Category Archives: Injury

Them Bones

stronger-bones

I’ve talked plenty about my bone density issues and speculated where they may have come from. We may never know completely why and how this came about, and what place it had in the perfect storm of the freak injury history of the last couple years. From now on, this is the going to be not just the primary focus of my recovery, but a major focus for the rest of my life. More on that and how it will impact my next few months in a moment.

I’ve posted this New York Times article ‘Is Bicycling Bad For Your Bones?’ before, but it is worth revisiting. The topic is controversial. I’ve talked to many who completely disagree and insist that my problems were due to other issues. They may be partially right, and I cannot blame cycling itself, but I can pinpoint where in my process that I started neglecting my bones and urge others not to make the same mistakes.

It has become clear that I most likely had some bone density issues before beginning to ride. Some of this probably has to do with diet. My worst habit has been soda products, most of which are not good for bone strength. Even now I find it difficult to cut them out completely, although I drink a lot less than I used to. Calcium has not been a major staple of my diet either. I don’t handle milk well, and tend to avoid fattening and high calorie dairy products just to keep slim.

Weight bearing has also been an issue. Even though I’ve dabbled with running and walking, cycling has been my sport of choice for years. Since I have worked at an office job and gone to school for the last several years, I’ve been off my feet a lot.

During the few years of intense cycling, I barely ran or even walked. The extent of my weight bearing was occasional strength exercises, but even those were not appealing to me. I preferred to develop strength on the bike. Climbing probably puts a little more weight on the leg muscles, but most likely not the hip. Proper cycling form minimizes the use of the hip. The flexors are being used to spin the pedals, but the quads and glutes do the heavy lifting.

When I wasn’t riding, I was recovering. That meant sitting on the couch. Sometimes I would do active recovery with short, easy rides, but I was not adding any weight bearing. After a tough mountain century, I would generally stay on the couch for the better part of a few days.

I was shocked when I had a scan last year and found that I had osteopenia in my hips. In hindsight, given my habits and training practice, I should not have been so surprised.

A couple weeks ago, we had a re-scan. I expected the numbers to be a little worse because I had surgery this year and a lot of recovery time. I’ve been on the couch a lot more in the last year than maybe the previous five years combined. The initial numbers that they gave me were discouraging. It sounded like the hip had gotten worse. On top of that, I was actually in osteoporosis levels in my hip joint. After receiving that news, I wondered seriously if I would ever ride again. I had even drafted a post basically ending this website. I have not and will not publish that one, because as has been typical with this roller coaster injury, the news got better.

When comparing my scan from April of last year with the one from a couple weeks ago, it turns out that my hip bones have actually improved by about 15%. That is significant enough for me to be encouraged. The osteoporosis is in my actual hip joint, the same one that was operated on in January, and it is barely at the level. The test last year did not scan the hip joint. Why would they? So there was nothing to compare, but I’d say the odds are that that bone was weaker last year than it is now.

The picture becomes clearer. What have I done differently? I’ve eaten dairy products, and over the past couple months have tried to walk around as much as possible. Over time walking has become less painful, which might be due to the bones strengthening along with the injury healing. The weight bearing will continue, but for now, any riding, running or jumping will not, at least for a couple or few months until my bones strengthen. The good news is I’m almost guaranteed to ride again and likely at a high level, but I will have to do things differently.

This is where I encourage all cyclists to learn from me. Implementing some form of weight bearing is important. Eating a balanced diet is important. A lot of us hate running. I’ve had a love/hate relationship with it, but know that eventually it will be a necessary evil. Strength training isn’t my thing either, but it’ll also be necessary. That can be squats, leg presses, or even upper body exercises while standing. It is important that some time is spent on a weekly basis doing some sort of weight bearing.

Things are again looking better for me, and I’m keeping a positive attitude. As far as pain goes, I am feeling better than I have in two years, and I cannot begin to express how liberating that feeling is. I’m able to get out, explore, see and experience things. I’ve been to three concerts in the past three weeks. I hadn’t been to a concert in years prior to this summer. It’s good to get outside. The couch is a brutal prison.

Standing near the front row for two hours felt amazing and not painful.

Standing near the front row for two hours felt amazing and not painful.

