Era Of Knowledge

AFGHANISTAN Transitional Islamic State of Afghanistan

2008-11-12T22:32:00.000-08:00

AFGHANISTAN
Transitional Islamic State of Afghanistan
Dowlat-e Eslami-ye Afghanestan
CAPITAL: Kabul
FLAG: Three equal vertical bands of black (hoist), red, and green, with a white emblem centered on the
red band; the emblem features a temple-like structure encircled by a wreath on the left and right and by
a bold Islamic inscription above.
ANTHEM: Esllahte Arzi (Land Reform), beginning “So long as there is the earth and the heavens.”
MONETARY UNIT: The afghani (AF) is a paper currency of 100 puls. There are coins of 25 and 50 puls
and 1, 2, and 5 afghanis, and notes of 10, 20, 50, 100, 500, and 1,000 afghanis. Af1 = $0.0211 (or $1
= AF47.3) as of May 2003.
WEIGHTS AND MEASURES: The metric system is the legal standard, although some local units are still in
use.
HOLIDAYS: Now Rooz (New Year’s Day), 21 March; May Day, 1 May; Independence Day, 18 August.
Movable religious holidays include First Day of Ramadan, ‘Id al-Fitr, ‘Id al-‘Adha’, ‘Ashura, and Milad
an-Nabi. The Afghan calendar year begins on 21 March; the Afghan year 1376 began on 21 March
1997.
TIME: 4:30 PM = noon GMT.
1LOCATION, SIZE, AND EXTENT
Afghanistan is a landlocked country in Central Asia with a long,
narrow strip in the northeast (the Wakhan corridor). Afghanistan
is slightly smaller than the state of Texas, with a total area of
647,500 sq km (250,001 sq mi), extending 1,240 km (770 mi)
ne–sw and 560 km (350 mi) se–nw. Afghanistan is bounded on
the n by Turkenistan, Uzbekistan, and Tajikistan, on the extreme
ne by China, on the e and s by Pakistan, and on the w by Iran,
with a total boundary length of 5,529 km (3,436 mi). Afghanistan’s
capital city, Kabul, is located in the east central part of the
country.
2TOPOGRAPHY
Although the average altitude of Afghanistan is about 1,200 m
(4,000 ft), the Hindu Kush mountain range rises to more than
6,100 m (20,000 ft) in the northern corner of the Wakhan panhandle
in the northeast and continues in a southwesterly direction
for about 970 km (600 mi), dividing the northern provinces from
the rest of the country. Central Afghanistan, a plateau with an
average elevation of 1,800 m (6,000 ft), contains many small fertile
valleys and provides excellent grazing for sheep, goats, and
camels. To the north of the Hindu Kush and the central mountain
range, the altitude drops to about 460 m (1,500 ft), permitting
the growth of cotton, fruits, grains, ground nuts, and other crops.
Southwestern Afghanistan is a desert, hot in summer and cold in
winter. The four major river systems are the Amu Darya (Oxus)
in the north, flowing into the Aral Sea; the Harirud and Morghab
in the west; the Helmand in the southwest; and the Kabul in the
east, flowing into the Indus. There are few lakes.
3CLIMATE
The ranges in altitude produce a climate with both temperate and
semitropical characteristics, and the seasons are clearly marked
throughout the country. Wide temperature variations are usual
from season to season and from day to night. Summer temperatures
in Kabul may range from 16° c (61° f) at sunrise to 38° c
(100° f) by noon. The mean January temperature in Kabul is 0° c
(32° f); the maximum summer temperature in Jalalabad is about
46° c (115° f). There is much sunshine, and the air is usually clear
and dry. Rainfall averages about 25 to 30 cm (10 to 12 in); precipitation
occurs in winter and spring, most of it in the form of
snow. Wind velocity is high, especially in the west.
4FLORA AND FAUNA
There are over 3,000 plant species, including hundreds of varieties
of trees, shrubs, vines, flowers, and fungi. The country is particularly
rich in such medicinal plants as rue, wormwood, and
asafetida; fruit and nut trees are found in many areas. Native
fauna include the fox, lynx, wild dog, bear, mongoose, shrew,
hedgehog, hyena, jerboa, hare, and wild varieties of cats, asses,
mountain goats, and mountain sheep. Trout is the most common
fish. There are more than 100 species of wildfowl and birds.
5ENVIRONMENT
Afghanistan’s most significant ecological problems are deforestation,
drought, soil degradation, and overgrazing. Neglect,
scorched earth tactics, and the damage caused by extensive bombardments
have destroyed previously productive agricultural
areas, and more are threatened by tons of unexploded ordnance.
Afghanistan has responded to the fuel needs of its growing population
by cutting down many of its already sparse forests. Consequently,
by late 2002, between 1 and 2% of Afghanistan’s land
area was forest land. That represented a 33% decrease from
1979. A four-year drought in 2002 emptied rivers and irrigation
canals. Another environmental threat is posed by returning refugees
to Afghanistan, of which there were over 4 million in Pakistan,
Iran, and other countries in 2002, who have migrated to
Kabul and other larger cities instead of returning to destroyed villages
and fields. This migration has placed stress on the infrastructure
of those cities, causing increased pollution and
worsening sanitation conditions.
By 2002, 11 species of mammals, 13 species of birds, and 4
plant species of were endangered. Endangered species in Afghanistan
included the snow leopard, long-billed curlew, Argali sheep,
musk deer, tiger, white-headed duck, Afghani brook salamander,
Kabul markhor, and the Siberian white crane. There were thought
to be fewer than 100 snow leopards in 2002. The country’s Caspian
tigers have virtually disappeared. In 2002, there was one
pair of Siberian white cranes, with one chick.
6POPULATION
The population of Afghanistan in 2003 was estimated by the
United Nations at 23,897,000, which placed it as number 46 in
population among the 193 nations of the world. In that year
approximately 3% of the population was over 65 years of age,
with another 43% of the population under 15 years of age. There
were 107 males for every 100 females in the country in 2003.
According to the UN, the annual population growth rate for
2000–2005 is 3.88%, with the projected population for the year
2015 at 35,473,000. The population density in 2002 was 42 per
sq km (110 per sq mi).
It was estimated by the Population Reference Bureau that 22%
of the population lived in urban areas in 2001. The capital city,
Kabul, had a population of 2,454,000 in that year. Other major
population centers include Kandaha¯r, 339,200; Maza¯r-e Sharif,
239,800; and Hera¯t, 166,600. According to the United Nations,
the urban population growth rate for 2000–2005 was 6.9%.
These figures are unreliable, however, because many city dwellers
have left their urban homes for refuge in rural areas. Approximately
20% of the population is nomadic.
Two decades of near constant warfare make Afghanistan’s
population—never certain in any case—even more difficult to
assess. As many as three million Afghans are estimated to have
died, and an additional six million sought refuge in Pakistan,
Iran, and elsewhere in the world during the worst of the fighting
when thousands of Soviet troops were present. The last official
census was taken in 1988.
7MIGRATION
Due to the U.S.-led bombing campaign in 2001–2002 carried out
against the Taliban regime, a large Afghan refugee population
was created in surrounding countries. The Afghan refugee population
in Pakistan in 2002 was approximately 3.7 million, and, in
Iran and the west, an additional 1.6 million. In 2002, there were
approximately 1 million internally displaced persons (IDP) within
the country. Since early-2002, there were many spontaneous
returnees, but the UN High Commissioner for Refugees
(UNHCR) began assisting refugees to repatriate in February
2002. As of October, more than over 1.5 million had returned to
their homes.
In mid-2002, there was a daily influx of homeless migrants
into Kabul, approximately 300–400 families a day. Seventy percent
of Kabul’s population was living in illegal structures.
In the summer of 2001, the majority of the over 1 million
internally displaced persons in Afghanistan had been driven off
their land and into refugee camps by ongoing conflict and four
years of drought. After September 11, 2001, the International
Organization for Migration (IOM) began to deliver shelter and
non-food supplies to help the IDPs survive the Afghan winter. It
dispatched road convoys from Iran, Tajikistan, and Turkmenistan
to destinations in Afghanistan, carrying blankets, winter clothing,
tents, and other essential items. Following the winter, with the
defeat of the Taliban and the beginning of the spring planting season,
the IOM worked to return the IDPs to their villages from the
refugee camps. The IDP families were offered wheat, seeds, blankets,
soap, agricultural tools, and other items. In addition to the
IOM and the UNHCR, the International Committee of the Red
Cross and UNICEF have been heavily involved in repatriating refugees.
Underway in the country is also the Return of Qualified
Afghans program, designed to bring back Afghan professionals
living abroad to participate in rebuilding the country. The program
had returned 227 people by mid-2002. A further 343 people
were identified to fill key jobs in ministries and
nongovernmental organizations (NGOs).
8ETHNIC GROUPS
About the middle of the second millennium bc, Indo-Aryans
began to move into and through the present area of Afghanistan.
Much later came other tribal groups from Central Asia—Pactyes
(from whom the present-day name “Pashtoons” derives), Sakas,
Kushans, Hephthalites, and others—and a procession of Iranians
and Greeks. In the 7th century ad, Arabs arrived from the south,
spreading the new faith of Islam. In the same century, Turks
moved in from the north, followed in the 13th century by Mongols,
and, finally, in the 15th century by Turko-Mongols. This
multiplicity of movements made Afghanistan a loose conglomeration
of racial and linguistic groups.
All citizens are called Afghans, but the Pashtoons (the name
may also be written as “Pushtun” or “Pukhtun,” and in Pakistan
as “Pathan”) are often referred to as the “true Afghans.” Numbering
about 38% of the population in 2001, they are known to
have centered in the Sulaiman range to the east; it is only in recent
centuries that they moved into eastern and southern Afghanistan,
where they now predominate. They have long been divided into
two major divisions, the Durranis and the Ghilzais, each with its
own tribes and subtribes.
The Tajiks, of Iranian stock, comprise nearly 25% of the population
and are mainly concentrated in the north and northeast. In
the central ranges are found the Hazaras (about 19%), who are
said to have descended from the Mongols. To the north of the
Hindu Kush, Turkic and Turko-Mongol groups were in the
majority until 1940. Each of these groups is related to groups
north of the Amu Darya and within the former USSR; among
them are the Uzbeks, who number about 6% of the population.
Other groups include the Aimaks, Farsiwans (Persians) and Brahiu.
In the northeast are the Kafirs, or infidels. After their conversion
to Islam at the end of the 19th century, they were given the
name of Nuristanis, or “people of the light.”
9LANGUAGES
Both Pashtu (or Pushtu) and Dari (Afghan Persian) are the official
languages of the country. Pashtu is spoken by about 35% of the
population while approximately 50% speak Dari. Although
Pashtu has a literature of its own, Dari, the language spoken in
Kabul, has been the principal language of cultural expression, of
the government, and of business. Both Pashtu and Dari are written
primarily with the Arabic alphabet, however, there are some
modifications. The Hazaras speak their own dialect of Dari. The
Turkic languages, spoken by 11% of the population, include
Uzbek and Turkmen, and the Nuristanis speak some seven different
dialects belonging to the Dardic linguistic group. There are
about 30 minor languages, primarily Balochi and Pashai, spoken
by some 4% of the population. Balochi belongs to the same linguistic
group, as do several languages spoken in the high Pamirs.
Bilingualism is common.
10RELIGIONS
Almost all Afghans are Muslims. Approximately 84% are Sunnis;
15% are Shi‘is; others comprise only 1%. The Pashtuns, most of
the Tajiks, the Uzbeks, and the Turkmen are Sunnis, while the
Hazaras are Shi‘is. The country’s small Hindu and Sikh population
is estimated at less than 30,000. Before the 1978 Communist
coup, Islam was the official religion of Afghanistan; in an effort
to win over religious leaders, the Marxist regime set up a Department
of Islamic Affairs in 1981 and began providing funds for
new mosques and for the maintenance of old ones. Following the
overthrow of the Communist regime, an Islamic State was again
proclaimed.
In 1994 the Islamic militants who called themselves the Taliban—
literally “the Seekers,” a term used to describe religious stu-
dents—began to impose their strict form of Islam observance in
the areas that they controlled. The Taliban, composed mostly of
Pashtoons, were puritanical zealots. Women were ordered to
dress in strict Islamic garb and were banned from working or
from going out of their houses unless accompanied by a male relative.
Some men were forced to pray five times a day and grow
full beards as a condition of employment in the government.
Under the Taliban, repression of the Hazara ethnic group, who
were predominantly Shi’is, was severe.
Since the fall of the Taliban in 2001, the 1964 constitution has
been used as a basis for the definition of religious freedom and
practices. The 1964 constitution proclaims Islam the "sacred religion
of Afghanistan" and states that religious rites of the state
shall be performed according to Hanafi doctrine. Religious toleration
for non-Muslims has been granted, according to the 1964
constitution and the 2001 Bonn Agreement.
11TRANSPORTATION
Many roads were built in the years prior to 1979 to connect the
principal cities and to open up formerly isolated areas. As of
2002, Afghanistan had an estimated 21,000 km (13,000 mi) of
roads, of which 2,793 km (1,736 mi) were paved. Roads connect
Kabul with most provincial capitals and with Peshawar in Pakistan
through the Khyber Pass. The road from Herat to Mashhad
in Iran was completed in 1971. The Salang Tunnel through the
Hindu Kush, completed with Soviet assistance in 1964, considerably
shortened the travel time between Kabul and northern
Afghanistan. The tunnel was modernized in the mid-1980s. However,
in May 1997 the Tajik leader, Ahmad Shah Masud, blew up
P A R O P A M I SU S M T S.
HINDU KUSH
PAMIRS
Khyber
Pass
Khojak
Pass
Chagai Hills
Nowshak
24,557 ft.
7485 m.
¯
Kuh-e Fuladi
16,847 ft.
5135 m.
¯ ¯¯¯
Rigestan
Desert
Vakhan¯
Hamun-e
Saberi
¯ ¯
¯ ¯
Arghandab ¯
Farah ¯
Harirud
Morghab ¯
Amu
Dar'ya
Qonduz
Helmand
Kabul
Konar
Panj
Helmand
Gowd-e Zereh
Kcwkcheh
¸
Meymaneh
Khowst
Zareh
Sharan
Kowt-e
'Ashrow
Baraki
Towraghondi
Sar-e
Pol
Termez
Mazar-e Sharif
Dowlatabad
Khorugh
Qal'eh-ye Panjeh
Quetta
Kabul
Peshawar
Dushanbe
Qala¯t
Tayyeb¯at
Lashkar
G¯ah
Fara¯h
Zaranj
Z¯abol
Chaghchara¯n
Feyza¯bad
Ta¯loqa¯n
Kondu¯z
Baghla¯n
Balkh
Jala¯l¯ab¯ad
Cha¯r¯ikar
Isla¯ma¯ba¯d
Asma¯r
Qandaha¯r
Hera¯t
Shebergh¯an
Ghazni ¯
Shindand Garde¯yz
T U R K M E N I S T A N
P A K I S T A N
U Z B E K I S T A N T A J I K I S T A N
IRAN
CHINA
KYRGYZSTAN
W
S
N
E
Afghanistan
AFGHANISTAN
0 150 Miles
0 50 100 150 Kilometers
50 100
LOCATION: 29°28' to 38°30' N; 60°30' to 74°53' E. BOUNDARY LENGTHS: China, 76 kilometers (47 miles); Iran, 936 kilometers (582 miles); Pakistan, 2,430 kilometers
(1,511 miles); Tajikistan, 1,206 kilometers (750 miles); Turkmenistan, 744 kilometers (463 miles); Uzbekistan, 137 kilometers (85 miles).
the southern entrance of the tunnel in an effort to trap the invading
Taliban forces. It was reopened in January 2002. The Kandahar-
Torghundi highway in the south was completed in 1965. In
2002 there were 35,000 passenger cars and 32,000 trucks and
buses in use.
The Khyber Pass in Pakistan is the best known of the passes
providing land access to Afghanistan. Transit arrangements with
Iran provide an alternative route for its commercial traffic. However,
the great bulk of the country’s trade moves through the
former USSR. At the same time, Afghanistan’s highways are
badly damaged from years of warfare and neglect. Land mines
are buried on the sides of many roads. Over $1.2 billion in international
aid was pledged to rebuiding Afghanistan’s highways in
2002.
The only railways in the country in 2001 were a 9.6-km (6-mi)
spur from Gushgy, Turkmenistan to Towrghondi, a 15 km (9.3
mi) line from Termez, Uzbekistan to the Kheyrabad transshipment
point on the south bank of the Amu Darya, and a short
span into Spin Baldak in the southeast. There are no navigable
rivers except for the Amu Darya, on Turkmenistan’s border,
which can carry steamers up to about 500 tons. In 2002, there
were 46 airports, 10 of which had paved runways, and 2 heliports.
Ariana Afghan Airlines is the national carrier. Most of Ariana
Airlines planes were destroyed during the civil war in
Afghanistan. Ariana lost six of its eight planes in US-led air
strikes against the Taliban. Kabul's international airport
reopened to international humanitarian and military flights in
late January 2002 after the UN's Security Council lifted the ban
early that month, and it began international flight service to Delhi
soon after.
12HISTORY
Afghanistan has existed as a distinct polity for less than three centuries.
Previously, the area was made up of various principalities,
usually hostile to each other and occasionally ruled by one or
another conqueror from Persia and the area to the west or from
central Asia to the north, usually on his way to India. These
included the Persian Darius I in the 6th century bc, and 300 years
later, Alexander the Great. As the power of his Seleucid successors
waned, an independent Greek kingdom of Bactria arose with
its capital at Balkh west of Mazar-i-Sharif, but after about a century
it fell to invading tribes (notably the Sakas, who gave their
name to Sakastan, or Sistan). Toward the middle of the 3rd century
bc, Buddhism spread to Afghanistan from India, and for
centuries prior to the beginning of the 9th century ad, at least
half the population of eastern Afghanistan was Buddhist.
Beginning in the 7th century, Muslim invaders brought Islam
to the region, and it eventually became the dominant cultural
influence. For almost 200 years, Ghazni was the capital of a powerful
Islamic kingdom, the greatest of whose rulers, Mahmud of
Ghazni (r.997-1030), conquered most of the area from the Caspian
to the Ganges. The Ghaznavids were displaced by the Seljuk
Turks, who mastered Persia and Anatolia (eastern Turkey), and
by the Ghorids, who, rising from Ghor, southeast of Herat, established
an empire stretching from Herat to Ajmir in India. They
were displaced in turn by the Turko-Persian rulers of the Khiva
oasis in Transoxiana, who, by 1217, had created a state that
included the whole of Afghanistan until it disintegrated under
attack by Genghis Khan in 1219. His grandson Timur, also called
“Timur the Lame” or Tamerlane, occupied all of what is now
Afghanistan from 1365 to 1384, establishing a court of intellectual
and artistic brilliance at Herat. The Timurids came under
challenge from the Uzbeks, who finally drove the them out of
Herat in 1507. The great Babur, one of the Uzbek princes, occupied
Kabul in 1504 and Delhi in 1526, establishing the Mughal
Empire in which eastern Afghanistan was ruled from Delhi, Agra,
Lahore, or Srinagar, while Herat and Sistan were governed as
provinces of Persia.
In the 18th century, Persians under Nadir Shah conquered the
area, and after his death in 1747, one of his military commanders,
Ahmad Shah Abdali, was elected emir of Afghanistan. The
formation of a unified Afghanistan under his emirate marks
Afghanistan’s beginning as a political entity. Among his descendants
was Dost Muhammad who established himself in Kabul in
1826 and gained the emirate in 1835. Although the British
defeated Dost in the first Afghan War (1838-42), they restored
him to power, but his attempts and those of his successors to play
off Czarist Russian interests against the British concerns about
the security of their Indian Empire led to more conflict. In the second
Afghan War (1877–79), the forces of Sher Ali, Dost’s son,
were defeated by the British, and his entire party, ousted. Abdur
Rahman Khan, recognized as emir by the British in 1880, established
a central administration, and supported the British interest
in a neutral Afghanistan as a buffer against the expansion of Russian
influence.
Intermittent fighting between the British and Pushtun tribes
from eastern Afghanistan continued even after the establishment,
in 1893, of a boundary (the Durand line) between Afghanistan
and British India. An Anglo-Russian agreement concluded in
1907 guaranteed the independence of Afghanistan (and Tibet)
under British influence, and Afghanistan remained neutral in
both World Wars. Afghan forces under Amanullah Khan, who
had become emir in 1919, briefly intruded across the Durand
Line in 1919. At the end of brief fighting—the third Afghan
War—the Treaty of Rawalpindi (1919) accorded the government
of Afghanistan the freedom to conduct its own foreign affairs.
Internally, Amanullah’s Westernization program was strongly
opposed, forcing him to abdicate in 1929. After a brief civil war,
a tribal assembly chose Muhammad Nadir Shah as king. In his
brief four years in power, he restored peace while continuing
Amanullah’s modernization efforts at a more moderate pace.
Assassinated in 1933, he was succeeded by his son, Muhammad
Zahir Shah, who continued his modernization efforts, governing
for 40 years, even though sharing effective power with his uncles
and a first cousin, who served as his prime ministers.
In the 1960s, there was considerable tension between Pakistan
and Afghanistan as a result of Afghanistan’s effort to assert influence
among, and ultimately responsibility for, Pushtu-speaking
Pathan tribes living on both sides of the Durand Line under a policy
calling for the establishment of an entity to be called “Pushtunistan.”
The border was closed several times during the
following years, and relations with Pakistan remained generally
poor until 1977.
In 1964, a new constitution was introduced, converting
Afghanistan into a constitutional monarchy, and a year later the
country’s first general election was held. In July 1973, Muhammad
Daoud Khan, the king’s first cousin and brother-in-law, who
had served as prime minister from 1953 until early 1963, seized
power in a near-bloodless coup, establishing a republic and
appointing himself president, and prime minister of the Republic
of Afghanistan. He exiled Zahir Shah and his immediate family,
abolished the monarchy, dissolved the legislature, and suspended
the constitution. Daoud ruled as a dictator until 1977, when a
republican constitution calling for a one-party state was adopted
by the newly convened Loya Jirga (Grand National Assembly),
which then elected Daoud president for a six-year term.
Afghanistan Under Communist Rule
On 27 April 1978, Daoud was deposed and executed in a bloody
coup (the “Saur Revolution” because it took place during the
Afghan month of Saur), and the Democratic Republic of Afghanistan
emerged. Heading the new Revolutionary Council was Nur
Muhammad Taraki, secretary-general of the communist People’s
Democratic Party of Afghanistan (PDPA), assisted by Babrak
Karmal and Hafizullah Amin, both named deputy prime ministers.
The former Soviet Union immediately established ties with
the new regime, and in December 1978, the two nations concluded
a treaty of friendship and cooperation. Soon after the
coup, rural Afghan groups took up arms against the regime,
which increasingly relied on Soviet arms for support against what
came to be known as mujahidin, or holy warriors.
Meanwhile, the Khalq (masses) and Parcham (flag) factions of
the PDPA, which had united for the April takeover, became
embroiled in a bitter power struggle within the party and the government.
In September 1979, Taraki was ousted and executed by
Amin, who had beat out Karmal to become prime minister the
previous March and who now assumed Taraki’s posts as president
and party leader. Amin was himself replaced on 27 December
by Karmal, the Parcham faction leader. This last change was
announced not by Radio Kabul but by Radio Moscow and was
preceded by the airlift of 4,000 to 5,000 Soviet troops into Kabul
on 25–26 December, purportedly at the request of an Afghan
government whose president, Hafizullah Amin, was killed during
the takeover.
The Soviet presence increased to about 85,000 troops in late
January 1980, and by spring, the first clashes between Soviet
troops and the mujahidin had occurred. Throughout the early
and mid-1980s, the mujahidin resistance continue to build, aided
by Afghan army deserters and arms from the United States, Pakistan,
and the nations of the Islamic Conference Organization
(ICO). Much of the countryside remained under mujahidin control
as the insurgency waged on year by year, while in Kabul,
Soviet advisers assumed control of most Afghan government
agencies.
By late 1987, more than a million Afghans had lost their lives
in the struggle, while the United Nations High Commission for
Refugees (UNHCR) estimated that some 5 million others had
sought refuge in Pakistan, Iran, and elsewhere. Soviet sources at
the time acknowledged Soviet losses of between 12,000 and
30,000 dead and 76,000 wounded. Soviet troop strength in
Afghanistan at the end of 1987 was about 120,000, while according
to Western sources, Afghan resistance forces numbered nearly
130,000.
In early 1987, Babrak Karmal fled to Moscow after being
replaced as the head of the PDPA in May 1986 by Najibullah,
former head of the Afghan secret police. Najibullah offered the
mujahidin a ceasefire and introduced a much publicized national
reconciliation policy; he also released some political prisoners,
offered to deal with the resistance leaders, and promised new
land reform. The mujahidin rejected these overtures, declining to
negotiate for anything short of Soviet withdrawal and Najibullah’s
removal.
International efforts to bring about a political solution to the
war—including nearly unanimous General Assembly condemnations
of the Soviet presence in Afghanistan—were pursued within
the UN framework from 1982 onward. Among these efforts were
“proximity talks” between Afghanistan and Pakistan conducted
by a Special Representative of the UN Secretary General, Under
Secretary-General Diego Cordovez. After a desultory beginning,
these talks began to look promising in late 1987 and early 1988
when Soviet policymakers repeatedly stated, in a major policy
shift, that the removal of Soviet troops from Afghanistan was not
contingent on the creation of a transitional regime acceptable to
the former USSR. On 14 April 1988, documents were signed and
exchanged in which the USSR agreed to pull its troops out of
Afghanistan within nine months, the US reserved the right to continue
military aid to Afghan guerrillas as long as the USSR continued
to aid the government in Kabul, and Pakistan and
Afghanistan pledged not to interfere in each other’s internal
affairs.
The Russians completed the evacuation of their forces on
schedule 15 February 1989, but in spite of continuing pressure by
the well-armed mujahidin, the Najibullah government remained
in power until April 1992, when Najibullah sought refuge at the
UN office in Kabul as mujahidin forces closed in on the city.
Afghanistan After the Soviet Withdrawal
With the fall of the Najibullah government, the Seven-Party Alliance
(SPA) of the Islamic groups based in Pakistan moved to consolidate
its “victory” by announcing plans to set up an Interim
Afghan Government (AIG) charged with preparing the way for
elections. Meanwhile, they moved to assert their control of
Afghanistan, but their efforts to establish the AIG in Kabul failed
when within ten days of Najibullah’s departure from office, wellarmed
forces of the Hizb-i-Islami and Jamiat-i-Islami—two of the
seven SPA parties—clashed in fighting for the control of the capital.
In July, Jamiat leader Burhanuddin Rabbani replaced Sibghatullah
Mojaddedi as president of the AIG, as previously agreed by
all the SPA parties but the Hizb-i-Islami.
Continued fighting between Jamiat and Hizb-i-Islami militias
halted further progress, and Rabbani’s forces, under Commander
Ahmad Shah Masoud, dug in to block those under the control of
interim “Prime Minister” Gulbuddin Hekmatyar’s Hizb-i-Islami
and his ally, General Rashid Dostum (a former PDPA militia
leader turned warlord from northern Afghanistan), from taking
control of Kabul. In a 24-hour rocket exchange in August 1992 in
Kabul, an estimated 3000 Afghans died, and before the end of the
year, upwards of 700,000 Afghans had fled the city. Deep differences
among the SPA/AIG leadership, embittered by decades of
bad blood, ethnic distrust, and personal enmity, prevented any
further progress toward creating a genuine interim government
capable of honoring the 1992 SPA pledge to write a constitution,
organize elections, and create a new Afghan polity. Despite UN
attempts to broker a peace and bring the warring groups into a
coalition government, Afghanistan remained at war.
Rise of the Taliban
By the summer of 1994 Rabbani and his defense minister, Ahmed
Shah Masoud, were in control of the government in Kabul, but
internal turmoil caused by the warring factions had brought the
economy to a standstill. It was reported that on the road north of
Kandahar a convoy owned by influential Pakistani businessmen
was stopped by bandits demanding money. The businessmen
appealed to the Pakistani government, which responded by
encouraging Afghan students from the fundamentalist religious
schools on the Pakistan-Afghan boarder to intervene. The students
freed the convoy and went on to capture Kandahar,
Afghanistan’s second-largest city. Pakistan’s leaders supported the
Taliban with ammunition, fuel, and food. The students, ultra-fundamentalist
Sunni Muslims who called themselves the Taliban
(the Arabic word for religious students, literally “the Seekers”)
shared Pashtun ancestry with their Pakistani neighbors to the
south. The Taliban also found widespread support among Afghan
Pashtuns hostile to local warlords and tired of war and economic
instability. By late 1996, the Taliban had captured Kabul, the capital,
and were in control of 21 of Afghanistan’s 32 provinces.
When Rabbani fled the capital, Pakistan and Saudi Arabia officially
recognized the Taliban government in Kabul. In areas under
Taliban control, order was restored, roads opened, and trade
resumed. However, the Taliban’s reactionary social practices, justified
as being Islamic, did not appeal to Afghanistan’s non-Pashtun
minorities in the north and west of the country, nor to the
educated population generally. The opposition, dominated by the
Uzbek, Tajik, Hazara, and Turkoman ethnic groups, retreated to
the northeastern provinces.
In May 1997 the Taliban entered Mazar-i-Sharif, Afghanistan’s
largest town north of the Hindu Kush and stronghold of Uzbek
warlord Rashid Dostum. In the political intrigue that followed,
Dostum was ousted by his second in command, Malik Pahlawan,
who initially supported the Taliban. Dostum reportedly fled to
Turkey. Once the Taliban were in the city, however, Pahlawan

