuracy and practicality
of ultrasound imaging in diagnosing anterior talofibular and calca-
neofibular ligament tears [7]. Lento and Primack further illustrate
the advantages of sonography over other diagnostic modalities, and
allude to its efficiency and ease of use in a clinical setting [16].
However, it should be noted that these studies confirm diagnostic
pathology based on direct ligament visualization and not infer-
ences based on characteristics and trends in deformation of specific
ligaments.
There is reason to consider that asymptomatic ligament defor-
mation trends can assist in the development of a diagnostic protocol
for Lisfranc ligament injuries. The load based deformation of the
Lisfranc ligament confirms its function in providing joint stability
and support to the medial column of the foot, in lieu of an absent
transverse ligament between the first and second metatarsal bases
[1,2,5,8,14,28,29]. An increase in load applied to the foot results in
Lisfranc ligament length elongation and joint diastasis [4,9,23]. In
agreement with data presented by Graves et al., our study shows
that the majority of the ligament deformation occurs between sit-
ting and bilateral standing load positions [8]. The small amount of
elongation observed beyond the 50% BW load may be attributed to
intrinsic and extrinsic muscle activation (not measured here) under
single leg support.
The data in the present study suggests subjecting load on the
foot, using the patient’s bodyweight only, allows detection of length
change in the dorsal Lisfranc ligament. Furthermore, in agreement
with Rettedal et al., methods of obtaining and comparing Lisfranc
ligament deformation values are highly reliable [21], reaching ICC
values greater than 0.7 for both interrater and intrarater measures.
It is possible that the current study protocol may translate into a
clinical exam that makes diagnosing Lisfranc injuries easier and
more definitive. The 6.76% and 8.76% average increase in ligament
length between low and medium, and low and high load positions,
respectively, noted within the study may provide a quantitative
value for clinical comparison purposes.
Ultrasound is not yet commonplace in diagnosing muscu-
loskeletal pathology in the foot. However, with the elusiveness
of the Lisfranc ligament injuries, there is a clinical need for addi-
tional diagnostic imaging modalities. The current study results do
not imply that ultrasound imaging replace traditional radiographic
evaluation of midfoot injuries. Yet, as previously mentioned, early
one in five Lisfranc ligament injuries are missed by standard radio-
graphic assessment [6,26] and presentation variability in such
injuries suggest the need for adjunctive studies [24,26]. The proto-
col described and the use of ultrasound imaging has been shown to
be reliable, with minimal complexity, making it applicable, repro-
ducible, that can be easily utilized directly in the clinical setting, in
real time, as a safe, low cost, and effective imaging modality.
The subjects recruited to participate in this study were asymp-
tomatic, young, active, healthy adults, which is consistent with
the age group most commonly presenting with Lisfranc ligament
injuries [5,11]. However, it is likely that the deformation trends
found in the Lisfranc ligament injury (ruptured/injured ligamen-
tous tissue) may not be represented by these findings. Although
ultrasound technology is readily accessible in most clinical settings,
it requires training in its application as a diagnostic modality. In the
present study, both raters received extensive training and utilized
an in house developed protocol. The present data are limited as to
single digital image capture and analysis under discrete load condi-
tions. Such image capture and analysis protocol may not reflect the
dynamic function of the Lisfranc ligament which could offer more
detailed information about its role.
Further assessment of the overall arch stiffness and its
influence/relationship to Lisfranc ligament deformation during
progressive loading can provide valuable information in regards to
its role during hind-, mid-, and fore-foot loading during daily tasks
such as walking, sit to stand, and stair ascend and descend. The
understanding of the Lisfranc ligament function during dynamic
tasks can be informative as to its susceptibility to injury. Addition-
ally, gender differences should also be assessed to determine trends
based on ligament laxity associated with the gender. There is evi-
dence in the current literature to support increased susceptibility to
ligamentous type injuries in women based on the phase of menses
and may have implications on deformation trends in the Lisfranc
ligament [27].
5. Conclusion
The asymptomatic dorsal Lisfranc ligament length was mea-
sured using ultrasound imaging in a clinical setting, under three
different loads; low load, medium load, and high load. A significant
elongation in the dorsal Lisfranc ligament length was seen upon
increase in load to the foot. The data presented and general
trends determined in this study could aid in the development of a
diagnostic protocol for Lisfranc ligament injuries using ultrasound
imaging, applicable to the clinical setting.
Conflict of interest statement
None.
Acknowledgements
The authors of the paper would like to thank Todd Jaramillo,
DPM15, and Julian Rivera, BS, for their assistance with data collec-
tion and management for this project, and the American Podiatric
Medical Student Association and Iowa Osteopathic Education &
Research fund for financial support.
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