In the meantime, I’m going to keep walking and eating calcium. My doctor said that I shouldn’t worry about the calories, and that adding a few pounds would not be the worst thing. It might even help strengthen my bones by giving me more weight to bear. And I know I can lose it later. As I get more comfortable on my feet and finish up with some other priorities, I’m going to mix up my training regimen. The idea for now is to start P90X3 in December. That will give me upper body strength and hopefully will turn some of that fat into muscle. It may not be the lean, climbing body that I strove for last year, but it’ll still be a functional and healthy body. I’ll be careful with any of the flexibility and jumping exercises that interact with my hip, and I’ll probably start easy.

When I’m on the other side of that, the bike will be waiting for me. So will the sneakers, and so will the leg press machine. It’ll be about balance, but if I’m smart, I’ll climb higher and stronger than ever.


Scar Tissue

I’m long overdue for some good news. The last post was a bit of a bummer, primarily saying that I was giving up in order to end the pain. My doctor was out on vacation, things weren’t going so well, and I suspected that I’d had yet another major setback. There had been talk of scar tissue complications, but given the amount of pain I was experiencing after each popping instance, my PA thought it sounded a little worse.

Finally last Thursday I was able to visit with my doctor. He gave me some good news, but rather than blab about it, I wanted to let it situate a few days and make it sure it would prove correct.

He said that it was almost definitely scar tissue. His way of wording was convincing. He said that of the top 5 things that it could possibly be, 1-4 would be scar tissue. The chances of the injury not being fixed and requiring surgery later are almost zero. I still have a labrum. It’s just that my pelvic muscles are inflamed because the scar tissue rubs them the wrong way. Every time the hip moves in a new direction, there’s an actual cut with bleeding deep down, and pain is completely normal. As I’ve found with everything involving hips, the pain can be worse than other parts of the body and takes longer to heal, so what I was enduring was completelyreasonable.

So what now?

Scar tissue does not heal. It is going to be there, although it will likely become a lesser issue over time. Some people find that they can never get completely away from it, and have to find ways to tolerate the pain. Others find that with patience and not overdoing things, it’ll gradually get better and they can be themselves again. For some people it takes longer than others.

He started me out on a low dose of prednisone. I groaned. I’ve taken it before and loathe the medication. It makes me feel bloated, keeps me up at night, and just gives me an overall blah feeling. I reluctantly took it, wanting to try anything at this point.

The problem is I had to stop taking my anti-inflammatory altogether. That had been the only thing taking the edge off the constant pain, so for the first two days on the medicine, I had a tough time. Not only did I have the prednisone side effects, but the hip felt like it was about to burst. That was Friday and most of Saturday.

Late on Saturday, as some pain medication had worn off, I felt surprisingly good. I went to sleep, and woke up the next morning still feeling good, and found that throughout the day, I didn’t require a single pain reliever. On Monday morning I still felt good. What do you know? The doctor might have been right. The prednisone has definitely helped.

Of course I cannot and don’t want to take prednisone forever. It is possible this dose will get me over the hump temporarily and I can continue improving. There’s also a possibility of getting a shot into my iliopsoas that will reduce the inflammation for a time.

The other good news is that I’ve recovered enough that my doctor thinks I am finished with physical therapy. As long as I can get around the scar tissue pain, I should be able to bike and swim as long as I don’t go too hard.

This coming weekend, my wife and I will be leaving for New York City for a week-long celebration tour of her Jeopardy win. By then I should be back on all of my anti-inflammatories, and I should be able to walk around mostly like any other human being. The thing is, as a tourist in New York, I’ll be walking a lot. It could get painful, but it’ll also be a test, and might actually be good for me to finally strengthen the hip without excessive impact. We’ll be leisurely and careful, and will make sure to have enough downtime to recover.

So this is definitely good news. At least better than last time.


Bad News is Good News?

sunrise

While all of the Jeopardy excitement was going on, I was slowly rehabilitating from what has now been nearly a two-year injury. The digression was good timing, because frankly, writing about a series of progressively lengthening training rides was not going to be fascinating. The idea was that once this was all over, I would write a recap of the rehab over the last couple of months.

Some bad news threw a wrench in my plans.

After that first ride in May, and a few more in June, I was well on my way. I managed 144 miles on the bike, mostly easy, tempo rides, with 10 total hours in the saddle. I had also done a lot of therapy work, spent some time on stationary bikes, and done a few other things to get my fitness level back up. The last ride was 27 miles, and while I struggled to keep up with my friends, I found that I had some fitness. I was on my way back.