6 Afghanistan
abruptly switched sides. In the subsequent fighting, the Taliban
were forced to retreat with heavy casualties. The forces of Ahmad
Shah Masoud, Tajik warlord and former defense minister in
ousted President Rabbani’s government, were also instrumental
in the defeat of the Taliban in Mazar. Masoud controlled the high
passes of the Panjshir Valley in the east of the country. The opposition
alliance was supported by Iran, Russia, and the Central
Asian republics, who feared that the Taliban might destabilize the
region.
By early 1998, the Taliban militia controlled about two-thirds
of Afghanistan. Opposition forces under Ahmad Shah Masoud
controlled the northeast of the country. Taliban forces mounted
another offensive against their opponents in August-September
1998 and nearly sparked a war with neighboring Iran after a
series of Shiite villages were pillaged and Iranian diplomats killed.
Iran, which supplied Masoud’s forces, countered by massing
troops along its border with Afghanistan. Although the crisis subsided,
tensions between the Taliban and Iran remained high.
Masoud’s opposition forces became known as the United Front
or Northern Alliance in late 1999.
Despite attempts to broker a peace settlement, fighting
between the Taliban and opposition factions continued through
1999 and into 2000 with the Taliban controlling 90% of the
country. In March 1999, the warring factions agreed to enter a
coalition government, but by July these UN-sponsored peace
talks broke down and the Taliban renewed its offensive against
opposition forces. By October, the Taliban captured the key
northern city of Taloqan and a series of northeastern towns,
advancing to the border with Tajikistan. Fighting between the
Taliban and Northern Alliance forces was fierce in early 2001.
In April 2001, Masoud stated that he did not rule out a peace
dialogue with the Taliban, or even of setting up a provisional government
jointly with the Taliban, but that Pakistan would have to
stop interfering in the conflict first. He stated that elections
would have to be held under the aegis of the UN and the “six plus
two” countries, including Iran, China, Pakistan, Tajikistan, Turkmenistan,
as well as Russia and the US. The Northern Alliance
was receiving financial and military assistance from its old enemy
Russia as well as from Iran. In addition to Pakistan, the Taliban
was recognized as the legitimate government of Afghanistan by
Saudi Arabia and the United Arab Emirates. Masoud was assassinated
on 9 September 2001, by two men claiming to be Moroccan
journalists. His killers are thought to have been agents of al-
Qaeda acting in concert with the plotters of the 11 September
2001 attack on the World Trade Center in New York and the
Pentagon in Washington, D.C.
Post-11 September 2001
The 11 September 2001 attacks carried out against the US by
members of al-Qaeda marked the beginning of a war on terrorism
first directed against the Taliban for harboring Osama bin
Laden and his forces. On 7 October 2001, US-led forces launched
the bombing campaign Operation Enduring Freedom against the
Taliban and al-Qaeda in Afghanistan. On 13 November the Taliban
were removed from power in Kabul, and an interim government
under the leadership of Hamid Karzai, a Pashtun leader
from Kandahar, was installed on 22 December. The campaign
continued, however, into 2002. In June 2002, a Loya Jirga, or
Grand Assembly of traditional leaders, was held, and Karzai was
elected head of state of a transitional government that would be
in place for 18 months until elections could be held. More than
60% of the cabinet posts in the government went to Ahmed Shah
Masoud’s Northern Alliance. Masoud was officially proclaimed
the national hero of Afghanistan on 25 April 2002. A special
committee collected signatures to award the Nobel Prize to
Masoud posthumously. Among those who signed the petition
were Czech President Vaclav Havel, American writer Elie Wiesel,
and deputies of the European Parliament. On 5 September 2002,
Karzai survived an assassination attempt, and another plot
against him was thwarted on 22 November. As of April 2003,
more than 10,000 coalition forces, led by 8,000 US troops, were
engaged in fighting remnants of the Taliban, al-Qaeda forces, and
former mujahidin commander Gulbuddin Hekmatyar, in the eastern
and southern regions of Afghanistan.
13GOVERNMENT
Between 1964 and 1973, Afghanistan was a constitutional monarchy,
for the first time in its history. The head of government
was the prime minister, appointed by the king and responsible to
the bicameral legislature. This system gave way to a more traditional
authoritarian system on 17 July 1973, when Afghanistan
became a republic, headed by Muhammad Daoud Khan, who
became both president and prime minister. A new constitution in
1977 created a one-party state with a strong executive and a
weak bicameral legislature. The communist PDPA abrogated this
constitution after they seized power in April 1978.
Between 1978 and 1980, a communist-style 167-member Revolutionary
Council exercised legislative powers. The chief of state
(president) headed the presidium of that council, to which the 20-
member cabinet was formally responsible. A provisional constitution,
introduced in April 1980, guaranteed respect for Islam and
national traditions, condemned colonialism, imperialism, Zionism,
and fascism, and proclaimed the PDPA as “the guiding and
mobilizing force of society and state.” Seven years later, a new
constitution providing for a very strong presidency was introduced
as part of the PDPA’s propaganda campaign of “national
reconciliation.” Najibullah remained as president until April
1992 when he sought refuge at the UN office in Kabul as mujahidin
forces closed in on the city.
With the fall of the Najibullah government a Seven Party Alliance
(SPA) of the Islamic groups announced plans to set up an
Interim Afghan Government (AIG) charged with preparing the
way for elections. However, Professor Burhanuddin Rabbani coopted
the process by forming a leadership council that elected
him president. Subsequent fighting among warring factions
plunged the country into anarchy and set the stage for the emergence
of the ultra-conservative Islamic movement, Taliban, which
ousted the Rabbani government and as of mid-2000 controlled
all but the northern most provinces of the country. No new constitution
was drafted since the end of the Najibullah government.
The Taliban, led by Mullah Mohammed Omar, formed a sixmember
ruling council in Kabul which ruled by edict. Ultimate
authority for Taliban rule rested in the Taliban’s inner Shura
(Assembly), located in the southern city of Kandahar, and in Mullah
Omar.
With the fall of the Taliban in December 2001, an interim government
was created under the leadership of Hamid Karzai by an
agreement held in Bonn, Germany. He was elected head of state
in June 2002 of the "Islamic Transitional Government of Afghanistan
(ITGA),” by the Loya Jirga convened that month. He
named an executive cabinet, dividing key ministries between ethnic
Tajiks and Pashtuns. He also appointed three deputy presidents
and a chief justice to the country's highest court. Elections
for a new government were scheduled for 2003.
14POLITICAL PARTIES
Political parties have usually been illegal in Afghanistan, forcing
most political activity—influenced by ideological, linguistic, and
ethnic considerations—to operate underground or from abroad
(or both). The 1964 constitution provided for the formation of
political parties. However, since the framers of the constitution
decided that political parties should be permitted only after the
first elections, and since the Parliament never adopted a law governing
the parties’ operation, all candidates for the parliamentary
elections of August and September 1965 stood as independents.
Because a law on political parties was not on the books four years
later, the 1969 elections were also contested on a non-party basis.
Throughout the 1964–1973 period, however, the de facto existence
of parties was widely recognized. Subsequently, the framers
reversed their plan to allow political parties. Under the 1977 constitution,
only the National Revolutionary Party (NRP), the
ruler’s chosen instrument, was allowed.
The 1978 coup was engineered by the illegal People’s Democratic
Party of Afghanistan (PDPA) which had been founded in
1965. During its brief history, this Marxist party had been riven
by a bloody struggle between its pro-Soviet Parcham (flag) faction
and its larger Khalq (masses) faction. Babrak Karmal was the
leader of the Parcham group, while the Khalq faction was headed
until 1979 by Nur Muhammad Taraki and Hafizullah Amin. The
factional struggle continued after the 1978 coup, prompting the
Soviet intervention of 1979. Factional bloodletting continued
thereafter also, with repeated purges and assassinations of Khalq
adherents as well as bitter infighting within Parcham, this last
leading to Babrak Karmal’s replacement as PDPA secretary-general
in May 1986 by Najibullah.
The Islamic resistance forces opposing the PDPA government
and its Soviet backers in Afghanistan represented conservative,
ethnically-based Islamic groups which themselves have had a long
history of partisan infighting (and repression by successive Kabul
governments). They came together in the early 1980s to fight the
common enemy, the communist PDPA and the Soviet invaders
and, in 1985, under pressure from Pakistan and the United States,
they were loosely united into a Seven Party Alliance (SPA), headquartered
in Peshawar, Pakistan. By 1987, commando groups
affiliated with one or more of these seven parties controlled more
than 80% of the land area of Afghanistan.
With arms flowing in from outside the country—a flow not
halted until the end of 1991—the fighting continued, but with the
final withdrawal of Soviet troops in February 1989, the SPA
stepped up its military and political pressure on the communist
PDPA government. However, President Najibullah proved to
have more staying power than previously estimated, using Soviet
arms supplies, which continued until the end of 1991 to buttress
his position, while playing upon divisions among the resistance,
embracing nationalism and renouncing communism, and even
changing the name of the PDPA to the Wattan (Homeland) Party.
It was only in April 1992, with the Soviet Union now history, his
army defecting from beneath him, and the mujahidin closing on
Kabul that he sought refuge at the UN office in the capital, leaving
the city in the hands of the rival ethnic and regional mujahidin
militias.
The leaders of the mujahidin groups agreed to establish a leadership
council. This council quickly came under the control of
Professor Burhanuddin Rabbani who was subsequently elected
President by the council. Fighting broke out in August 1992 in
Kabul between forces loyal to President Rabbani and rival factions.
A new war for the control of Afghanistan had begun.
On September 26–27, 1996, the Pashtun-dominated ultra-conservative
Islamic Taliban movement captured the capital of Kabul
and expanded its control to over 90% of the country by mid-
2000. The Taliban were led by Mullah Mohammed Omar.
Ousted President Rabbani, a Tajik, and his defense minister
Ahmad Shah Masoud relocated to Takhar in the north. Rabbani
claimed that he remained the head of the government. His delegation
retained Afghanistan’s UN seat after the General Assembly
deferred a decision on Afghanistan’s credentials. Meanwhile, the
Taliban removed the ousted PDPA leader Najibullah from the UN
office in Kabul, tortured and shot him, and hung his body prominently
in the city. General Rashid Dostum, an ethnic Uzbek, controlled
several north-central provinces until he was ousted on 25
May 1997 by his second in command Malik Pahlawan. Dostum
fled to Turkey, but he returned that October. The Shia Hazara
community, led by Abdul Karim Khalili, retained control of a
small portion of the center of the country.
After the fall of the Taliban, various warlords, leaders, and
political factions emerged in Afghanistan. Dostum, as head of
Jumbish-e Melli Islami (National Islamic Movement), consolidated
his power in Mazar-i-Sharif. He was named interim deputy
defense minister for the transitional government in 2002. Rabbani,
as nominal head of the Northern Alliance, is also the leader
of Jamiat-e-Islami, the largest political party in the alliance.
Ismail Khan, a Shiite warlord of Tajik origin earned a power base
in the western city of Herat by liberating it from Soviet control,
and for a time in the '90s, kept it from Taliban control. Khan is
thought to be receiving backing from Iran. Abdul Karim Khalili is
the leader of the Hezb-e-Wahdat (Unity Party) and the top figure
in the Shia Hazara minority. Wahdat is the main benefactor of
Iranian support, and the second most-powerful opposition military
party. Gulbuddin Hekmatyar, the most notorious of the warlords
who emerged from the fight against Soviet occupation,
leads the party Hezb-e Islami. Pir Syed Ahmed Gailani is a moderate
Pashtun leader and wealthy businessman who is also the
spiritual leader of a minority Sufi Muslim group. Gailani is supported
by pro-royalist Pashtuns and Western-educated elites of
the old regime. He has called for an Islamic constitutional republic.
Former King Zahir Shah, who said he had no intention of
returning to power, volunteered to help build a power-sharing
administration for the country. Shah is a Pashtun. Younis
Qanooni, an ethnic Tajik, who was named Interior Minister for
the interim government, was also the interior minister in the
country's previous interim administration, in 1996, before the
Taliban came to power, and has opposed the presence of U.N.
peacekeepers in Afghanistan. And Abdullah Abdullah, of the
Northern Alliance, was a close friend of Ahmad Shah Masoud.
Like Masoud, Abdullah is from the Tajik heartland of the Panshir
Valley, but his mother is Pashtun. He has been seen as less willing
to relinquish the Northern Alliance's grip on power.
15LOCAL GOVERNMENT
Afghanistan was traditionally divided into provinces governed by
centrally appointed governors with considerable autonomy in
local affairs. There are currently 32 provinces. During the Soviet
occupation and the development of country-wide resistance, local
areas came increasingly under the control of mujahidin groups
that were largely independent of any higher authority; local commanders,
in some instances, asserted a measure of independence
also from the mujahidin leadership in Pakistan, establishing their
own systems of local government, collecting revenues, running
educational and other facilities, and even engaging in local negotiations.
Mujahidin groups retained links with the Peshawar parties
to ensure access to weapons that were doled out to the parties
by the government of Pakistan for distribution to fighters inside
Afghanistan.
The Taliban set up a shura (assembly), made up of senior Taliban
members and important tribal figures from the area. Each
shura made laws and collected taxes locally. The Taliban set up a
provisional government for the whole of Afghanistan, but it did
not exercise central control over the local shuras.
The process of setting up the transitional government in June
2002 by the Loya Jirga took many steps involving local government.
First, at the district and municipal level, traditional shura
councils met to pick electors—persons who cast ballots for Loya
Jirga delegates. Each district or municipality had to choose a predetermined
number of electors, based on the size of its population.
The electors then traveled to regional centers and cast
ballots, to choose from amongst themselves a smaller number of
loya jirga delegates— according to allotted numbers assigned to
each district. The delegates then took part in the Loya Jirga.
The warlords who rule various regions of the country exert
local control. The transitional government is attempting to integrate
local governing authorities with the central government, but
it lacks the loyalty from the warlords necessary to its governing
authority. More traditional elements of political authority—such
as Sufi networks, royal lineage, clan strength, age-based wisdom,
and the like—still exist and play a role in Afghan society. Karzai
is relying on these traditional sources of authority in his challenge
to the warlords and older Islamist leaders. The deep ethnic, linguistic,
sectarian, tribal, racial, and regional cleavages present in
the country create what is called “Qawm” identity, emphasizing
the local over higher-order formations. Qawm refers to the group
to which the individual considers himself to belong, whether a
subtribe, village, valley, or neighborhood. Local governing
authority relies upon these forms of identity and loyalty.
16JUDICIAL SYSTEM
Under the Taliban, there was no rule of law or independent judiciary.
Ad hoc rudimentary judicial systems were established based
on Taliban interpretation of Islamic law. Murderers were subjected
to public executions and thieves had a limb or two (one
hand, one foot) severed. Adulterers were stoned to death in public.
Taliban courts were said to have heard cases in sessions that
lasted only a few minutes. Prison conditions were poor and prisoners
were not given food. Normally, this was the responsibility
of the prisoners’ relatives who were allowed to visit to provide
them with food once or twice a week. Those who had no relatives
had to petition the local council or rely on other inmates.
In non-Taliban controlled areas, many municipal and provincial
authorities relied on some form of Islamic law and traditional
tribal codes of justice. The administration and implementation of
justice varied from area to area and depended on the whims of
local commanders or other authorities, who could summarily
execute, torture, and mete out punishments without reference to
any other authority.
As of 2002, Afghanistan's judicial system was fragmented,
with conflicts between such core institutions as the Ministry of
Justice, Supreme Court, and attorney general's office. In addition,
the judicial system's infrastructure was destroyed; the absence of
adequate court or ministry facilities, basic office furniture, and
minimal supplies made substantive progress difficult. There are
also tensions between religious and secular legal training with
regard to appointments of new judicial personnel. Until Afghanistan's
new constitution is adopted, the country's basic legal
framework will consist of its 1964 constitution and existing laws
and regulations to the extent that they accord with the Bonn
Agreement of 2001 and with international treaties to which
Afghanistan is a party. The Ministry of Justice is charged with
compiling current Afghan laws and assessing their compatibility
with international standards. However, texts of Afghan laws are
largely unavailable, even among attorneys, judges, law faculty,
and government agencies such as the Ministry of Justice. While in
power, the Taliban burned law books. There was no adequate law
library in the country as of June 2002.
17ARMED FORCES
Weapons information dates back to 1992, at which time there
were SU-17, MiG21, and Mi-8 combat aircraft in the country. In
1998, defense spending was estimated at $250 million or 14.7%
of GDP. In 2002, the US was leading the efforts in creation of a
national army. The international community as a whole made
commitments to helping Afghanistan build security institutions.
In 2002, Afghanistan requested $235 million from the UN for
60,000 men for the land army, 8000 for the airforce, and 12,000
border guards. Most of the army's infrastructure, barracks, and
depots were destroyed along with the Taliban.
18INTERNATIONAL COOPERATION
Afghanistan has been a member of the UN since 19 November
1946. Afghanistan also belongs to the Asian Development Bank,
the Colombo Plan, the Economic and Social Commission for Asia
and the Pacific (ESCAP), the G-77, the Islamic Development
Bank (IDB), and the Organization of the Islamic Conference.
19ECONOMY
Afghanistan’s economy has been devastated by over 20 years of
war. Hampered by an unintegrated economy until relatively late
in the post-World War II period, only in the 1950s did the building
of new roads begin to link the country’s commercial centers
with the wool and fruit-producing areas. Largely agricultural and
pastoral, the country is highly dependent on farming and livestock
raising (sheep and goats). In Afghanistan, 85 percent of the
people are engaged in agriculture. Industrial activity includes
small-scale production of textiles, soap, furniture, shoes, fertilizer,
cement, and handwoven carpets. The country has valuable mineral
resources, including large reserves of iron ore at Hajigak discovered
before the 2-decade old war, but only coal, salt, lapis
lazuli, barite, and chrome are available to be exploited. The discovery
of large quantities of natural gas in the north, for which a
pipeline to the former USSR was completed in 1967, increased
the country’s export earnings, at least until escalation of civil
strife in the late 1970s and 1980s.
Since the outbreak of war in the late 1970s, economic data
have been contradictory and of doubtful reliability. In September
1987, the Afghan foreign minister asserted that 350 bridges and
258 factories had been destroyed since the fighting began in
1979. By the early 1990s, two-thirds of all paved roads were
unusable, and the countryside appeared severely depopulated,
with more than 25% of the population—twice the prewar level—
residing in urban areas. What little is left of the country’s infrastructure
has been largely destroyed due first to the war, and then
to the US-led bombing campaign. Severe drought added to the
nation's difficulties in 1998-2001. The majority of the population
continues to suffer from insufficient food, clothing, housing, and
medical care, problems exacerbated by military operations and
political uncertainties. The presence of an estimated 10 million
land mines has also hindered the ability of Afghans to engage in
agriculture or other forms of economic activity. Inflation remains
a serious problem.
Opium poppy cultivation is the mainstay of the economy.
Major political factions in the country profit from the drug trade.
In 1999, encouraged by good weather and high prices, poppy
producers had increased the area under cultivation by 43 percent
and harvested a bumper crop—a record 4,600 tons, compared
with 2,100 tons the year before. A ban on poppy production cut
cultivation in 2001 by 97% to 1695 hectares (4188 acres), with a
potential production of 74 tons of opium. Afghanistan is a major
source of hashish, and there are many heroin-processing laboratories
throughout the country.
International efforts to rebuild Afghanistan were addressed at
the Tokyo Donors Conference for Afghan Reconstruction in January
2002, when $4.5 billion was collected for a trust fund to be
administered by the World Bank. Priority areas for reconstruction
included the construction of education, health, and sanitation
facilities, enhancement of administrative capacity, the development
of the agricultural sector, and the rebuilding of road, energy,
and telecommunication links.
20INCOME
The US Central Intelligence Agency (CIA) reported that in 2000
Afghanistan’s gross domestic product (GDP) was estimated at
$21 billion. The per capita GDP was estimated at $800. The CIA
defines GDP as the value of all final goods and services produced
within a nation in a given year and computed on the basis of purchasing
power parity (PPP) rather than value as measured on the
basis of the rate of exchange. It was estimated that agriculture
accounted for 60% of GDP, industry 20%, and services 20%.
Foreign aid receipts amounted to about $15 per capita.
21LABOR
Afghanistan’s labor force is estimated at 10 million. As of 2002,
85% of the economically active population was engaged in agriculture.
The textile industry is the largest employer of industrial
labor; weaving of cloth and carpets is the most important home
industry. In 1978, the government established the Central Council
of Afghanistan Trade Unions in order to develop the trade
union movement. In the mid-1980s, the council had some
285,000 members. Under the Taliban, the government did not
have the means to enforce worker rights, as there was no functioning
constitution or legal framework that defined them. Little
was known about labor laws and practices under Taliban rule.
There is no information pertaining to minimum wages or work
hours and conditions. The vast majority of workers are in the
informal economy. Children as young as six years old are reportedly
working to help sustain their families.
22AGRICULTURE
About 12% of the land is arable and less than 6% currently is
cultivated. Normally, Afghanistan grew about 95% of its needs in
wheat and rye, and more than met its needs in rice, potatoes,
pulses, nuts, and seeds; it depended on imports only for some
wheat, sugar, and edible fats and oils. Fruit, both fresh and preserved
(with bread), is a staple food for many Afghans. Agricultural
production, however, is a fraction of its potential.
Agricultural production is constrained by an almost total dependence
on erratic winter snows and spring rains for water; irrigation
is primitive. Relatively little use is made of machines,
chemical fertilizer, or pesticides.
The variety of the country’s crops corresponds to its topography.
The areas around Kandahar, Herat, and the broad Kabul
plain yield fruits of many kinds. The northern regions from
Takhar to Badghis and Herat and Helmand provinces produce
cotton. Corn is grown extensively in Paktia and Nangarhar provinces,
and rice mainly in Kunduz, Baghlan, and Laghman provinces.
Wheat is common to several regions, and makes up 80% of
all grain production. Aggregate wheat production in 2002 was
estimated at 2.69 million tons, some 67 percent more than was
achieved in 2001. Following wheat, the most important crops in
2000 were barley (74,000 tons) corn (115,000 tons), rice
(232,800 tons), potatoes (235,000 tons), and cotton. Nuts and
fruit, including pistachios, almonds, grapes, melons, apricots,
cherries, figs, mulberries, and pomegranates are among Afghanstan's
most important exports.
Agricultural products accounted for about 53% of Afghanistan’s
exports in 2001, of which fruits and nuts were a large portion.
In some regions, agricultural production had all but ceased
due to destruction caused by the war and the migration of
Afghans out of those areas. A law of May 1987 relaxed the
restrictions on private landowning set in 1978: the limit of permitted
individual holding was raised from 6 to 18 hectares (from
15 to 45 acres). Opium and hashish are also widely grown for the
drug trade. Opium is easy to cultivate and transport and offers a
quick source of income for impoverished Afghans. Afghanistan
was the world's largest producer of raw opium in 1999 and 2000.
In 2000 the Taliban banned opium poppy cultivation but failed to
destroy the existing stockpile and presumably benefited substantially
from resulting price increases. Later, in 2001, the Taliban
reportedly announced that poppy cultivation could resume.
Much of Afghanistan's opium production is refined into heroin
and is either consumed by a growing South Asian addict population
or exported, primarily to Europe. Replacing the poppy
industry is a goal of the Karzai administration.
23ANIMAL HUSBANDRY
The availability of land suitable for grazing has made animal husbandry
an important part of the economy. Natural pastures cover
some 3 million hectares (7.4 million acres) but are being overgrazed.
The northern regions around Mazar-i-Sharif and Maymanah
were the home range for about 6 million karakul sheep in
1998.
The output of livestock products in 1998, as projected by the
FAO, included 300,000 tons of cows’ milk, 201,000 tons of
sheep’s milk, 41,000 tons of goats’ milk, 18,000 tons of eggs,
16,000 tons of wool (greasy basis), and 16,000 tons of sheepand
goatskins. Much of Afghanistan’s livestock was removed
from the country by early waves of refugees who fled to Pakistan
and Iran. Total meat output in 2000 was 356,840 tons.
In 2001, the livestock population in Afghanistan had declined
by about 40 percent since 1998. In 2002, this figure was estimated
to have declined further to 60 percent. An FAO survey
done in the Northern Regions during the spring of 2002 showed
that in four provinces (Balkh, Juzjan, Saripol and Faryab), there
was a loss of about 84 percent of cattle (1997/98: 224,296 head;
2002: 36,471 head) and around 80 percent of sheep and goats
(1997/98: 1,721,021 head; 2002: 359,953 head).
24FISHING
Some fishing takes place in the lakes and rivers, but fish does not
constitute a significant part of the Afghan diet. Using explosives
for fishing or so-called dynamite fishing is trend that has become
very popular since the 1980’s and is common practice in the
country. The annual catch was about 1,000 tons in 2000.
25FORESTRY
Afghanistan’s timber has been greatly depleted, and since the
mid-1980s, only about 3% of the land area has been forested,
mainly in the east. Significant stands of trees have been destroyed
by the ravages of the war. Exploitation has been hampered by
lack of power and access roads. Moreover, the distribution of the
forest is uneven, and most of the remaining woodland is presently
found only in mountainous regions in the southeast and south.
The natural forests in Afghanistan are mainly of two types: (1)
dense forests, mainly of oak, walnut and other species of nuts
that grow in the southeast, and on the northern and northeastern
slopes of the Sulaiman ranges; and (2) sparsely distributed short
trees and shrubs on all other slopes of the Hindu Kush. The dense
forests of the southeast cover only 2.7% of the country. The
destruction of the forests to create agricultural land, logging, forest
fires, plant disease and insect pests are all causes of the reduction
in forest coverage. However, the most important factor in
this destructive process is illegal logging and clear-cuttings by timber
smugglers. According to a report in 1997, two and half million
cubic feet of lumber were smuggled out of Afghanistan
between 1995 and 1996, and sold in Pakistan with permission
from the Pakistani Government of that time. However, the unofficial
numbers for the amount of lumber smuggled into Pakistan
from Afghanistan is estimated to be much higher than this.
26MINING
Afghanistan has valuable deposits of barite, beryl, chrome, coal,
copper, iron, lapis lazuli, lead, mica, natural gas, petroleum, salt,
silver, sulfur, and zinc. Reserves of high-grade iron ore, discovered
years ago at the Hajigak hills in Bamyan Province, are estimated
to total 2 billion tons.
On average, some 114,000 tons of coal were mined each year
during 1978–84. It is estimated that the country has 73 million
tons of coal reserves, most of which is located in the region
between Herat and Badashkan in the northern part of the country.
Production in 2000 amounted to 200,000 tons. In 2000,
Afghanistan produced 13,000 tons of salt, 3,000 tons of gypsum,
5,000 tons of copper, and 120,000 tons of cement. Deposits of
lapis lazuli in Badakhshan are mined in small quantities. Like
other aspects of Afghanistan’s economy, exploitation of natural
resources has been disrupted by war. As well, the remote and rug- ged terrain, and an inadequate transportation network usually
have made mining these resources difficult.
27ENERGY AND POWER
Two decades of warfare have left Afghanistan’s power grid badly
damaged. As of October 2002, only 6% of the population had
access to electricity. In 2000, net electricity generation was 0.4
billion kWh, of which 36% came from fossil fuel, 64% from
hydropower, and none from other sources. In the same year, consumption
of electricity totaled 453.8 million kWh. Total installed
capacity at the beginning of 2001was 0.497 million kW. Three
hydroelectric plants were opened between 1965 and 1970, at
Jalalabad, Naghlu, and Mahi Par, near Kabul; another, at Kajaki,
in the upper Helmand River Valley, was opened in the mid-1970s.
In addition to the Naghlu, Mahi Par, and Kajaki plants, other
hydroelectric facilities that were operational as of 2002 included
plants at Sarobi, west of Kabul; Pol-e Khomri; Darunta, in Nangarhar
province; Dahla, in Kandahar province; and Mazar-i-
Sharif. In 1991, a new 72-collector solar installation was completed
in Kabul at a cost of $364 million. The installation heated
40,000 l of water to an average temperature of 60°C (140°F)
around the clock. Construction of two more power stations, with
a combined capacity of 600 kW, was planned in Charikar City.
The drought of 1998–2001 negatively affected Afghanistan’s
hydroelectric power production, which resulted in blackouts in
Kabul and other cities. Another generating turbine is being added
to the Kajaki Dam in Helmand province near Kandahar, with the
assistance of the Chinese Dongfeng Agricultural Machinery Company.
This will add 16.5 megawatts to its generating capacity
when completed. The Dahla Dam in Kandahar province was
restored to operation by 2001, along with the Breshna-Kot Dam
in Nangarhar province, which has a generating capacity of 11.5
MW. The 66-MW Mahipar hydro plant is operating as well.
Natural gas was Afghanistan’s only economically significant
export in 1995, going mainly to Uzbekistan via pipeline. Natural
gas reserves were once estimated by the Soviets at 140 billion cu
m. Production started in 1967 with 342 million cu m but had
risen to 2.6 billion cu m in 1995. In 1991, a new gas field was discovered
in Chekhcha, Jowzjan province. Natural gas was also
produced at Shiberghan and Sar-i-Pol. As of 2002, other operational
gas fields were located at Djarquduk, Khowaja Gogerdak,
and Yatimtaq, all in Jowzjan province. As of 1997, natural gas
production was 543,000 cu m (19 million cu ft). It was used
domestically for urea production, power generation, and at a fertilizer
plant.
In August 1996, a multinational consortium agreed to construct
a 1,430 km (890 mi) pipeline through Afghanistan to carry
natural gas from Turkmenistan to Pakistan, at a cost of about $2
billion. However US air strikes led to cancellation of the project
in 1998, and financing of such a project has remained an issue
because of high political risk and security concerns. As of 2002
interim president Hamid Karzai was attempting to revive the
pipeline project.
A very small amount of crude oil is produced at the Angot field
in the northern Sar-i-Pol province. Another small oilfield at Zomrad
Sai near Shiberghan was reportedly undergoing repairs in
mid-2001. Petroleum products such as diesel, gasoline, and jet
fuel are imported, mainly from Pakistan and Turkmenistan. A
small storage and distribution facility exists in Jalalabad on the
highway between Kabul and Peshawar, Pakistan. Afghanistan is
also reported to have oil reserves totaling 95 million barrels and
coal reserves totaling 73 million tons.
28INDUSTRY
As with other sectors of the economy, Afghanistan’s already
beleaguered industries have been devastated by over two decades
of civil strife and war that left most of the countries factories and
even much of the cottage industry sector inoperative. Still in an
early stage of growth before the outbreak of war, industry’s development
has been stunted since; those few industries that have
continued production remain limited to processing of local materials.
The principal modern industry is cotton textile production,
with factories at Pol e Khomri, Golbahar, Begram, Balkh, and
Jabal as Saraj, just north of Charikar. Important industries in
2000 included textiles, soap, furniture, shoes, fertilizer, cement,
handwoven carpets, natural gas, coal, and copper.
Carpet making is the most important handicraft industry, but
it has suffered with the flight of rug makers during the civil war
and since the 2001 US-led bombing campaign. Carpet-making is
centered around the north and northwest regions of the country.
Afghan carpets are made of pure wool and are hand-knotted, and
much of the work is done by women. Production has fluctuated
widely from year to year, increasing somewhat during the early
1990s with the establishment of selected “zones of tranquility”
targeted for UN reconstruction assistance. Other handicrafts
include feltmaking and the weaving of cotton, woolen, and silk
cloth. Wood and stone carving have been concentrated in the
northeastern provinces, while jewelrymaking has been done in
the Kabul area. The making of leather goods has also been a
handicraft industry.
29SCIENCE AND TECHNOLOGY
The Afghanistan Academy of Sciences, founded in 1979, is the
principal scientific institution. As of 2002, it had about 180 members.
Prospective members of the Academy must take a written
exam, present samples of their work, and pass a proficiency exam
in one of the official languages of the UN. Many Afghan scientists
migrated to Europe, the US, and Pakistan during over two
decades of war. Under the Taliban, professors who did not teach
Islamic studies were relieved of their duties.
The Department of Geology and Mineral Survey within the
Ministry of Mines and Industries conducts geological and mineralogical
research, mapping, prospecting and exploration.
The Institute of Public Health, founded in 1962, conducts public
health training and research and study of indigenous diseases,
has a Government reference laboratory, and compiles statistical
data.
Kabul University, founded in 1932, has faculties of Science,
Pharmacy, Veterinary Medicine, and Geo-Sciences. Its faculty
numbers close to 200. The University of Balkh has about 100
faculty members. Bayazid Roshan University of Nangarhar,
founded in 1962, has faculties of Medicine and Engineering—its
faculty numbers close to 100. The Institute of Agriculture,
founded in 1924, offers courses in veterinary medicine. Kabul
Polytechnic College, founded in 1951, offers post-graduate
engineering courses. Kabul Polytechnic was the site of the June
2002 Loya Jirga, and the international community spent over $7
million to refurbish part of the campus for the assembly.
Buildings on campus had suffered heavy bomb damage. During
the 1990s, the campus was shelled and looted by mujahidin
groups who fought amongst themselves for control of the capital.
Boarding students studying under the rule of the Taliban lived in
makeshift dormitories.
30DOMESTIC TRADE
Kabul, Kandah ¯ ar, Maz ¯ ar-e-Sharif, and Her ¯ at are the principal
commercial cities of eastern, southern, northern, and western
Afghanistan, respectively. The first two are the main distribution
centers for imports arriving from the direction of Pakistan; the
latter two, for materials arriving from Iran and the former USSR.
Hours of business vary. The destruction of paved roads has
severely constrained normal domestic trade in most rural parts of
the country. Heavy fighting in Kabul has completely destroyed
the city’s infrastructure.
31FOREIGN TRADE
Although the Taliban had brought a repressive order to the 90%
of the country under its rule, it was unable to attract foreign
investment as long as it was unable to gain international recognition.
Hyperinflation had increased the number of Afghanis (the
country’s currency) needed to equal one US dollar from 50 in the
early 1990s to a virtually worthless 42,000 in 1999. On October
7, 2002, the first anniversary of the start of the US-led bombing
campaign in Afghanistan, a new Afghan currency came into use.
Also called the Afghani, the new notes were worth 1000 of the
old notes, which were phased out. The government will exchange
the dostumi currency, which is used in northern Afghanistan and
named after the region’s warlord Abdul Rashid Dostum, into new
Afghanis at half the value of old Afghanis. Around 1800 tons of
old Afghanis were due to be burned or recycled.
The value of exports, including fruits and nuts, carpets, wool,
cotton, hides and pelts, and gems totaled an estimated $1.2 billion
in 2001. Imports, including food, petroleum products, and
most commodity items totaled an estimated $1.3 billion.
Principal trading partners in 2000 (in percentages) were as follows:
COUNTRY EXPORTS IMPORTS
Pakistan 27.8 23
India 7.7
Turkmenistan 7.1
Japan 9.9
China (inc. Hong Kong) 4.9
Kenya 8
Belgium 13
Finland 6.8
Kazakhstan 10.9
32BALANCE OF PAYMENTS
Between 1951 and 1973, Afghanistan’s year-end international
reserves were never lower than $38 million or higher than $65
million. Development of the natural gas industry and favorable
prices for some of the country’s agricultural exports led to
increases in international reserves, to $67.5 million in 1974 and
to $115.4 million as of 31 December 1975. Exploitation of natural
gas also freed Afghanistan from extreme dependence on petroleum
imports and from the rapid increases in import costs that
most countries experienced in 1973 and 1974. Increased trade
with the former USSR and Eastern Europe in the late 1970s and
1980s resulted in a reduction of foreign exchange earnings, since
trade surpluses are counted as a credit against future imports.
Foreign exchange reserves declined from $411.1 million at the
close of 1979 to $262 million as of 30 May 1987. The public foreign
debt in 1997 stood at $5.49 billion. Reliable statistics are not
available for the ensuing years. However, the US Central Intelligence
Agency (CIA) reports that in 2001 the purchasing power
parity of Afghanistan’s exports was $1.2 billion while imports
totaled $1.3 billion resulting in a trade deficit of $100 million.
33BANKING AND SECURITIES
The government central bank, the Bank of Afghanistan, was
founded in 1939. In 1999, the UN Security Council passed a resolution
placing the Bank of Afghanistan on a consolidated list of
persons and entities whose funds and financial resources should
be frozen, due to the fact that the bank was controlled by the Taliban
regime. The Interim Administration of Afghanistan
requested in January 2002 that the bank be removed from the
consolidated list, and the Security Council agreed.
All banks in Afghanistan were nationalized in 1975. In the
early 1980s there were seven banks in the country, including the
Agricultural Development Bank, the Export Promotion Bank, the
Industrial Development Bank, and the Mortgage and Construction
Bank.
There is no organized domestic securities market.
34INSURANCE
The fate of the Afghan National Insurance Co., which covered
fire, transport, and accident insurance, is unknown as of 2002.
35PUBLIC FINANCE
The fiscal year ends 20 March. Budget breakdowns have not been
available since 1979/80, when revenues totaled Af15,788 million
and expenditures Af16,782 million. In 2002, the Interim and
Transitional governing authorities were working with donor aid
agencies to finance the rebuilding of Afghanistan’s infrastructure
and society. The Interim Administration was supported by the
Asian Development Bank, the Islamic Development Bank, UNDP,
and the World Bank. An Implementation Group was established
to operate an “Operational Costs Trust Fund” for Afghanistan,
to be effective when the UNDP “Start-up Fund” ceased, to cover
expenditures normally financed by domestic revenue. The Operational
Costs Trust Fund will cease to operate when the situation
in Afghanistan would approach fiscal normality, estimated by
2006, when the government would be able to finance most or all
of its own costs.
The US Central Intelligence Agency (CIA) estimates that in
2000 Afghanistan’s external debt totaled $5.5 billion.
36TAXATION
In the early 1980s, direct taxes accounted for about 15% of government
revenues. The share provided by indirect taxes declined
from 42% to 30%, as revenues from natural gas and state enterprises
played an increasing role in government finance. Tax collection,
never an effective source of revenue in rural areas, was
essentially disabled by the disruption caused by fighting and mass
flight. Under the Taliban, arbitrary taxes, including those on
humanitarian goods, were imposed.
37CUSTOMS AND DUTIES
Before the turmoil of the late 1970s, customs duties, levied as a
source of revenue rather than as a protective measure, constituted
more than one-fourth of total government revenue. As of 1993,
both specific and ad valorem duties of 20–35% were levied on
imports. Other costs included service and Red Crescent charges;
monopoly and luxury taxes; authorization and privilege charges,
and a commission-type duty.
After the fall of the Taliban, Afghanistan’s warlords collected
customs duties for themselves rather than transferring the funds
to the Interim and Transitional authorities in Kabul. In May
2002, it was estimated that between $6 and $7 million in customs
duties were paid each month at Afghanistan’s borders with Pakistan,