Each ride would leave me sore, although it steadily got easier and easier. I would need some recovery time, but I started feeling better faster. It was clear, steady improvement, just like the doctor ordered.

After Jeopardy, we spent our weekends traveling to visit family, and I made a short sojourn to Boone to put on my reporter hat. Finding time to ride was difficult because I had PT during the week. That always results in a little bit of soreness even though we were being careful not to push too hard. I wisely decided against riding when sore. The way it turned out, I wasn’t able to ride for a couple weeks.

A week ago on Thursday, I had a particularly tough day at therapy that included the exercise bike. I was sore that evening and the next day, and then felt better on Saturday. That was pretty much the norm. Aside from a couple hiccups, after a short recovery period I would be fine. Occasionally the hip would randomly pop and give me some added soreness for a couple of days, but it would pass.

This past Saturday, when my wife and I were sitting on a couch talking about her Jeopardy experience with my family, I moved my leg slightly to adjust. I moved it at most three inches outward.

POP!

Did you hear that? My wife said that she had. It wasn’t sore right away, but I had a feeling it would be. The next day we returned home and it was only tender, so I was encouraged it would pass. This wasn’t the first time it had popped. The other times I had written it off as scar tissue redeveloping, and I didn’t worry much. It had never popped this loudly.

It started to hurt the next day, and by Monday, it was nearly excruciating. It is hard to describe hip pain when it is bad. It feels like someone is clawing at you from your insides, and you cannot get comfortable no matter how you sit or lie down. It radiates to other parts of the leg, making each muscle feel like they had just run a marathon. Of all the different types of pain I’ve experienced, this is my least favorite.

I had to dip back into my pain medication to get through Monday. Tuesday was no better. I took half a day off work just to rest the hip, again in bed with medication.

I was concerned. This couldn’t be scar tissue, could it? I called the doctor’s office and they were also concerned. No, it didn’t sound like scar tissue to them either. Usually that doesn’t hurt as bad or last as long. They told me to stop everything except for stretching until the doctor can see me. Since he left for vacation on Wednesday, that’ll be two weeks from now.

At first I was disappointed, a little depressed even. As you blog readers know all too well, every time I begin to make some progress, something happens to set me back a ways. After the pain had barely subsided by Wednesday, and stayed about the same Thursday, I knew this was a major setback. Since I am now nearly six months from surgery, the implications are dire. Unless I am the slowest healer on the planet, it is clear that the surgery was not successful. If only the surgeon had repaired the hip instead of cutting off the torn portion, then I probably wouldn’t be in this situation.

The bad news is that I am off the bike and everything indefinitely. I have a feeling the doctor will say it is okay to pool walk or do easy swimming, but even that will probably bring back pain. It is time for a long period of rest, maybe a couple of months, maybe the rest of the year. This is no longer about me returning to the sport I love. This is about me living my life and being able to perform daily activities.

The above 800 words sound depressing, and like I said, that’s how I first interpreted them. Since then, I have actually come to a place of relief and acceptance. That’s why I think this setback was partially good news.

Knowing that I need to let myself heal has taken a weight off my shoulders. In a few weeks, I should be able to walk normally again and pain free. Rather than continue to push myself into a perpetual state of agony, I’ll enjoy being recovered and having as much mobility and comfort as possible.

The random popping should end because it only happens after workouts. That’s my hip telling me it isn’t ready. I need more time.

The potential downside is that there’s an outside chance that I’ll need another surgery. The hip may need to be completely repaired. I’ve been through this surgery once and am not excited about going through it again, but I will take that step if it’s a matter of me never being active again.

When my friends and family have heard this news, they have apologized to me, and given me plenty of prayers, support and encouragement. I cannot express enough how much it is appreciated. But this isn’t a funeral. This is part of a lengthy rebirth. Everyone goes through hurdles in life, and everyone finds a way to deal with them. While I’ve had to endure a lot more than the average person, I’ve still found a way to love life. That’s not going to change. There are plenty of adventures waiting for me. The question is whether they’ll be in a few months, next year, or yes, maybe even the year after.