Iran, and Uzbekistan, very little of which went into the government
treasury.
38FOREIGN INVESTMENT
A 1967 law encouraged investment of private foreign capital in
Afghanistan, but under the PDPA government, Western investment
virtually ceased. Between 1979 and 1987, the former USSR
provided technical and financial assistance on more than 200
projects, including various industrial plants, irrigation dams, agricultural
stations, and a new terminal at the Kabul airport. After
1990, reconstruction investments from Russia, Japan, and the US
were channeled through the United Nations. The Taliban called
for Western support to help reconstruct Afghanistan, but Western
donors—already reluctant to support UN programs in the country—
did not respond. After the fall of the Taliban, head-of-state
Hamid Karzai encouraged foreign countries for direct investment
in Afghanistan, first to reach the people in the provinces who
require salaries and owe taxes, and then to invest in businesses
that would lead to industrial and technological development.
39ECONOMIC DEVELOPMENT
As of 2002, the World Bank was managing an Afghan Reconstruction
Trust Fund (ARTF) to assist the Interim Administration
in funding physical reconstruction projects, including in the
health sector, as well as managing expenses such as salaries for
state employees. The ARTF began in May 2002, as a joint proposal
of the World Bank, the UN Development Program (UNDP),
the Asian Development Bank, and the Islamic Development
Bank. It was set up to streamline international support to
Afghanistan by organizing aid pledges within a single mechanism.
Contributions to the ARTF are anticipated to total more than
$60 million in the first year, and $380 million over 4 years. As of
November 2002, pledges of funding for Afghanistan reached
more than $4.5 billion for the first 30 months.
40SOCIAL DEVELOPMENT
Social welfare in Afghanistan has traditionally relied on family
and tribal organization. In the villages and small towns, a tax is
levied on each man to benefit the poor. Disabled people are cared
for in social welfare centers in the provincial capitals. Most other
welfare activities are still unorganized and in private hands. In the
early 1990s, a social insurance system provided old age, disability,
and survivors’ pensions, sickness and maternity benefits, and
workers’ compensation.
Women have traditionally had few rights in Afghanistan, with
their role limited largely to the home and the fields. Advances in
women’s rights were made from 1920 onward, and by the time of
the communist coup, women attended school in large numbers,
voted and held government jobs—including posts as cabinet ministers,
and were active in the professions. The Communist regime
also promoted women’s rights, but the victory of the extremely
conservative Taliban in 1996 reversed this trend. Strict limits on
the freedoms of women were put in place. Women were only
allowed to appear in public if they were dressed in a chadri, or
burka, a long black or blue garment with a mesh veil covering the
face, and only if accompanied by a male. The Taliban also
banned girls from attending school, and prohibited women from
working outside the home. Certain restrictions on women were
reportedly lifted in 1998. Women were allowed to work as doctors
and nurses as long as they treated only women, and were
able to attend medical schools. Widows with no means of support
were allowed to seek employment.
The human rights record of the governing Taliban was
extremely poor. Taliban forces were responsible for disappearances
and political killings, including massacres and summary
executions. In areas controlled by the Taliban, Islamic courts and
religious police imposed strict order based on conservative interpretations
of Islamic law that mandated, among other measures,
public execution for adultery and amputation for theft. Homes
were burned and livestock destroyed in a military offensive in the
summer of 1999 that resulted in the forcible relocation of many
civilians. Basic freedoms of speech, assembly, religion, and association
were abridged under Taliban rule.
With the end of the Taliban, women and girls were permitted
to attend schools and universities, and the enforced wearing of
the burka was ended. Men were allowed to shave, music and television
were permitted, and a host of Taliban-imposed restrictions
on society ended. A broad-based, pluralistic society is being fostered,
with a high degree of respect for human rights and basic
freedoms.
41HEALTH
Starvation, disease, death, war, and migration had devastating
effects on Afghanistan’s health infrastructure in the 1990s.
According to the World Health Organization, medication was
scarce. Infectious diseases accounted for more than half of all
hospital admissions (mostly malaria and typhoid) in 1994. Even
before the war disrupted medical services, health conditions in
Afghanistan were inadequate by western standards. A national
medical school was established in 1931 and, in the following
year, the first tuberculosis hospital was built. In 1990, for every
100,000 people, 278 were stricken with tuberculosis.
Efforts to take medical services to war-ravaged areas of
Afghanistan and to areas left without public health programs due
to the termination of services were waged by volunteer medical
programs from France, Sweden, the US, and other countries.
In 1991, there were 2,233 doctors, 510 pharmacists, 267 dentists,
1,451 nurses, and 338 midwives. Between 1985-1995 only
29% of the population had access to health services. During
those same years, few of the population had access to safe water
(10%) and adequate sanitation (8%). For children under one the
immunization rates were as follows: tuberculosis (44%), diphtheria,
pertussus, and tetanus (18%), polio (18%), and measles
(40%) between 1990–94.
In 2002, estimated life expectancy was 46.6 years—one of the
lowest in the world—and infant mortality was estimated at 145
per 1,000 live births, which makes the country have the world's
fourth highest mortality rate for children under age 5. The maternal
mortality rate in 2002 was one of the highest in the Central
Asia region with 1,600 maternal deaths per 100,000 live births.
The death rate in 2002 was 17 per 1,000 people. Cholera reached
epidemic proportions with 19,903 cases reported in 1995. In
2002, 80,000 children a year were dying of diarrheal disease.
From 1978 to 1991, there were over 1,500,000 war-related
deaths. It is estimated that 3767 civilians died because of US
bombs in Afghanistan between October 7 and December 7 of
2001. Approximately 300–400 civilians were killed betweeen
October 2001 and July 2002.
As of 2002, Afghanistan had an average of four hospital beds
for every 10,000 people. Most of the country's facilities are in
Kabul, and those needing treatment must traverse the countryside
to get there. Health care is being provided by the international
community primarily. Some military field hospitals were set up as
a result of the US-led coalition war. There are some medical facilities
supported by the Red Cross operating in the country. In 24
of 31 provinces there are no hospitals or medical staff. For every
10,000 people in the country, there is an average of 1.8 physicians.
Primary care physicians are most needed for pediatrics,
women’s health, internal medicine, and ob-gyn. Afghan physicians
need training and retraining to upgrade their skills and
knowledge base.
42HOUSING
Houses in farming communities are built largely of mud brick
and frequently grouped within a fortified enclosure, to provide
protection from marauders. The roofs are flat, with a coating of
mixed straw and mud rolled hard above a ceiling of horizontal
poles, although in areas where timber is scarce, separate mud
brick domes crown each room. Cement and other modern building
materials are widely used in cities and towns. Every town has
at least one wide thoroughfare, but other streets are narrow lanes
between houses of mud brick, taller than those in the villages and
featuring decorative wooden balconies. The war and bombing
campaign has severely damaged or destroyed countless houses.
According to an official report, there were 200,000 dwellings in
Kabul in the mid-1980s. The latest available figures for 1980–88
show a total housing stock of 3,500,000 with 4.4 people per
dwelling.
In 2002, over 100,000 shelters were needed throughout
Afghanitan for returning refugees, internally displaced persons,
and the extremely poor who had very limited covered space, in
both rural and urban areas. The UN High Commissioner for Refugees
(UNHCR) is the leader in the firld of shelter. Other funders
include the UN Development Program, the International Organization
for Migration, and CARE International, while the agencies
implementing the programs are the Ministry for Rural Rehabilitation
and Development (MRRD) in Afghanistan, the United
Nations Human Settlement Program (Habitat), the International
Rescue Committee (IRC) as well as an assortment of international
and local nongovernmental organizations (NGOs).
43EDUCATION
Adult illiteracy for the year 2002 for males was 49%; females,
79%. This is the highest illiteracy rate in Asia. Education is free
at all levels. Primary education lasts for six years and is theoretically
compulsory for 6 years, but only 53% of boys and 5% of
girls were enrolled in elementary school in 2002. Boys and girls
are schooled separately. A teacher has on average 58 pupils in an
elementary school classroom, but only 28 students in a secondary
school classroom. Only 32% of the males and 11% of females
graduating from elementary school continue into secondary education.
Vocational training is provided in secondary schools and
senior high schools, and six percent of students are enrolled in the
vocational system. Secondary education lasts for another six
years. Children are taught in their mother tongue, Dari (Persian)
or Pashtu (Pashto), during the first three grades; the second official
language is introduced in the fourth grade. Children are also
taught Arabic so that they may be able to read the Koran
(Qur’an). The school year extends from early March to November
in the cold areas and from September to June in the warmer
regions. The school-aged population in Afghanistan is 6,650,000.
In addition to the secular public education system, the traditional
Islamic madrassa school system is functioning. At the
madrassas, children study the Koran, the Hadith (Sayings of the
Prophet Mohammad), and popular religious texts.
Under the Taliban regime, girls were not allowed to have education
at all levels. All teachers have civil service status. The educational
system is totally centralized by the state.
The University of Kabul, which is now coeducational, was
founded in 1932. In 1962, a faculty of medicine was established
at Jalalabad in Nangarhar Province; this faculty subsequently
became the University of Nangarhar. By 2002 a total of 8 universities
had been established in Afghanistan along with 9 pedagogical
institutes. The number of Afghans enrolled in higher
education was expected to double from 26,000 to 52,000 by
2003. An estimated one thousand women throughout Afghanistan
participated in university entrance examinations in 2002.
44LIBRARIES AND MUSEUMS
For centuries, manuscript collections were in the hands of the rulers,
local feudal lords, and renowned religious families. Printing
came fairly late to Afghanistan, but with the shift from the handwritten
manuscript to the printed book, various collections were
formed. Kabul has a public library (1920) with 60,000 volumes,
and the library of the University of Kabul has 250,000 volumes.
There is a library at Kabul Polytechnic University with 6,000 volumes
and a government library, at the ministry of education, also
in Kabul, with 30,000 volumes.
Prior to the devastating civil war, the Kabul Museum (founded
in 1922) possessed an unrivaled collection of stone heads, basreliefs,
ivory plaques and statuettes, bronzes, mural paintings,
and Buddhist material from excavations at Hadda, Bamian,
Bagram, and other sites. It also contained an extensive collection
of coins and a unique collection of Islamic bronzes, marble
reliefs, Kusham art, and ceramics from Ghazni. In nearly a
decade of warfare, however, the museum was plundered by the
various armed bands, with much of its collection sold on the
black market, or systematically destroyed. As of 2003, the Kabul
museum is slowly beginning some restoration. Also in Kabul, is
the Kabul University Science Museum, with an extensive zoological
collection and a museum of pathology. There are provincial
museums at Bamyan, Ghazni, Herat, Mazar-i-Sharif, Maimana,
and Kandahar. Major religious shrines have collections of valuable
objects. Due to the chaotic political situation in the 1990s, it
is impossible to determine the state of any of its collections.
In March 2001, the Taliban dynamited the Bamiyan Buddhas
and sold the debris and the remains of the original sculpture.
Small statues of the Buddhas in Foladi and Kakrak were
destroyed. Most of the statues and other “non-Islamic art” works
in the collections of the Kabul Museum were destroyed, including
those stored for security reasons in the Ministry of Information
and Culture. UNESCO has undertaken a plan to conserve the
archaeological remains and the minaret at Jam, and to make it a
World Heritage site. The minaret was built at the end of the 12th
century and at 65 meters is the second tallest in the world after
the Qutub Minar in New Delhi.
45MEDIA
Limited service to principal cities and some smaller towns and villages
is provided by the government-operated telegraph and telephone
services. Prior to 2001, there were some 30,000 telephones
currently in use. Local telephone networks were not operating
reliably in 2002. There is no commercial satellite telephone service
locally. The first television broadcast took place in 1978. As
of 1997, there were 63 radios and 4 television sets per 1,000 population.
Prior to the fall of the Taliban, the major newspapers, all headquartered
in Kabul, (with estimated 1999 circulations) were Anis
(25,000), published in Dari and Pashto; Hewad (12,200), and
New Kabul Times (5,000), in English. In January 2002, the independent
newspaper Kabul Weekly was published after having disappeared
when the Taliban seized power. The first issue carried
news in Dari, Pashto, English, and French. UNESCO is providing
aid to journalists and technical media staff, including those of
national television. It works to strenghthen the Afghan News
Agency by training journalists, and has projects for the development
of public service broadcasting. More than 100 high-quality
television productions from all over the world were sent to Radio
Television Afghanistan in 2002. That year, an Internet-equipped
computer training center was established within the Ministry of
Education in Kabul.
46ORGANIZATIONS
Organizations to advance public aims and goals are of recent origin
and most are sponsored and directed by the government. The
National Fatherland Front, consisting of tribal and political
groups that support the government, was founded in June 1981
to bolster the PDPA regime and to promote full and equal participation
of Afghan nationals in state affairs.
The Women’s Welfare Society carries on educational enterprises,
provides training in handicrafts, and dispenses charitable
aid, while the Maristun, a social service center, looks after children,
men, and women and teaches them crafts and trades. The
Revolutionary Association of the Women of Afghanistan
(RAWA), established in Kabul, Afghanistan, in 1977, is an independent
political organization of Afghan women focusing on
human rights and social justice.
With political changes in the country throughout the past
decade, a number of new women’s groups have developed. These
include the Afghan Women Social and Cultural Organization
(AWSCO, est. 1994), the Afghan Women’s Educational Center
(AWEC, est. 1991), the Afghan Women’s Network (AWN, est.
1995), the Educational Training Center for Poor Women and
Girls of Afghanistan (ECW, est. 1997), the New Afghanistan
Women Association (est. 2002 as a merger of the Afghan Women
Journalist Association and the Afghan Feminine Association),
and the World Organization for Mutual Afghan Network
(WOMAN, est. 2002).
The Union of Afghanistan Youth is a national non-government
organization representing the concerns of the nation’s youth and
young adults in the midst of transition and reconstruction. The
organization serves as a multi-party offshoot of the Democratic
Youth Organization of Afghanistan (DYOA), which has worked
closely with the People’s Democratic Party of Afghanistan.
Though the Scouting Movement of Afghanistan was disbanded in
1978, the World Organization of the Scout Movement (WOSM)
began conducting seminars in July 2003 to encourage and support
the rebirth of scouting programs.
The Red Crescent, the equivalent of the Red Cross, is active in
every province, with a national chapter of Red Crescent Youth
also active. An institute called the Pashto Tolanah promotes
knowledge of Pashto literature and the Historical Society (Anjuman-
i-Tarikh) amasses information on Afghan history. The
Afghan Carpet Exporters’ Guild, founded in 1987, promotes foreign
trade of Afghan carpets and works for the improvement of
the carpet industry.
47TOURISM, TRAVEL, AND RECREATION
The tourism industry, developed with government help in the
early 1970s, has been negligible since 1979 due to internal political
instability. A passport and visa are required for entrance into
Afghanistan. In 1999, the UN estimated the daily cost of staying
in Kabul at $70. Approximately 61% of these costs were estimated
to be the price of a room in a guest house. As travel was
highly restricted in the country due to the US-led campaign
against the Taliban and al-Qaeda, it is unknown what the daily
cost of staying in the country was in 2002.
48FAMOUS AFGHANS
The most renowned ruler of medieval Afghanistan, Mahmud of
Ghazni (971?–1030), was the Turkish creator of an empire
stretching from Ray and Isfahan in Iran to Lahore in India (now
in Pakistan) and from the Amu Darya (Oxus) River to the Arabian
Sea. Zahir ud-Din Babur (1483–1530), a Timurid prince of
Ferghana (now in the former USSR), established his base at Kabul
and from there waged campaigns leading to the expulsion of an
Afghan ruling dynasty, the Lodis, from Delhi and the foundation
of the Mughal Empire in India.
Many eminent figures of Arab and Persian intellectual history
were born or spent their careers in what is now Afghanistan. Al-
Biruni (973–1048), the great Arab encyclopedist, was born in
Khiva but settled in Ghazni, where he died. Abdul Majid Majdud
Sana‘i (1070–1140), the first major Persian poet to employ verse
for mystical and philosophical expression, was a native of
Ghazni. Jalal ud-Din Rumi (1207–73), who stands at the summit
of Persian poetry, was born in Balkh but migrated to Konya (Iconium)
in Turkey. The last of the celebrated Persian classical poets,
Abdur Rahman Jami (1414–92), was born in Khorasan but spent
most of his life in Herat. So did Behzad (1450?–1520), the greatest
master of Persian painting.
The founder of the state of Afghanistan was Ahmad Shah
Abdali (1724–73), who changed his dynastic name to Durrani.
He conquered Kashmir and Delhi and, with his capital at Kandahar,
ruled over an empire that also stretched from the Amu Darya
to the Arabian Sea. Dost Muhammad (1789–1863) was the
founder of the Muhammadzai (Barakzai) dynasty. In a turbulent
career, he both fought and made peace with the British in India,
and unified the country. His grandson, Abdur Rahman Khan
(1844–1901), established order after protracted civil strife.
Amanullah Khan (1892–1960), who reigned from 1919 to 1929,
tried social reforms aimed at Westernizing the country but was
forced to abdicate. Muhammad Nadir Shah (d.1933), who was
elected king by a tribal assembly in 1929, continued Amanullah’s
Westernization program. His son, Muhammad Zahir Shah
(b.1914), was king until he was deposed by a coup in July 1973.
Lieut. Gen. Sardar Muhammad Daoud Khan (1909–78), cousin
and brother-in-law of King Zahir, was the leader of the coup and
the founder and first president of the Republic of Afghanistan.
Leaders in the violent years since the 1978 “Saur Revolution”
have been Nur Muhammad Taraki (1917–79), founder of the
PDPA; Hafizullah Amin (1929–79), Taraki’s successor as president
of the Revolutionary Council and secretary-general of the
PDPA; Babrak Karmal (1929), leader of the pro-Soviet Parcham
group of the PDPA and chief of state from December 1979 until
May 1986; and Dr. Najibullah (1947–96), former head of the
Afghan secret police who was brutally executed by the Taliban
militia after they seized control of Kabul.
49DEPENDENCIES
Afghanistan has no territories or colonies.
50BIBLIOGRAPHY
Adamec, Ludwig W. Dictionary of Afghan Wars, Revolutions,
and Insurgencies. Lanham, Md.: Scarecrow Press, 1996.
Bonner, Arthur. Among the Afghans. Durham, N.C.: Duke
University Press, 1987.
Clifford, Mary Louise. The Land and People of Afghanistan.
New York: Lippincott, 1989.
Emadi, Hafizullah. State, Revolution, and Superpowers in
Afghanistan. New York: Praeger, 1990.
Ewans, Sir Martin. Afghanistan: A Short History of Its People
and Politics. New York: HarperCollins, 2002.
Giustozzi, Antonio. War, Politics, and Society in Afghanistan,
1978–1992. Washington, D.C.: Georgetown University Press,
2000.
Goodson, Larry P. Afghanistan’s Endless War: State Failure,
Regional Politics, and the Rise of the Taliban. Seattle:
University of Washington Press, 2001.
Grasselli, Gabriella. British and American Responses to the
Soviet Invation of Afghanistan. Aldershot, England:
Dartmouth, 1996.
Kakar, M. Hasan. Afghanistan: The Soviet Invasion and the
Afghan Response, 1979–1982. Berkeley: University of
California Press, 1995.
Magnus, Ralph H. Afghanistan: Mullah, Marx, and Mujahid.
Boulder, Colo.: Westview Press, 1998.
Muhammad, Fayz. Kabul under Siege: Fayz Muhammad’s
Account of the 1929 Uprising. Princeton: Markus Wiener
Publishers, 1999.
O’Balance, Edgar. Afghan Wars, 1839–1992: What Britain Gave
Up and the Soviet Union Lost. New York: Barssey’s, 1993.
Rall, Ted. To Afghanistan and Back: A Graphic Travelogue. New
York: Nantier, Beall, Minoustchine, 2002.