In the meantime, I have this blog. My past adventures are well documented, and just recently I found a way to enjoy my passion from another perspective. That will continue. With some of this free time, there will be other avenues to get involved. I’ve already been participating with a number of local bike planning and advocacy groups. The 50 State Project may be on hold, but there are plenty of other projects waiting around the corner. Stay tuned.


I’ve Made a Huge Mistake

When I had surgery, my appointment was initially scheduled for 2pm with me arriving at noon. Some sort of delay happened that they didn’t tell me about. It is possible there was another, more serious surgery that needed to be performed. Since my doctor works on collegiate and professional athletes, it is possible their surgery took precedence because of a game. Who knows? Whatever it was, I was fine with it.

The delay went on awhile. 2pm came and went, then 3pm, then 4pm. The hospital staff was terrific and they checked on me periodically, apologizing for the delay and giving me an ETA on when I would go in. They even gave my starving wife a sandwich.

Chilling before surgery.

I sat in this room waiting patiently for many hours.

The procedure began sometime before 5pm, and I woke up in the recovery room around 7pm, drugged to the gills, pleasantly telling people “good morning” as they passed by.

After the procedure and recovery, there was supposed to be someone to show me how to properly operate the crutches. It would be unlikely I would remember, but at least my wife would be there to take mental note, and practice would make perfect.

By the time we arrived back at the nurses station, a lot of people had gone home. It was 8pm on a Friday night after all. If I worked there, I wouldn’t have wanted to stick around either. On top of that, it had been a long day for both of us. My wife was tired, and of course I was blitzed.

We had also left the crutches in the car. So when they asked if we needed help, my half-drugged response was “nah, I know how to use crutches.” That was not entirely true. I’ve used them before, but not for something like this. My wife believed me, and we went home.

For the first few weeks, I barely got around anyway, so it hardly mattered. During week three when we went to Jeopardy, I had to get around more than I would have liked, and I was often very sore.

My big mistake was that I did not use the proper toe-touching method of crutch walking, as demonstrated in the video below. I was using the crutches to support my right hip, but I was unwittingly putting some weight on it.

When I returned to work in week 4, I had to get around more and more. The recovery seemed to stall and I wondered why. The answer is clear now. I was putting too much weight on my hip!

Just before week 6, I saw my surgeon again. He asked how everything was going. Good, I said. I had recovered far more than the surgery date, which was true, and was progressing slower now, but felt I was still making a little bit of progress. He didn’t seem alarmed, and he said he would allow a little more weight bearing.

Guess what? He was allowing the same thing I had been doing the whole time.

Oops.

This week when talking to my Physical Therapist, I wondered why it was hurting so much, especially after therapy. You would think it would get better. She said that after PT, I should try to go back to no weight bearing for a day or two. Okay. So I continued along the same way I had been, thinking that was right.

The pain continued, and it made me think. Last night I started googling around, and found that video.

Oops.

Today is the 7-week mark and I don’t feel too much better than week four, probably because of a combination of this and weaning off the pain pills. I spoke with my Physician’s Assistant and there’s really nothing that can be done at week 7.

The good news is that now that I know, I can start doing it the right away and I should start feeling better. The bad news is this probably extends my crutch time to perhaps another month or longer.

The lesson here folks is that if you have surgery and they offer to show you something, take them up on it regardless of the hour, or how drugged up you are. They won’t babysit you to make sure you are doing it right.


The Injury. The Answers.

Although I was confused shortly after surgery, over the last few weeks I’ve visited with doctors, physician’s assistants, and physical therapists. We’ve gone over the surgery pictures, examined how my body has responded to surgery, and finally been able to find some answers.

As you can see in my injury history, I had been looking for answers for a long time. We looked into several potential diagnoses, ruling them out one at a time. Since I’ve been blogging along the way, I’ve received numerous suggestions on what it could be, most of which were well informed and definitely possible. It’s amazing that after all this searching, with a help of a few surgical instruments, all my questions over the last 1.5 years were answered.

In the diagnosis phase, there was one thing that kept popping up that was a possibility – a torn labrum. There were plenty of symptoms, the most notable being that my hip would audibly pop. We had four MRIs. Yes, four, and none of them showed a major tear. One of them did show a minor tear, not one that was serious enough to require surgery.

In reading the surgeon’s report, it’s clear that he didn’t know what he would find. He just knew that my condition had deteriorated enough that surgery was the only way to get answers.