Marc Forné Molné ANDORRA

2008-11-12T22:29:00.000-08:00

Executive Council President
(pronounced “MARK for-NAY mol-NAY”)
“Institutions are the pillars of our community: a democratic parliamentary system that began in
1419, and a culture of peace which has continued uninterrupted since 1278.”
The Principality of Andorra, despite its name, has been a
constitutional republic since 1993. It is a landlocked state
between Spain and France, and its culture, economy, and
political life reflect the influence of those two neighboring
countries. One of the smallest countries in the world,
Andorra has only 468 sq km (181 sq mi) of territory, making
it slightly more than twice the size of Washington, D.C. The
capital city is Andorra la Vella. Andorra’s population was
estimated at 68,403 in July 2002, with a growth rate of
approximately 1.1%. Only about 30% of the population are
Andorran citizens. More than 60% of its inhabitants are
Spaniards and most of the rest are French nationals. Its large
foreign population is comprised of migrant laborers seeking
employment in its tourist industry and light manufacturing
companies, and of wealthy individuals residing in Andorra
because of its status as a tax haven. Historically, Andorra
used both the Spanish peseta and the French franc as official
currencies, but all three nations adopted the euro in 2002.
Catalan, spoken primarily in northeastern Spain, is the
official language, but most residents speak French and
Spanish as well. Ethnically, Andorran citizens are indistinguishable
from their French and Spanish neighbors. The
population is overwhelmingly Roman Catholic. There is no
state religion in Andorra and the Constitution explicitly
permits all faiths. Andorra produces raw tobacco, cigarettes,
and cigars, but its economy is built around tourism and a
growing banking industry.
POLITICAL BACKGROUND
Andorra has been considered a state since the 13th century,
but only recently has its population attained a large measure
of control over the country’s affairs. Archaeological evidence
indicates that Andorra’s mountain valleys were inhabited as
early as 4000 BC. During the early Christian era, the Romans
encouraged resident tribes to surrender their nomadic life and
form settlements there.
In 1278, the French count of Foix and the Spanish bishop
of Urgel became the “co-princes” of the country, granting
Andorra nominal independence but retaining authority over
its foreign contacts and trade. For centuries, Andorra was an
anomaly among states. Councils of Andorrans exercised an
element of self-expression; at the same time, ultimate
authority rested in the hands of the co-princes. The state was
therefore neither a principality nor a republic.
France and Spain ultimately spurred the Andorrans to
assume greater responsibility over their own affairs and to
move towards more democratic practices. For most of
Andorra’s history, there was no functioning executive office
within the government. Local councils and a national legislative
body provided day-to-day governing authority. Until
1970, the vote was given only to males who were from
families that had lived in Andorra for at least three generations.
In that year, women obtained the vote. Few foreigners
were allowed to gain citizenship. The Andorrans permitted
no political parties and no labor unions. In 1975, the Spanish
dictator Francisco Franco died and Spain embraced
democracy. From that moment, Spain, together with France,
encouraged reform in Andorra. In 1981, an institution with
vague executive powers was created, but efforts to codify a
coherent body of law and a constitution failed. In 1993,
Andorrans declared their independence. A Constitution gave
Andorra sovereignty over most of its domestic affairs, trade,
and general foreign policy.
France and Spain, however, continue to guide important
aspects of life in Andorra. French and Spanish officials
oversee Andorra’s judicial system. Appeals to an ultimate
court of jurisdiction are heard in courts in either France or
Spain. Andorra has a small army comprised of males who
own firearms. They have not been engaged in a conflict for
over 700 years and today their duties are largely ceremonial.
France and Spain maintain responsibility for Andorran
defense policy.
The growing foreign population has provided much of the
capital for Andorra’s economy. By the 1970s, foreign
nationals began to seek a greater definition of their rights,
including eligibility for citizenship and the right to organize.
Andorrans, a minority in their own country, had traditionally
sought to limit foreigners’ rights. The Constitution is a
compromise in that it recognizes foreigners’ aspirations by
opening the door to citizenship but preserves political power
in the hands of the indigenous population. Political parties
and unions are now legal. Andorran families of long standing
dominate political life. Foreigners may gain citizenship after
30 years of residency or if they have lived in the country since
before 1975. Conservative Roman Catholic traditions are
strong in Andorra. Although women may vote, few have
succeeded in politics or business.
The Executive Council president is chosen by the General
Council, which has 28 members and is elected every four
years by a direct vote of all citizens over 18. The Executive
Council president appoints the cabinet, but the General
Council may bring down the government at any time by a
majority vote. These practices resemble a parliamentary
system, with the Executive Council president and the cabinet
functioning as the executive branch and the General Council
as the legislature. The most important cabinet offices are
foreign affairs, finance, the economy, and justice.
Power is fragmented among several parties. In the legislative
elections of 4 March 2001, more than 80% of eligible
voters cast ballots. The Liberal Party of Andorra (Partit
Liberal Andorra—PLA), a center-right party, won 16 seats on
the General Council; the center-left National Democratic
Group (Agrupament Nacional Democratic—AND) won six
seats. Three smaller parties—New Democracy (Nova Democracia—
ND), the National Democratic Initiative (Initiativa
Democratic Nacional—IDN), and the Union of Ordino
People (Unio Parroquial d’Ordino—UPO)—each won seats.
In 2001, the PLA formed a government for the third time (the
previous times were 1994 and 1997), again under Marc
Forné Molné.
PERSONAL BACKGROUND
Marc Forné Molné became Executive Council president in
1994 when the General Council removed Oscar Ribas Reig
on a vote of confidence motion. Forné (the custom in
Andorra is to use the second name as the last name) was born
on 30 December 1946, in La Massana. He received his
education at the University of Barcelona, Spain. He was
trained as an attorney and worked in his family law firm from
1974–94, where he practiced criminal and real estate law. He
also served as editor of a magazine for 11 years. Like most
Andorrans, Forné is a practicing Roman Catholic. He has
been active in Andorran political life since the 1970s, but
restrictions on political organization meant that he and other
political figures in Andorra kept a low profile until the
passage of the Constitution in 1993. In that year he founded
the Liberal Union Party, later renamed the Liberal Party of
Andorra (PLA). He was elected to Parliament in 1993 and a
year later became head of government.
RISE TO POWER
The government of Oscar Ribas fell because he was exploring
the possibility of instituting a broader system of taxation in
order to combat a growing budget deficit. By a vote of 20 to
eight, the General Council removed his government on 25
November 1994; only the members of his own party voted
for him. Forné was chosen to replace him because he was
viewed as a well-educated moderate who would continue
reform, but at a slower pace. Forné assumed power on 21
December 1994. Forné remained Executive Council president
following the 1997 and 2001 elections when his party won
the majority of seats in the General Council.
LEADERSHIP
Forné believes that for Andorra’s prosperity to continue, the
country must gradually become more engaged in the outside
world. Forné opposed Ribas’s efforts to institute broader
taxation and instead has concentrated on strengthening
Andorra’s links to the outside world in order to attract trade
and investment. His leadership is evident in several steps
taken shortly after he rose to power. In 1995, he attended
meetings of the United Nations (UN) in New York and used
the occasion to hold discussions with a number of current
and future potential trading partners. In 1996, Forné’s
government took a firm stand on a key international issue by
signing the Non-Proliferation Treaty. Signatories of this treaty
do not possess chemical, nuclear, or biological weapons and
pledge not to obtain them in the future. The treaty could
prove to be an important step in the effort to stem the sale
and development of weapons of mass destruction in the
aftermath of the Cold War. The Forné government is expected
to continue to support positions in the security field that
promote peaceful relations among nations.
DOMESTIC POLICY
Andorrans had traditionally pursued agriculture to make
their living. While sheep are still raised and the traditional
crops of tobacco and potatoes are still sown, Andorra’s
livelihood now depends upon tourism and an emerging
service industry of financial institutions. Domestic policy,
therefore, centers upon efforts to assure that outside guests
and capital continue to flow into the country. There is no
income tax in Andorra, a tradition that has attracted wealthy
residents who live in the country and, in some cases, establish
financial institutions such as banks and insurance companies.
Andorra has tight banking secrecy laws to encourage the
continued presence of such institutions. The U.S. government
and several European governments have expressed concern
that such laws encourage money laundering and the
investment of illegally gained capital in Andorra.
Raising revenue has become an important problem for
Andorra’s government. Because large numbers of foreign
laborers have been necessary to build Andorra’s many hotels
and restaurants, there has been a need to construct housing,
hospitals, and schools for these laborers and their families. In
addition, it has been necessary to improve roads, lay sewer
F R A N C E
S P A I N
A N D O R R A
Soldeu
Santa
Coloma
Arcabell
Anyos
Llorts
Pal
Farga
de Moles
Pas de
la Casa
Arinsal
El Serrat
Sant Juliá
de Lòria
Les
Escaldes
Encamp
Ordino
La Massána
Andorra
la Vella
Valira
Valira d'Orient
Valira del Nord
Os
Estany
d'Engolaster
ANDORRA
0 10 Miles 0 2 4 6 8 10 Kilometers 2 4 6 8
lines, and undertake a range of other tasks endemic in
countries experiencing rapid growth—and to accomplish
such efforts without an income tax. Some steps have been
taken to keep the Andorran treasury at least partly filled.
Foreigners must pay an annual levy in order to maintain the
right to stay in the country. This annual levy provides funds
for a substantial part of the country’s budget. A small import
tax on the large amount of consumer goods brought into the
country for sale to visitors also supplies revenue for the
country’s treasury. The only tax on the individual Andorran
citizen is a modest fee collected for telephone and electricity
use. The Andorran government has run a deficit since the
early 1990s and methods short of an income tax are being
considered to raise further revenues.
FOREIGN POLICY
Andorra has no armed forces trained for combat and its
defense policy is handled by France and Spain. In part
because it is landlocked between two large, powerful
neighbors with which it is on good terms, Andorra has no
apparent need for armed forces and defense arrangements
beyond the protection or assistance that France and Spain
provide.
From the mid-1980s, France and Spain attempted to
nudge Andorra not only towards independence and
democracy, but into firmer contacts with the outside world.
To some extent, this effort by Andorra’s neighbors was
economically based: citizens from France and Spain sought
greater certainty from their Andorran hosts when applying
for work or residence permits. Politically, Paris and Madrid
wished to see these workers gain rights of representation,
something that was not allowed until a constitution guaranteeing
such rights could be adopted. Independence in March
1993 was quickly followed by openings to the outside world
and the establishment of civil and political norms common in
European democracies. In July 1993, Andorra joined the UN.
It has established diplomatic and trade relations with a
number of countries, such as China, Cuba, South Korea, and
Indonesia, from which it imports raw materials or finished
goods for resale to foreign visitors. Although it has diplomatic
relations with these countries, it has no diplomatic
representation except in Paris, Madrid, and New York, at the
UN. Andorra’s ambassador to the UN is also its ambassador
to the United States. As a further step towards marking its
place as an independent, democratic state, in October 1994 it
joined the Council of Europe, an international institution that
sets standards for human and civil rights.
The Spanish and French governments have encouraged
Andorra to take advantage of the European Union’s (EU) free
trade regulations by developing export industries. Through
an agreement with the EU, Andorra obtained the right to
export to EU countries with minimal tariffs on its goods.
Tension between the countries of the EU and Andorra
developed during the 1990s because of growing evidence of
widespread cigarette smuggling through Andorra. In the late
1990s, European nations estimated that they were losing
about €400 million (us$428 million) in tax revenue from
illegal sales of cigarettes through Andorra. In response, in late
1999, the Andorran government tightened customs laws and
modified regulations to make smuggling specifically illegal.
Andorra’s future may well depend upon its continued
efforts to mesh into broader European life. Because it depends
heavily upon its neighbors and foreign guests to survive,
Andorra is likely to continue to be accommodating to France
and Spain when those countries insist upon changes of policy.
In the twenty-first century, Paris and Madrid are most likely
to urge reform of citizenship laws in order to provide a
guarantee of rights for long-time foreign residents who wish
to become Andorrans, as well as a softening of the banking
secrecy laws in order to limit the flow of illegal capital into
the country.
Forné is dedicated to furthering Andorra’s international
relationships. He regularly addresses the UN; in 2001,
Andorra began a three-year term on the UN’s Economic and
Social Council. The Council’s 54 seats are assigned based on
geographical representation (14 to Africa, 11 to Asia, 6 to
Eastern Europe, 10 to Latin America and Caribbean, and 13
to Western Europe and others).
ADDRESS
Office of the Cap de Govern
Andorra-la-Vella
Andorra
Web site: http://www.govern.ad
REFERENCES
Bureau of Democracy, Human Rights, and Labor. U.S.
Department of State. 1999 Country Reports on Human
Rights Practices. http://www.state.gov/www/global/
human_rights/1999_hrp_report/andorra.html (accessed
March 10, 2000).
Duursma, Jorri. Self-Determination, Statehood, and International
Relations of Micro-states: The Cases of Liechtenstein,
San Marino, Monaco, Andorra, and the Vatican
City. New York: Cambridge University Press, 1996.
Forné Molné, Marc. Speeches delivered before the United
Nations, October 24, 1995 and September 20, 1999.
Ganz, Michael T. “Oh, Andorra.” Swiss Review of World
Affairs, January 1994.
“Global Opportunity.” Presidents & Prime Ministers,
September 1999, vol. 8, no. 5, p. 19.
Walker, Jane and Rod Usher. “Smuggling’s a Hard Habit to
Kick.” Time International, 25 May 1998, vol. 150, no. 39,
p. 45.
“Country Profile: Andorra,” BBC News, http://
news.bbc.co.uk/2/hi/europe/country_profiles/992562.stm
(January 16, 2003).
Profile researched and written by Paul E. Gallis (8/96; updated
3/2000, 3/2002, and 2/2003).

Abdelaziz Bouteflika Algeria

2008-11-12T22:27:00.001-08:00

In January 1995, most opposition parties
(including the banned FIS) met in Rome and agreed on a
national platform for resolving the crisis, but the government
rejected it. A multiparty presidential election was held later
that year, and incumbent General Liamine Zeroual won by
61% of the vote. A new political party, the National and
Democratic Rally (Rassemblement National pour la
Démocratie—RND), was created to support his candidacy. In
1996, a constitutional amendment was introduced. It reconfirmed
Islam as the state’s religion, prohibited parties based
on “religious, linguistic, racial, gender, corporatist or
regional” grounds, and reinforced the powers of the
president. A second parliamentary chamber, the Council of
the Nation, was created. New parliamentary elections held in
June 1997 resulted in Algeria’s first multiparty Parliament.
The main winners were RND, FLN, and the moderate
Islamist parties, Movement of Society for Peace (Mouvement
de la Société pour la Paix—MSP) and al-Nahda (Renaissance).
The RND and the FLN constituted a progovernment
coalition that controlled an absolute majority and seven
ministerial posts each. The Islamists were also awarded seven
posts.
Economic and security conditions continued to worsen,
and thousands of people were killed. The Islamist violence
widened and new organizations, mainly the Armed Islamic
Group (GIA) and the Army of Islamic Salvation (AIS),
engaged in a series of killings. Their victims were not only
military and police personnel, but also civilians and
foreigners. The state countered with measures that left scores
dead and thousands jailed. It was in this context that Zeroual
decided in the fall of 1998 to resign from the presidency, well
before the end of his term, and call for a new vote in April
1999. Abdelaziz Bouteflika quickly became the candidate
favored by the military and many elements in society.
Following his election, Bouteflika succeeded in establishing a
tentative peace in Algeria. In response to his election, the FIS
dissolved its armed branch, the Islamic Salvation Army, in
January 2000.
PERSONAL BACKGROUND
Abdelaziz Bouteflika was born on 2 March 1937 in the
Moroccan town of Oujda, near the Algerian border. In 1956,
he joined the Algerian nationalist movement, which was
fighting for independence from France. When Algeria gained
its independence in 1962, President Ahmed Ben Bella
appointed Bouteflika to be minister of youth, sports, and
tourism. The following year he became the foreign minister.
Despite the overthrow of the Ben Bella government by
Colonel Houari Boumedienne in 1965, Bouteflika was able to
retain his post until 1979. As foreign minister, he distinguished
himself by successfully articulating Algeria’s
economic and political nationalism in the 1970s. He led
negotiations with France that preceded the 1971 nationalization
of the hydrocarbon industry. Bouteflika chaired the
1974 United Nations’ special session on the new international
economic order. He was also successful in making Algeria’s
influence felt on the nonaligned movement.
After the death of Boumedienne in December 1978, Bouteflika
was considered a possible successor. However, he lost
the ensuing power struggle and the military imposed Colonel
Chadli Benjedid as Algeria’s new president. Bouteflika
remained in the government as minister without portfolio and
advisor until 1980 when Benjedid dismissed him. The
following year, Bouteflika was accused of having embezzled
close to us$12 million while he was foreign minister. Bouteflika
abandoned Algerian politics and spent 16 of the next 19
years in exile in Switzerland. There he worked as a consultant
to several Persian Gulf nations.
RISE TO POWER
In February 1999, Bouteflika returned to Algeria after a
group of top military, political, and business leaders
persuaded him to run in the upcoming presidential elections.
Six other candidates were on the ballot, but two days before
the elections they decided to withdraw from the vote after the
state refused to act on their complaints of electoral irregularities.
By default, Bouteflika became the only candidate. This
situation hurt the credibility of both the poll and its winner.
Bouteflika had secured the support of the military and that of
the FLN, the RND, and the MSP parties. Being from the era
of the authoritarian but well-liked President Boumedienne, he
was thought to be the ideal person to lead his country out of
its deep and multidimensional crisis. According to official
results, he won the election on 15 April 1999 by 73.79%, or
7.4 million, of the vote cast, becoming the first civilian
president since 1965. In 2003, he announced his plans to run
for reelection in 2004 and sought support for his reelection
bid from French president Jacques Chirac.
LEADERSHIP
During his electoral campaign and in his first presidential
speech on 29 May 1999, Bouteflika promised to work hard
to restore the trust of Algerians in their institutions,
something that he regarded as essential for ending political
violence in the country. To dispel the distrust that resulted
from allegations that the election was rigged, he initiated
Niger
Benue
MAURITANIA
NIGER
NIGERIA
A L G E R I A L I B YA
MALI
MOROCCO
TUNISIA
BURKINA
FASO
SPAIN
Rabat
Bamako
Abuja
Tripoli
Niamey
Ouagadougou
Algiers Tunis
Oran
Marrakesh
Tamanrasset
Zinder
Agadez
Chegga
Néma Tombouctou
Kano
M editerr a n e a n S e a
ALGERIA
0 800 Miles
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200 400 600