He found a torn labrum and a lot of messed up cartilage, and he corrected it. More on that in a moment.

The torn labrum was probably there from the very beginning. The only real question is how it materialized in the first place. Could it have happened on Grandfather Mountain? Could it have been a combination of all of my big riding in 2012? Could it have been there a year earlier and only started bothering me with heavy riding? We’ll never know the answer to that question. All we know is that it was exacerbated as a product of cycling.

He said that the stress fracture and the torn labrum were two different things, but they are clearly related on some level. The labrum protects the bone, and with it torn, it probably made me susceptible to a fracture. I’m lucky I didn’t get another one.

After the stress fracture healed and I was able to train again, I still had the torn labrum, even though I didn’t know it. What he found during surgery was that there was a lot of beat up cartilage. That was probably due to me riding on the tear. The doctor showed me all of the damage on the pictures (which looked like cloudy planets), and it was pretty severe.

What’s interesting is that the torn labrum wasn’t the cause of any the pain. The labrum does not have any sensation. It cannot breath, and that is why it can only be healed with surgery. The pain was all the cartilage damage, and that would reoccur later.

As I continued training and riding harder, the popping would be more frequent. At times it would hurt quite awhile after. At some point in September, anytime I tried to ride, it was pure pain. It felt like I had a pebble in my hip, and the strongest of the strongest could not have ridden through this. Now I know why.

Remember that this is an unscientific description, and I’m translating what the doctor told me that I barely understand. Somehow because of the bad cartilage, the torn labrum and the instability of the bone, things became out of alignment. It caused a pinching every time I moved my hip flexor. That meant with every pedal stroke, it would pinch. The more I pedaled, the more it would hurt.. It came to a point that after every ride, I would have to take a few days off just to let the pain subside. Then I would ride again, hoping it had healed, and repeat the cycle of pain.

The pain became so bad that I had to get off the bike completely and walk with a cane for the majority of the winter. If I walked regularly, I would engage the hip flexor and feel pain. I had two cortisone shot and one iliopsoas shot, neither of which gave me any relief.

When the surgeon found the tear, he had to make a tough decision. Would he debride or repair? He decided to debride, which means he removed the part of the labrum that was torn. I wish I had a say in the matter, because I would have asked him to repair it. He expects me to make a full recovery, but whether I can achieve the same athleticism that I had before and more, is still up in the air. Without a full labrum, I could be susceptible to the same sort of problems (stress fractures) that I had before. Or maybe not. It depends on a lot of things, and that’s a conversation we still need to have. Right now it is about recovery.

I mentioned already that he performed a microfracture on my hip. That means he broke the bones so that my labrum would heal correctly. As he subtly put it, “we poked a few small holes in you.” He also performed what’s called a chondroplasty, which is pretty much like the microfracture, but instead of breaking the bone, he dug in and broke the cartilage.

The bone and the cartilage will normally take 8 weeks to heal. Right now I’m at 6.5 and I’ve made improvements, but the challenge is that it is difficult to not bear weight on a hip. Even when sitting down, I am putting a little bit of weight there. A few weeks ago it seemed I was ahead of schedule. As of now, it feels like I’m behind, so it could be another few weeks on crutches. The great thing is that the doctor thinks my body has healed enough for me to take anti-inflammatory drugs, which make a world of difference.

At this point, recovery is up in the air until the surgery wounds heal. That’ll probably be the subject of another post that will focus more on the physical therapy techniques to rebuild strength and expectations on when I can return to exercise.

I know this all sounds like a downer, and I’ll admit that it has been trying on my patience, but I’ve actually enjoyed my downtime. I have dedicated my time to some other interests, and found that being a couch potato is not all that bad. I just have to keep reminding myself that this is temporary, and that soon enough, maybe sooner than I think, I’ll be back out there.


Successful Hip Arthroscopy

Chilling before surgery.

Chilling before surgery.

Doctor Guy visited me before the operation to chat about how things were going, what to expect, and so forth. He asked how I was doing, and I told him that to my surprise, I had felt a little better these last couple days. I even wondered if maybe rest was helping heal whatever condition I had.

He told me that there was still an option to back out. I could still leave if I wanted. I seriously considered it. I even asked him what he would do in my shoes. He didn’t answer that (and frankly, he couldn’t), but he did get into specifics about possible outcomes. My main concern was that they would find nothing, and I would be spending a lot of money and pain for nothing.