dialogue with the opposition party leaders and sought to
implement reforms that would make the election process less
vulnerable to rigging. Initially, Bouteflika enjoyed the support
of the army, which holds real power in the country. Bouteflika
has been called the “consensus candidate,” since he has
sought support of all the parties in crafting a solution to the
violence rooted in the country’s economic crisis.
Bouteflika is committed to solving the crisis, but balancing
the interests of international investors, Islamic fundamentalists,
and the army has proven challenging. By early 2003 he
was reportedly ready to purge the government of army
generals, citing their iron-fisted control of the government.
DOMESTIC POLICY
In his first speech after taking office in 1999, Bouteflika
acknowledged that the state’s institutions were ailing from
abuses of authority, inefficiency, waste, and corruption. He
indicated that social cohesion and peace depended on a regeneration
of the state, which must be based on the rule of the
law and on the promotion of the interests of the entire nation.
Among the tasks at hand were a much-needed reform of the
educational system, a better-orchestrated economic reform, a
firm and tangible encouragement of private investment, the
modernization of agriculture, and special attention to the
country’s youth. He reaffirmed Algeria’s Islamic and Arab-
Berber identity and called for the renewal of regional
integration efforts. When he hosted the July 1999 Organization
of African Unity (OAU) summit meeting in Algiers, 44
heads of African states were present, an indication that others
in the region were open to working with the Bouteflika-led
government.
Like his predecessors, Bouteflika is committed to reviving
the economy and to addressing the most urgent social grievances
while maintaining law and order. His task is huge,
complex, and not without risks. In May 2000, as his first year
in office was coming to an end, 30 members of the national
assembly presented Bouteflika with a signed petition
expressing dissatisfaction over the limited amount of legislative
work completed during the previous 12 months. By
2001, Bouteflika still had not achieved an end to political
violence and continued to struggle to unite the country’s
many factions. He reshuffled his government in May 2001,
hoping to eliminate internal opposition to his programs.
In April 2001, Bouteflika was forced to face the deep
resentment of citizens in the Kabylie region (between Algiers
and Constantine). The Berbers who live in the region
adamantly adhere to Tamazight, their ethnic language,
refusing to adopt the official government language of Arabic.
The death of a Kabylie teenager while in police custody
sparked violent protests, but Bouteflika initially took ten days
to issue a response, adding to the resentment. Bouteflika, in
an attempt to address Berber sentiments, took several actions
aimed at winning their support (or at least calming their
violence). In March 2002, Bouteflika announced that the
Berber language would be added to the Constitution as an
official language of the country (along with Arabic).
While concentrated in Kabylie, the violence was seen by
many observers as a reflection of the frustration felt by all
Algerian youth, who face widespread unemployment and
repression at the hands of the Algerian military. As of 2002,
about half of the population was under the age of 20. The
economy must come out of its slump to offer significant job
prospects.
Bouteflika expressed commitment to speeding up privatization
to stimulate economic development, but after two
years in office his efforts had not made much headway. He
seemed more interested in mediating international crises in
the region than attending to the country’s domestic problems.
Frustrated by his inability to make legislative progress,
following the October 2002 legislative elections Bouteflika
proposed a law that would exclude any political party that
did not garner at least 5% of the total votes cast from participating
in future political contests, a move designed to cut
down on political conflict.
In December 2002, in a conciliatory gesture, Bouteflika
marked Id al-Fitr, the end of the Muslim holy period of
Ramadan, by pardoning or reducing the jail terms of 5,000
prisoners.
FOREIGN POLICY
The United States and some Western European countries have
criticized the way the last presidential election was
conducted, but they have refrained from criticizing Algeria’s
human rights practices. This tolerance has always been predicated
on there being at least a semblance of a democratic
process in place. The last election failed to offer such
semblance.
At the time when Bouteflika was foreign minister, Algeria
played a central role in anticolonialism, the nonaligned
movement, the call for a restructuring of the international
system, and the establishment of a new international
economic order to help poor countries develop and gain
economic independence. It has also fulfilled an important role
within the Organization of Petroleum Exporting Countries
(OPEC). Algeria has been a staunch supporter of the Palestinian
struggle for statehood and has, since 1975, given moral
and material support to the Western Sahara liberation
movement (POLISARIO) in its struggle against Morocco’s
annexation of former Spanish Sahara. Under Bouteflika’s
leadership, Algeria remained committed to these issues and
principles, but began to be more outspoken in the international
arena. In a September 2002 address before the General
Assembly of the United Nations, Bouteflika described Iraq’s
decision to allow the return of weapons inspectors as “courageous”
and urged the nations of the world to lift sanctions
against Iraq in response. During later discussions in the
General Assembly, Bouteflika emphasized that the creation of
a Palestinian state was critical to ending international
terrorism.
Bouteflika has begun to try to reestablish Algeria’s influential
role in world affairs in general, and among the Third
World in particular, by attending mediation efforts in various
trouble spots. However, he has been criticized for not
focusing more attention on the needs of his own people,
which are at a crisis point due to years of civil conflict and
deprivation.
In July 2001, Bouteflika traveled to the United States to
meet with President George W. Bush. He sought support for
an increase in U.S. foreign direct investment (FDI) in the
economy in areas other than the petrochemical industry. After
the terrorist events of 11 September 2001, Bouteflika was one
of the first leaders of a Muslim nation to offer assistance to
the United States. In October 2002, Bouteflika participated in
the ninth summit of the African Union held in Beirut,
Lebanon, where, at Bouteflika’s urging, the African Union
adopted a plan to implement border controls and information
exchange to curb international terrorism.
ADDRESS
Presidence de la Republique
El Mouradia
Algiers, Algeria
E-mail: President@el-mouradia.dz
REFERENCES
“Algeria: President Pardons Thousands of Prisoners on End
of Ramadan.” Asia Africa Intelligence Wire, December 2,
2002.
“Algeria: President Said Set to Turn Against Army Generals.”
Asia Africa Intelligence Wire, January 5, 2003.
Amodeo, Chris. “Tamazight, the Berber Language, Is to Be
Given Official Constitutional Status by Algeria’s President,
Abdelaziz Bouteflika.” Geographical, June 2002, vol. 74,
no. 6, p. 6.
“A One Horse Race: Can Algeria’s New President Find
Solutions, or Is He Part of the Problem?” Time International,
April 26, 1999, vol. 153, no. 16, p. 45.
Spencer, William. The Middle East. 8th ed. Guilford, CT:
Dushkin/McGraw-Hill, 2000.
“The Warm Embrace: Europe Is Showing Signs That It’s Keen
to Better Its Often Uneasy Relations with the Maghreb
Nations.” Time International, June 26, 2000, vol. 155, no.
25, p. 30.
Profile researched and written by Azzedine Layachi, St. John's
University (9/99; updated 2/2003).

Fatos Thanas Nano ALBANIA

2008-11-12T22:23:00.001-08:00

Prime Minister
(pronounced “FAH-toess TAHN-ahs NAH-no”)
''We [Balkan nations] all have the same priorities, but real change can happen
only if we build a regional authority to lead the way.”
The Republic of Albania is situated in southeastern Europe
and is bordered to the south by Greece, to the east by the
Former Yugoslav Republic of Macedonia (FYROM), to the
north by Serbia and Montenegro, and to the west by the
Adriatic Sea. The total area is 28,748 sq km (17,864 sq mi),
of which over two-thirds is mountainous and the rest river
valleys and coastal lowlands.
The country’s total population was estimated at 3.5
million in July 2002. Over 95% are ethnic Albanian, with
Greeks comprising most of the rest. Outside of the country’s
borders live about an equal number of ethnic Albanians,
mainly in the Kosovo region within Serbia and Montenegro,
and also in Macedonia, Greece, and Italy. About 70% of the
population are Muslim; however, atheism is also widespread
as a result of an official ban on religious worship from the
1960s to 1990. By 2002 the government had relaxed this ban,
and the practice of religion increased slightly. The Albanian
language has two main dialects, Geg and Tosk (considered
the official dialect).
The country’s gross domestic product (GDP) was
estimated at US$13.2 billion in 2001, with per capita GDP
estimated at US$3,800 that year. The national currency is the
lek. Albania’s natural resources include oil, gas, coal, and
metals. Agriculture and mining constitute the largest industries.
Frequent drought, obsolete equipment, and the need to
consolidate numerous small farms have hampered the growth
of the agriculture sector.
POLITICAL BACKGROUND
Albania experienced a brief period of independence in the
fifteenth century but was otherwise subjected to foreign rule.
Independence was finally gained in 1912 after four and onehalf
centuries of Turkish Ottoman rule, and its national
boundaries were set for the first time in 1913. After World
War I, following a period of occupation by Italy, France, and
Yugoslavia, the national independent state of Albania was
reestablished. Italy occupied the country in 1939, forcing
Ahmet Zogu (who called himself King Zog I) into exile. The
Communist-led National Liberation Front (NLF) resistance
movement, assisted by Yugoslav partisans, took power in
November 1944. NLF leader, Enver Hoxha (1908–85),
headed both the Albanian Communist Party and the country
for four decades, until his death in 1985.
The Hoxha era was known for its extreme internal
repression and isolationist tendencies. Albanian industries
and agriculture were collectivized. The population was rigidly
controlled by the ruling Albanian Workers Party (the
Communist Party, known in 2003 as the Albanian Socialist
Party—PS) and its secret police apparatus. In foreign policy,
Hoxha’s regime pursued increasingly isolationist tendencies.
Albania broke away from Yugoslav tutelage after the 1948
split between Yugoslav leader Tito and Soviet leader Joseph
Stalin. Ties with the former Union of Soviet Socialist
Republics (USSR) were broken in 1961, and Albania
withdrew from the Warsaw Pact in 1968. China became its
main ally in the 1960s, but that relationship cooled in the
1970s, leaving Albania almost completely isolated.
Albania was the last Eastern European country to embark
on democratization and market economic reforms in the
1980s. Hoxha’s successor, Ramiz Alia, was considered
somewhat less repressive and began to increase Albania’s
exposure to the outside world while maintaining the
Communist Party’s exclusive hold on power. Large demonstrations
in December 1990, triggered by widespread internal
unrest, pushed the Alia government to accept multiparty
elections. Albania held its first free elections in 45 years in
March 1991, with candidates from both the newly formed
Democratic Party (PD) and the Albanian Workers Party.
Although its fairness was questioned by outside observers, the
Albanian Workers Party (later renamed the Albanian Socialist
Party—PS) won two-thirds of the vote and formed a
government under Albanian Workers Party leader Fatos
Nano, who formed a government made up entirely of
Workers Party members. Following large-scale strikes and
demonstrations, the Nano government ceded power in June
1991 to a coalition government including the renamed
Socialist Party (PS) and the opposition Democratic Party.
Members of the PD were given most of the key economic
positions and were primarily responsible for initiating new
economic policies. However, in December 1991, frustrated by
their inability to pass any reforms, the PD withdrew from the
government, forcing new elections.
General elections held in March 1992 resulted in a
resounding victory for the PD, which gained 62% of the vote.
The PS won only 25% of the vote (down from more than
67% the previous year). In April 1992, Alia resigned as the
last Communist leader in Albania, and the new People’s
Assembly (Parliament) convened, electing PD chairman Sali
Berisha to the presidency. Berisha named Aleksander Meksi
prime minister, and members of the PD dominated his
cabinet. In the following years, the PD undertook measures to
stifle political opposition, including the arrest of opposition
political leaders.
Albania’s next parliamentary elections were held on 26
May and 2 June 1996. Amidst charges of voting fraud,
virtually all opposition parties pulled out before polling
ended and boycotted the second round. The Organization for
Security and Cooperation in Europe (OSCE), as well as other
international observers, noted serious irregularities during the
vote, including fraud, ballot stuffing, intimidation, and
coercion tactics. The PD won almost all of the parliamentary
seats. The new Parliament was inaugurated on 1 July, but the
PS boycotted the session. Berisha nominated a new
government under Prime Minister Meksi on 11 July 1996.
Beginning in late 1996, numerous popular yet high-risk
investment schemes collapsed, prompting violent riots in
many Albanian cities. Over the previous two years, the socalled
“pyramid schemes” promised exorbitant returns on
investment, attracting over us$1 billion from Albanian
citizens. The collapse of these schemes led to widespread
demonstrations, as many Albanians blamed the government
for corruption and mismanagement in regulating the
investment enterprises. In early March 1997, the demonstrations
turned into armed rebellion in numerous cities in the
south as anti-Berisha rebels stormed arms depots. Estimates
of the number of Albanians killed in the ensuing conflict
ranged from several hundred to 2,000. Thousands more fled
to Italy and other countries. After international mediation
and the installation of an international peacekeeping force,
Berisha dismissed the Meksi government, released Fatos
Nano from prison, pardoned him, and appointed him prime
minister. Berisha and Nano agreed to hold parliamentary
elections by June 1997.
New elections were held under close international scrutiny
on 29 June and 6 July 1997. The opposition PS won a
landslide victory at the expense of Berisha’s PD. In
Parliament, the PS won an absolute majority of 101 out of
155 seats. Berisha resigned on 23 July 1997. The Parliament
elected PS leader Rexhep Mejdani to the presidency. Mejdani
named Fatos Nano to be prime minister (for the second time)
of the PS-led government, which was sworn in on 25 July 1997.
Relations between the ruling PS and Berisha’s PD remained
extremely contentious after the 1997 vote. The PD called for
a boycott of some sessions of Parliament and favored early
elections. Albania appeared on the verge of chaos again in
mid-September 1998 when the murder of a prominent PD
member led to violent demonstrations. Government authorities
quickly regained control of sites that had been stormed
by PD supporters. Nano accused Berisha of attempting to
stage a coup. The United States, the European Union (EU),
and major international organizations condemned the
violence and appealed to all parties to work toward a
peaceful solution. Nano resigned at the end of September, and
the PS nominated Pandeli Majko to succeed him. Majko was
sworn in on 2 October 1998.
In spring 1999, in the wake of bloody conflict between
ethnic Albanians living in neighboring Kosovo and Serb
forces who wanted to reclaim the land there, thousands of
ethnic Albanians poured into the country, straining an
already weak economy. President Mejdani, hoping that
change might foster stability, appointed Ilir Meta to replace
Majko in the post of prime minister. On 27 October 1999,
Meta took over the post, but he was unable to bring an end to
the conflict among factions in the Albanian government. In
late January 2002, Meta resigned suddenly over unresolved
conflicts with PS leader Fatos Nano. President Mejdani
replaced Meta with his predecessor, Pandeli Majko, as prime
minister. Majko, like Meta, could not bring the factions into
alignment; he resigned in July 2002, to be replaced by Fatos
Nano.
PERSONAL BACKGROUND
Fatos Thanas Nano was born 16 September 1952 in the
capital, Tirana. His family was Albanian Orthodox Christian,
but religion was officially banned in Albania in 1960.
However, religious identity persisted in a subtle way, and
Christians were a minority, representing an estimated 20% of
the population, with Muslims representing the majority
(70%). His father, Thanas Nano, was a journalist who
directed the state radio and television broadcasts during the
decades of Communist control of the government.
Fatos Nano studied economics at the University of Tirana;
he graduated in 1975 with a degree in political economy. He
spent the following years as a researcher and lecturer in
agricultural economics. In 1990, he entered government
service when he was appointed by President Ramiz Alia to
serve as secretary general of the Council of Ministers (the
prime minister’s cabinet).
Nano has two grown children. He is fluent in Italian and
English, and is proficient in Russian, French, Serbian, and
Spanish. In addition, he has some ability to communicate in
Greek.
ROMANIA
BULGARIA
GREECE
VATICAN
CITY
SAN
MARINO
ITALY
SLOVAKIA
HUNGARY
AUSTRIA
BOSNIAHERZEGOVINA
CROATIA
SLOVENIA
ALBANIA MACEDONIA
UKRAINE
Skopje
Zagreb
Belgrade
Ljubljana
Sarajevo Sofia
Tirana
Rome
Venice
Florence
Naples
Peloponnesus
Patras
Ioánnina
Pristinà
Graz
Pécs
Cluj-Napoca
Salonika
Palermo
Tyrrhenian
Sea
Ionian
Sea
Adriatic Sea
Danube
Sicily
Corfu
ALBANIA
0 300 Miles
0 100 200 300 Kilometers
100 200
SERBIA &
MONTENEGRO
RISE TO POWER
In December 1990, widespread civil unrest forced President
Ramiz Alia to allow multiparty elections. He acted quickly to
reorganize the cabinet, and Fatos Nano was among his
appointments. Nano, named secretary general of the Council
of Ministers, served briefly as deputy prime minister for
economic reform in the months leading up to the March 1991
elections. Since then, Fatos Nano has never been far from the
political fray in Albania.
Although the fairness of the 1991 election—the first multiparty
election in over five decades—was questioned by
outside observers, the voting was viewed as a first step in
Albania’s transition to democracy. The Albanian Workers
Party (later renamed the Albanian Socialist Party—PS) won
two-thirds of the vote and formed a government under Fatos
Nano. Following large-scale strikes and demonstrations, the
Nano government ceded power in June 1991, and Nano
resigned.
The Albanian Workers Party reorganized as the Socialist
Party and held its founding congress in June 1991. Nano,
after having been forced to resign the prime minister post,
was elected chairman of the PS, and won election to
Parliament. The coalition government included the PS and the
opposition PD. Nano won reelection to Parliament in 1992,
but he was unable to fulfill his term. In July 1993, he was
arrested on charges of corruption, including misappropriation
of state funds, dereliction of duty, and falsifying
documents. He was found guilty and sentenced to 12 years in
prison. Amnesty International and other human rights groups
declared the trial improper. While in prison, Nano was
reelected chair of the PS in August 1996.
The economic crisis caused by the collapse of the pyramid
investment schemes triggered widespread social unrest. In
early March 1997, desperate to restore order, President
Berisha dismissed the Meksi government, released Fatos
Nano and others from prison, and issued pardons. Berisha
then appointed Nano prime minister. Berisha and Nano
agreed to hold parliamentary elections by June 1997. Nano
was named prime minister, but his term would last just until
October 1998, when continuing upheaval in the government
forced his resignation; the PS nominated Pandeli Majko to
succeed him. In November, Nano resigned as head of the PS.
Although not officially leading the PS, Nano continued to
wield power over the next 11 months. Nano supported the
government headed by Prime Minister Majko, but his faction
within the PS continued to battle head-to-head with the
faction led by Ilir Meta. In the face of growing violent conflict
between ethnic Albanians and Serbs in neighboring Serbia,
President Rexhep Mejdani named Ilir Meta prime minister;
Meta took office in October 1999. When the PS held their
congress that month, Nano was returned to the chairmanship.
Meta was unable to bring stability to the
government, although his PS would maintain their dominant
position in the Parliament, even with a slim majority (73 of
140 seats) following the June 2001 elections. Meta resigned
in June 2002, to be replaced by Majko.
The loyalties of the PS representatives were divided
between Meta and Nano. Majko was seen as a possible
mediator between the two factions, and his confirmation by
Parliament in March 2002 supported that hope. Nano was
not inclined toward compromise or conciliation. PS infighting
continued to exacerbate the country’s ills.
On 15 July 2002, the PS’s steering committee passed a
resolution that the party’s chairman should hold the post of
prime minister. Ten days later, on 25 July 2002, Pandeli
Majko resigned after only five months as prime minster.
Majko stated that he hoped his resignation would bring an
end to the conflict between factions of the PS. On 29 July,
President Alfred Moisiu appointed Fatos Nano prime
minister, and Nano took office two days later, on 31 July.
Nano and Meta appear to have reached a delicate
compromise. When Nano formed a government, it included
Ilir Meta as deputy prime minister and foreign minister, and
Pandeli Majko as minister of defense.
LEADERSHIP
While Nano has been at or close to the seat of power in the
Albanian government since 1990, his ongoing disputes with
Ilir Meta contributed to instability in the late 1990s through
2002. As of July 2002, it appeared that the factions had
finally found a way to coexist and perhaps even cooperate.
Nano, in an address given in 2002 at the start of his threeyear
term as prime minister, noted his priorities for the new
government: improving the economy; fighting smuggling,
corruption, and terrorism; and preparing for talks on the
Stabilization and Association Agreement (SAA) with the EU.
DOMESTIC POLICY
While there was no shortage of challenges facing Nano’s
government in 2003, the problem of infighting and turmoil
that characterized Albanian politics in the first years of the
twenty-first century seemed to be resolved.
The government continues to grapple with such basic and
urgent problems as providing electricity to its citizenry, while
developing a plan to curb the country’s widespread and
sophisticated organized crime.
In the late 1990s, Ilir Meta’s government introduced
reforms to restructure the judiciary system and to stem the
decades-long practice of bribes for judicial action. Continuing
these reforms is crucial for Albania to be successful in their
quest to join the EU and the North Atlantic Treaty Organization
(NATO).
Albania’s future is closely tied to support from international
organizations such as the International Monetary Fund
(IMF) and the World Bank. In January 2003, Nano signed a
memorandum with the IMF that outlined the government’s
2003 plans for stabilizing the country’s economic and
political structure. The plans set goals of 6% real economic
growth, inflation held between 2–4%, and the budget deficit
maintained at just over 6%. Nano described the
memorandum as “an important commitment for 2003 that
reconfirms the successful and serious cooperation of Albania
with the IMF.”
FOREIGN POLICY
Nano served as chair of the Foreign Affairs Committee in the
government of Ilir Meta, and was the first representative of
the Albanian government to visit Yugoslavia after the two
countries reestablished relations in December 2001.
In 2002, Nano’s predecessor, Pandeli Majko, participated
in a number of international meetings, including one in
Bucharest, Romania, of the heads of the ten countries
(Albania, Bulgaria, Croatia, Estonia, Latvia, Lithuania,
Macedonia, Romania, Slovakia, and Slovenia) that are candidates
for membership in NATO. The prospect of joining
NATO has widespread support in Albania, but the country
must demonstrate firm commitment to economic and judicial
reforms to gain membership.
Another notable meeting was Majko’s March 2002 visit
with the ambassador from China. That nation was formerly
one of Albania’s closest allies, although relations cooled
during the 1970s and had not recovered as of the end of the
twentieth century. The Chinese are particularly interested in
becoming involved in the construction of a dam and hydroelectric
power plant in Albania, a project under consideration
for funding by the IMF and the World Bank that would
bolster Albania’s inadequate power supply.
The EU has been working with Albania since the late
1990s on an SAA. A draft, presented in November 2001, was
aimed at preparing Albania for eventual EU membership.
Stabilizing the government is a necessary first step, and the
EU wants Albania to clean up its election procedures, to
privatize the country’s banks, to eliminate political interference
in the court system, and to improve management of
the country’s electric utilities.
Every Albanian prime minister must try to convince other
governments that his government will soon restore order to
Albanian politics, and Nano appeared to be achieving some
success in the months following his taking office in July 2002.
By October, the EU agreed to reopen negotiations with
Albania on the SAA, and established February 2003 as the
date for the next round of negotiations.
As of 2002, Greece held the rotating EU presidency, and
Greek foreign minister George Papandreou listed EU ratification
of SAA accords for Albania and Macedonia and their
Balkan neighbors as a top priority. Thus, Nano realized that,
with Greece as an important ally, Albania needed to work
quickly and with commitment to achieve the goals of the
SAA. He aggressively sought support from Albania’s
neighbors in the Balkans to form a regional Parliament as
evidence that the days of factional squabbling in the region
are in the past.
ADDRESS
Office of the Prime Minister
Tirana, Albania
REFERENCES
“Albania, EU Agree to Start SAA Talks Soon,” Xinhua News
Agency, January 14, 2003, p. 1008014h5713.
“Albanian Parliament Approves New Government,” Xinhua
News Agency, July 31, 2002, p. 1008212h0878.
“Albanian PM Hails Talks on Stability-Association
Agreement with EU,” Xinhua News Agency, October 22,
2002, p. 1008294h7455.
“Albanian Premier Says 2003 Memo Signed with IMF
‘Important Commitment,’” Asia Africa Intelligence Wire,
January 8, 2003.
“Fatos Nano,” International Who’s Who 2003, London:
Europa Publications, 2003.
“Fatos Nano,” Political/Economic Section, U.S. Embassy,
Tirana, November 2002.
Frosina Information Network, http://www.frosina.org
(accessed January 22, 2003).
“Just for Show: Albania,” The Economist (US), April 9,
1994, vol. 331, no. 7858, p. 53+.
Simpson, Daniel. “In Albania Politics, Are the Changes Skin-
Deep?” New York Times, November 21, 2002, p. 4.
“UK Reportedly Wants to See Albania in NATO ‘Very
Soon’,” Asia Africa Intelligence Wire, October 12, 2002.
Profile researched and written by Susan Gall (3/2002).

Hamid Karzai

2008-11-12T21:02:00.000-08:00

President of the Afghan Transitional Authority
(pronounced “HA-mehd CAHRZ-eye”)
“Having experienced the ravages of war for 23 years and having been taken hostage by a group of
terrorists, we are once again free to determine our destiny.”
The Islamic Republic of Afghanistan, located in Central Asia,
is a landlocked nation slightly smaller than Texas. It has a
total land area of 647,500 sq km (250,001 sq mi). It is
bordered on the north by the former Soviet republics of
Turkmenistan, Uzbekistan, and Tajikistan, on the east and
south by Pakistan, and on the west by Iran. A strip of land
less than 80 km (50 mi) wide and known as the Wakhan
corridor extends to the northeast. It forms a 76-km (47-mi)
border with China. The population was estimated in 2002 at
27.7 million, although decades of warfare make accurate
population counts impossible. The capital, Kabul, is located
in the east-central part of the country. The 2002 population
of Kabul was estimated at 2.1 million; a large number of
displaced persons, many of them refugees from neighboring
countries, returned to the city in 2002.
The average elevation is 1,200 m (4,000 ft). The towering
Hindu Kush mountain range, running southwest from the
Wakhan corridor in the northeast, has elevations of more
than 6,200 m (20,000 ft). In the provinces north of the Hindu
Kush the altitude drops to about 460 m (1,500 ft), enabling
farmers to grow cotton, fruit, grains, and other crops. The
central part of the country features a plateau with lush valleys
suitable for grazing sheep, goats, and camels. In the
southwest, the land is a barren desert where the temperature
extremes are the greatest found anywhere in the country.
Decades of violent civil and international conflicts have
caused widespread poverty, devastated the roads, bridges,
and infrastructure, and left the countryside riddled with
dangerous land mines. (The United Nations [UN] estimates
that 7–10 million land mines remain buried in Afghanistan,
rendering much farming and grazing land useless.) Earthquakes
in the northern Hindu Kush region, overgrazing, and
rampant deforestation by citizens in search of fuel and
building materials all combine to present the government in
2002 with the challenge of resurrecting even the most basic
services.
Pashtu and Dari (Afghani variant of Persian) are the
official languages. Dari is the language spoken in Kabul and
has historically been the principal language of Afghan literature,
government, and business. Many Afghans are bilingual
and almost all are Muslim.
POLITICAL BACKGROUND
The former Union of Soviet Socialist Republics (USSR)
occupied Afghanistan from 1979 until early 1989. By late
1987, the United Nations High Commissioner for Refugees
(UNHCR) estimated that one million Afghans had died in the
fighting between Soviet troops and the mujahidin resistance
forces (supported by arms from the United States and Islamic
nations such as Pakistan). The Soviets withdrew in 1989,
partly because of instability in their own government. (The
USSR broke apart into independent states in 1991.) Afghanistan
experienced internal chaos and President Muhammad
Najibullah struggled to maintain control of the country as
pressure from the mujahidin and outside forces increased.
The country floundered, with rival factions battling for
control of the government. In 1992, the mujahidin gained
control of Kabul and Najibullah’s government fell.
An interim government was established by a coalition of
Islamic groups known as the Seven Party Alliance (SPA).
Rival groups continued to clash violently and UN attempts to
broker peace among the groups were unsuccessful.
Burhanuddin Rabbani became president of the Interim
Government in 1992, but maintaining control of the various
factions in the country proved nearly impossible. Alliances
continually shifted after President Rabbani took office; he
was scheduled to leave office in December 1994 but refused
on the grounds that political authority would disintegrate
totally.
One of the major forces vying for power was the Uzbek
militia of General Abdul Rashid Dostum, whose break with
Najibullah in early 1992 helped overthrow the communist
regime. In January 1994, Dostum led an unsuccessful
rebellion against Rabbani. Another faction was the Iranbacked
Hizb-e-Wahdat (Unity Party, an alliance of eight Shia
Muslim groups). In early June 1992 Hizb-e-Wahdat had
agreed to join the mujahidin regime but broke with Rabbani
in January 1994.
In 1994, a new group known as the Taliban (Students of
Religion, or Seekers) formed and began rallying to control the
country. Consisting of Islamic clerics and students from
seminaries that sprung up in Pakistan among the communities
of Afghan refugees, the Taliban movement came into
being after the war against the Soviets and Najibullah. The
Taliban seized control of the southeastern city of Kandahar in
November 1994 and continued to gather strength.
In February 1995, the Taliban gained control of areas on
the outskirts of Kabul and demanded that Rabbani surrender.
When Rabbani refused, and the Taliban rejected UN efforts
to include it in a peaceful transition, an 18-month stalemate
around Kabul ensued. In its drive to Kabul, the Taliban
amassed about 25,000 troops, a few hundred tanks, and ten
combat aircraft. In September 1996, Taliban victories east of
Kabul led to the destruction of the Rabbani government’s
defenses, and the government withdrew to the valley north of
Kabul. With the Taliban capture of Kabul, the Northern
Alliance formed, made up of differing factions that had one
thing in common: their passionate interest in ousting the
Taliban. Northern Alliance forces continued to fight for
control of the north.
In spring 2000, the Taliban, claiming a series of defections
from the Rabbani Northern Alliance camp, began preparations
for a renewed offensive to gain the remaining part of
Afghanistan not under their control. The Taliban government
was led by mujahidin fighter-turned-religious-scholar,
Muhammad Omar. He is thought to have been born in
Kandahar in 1962. Described as a determined man, Omar
had served as deputy chief commander in the Harakat-i-
Inqilab-i Islamic party of Mohammad Nabi Mohammadi
during the Soviet occupation of Afghanistan in the 1980s.
Virtually unknown until the Taliban’s capture of Kandahar,
Omar remained a mysterious figure with reportedly strong
ties to Osama bin Laden and other Islamist radicals. Under
Omar’s Taliban government, the Afghan people were
subjected to harsh imposition of Islamic law. Women were
forbidden from working outside the home (except health
workers), girls’ schools were closed, and a strict Islamic dress
code was imposed. The Taliban lost international support as
it imposed harsh punishments on those who violated Islamic
law. The UN and other international aid organizations
(including UNHCR, UNICEF, Save the Children, and Oxfam)
cut back or ceased operations in protest; many staff members
were female and unable to adhere to the strict regulations.
Taliban control did restore peace by suppressing and
disarming members of rival militias. The roads were
reopened, leading to a greater availability of food in areas
under Taliban control.
When terrorists attacked the World Trade Center in New
York and The Pentagon in Washington, D.C., on 11
September 2001, international attention focused on Afghanistan.
Most experts implicated Osama bin Laden and his close
associate, Taliban leader Mullah Muhammad Omar, in the
attacks. The U.S. government, with support of its allies,
undertook a month of massive air attacks until the Taliban
was driven out of power in October 2001 and an interim
government was installed in December 2001. Hamid Karzai
was named chairman of the interim government.
In the weeks and months following the fall of the Taliban,
life in Afghanistan was fraught with danger. U.S.-led military
operations were ongoing. International peacekeepers, aid
workers, and Afghans became victims of grenade attacks, fire
fights, and bombings, making the security situation
precarious. Thus, the task of reconstruction and providing
aid to Afghanistan has proven difficult. In January 2002,
donor countries pledged US$4.5 billion for the reconstruction
effort. However, less than half of the amount earmarked for
2002 was ever actually delivered.
In June 2002, a loya jirga (council of elders) was convened
to choose a government to lead the country for 18 months to
two years until elections are held. Karzai was elected transitional
head of state, garnering 1,295 of a possible 1,575
votes. On 19 and 22 June Karzai introduced a 28-member
cabinet representative of many different ethnic and political
backgrounds. He named three vice presidents—Mohammed
Qasim Fahim, Karim Khalili, and Haji Abdul Qadir. Vice
President Qadir was assassinated on 6 July 2002. Karzai
himself narrowly escaped assassination on 5 September 2002,
as a gunman dressed in an Afghan military uniform shot at
him and Kandahar’s governor Gul Agha Sherzai as they were
getting into their car. On 22 November 2002, a plot to
assassinate Karzai or his defense minister, Mohammed Fahim,
was thwarted.
As of January 2003, there were still two million Afghan
refugees in Iran and approximately 1.5 million in Pakistan. In
2002, an estimated two million Afghans returned home.
PERSONAL BACKGROUND
Hamid Karzai was born 24 December 1957 in Karz, a village
near Kandahar. His father, Abdul Ahad Karzai, was a senator
in the Afghan parliament before the overthrow of King
Mohammed Zahir Shah in 1973. Hamid Karzai has eight
siblings, five of whom (four brothers and one sister) live in
the United States where they run a chain of Afghan restaurants,
Helmand (named after an Afghan province), with
establishments in Chicago, Boston, Baltimore, and San
Francisco. Karzai is a member of the Popolzai clan of
southern Afghanistan; the Popolzai are one of the clans
making up the largest ethnic group in Afghanistan, the
Pashtun. Throughout history, most of the country’s leaders
have been Pashtun; Karzai’s family and the family of the
former king, Mohammed Zahir Shah, are both from the
Popolzai clan.
After his early education was completed in Karz, Karzai
attended secondary school in Kabul. In December 1979, the
USSR invaded Afghanistan, beginning an occupation that
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AFGHANISTAN
PAKISTAN
NEPAL
BANGLADESH
BHUTAN
TURKMENISTAN
UZBEKISTAN
TAJIKISTAN
I N D I A
C H I N A
R U S S I A
IRAN
Tashkent
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Kabul
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Gulf of Oman
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Sea
0 250 500 750 1000 Kilometers
250 500 750 Miles
KAZAKHSTAN
KYRGYZSTAN
would last until February 1989. The Karzai family fled the
country, taking up a life in exile in Quetta, Pakistan. At age
24, Hamid left to study political science at the Himachal
Pradesh University in Simla, India. Later (1985–86), he
studied journalism in Lille, France, at Ecole Superieure de
Journalism de Lille. As a student he was an enthusiastic
participant in the Afghan national sport, buzkashi, a game
similar to polo played on horseback by two teams.
Karzai and his wife, Zinat, a medical doctor, married when
Karzai was over 40, considered fairly late for marriage by
Afghan standards. Karzai’s aptitude for languages—he is
fluent in six languages including English—helps him in international
relations, notably with the powerful United States
and United Kingdom. He is a memorable figure, traveling in a
striking costume that combines business attire with traditional
ethnic garments, such as a lambskin cap and dramatic,
colorful cape.
RISE TO POWER
Hamid Karzai first became involved in the mujahidin
government of Burhanuddin Rabbani, serving as deputy
foreign minister from 1992 to 1994. As was the case during
the 1980s, the government in those years was immobilized by
ethnic infighting. When the Taliban took control of Kabul 27
September 1996, Karzai initially supported them; in fact, the
Taliban government unsuccessfully tried to name him as their
ambassador to the UN, but the UN did not recognize the
Taliban’s right to Afghanistan’s seat. Karzai and his father,
growing suspicious that the Taliban was being controlled by
foreign influences, broke with the Taliban and began to
criticize the religious movement while in exile in Quetta,
Pakistan. When Karzai’s father was assassinated in 1999 as
he walked home from a mosque, most in the government and
in international organizations attributed the act to members
of the Taliban.
Following his father’s death, Karzai became leader of the
Popolzai clan from his exile post in Quetta. He and his
followers continued to campaign against the repressive
Taliban regime, but they received little international attention
or support. Karzai frequently traveled to the United States
from Quetta to lobby for support to overthrow the Taliban.
His visits included stops at the University of Nebraska where
the faculty includes experts on Afghanistan; in 2001 Karzai
testified before the U.S. Senate Foreign Relations Committee.
When the 11 September 2001 terrorist attacks against the
United States brought Afghanistan to the center of international
attention, U.S. government officials began to listen
more seriously to Karzai’s ideas. In October, Karzai secretly
entered Afghanistan in an attempt to build support for a plan
to oust the Taliban and to convene a loya jirga (council of
elders) to install a new government.
In 2001, after the Taliban government crumbled, the UN
convened a meeting in Bonn, Germany, of four Afghan
factions to begin to build a coalition government to lead the
country in its next stage of rebuilding. All factions agreed to
name Hamid Karzai as chairman of the interim administration;
in addition, the factions agreed that the popular
former king, Mohammed Zahir Shah, should return to
Afghanistan (from Italy, where he had been living in exile) to
play a symbolic role in the next administration. At a separate
meeting at the same time, representatives of UN member
nations were considering funding and other issues of support
for Afghanistan.
The loya jirga met from 11–19 June 2002 and Karzai was
elected president of the Transitional Authority. The meeting
of the loya jirga highlighted the power of faction leaders from
the mainly Tajik former Northern Alliance, who were influential
in assuring Karzai’s election.
LEADERSHIP
Karzai was initially designated leader of the interim
government established in December 2001; the interim
government prepared for the loya jirga in June 2002, which
elected Karzai president of the Transitional Authority. He was
to govern the country for 18 months to two years, until
elections are held.
In August 2002, Karzai made his first national address on
radio, focusing on the importance of national security. He
called for the building of a national army representing
Afghanistan’s diverse populations. Karzai emphasized that
having an army dedicated to protecting national sovereignty
would serve to unify the country.
In November 2002, Karzai fired 24 regional officials in an
attempt to curb abuses of power in office, including
corruption, allegations of drug trafficking, and disobeying the
law. Since becoming president, Karzai has struggled to
exercise authority outside of Kabul, as many provincial
warlords maintain control—including taxation, customs, and
security—over their territories. They use violence to resolve
ethnic and territorial disputes. In December, Karzai banned
political leaders from taking part in military activity as
another way of asserting authority over the warlords.
DOMESTIC POLICY
After assuming the leadership of Afghanistan’s interim
government, Karzai confronted problems of the most basic
sort—repairing roads to allow trade to resume, rebuilding
schools and medical clinics, and installing basic utilities such
as telecommunications, reliable electricity, and safe water. He
struck a conciliatory tone by issuing pardons for over 300
Taliban members who agreed to surrender their weapons.
Karzai also faced the need to build a new police force and
military defense, and a system for collection of taxes and
other revenues to begin to build self-sufficiency.
Karzai’s stated top priority was the restoration of peace
and security by bringing the conflicting factions of the
country together. The UN delegation charged with creating
the interim government put forward the names of 30
potential government ministers, representing the key factions
still holding power within the country. Representatives of the
Northern Alliance (made up primarily of Uzbeks and Tajiks),
the group that assumed control of the capital, Kabul, when
the Taliban collapsed, were named to three powerful ministries—
interior, defense, and foreign affairs. To reflect the
UN’s position that any new Afghan government must
guarantee women’s rights, two women were among those
recommended for ministerial positions. At the loya jirga held
in June 2002, 160 seats were guaranteed to women, a representation
of 11%.
Since becoming president of the Transitional Authority,
Karzai has devoted the majority of his time trying to heal
ethnic divisions, reining in the powerful warlords, arranging