Ultimately I did not take the door. That was the right decision. If I had left, I probably would have started riding again, and the cycle would repeat itself. The solution to this problem was only going to be found in the operating room.

We were pretty convinced that the problem I had was in the hip joint. As he put it, neither of my MRIs were very “exciting,” but they might not always show everything. If they found a tear, they would either repair or debride. Even if they didn’t find anything, they would still do the iliopsoas release where they trim the tendon to relieve me of the clicking and popping. That set my mind at ease. Even if they found nothing, there was going to be a surgical fix.

I gulped and said, “Let’s do it.”

Hours later, there were a lot of people yelling at me to wake up. I was disoriented, temporarily forgetting where I was. As they wheeled me through the hospital, I found myself telling people “good morning” as we passed by.

I would later learn that I had a labral tear and they had fixed it with debridement. Doctor Guy spoke extensively with my wife, even showing her pictures, which she translated for me.

During their first pass through the labrum, they didn’t see anything. As they delved deeper, they finally found the tear. Dr. Guy said that if I were younger, in my 20s, he would have repaired it. Instead, he debrided, removing damaged cartilage. He felt that this was the cause of all of my pain, all of the popping, and this should fix the problem. There was no need to do anything with the iliopsoas.

As I slowly came out of my fog and realized what had happened, I was thrilled. This was the cause of all of these problems over the last 17-months, and they would be no more. In the back of my mind, there was a worry that I would never ride again. That won’t be the case.

This was almost the best possible outcome of surgery. Even though today I’m in a little pain because of the surgery, I can tell that it is different. Even today, it is less painful than the worst days living with the injury. Before I felt like there was always something in there, like a big walnut as my anesthesiologist said, who was also dealing with a torn labrum of his own. That feeling is gone, and I couldn’t be happier.

As I understand it, there are advantages and disadvantages of the debridement. The best part is that this will be the quickest recovery, possibly even 3 weeks. Repair or release would have been at least 4-6 weeks. The downside is that this was not a total fix, and it might limit me my physical capacity. Or it might not. I may come back stronger than ever. The key is that I WILL come back.

This long nightmare is over. I’ve said this many times before, but I cannot thank all of you readers enough. Having so much positive encouragement and prayers through this blog has made this process so much easier. If not for all the great advice I’ve received, I might have given up long ago.

For now, I will rest. Eventually I will climb.

I feel like shouting from the rooftops! YES!!


All Systems Go

After a slight scare with the weather, my surgery appointment has been confirmed. In fact, it was moved up an hour, which is alright by me. In just a few hours, I’ll head to the hospital and get myself ready.

As I’ve mentioned recently, the rest has done me a little better. Over the last few days I worried that I was healing and this surgery was going to be unnecessary. Yesterday I felt so much better that I hardly even noticed the hip. Just to make sure, I busted out the mountain bike and took it out for a spin.

Despite the sub-40 degree temperature, it felt great riding around the melting snow. If I was going to ride a mile, this was the day to do it.

The hip did not bother me whatsoever on the ride. It actually felt pretty good. My heart, on the other hand, was going bonkers. I really have lost a ton of fitness. I arrived back home feeling alright, but winded.

As I cooled down, the hip started to get tight again. A slight burning soreness developed, just like what I’ve been dealing with for these many months. If I had kept riding a few more miles, I would have been right back where I was a few months ago — sitting on the couch on a lot of pain.

Something is still amiss down there, and I’m glad that I had the chance to re-confirm the need for surgery.

Rather than indulge in the steak dinner I’d been hoping for, we instead chose a plentiful but digestible meal of Mediterranean fare last night. A plateload of hummus, tabouli, feta and falafel filled me up for the evening, and will hopefully keep the nausea at bay later today. I also had a Clif bar just before bed.

The hope was that I would sleep in, and wake up just before surgery. Sleep happened without issue, thankfully, but sleeping in was not to be. I woke up the same time I normally do for work, which is early, well before the crack of dawn. I had a black cup of coffee, and that’ll be it until I leave the hospital.

I expected to be nervous, and maybe I will be as I get closer to the appointment, but this morning I’m pretty chill. I’m going to watch an old, quiet movie to pass some time, and then get going.

Here goes nothing.