for the security of the country, and surviving assassination
attempts. Karzai is guarded by U.S. Special Forces, who are
backed up by international peacekeepers. The Afghan police
are undertrained and the national army had, as of January
2003, only begun to take shape. Karzai also found it
necessary to negotiate with his defense minister, Mohammed
Fahim, whose ministry is dominated by ethnic Tajiks loyal to
him. The goal—to create a unified, well-trained army of
250,000 with all men ages 22 to 24 fulfilling two years of
military service—was little more than a plan on paper as of
early 2003.
Fahim, a former mujahidin leader, estimated that 20% of
the men serving in the Afghan military as of 2003 were
former Taliban fighters. Sizable weapons stocks had yet to be
handed over to the national army. International observers are
wary that, unless Karzai’s government can wield complete
control over the military, Taliban and al-Qaeda factions could
channel arms to fighters in and outside Afghanistan. In
addition, the military must address the dangerous problem of
the millions of land mines remaining in the country; it will
likely require 12 years and us$500 million to clear the vast,
mountainous terrain.
In September 2002, Karzai announced a nationwide
campaign to eliminate the production of poppies (used to
produce opium and heroin), one of Afghanistan’s major
crops. The country is the main source of opium and heroin
sold in Europe. Karzai stated: “The drug destroys our
agriculture; it destroys our crops; it destroys our good family
life. Worst of all, it goes hand and hand with terrorism. It
funds terrorism in Afghanistan and the rest of the world.”
In November 2002, four Kabul University students were
killed during protests demanding food and electricity. Karzai
fasted in response and called the students’ families to console
them. “Just the basics is all they wanted,” he said.
Although as of January 2003 Karzai had yet to travel to
most areas of his own country to see the problems firsthand,
he was attempting to improve the quality of life of Afghans
and to make the government more representative, which will
give his administration more credibility.
FOREIGN POLICY
Karzai, in an early address after becoming chairman of the
interim government, stated, “We will strive to build a
government that responds to the wishes of our people and
behaves as a responsible member of the international
community, to whom we owe a great deal.”
In January 2002 he traveled to the United States, where he
was seated next to First Lady Laura Bush for President
George W. Bush’s State of the Union address. Karzai,
speaking at Georgetown University in Washington, D.C., to
an audience that included many expatriated Afghanis,
encouraged Afghanis living outside their country to return to
join him in rebuilding their nation. During his North
American visit, he also addressed the UN General Assembly.
His travels in the weeks following his appointment
included the United Kingdom, Germany, and India. Wherever
he spoke, he urged foreign government officials and business
people to consider investing in Afghanistan. With the Central
Bank of Afghanistan essentially bankrupted by the Taliban
regime, the interim administration actively sought international
help to build a financial system that could eventually
support Afghanistan’s participation in the global economy.
Karzai also emphasized that, for the immediate future,
Afghanistan would depend heavily on the International
Security Assistance Force (made up of forces from the United
States, United Kingdom, Canada, and others) to keep the
peace in urban areas and remote villages. He also noted that
the Afghan people regard the presence of the international
forces as evidence that Afghanistan won’t be abandoned at
this critical stage in their development as a nation.
Karzai also traveled to Paris, France, where he joined
President Jacques Chirac at the opening of a museum
exhibition of Afghan art and sculpture, most of which had
been collected by French archaeologists with the assistance of
the United Nations Educational, Scientific, and Cultural
Organization (UNESCO), who feared the Taliban would
destroy these important artifacts from Afghanistan’s rich
history. The artifacts will be returned to Afghanistan when
the Museum of Kabul has sufficiently recovered to preserve
and protect them.
Karzai met with U.S., Japanese, and European leaders
after becoming president. In late September 2002, Karzai also
traveled to the Persian Gulf to solicit aid for Afghanistan’s
reconstruction and security, speaking with leaders from Saudi
Arabia, Qatar, and the United Arab Emirates. However, the
large amount of international money pledged for reconstruction
has been slow to arrive.
U.S. and European intelligence agencies agree that, as of
January 2003, al-Qaeda and the Taliban were regrouping in
camps on both sides of the border with Pakistan. Many are
allied with a former mujahidin commander, Gulbuddin
Hekmatyar. The security threat posed by these groups is
another challenge confronting Karzai he struggles to lead
Afghanistan to stability.
ADDRESS
Office of the Afghan Transitional Authority
Kabul, Afghanistan
REFERENCES
“Hamid Karzai Profile,” Afghan Politics, http://www.afghaninfo.
com/Politics/Hamid_Karzai_Profile.htm (April 22,
2002).
Gannon, Kathy. “‘Loya Jirga’ Endorses New Afghan
Cabinet,” The Independent, http://
news.independent.co.uk/world/asia_china/
sotry.jsp?story=307113 (January 14, 2003).
“Karzai Moves to Rein in Warlords,” BBC News, http://
news.bbc.co.uk/2/hi/south_asia/2580217.stm (January 14,
2003).
“Karzai Survives Assassination Attempt,” PBS Online
Newshour, http://www.pbs.org/newshour/updates/
afghan_09-05-02.html (January 14, 2003).
“The Rebirth of a Nation,” The Economist, January 11,
2003, pp. 33–34.
“Rebuilding a Battered Afghanistan,” CBSNews, http://
www.cbsnews.com/stories/2002/12/16/null/
main533217.shtml (January 14, 2003).
Profile researched and written by Jeneen Hobby, Ph.D. (2/2003).

101 ROMANTIC IDEAS (d)

2008-11-12T20:46:00.002-08:00

IDEA # 71
On a special occasion create a unique present for your partner by buying two white t-shirts and some fabric paint. Draw half a heart and the letters LO on one t-shirt and the half a heart and the letters VE on the other t-shirt.

When you walk down the street holding each other close, the heart will be made whole and your message of love revealed.
An example is shown below.

*
IDEA # 72
On a hot summers day, buy two large water pistols and take them to the beach with you.

Pull them out and throw one to your partner and then have a huge water fight.

*
IDEA # 73
Share your food with your partner. When you go out for a meal, hold a forkful up to her mouth and say, "You've got to try this."

Sharing your food and even feeding each other is a great way to become closer as a couple.

*
IDEA # 74
Compliment your partner in public. If you are talking in a group and it is appropriate to the conversation say something like, "Kate makes the most incredible roast." Squeeze her hand while you are talking about her.

*
IDEA # 75
Arrange a special day off from work. Start with breakfast, go for a walk in the park, go shopping, have afternoon tea in a cozy cafe and finish off with a romantic dinner.

*
IDEA # 76
Buy a gift voucher for a facial at a local beauty clinic and place it in a card accompanied by the message,

A special treat for
someone special

*
IDEA # 77
Even if you are just going down the road to buy some milk, act as though you are returning home after a major adventure.

Say something like, "Well it was touch and go there for a while with the snow and the wolves but I made it!" and then give your partner a huge bear hug.

*
IDEA # 78
Send your partner a thank-you note. For example:

Dear Bec,
Thanks for helping me move house.
Having you there made a huge difference.
I really appreciate your help and your love.
Tim

*
IDEA # 79
If you have kids, organize for them to stay at their grandparents for the weekend.

On Friday evening, announce that the weekend is yours and start planning how you are going to spend your special time together.

*
IDEA # 80
Give your partner a magic gift box. Every month, place a new small gift in the box for her to discover.

*
IDEA # 81
Research your partner's favorite hobby and identify a gift that is really useful for her. The more specialized the gift the more impact it will have. Talk to her friends and family and use the Net to find the information you need.

*
IDEA # 82
Go to a masquerade ball. Send an invitation to your partner telling her to meet you at a specific spot at the stroke of eight.

Wear a mask and when you meet her, don't say a word. Just take her hand and lead her on to the dance floor.

*
IDEA # 83
On Thursday, ask your partner to pack a bag for the weekend. Tell her she'll need casual clothes and walking shoes but don't tell her what you have got planned.

Pick her up after work on Friday and drive to a romantic bed and breakfast for a romantic weekend of relaxation.

*
IDEA # 84
When you are relaxing at home one night, take two large sheets of paper and some pencils or crayons. On each piece of paper, draw the outline of a large crystal ball sitting on a stand.

Tell your partner to look into her crystal ball and draw what she sees five years in the future. Do the same thing yourself and then come together to share and discuss your drawings.

*
IDEA # 85
Create a loving nickname for your partner. This could be the name she was called by her family when she was a little girl or something that is special just for the two of you.

*
IDEA # 86
If you are musically inclined, write a love song for your partner. Call it something like "Natasha's Song".

Produce a professional looking manuscript, print it out and get it framed. Record your song onto CD and take a photo of your partner and get a print shop to create a CD cover if you can’t create one on your computer.

Place the framed manuscript and the CD in a box and give it to your partner as a special gift.

*
IDEA # 87
Pick your partner up for a date and blindfold her before driving to a special destination.

Try to make the destination something really unexpected like a table set up at the top of a cliff or a dinner on a boat or old-fashioned ship. It needs to be something that will have an impact when she removes the blindfold.

*
IDEA # 88
Have a really big pillow fight. Set up for it by buying two pillows that are filled with feathers. Put holes in the pillows so the feathers will start to fly and then attack your partner when you feel the time is right.

*
IDEA # 89
Get out into the great outdoors. After a day of hiking, build an open fire. Sit by the fire with your partner, toast marshmallows and watch as the embers of the fire climb into the night sky.

*
IDEA # 90
If your partner uses a computer, take a photo of the two of you and get it scanned at a print shop (or scan it at home) and store it on disk as a .bmp file.

Transfer the file onto your partner's computer and set the image as the computer's wallpaper.

To do this on a Windows machine, select Start / Settings / Control Panel / Display. Choose the Background tab and click the Browse button to find your .bmp file.

*
IDEA # 91
If you are artistically inclined, do a life drawing course, practice until you are confident and then ask your partner to pose for you.

*
IDEA # 92
Take your partner to a carnival or festival. Try the following:

(1) Food festival
(2) Jazz festival
(3) Wine festival
(4) Music festival

*
IDEA # 93
Develop a video time capsule. Start with the two of you sitting together on a couch introducing the video. Say something like, "It is currently July 14th 2002. We have decided to make this video so that we can watch it together on our 25th wedding anniversary."

Then have a section where you talk to the camera by yourself, telling the camera how you feel about your partner and why you love her. Get her to do the same thing. When you are done, place the video in a bank vault and on your 25th wedding anniversary you will be able to look back in time and reminisce about everything that you have shared.

*
IDEA # 94
If you are in a secluded spot near a beach or lake and the weather is warm, go for an impromptu skinny dip with your partner.

*
IDEA # 95
This one is great for long distance relationships. It takes a bit of organization but if you can pull it off, it is sure to be a surprise that your partner will never forget. Organize to catch up with her regularly over the internet using either a chat room or an Instant Messenger program. Then arrange a secret trip to meet her without telling her that you’re coming.

When it comes time for your usual chat over the Net, arrange for a close friend back home to log on using your nickname while you position yourself outside her door. Phone your friend on your mobile and be speaking to him in real time. Tell him to type in the following sentence, “I really miss you honey, I wish I could be there and just reach out and knock on your door.” As soon as he has sent the message, knock on the door!

*
IDEA # 96
Buy your partner a gold fish in a bowl and give it to her with a card saying,
“Of all the fish in the sea,
you're the fish for me!”

*
IDEA # 97
Go for a drive either early in the morning or at dusk. Get a CD/tape that contains sounds of nature such as Sounds Of the Rainforest and play it as you hold your partner's hand and drive.

*
IDEA # 98
The day before your partner's birthday buy some helium balloons, streamers and flowers and hide them in a closet.

When your partner has fallen asleep, string the streamers around the room and bring out the balloons and flowers. Place them around the bed so that your partner wakes up to a real birthday surprise.

*
IDEA # 99
Spend a leisurely afternoon with your partner in a large book shop such as Borders where you can browse the shelves, share a coffee and sit down to peruse your purchases.

*
IDEA # 100
If you can afford it, hire a sports car for a weekend. Pick up your partner and give her a long white cashmere scarf to wear with her sunglasses. Go for a drive along the coast with the top down.

*
IDEA # 101
Serve your partner breakfast in bed. Try the following:

(1) A poached egg in the shape of a heart - you can pick up a heart shaped poacher at most shops that sell kitchen wares.

(2) French toast with cinnamon and maple syrup.

(3) Cereal.

(4) Fruit juice.

(5) A fresh flower.

101 ROMANTIC IDEAS (c)

2008-11-12T20:46:00.001-08:00

IDEA # 51
When your partner is sitting at a table or desk, come up behind him or her and give her a back, shoulder and head massage. Finish with a gentle kiss on the cheek.

*
IDEA # 52
Place an ad in the paper on a normal day saying something like:

Dear Amanda,
With you by my side, everyday
feels like Valentines Day.
Thank you for being you.
Love,
Graham

*
IDEA # 53
Buy a book that you and your partner are both interested in reading.

Read one chapter each night in bed with each of you taking turns to read out loud.

This can be a great alternative to television.

*
IDEA # 54
When your partner is having a shower or bath, take her towel and place it in the dryer to make it really warm and then wrap her up in it when she is done.

*
IDEA # 55
Photocopy your hand and fax a copy of it to your partner with a message saying, "Do ya wanna hold hands?"

*
IDEA # 56
Next time you order a pizza, ask to have it cut into a heart shape before it is delivered to your home.

*
IDEA # 57
Buy a box of chocolates and very carefully open one side of the plastic wrap so that you can gently slide the box out. Open the box and place a love note inside. Then slide the box back into its plastic wrap and reseal it.

*
IDEA # 58
Rent a tandem bike and go for a ride with your partner. At the end of your ride have a picnic in the park.

*
IDEA # 59
If you are away on a business trip, document a day in your life for your partner. For example:

'A Day In The Life Of Mark'

6am: Just woke up and thought of you - Wish you were laying next to me. Well, I better get ready for work.

7am: Am on the train. It's crowded; everyone looks like they are half dead. I miss ya heaps.

8.30am: Have just organized my day, it's going to be a busy one.

9.30am: Am in the middle of a really boring meeting. I am trying to concentrate on this months sales figures but I keep thinking of your beautiful eyes.

...

6.30pm: Thank goodness the day is over. I am counting the days until we’re together again.

Send your letter to your partner. This is a wonderful way to tell your partner how often you think about her during the day and to share your life with her in a special way.

*
IDEA # 60
Speak to your partner's family and find out what her favorite book was when she was a little girl.

Buy a copy of the book and read it to her in bed.

*
IDEA # 61
Write an email story with your partner. Start the ball rolling with an email that says something like:

Chapter 1:
This is the story of Pete and Kate who met at a friend's engagement party one summer afternoon.

The email can then continue to develop the beginnings of a story which can be completely fictitious or a combination of fiction and reality.

Finish your email by saying, "And now for Chapter 2, its over to you..."

*
IDEA # 62
Buy a kite and on a windy day find a park and fly the kite with your partner.

If you can afford it, buy a large kite that you control with two hand lines. These kites are great fun.

*
IDEA # 63
When you and your partner are planning to go out for dinner, suggest that you have an 'Adventure Dinner'. Here's how it works

Set the timer on your stopwatch to count down twenty minutes. Next, ask your partner to choose a number between 5 and 10. Lets say she chooses 7.

Give your partner a coin and tell her that at every 7th intersection, she has to flip the coin. If it is heads you will turn left. If it is tails you will turn right. When your watch timer goes off you have to both keep a look out for the nearest place to eat.

This is a fun way to get out and about and try new places to eat.

*
IDEA # 64
When you and your partner are going somewhere special, get your camera, buy a new roll of film and wait for her to come out of the house.

When she appears, act like a professional photographer and go wild taking pictures of her with the flash. While you are taking photos, bombard her with questions as though she was a famous actress and you are trying to get a scoop for the magazine you represent.

Not only is this fun but you will also get some great photos to look back on together.

*
IDEA # 65
When your partner is sick at home, take a day off to look after her.

Rent some videos, make her some soup, wrap her up in a blanket and just be with her.

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IDEA # 66
When you are having dinner one night, ask your partner about the things she has always wanted to do.

Later on, write these things down so you don't forget them and over time try and help make them happen. For example she may say that one thing she has always wanted to do is swim with dolphins. Find out where she can do this and organize it for her as a special surprise.

*
IDEA # 67
Rent the video, "An Affair To Remember". Buy some popcorn, champagne and chocolate covered strawberries and have a special film night at home.

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IDEA # 68
Go to the drive in but instead of sitting in the car, spread a picnic blanket on the ground. Light a candle and buy popcorn. Cuddle your partner and enjoy the film.

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IDEA # 69
Create a personalized magazine cover for your partner. To do this, get hold of a good quality photo of her and a copy of a popular entertainment magazine.

Take these two items to a print shop or graphic design agency. Ask them to scan your partner's photo and develop a magazine cover with the lead story being, "The 30 most beautiful women of 2003".

When you get the cover, stick it on the front of a real magazine and ask your local shop owner whether you can place it in the magazine rack. Organize to meet your partner at the shop before going out. When she arrives, tell her that you are just looking for a magazine. Let her browse the rack and discover her magazine.

*
IDEA # 70
Fill the trunk of your car with helium balloons. Drive to a romantic spot in the country to go for a walk. The ideal spot is somewhere up high with a clear view of the surrounding countryside.

Get out of the car and act as though you are about to set off for your walk. Make sure your partner is closer to the car than you and then throw her the keys and ask if she can get your jacket from the trunk while you tie your shoelace.

When she opens the boot the balloons will be released. You can also place a sign saying, "I Love You" on the inside of the trunk so that it will be revealed when the trunk opens.

101 ROMANTIC IDEAS (b)

2008-11-12T20:45:00.000-08:00

IDEA # 21
Invite your partner to go for a walk. Get a back pack and pack the following items: A picnic blanket, a selection of fruit in small containers eg. strawberries, grapes, watermelon and kiwi fruit. Some cheese and crackers. Some sandwiches. A small tin of caviar. A half bottle of champagne and two plastic champagne glasses. If your partner asks what's in the backpack, just say a jacket and some lunch.

When you find a romantic spot, ask if she would like to stop for a bite to eat. Open your pack and remove the items one by one to set up your picnic. The last item you remove should be the glasses and champagne.

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IDEA # 22
If you play a musical instrument, create a romantic environment in which to play for your partner. For example, let's say you play the saxophone. Contact your partner's roommate and arrange for her to make sure that your partner steps out onto the balcony of their apartment at exactly 9.30pm.

Drive to her apartment and set up before hand. Place a large sparkler in the music holder of your sax and light it as your partner steps on to the balcony. Play something slow and romantic.

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IDEA # 23
Use this idea if your partner is going to work and you are staying at home for some reason (Perhaps you are sick or are working from home).

Say goodbye to her at the front door and then immediately send an email to her work address. The email should simply say,

"Miss you already".

The email will be in her in-box when she does her morning email check.

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IDEA # 24
If your partner has long hair, take the time to brush it using long slow strokes. This is particularly effective after she has had a shower or when she is getting ready for bed.

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IDEA # 25
On a special occasion like your partner's birthday, plan a treasure hunt for her. The fun begins when you suggest going for a walk on the beach.

When you get to the beach, carry a small bag with you. The bag contains a bottle that you prepared earlier. Inside the bottle is a treasure map. To make the treasure map look authentic, burn the edges with a match.

As you are walking, slip the bottle out of your bag and let it drop to the sand near the water's edge. You may have to pause and kiss your partner to do this unnoticed. Walk a little further up the beach then turn around and retrace your steps to 'discover' the bottle.

On the map have a dotted line leading from the beach to a nearby cafe. At the cafe, your partner won't know what to look for so suggest that you just sit down and have a cup of coffee.

When the waitress delivers the coffee, she suggests to your partner that she might find what she is looking for under the coaster. When your partner turns over the coaster she finds a key taped to the bottom. Obviously you will have to set this up before hand with the waitress. Most waitresses will be happy to help a romantic guy out with this type of thing.

At the next stop on the map, your partner finds or is given a spade. Then at the last stop on the map your partner finds a large 'X' made up of two crossed sticks. She digs and discovers a locked box. The key unlocks the box to reveal her present.

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IDEA # 26
Invite your partner on a date by sending her a plain brown envelope containing a tape. On the tape, record the Mission Impossible sound track and then record yourself saying, “Your mission if you choose to accept it is to make your way to Café Venoli, 123 Park Lane at 18.30 Eastern Standard Time. There you will rendezvous with a stunningly attractive man wearing a red carnation. The future of the free world is now in your hands. This tape will self destruct in five seconds.” Then record ten beeps from a stopwatch and record yourself saying, “Would you believe ten seconds…” Its corny but it usually gets a laugh!

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IDEA # 27
Contact your partner's family and ask if there was anything she always wanted when she was a little girl.

For example if she always wanted a porcelain doll, buy one for her birthday. She will not only appreciate the gift but also the fact that you were thoughtful enough to find out what she always wanted.

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IDEA # 28
Organize a professional photo shoot to obtain a portrait of the two of you as a couple. Frame the picture and put it somewhere prominent. Remember to make sure you give your partner plenty of notice so that she can get ready.

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IDEA # 29
Write a note saying

"I thought of you today, and it made me smile."

Leave the note somewhere where your partner is sure to find it.

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IDEA # 30
For Valentines Day, buy your partner a charm bracelet with at least 14 charms.

Remove all the charms and let your partner 'find' one charm each day for the first fourteen days of February. On Valentines Day give her the bracelet and any remaining charms.

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IDEA # 31
When you and your partner are in a shopping center or airport, stop at one of those booths that allow you to take an instant photo and print them out as stickers.

Choose a romantic background and kiss your partner while the photo is being taken.

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IDEA # 32
If your partner has voice mail at work or on her mobile, leave a message saying

"Just wanted to let you know that I'm thinking of you."

She will appreciate this anytime but especially when she is going through a rough period.

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IDEA # 33
Organize a mystery trip for you and your partner. Some travel agents will organize mystery packages where the destination of the trip is kept secret until you are actually on the plane or arrive at the destination.

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IDEA # 34
Buy some rose petals and place them behind the sun visor on the passenger side of your car. Take a post it note and write, "I Love You" on it and stick it to the back of the sun visor.

As you are driving to a romantic destination, look at your partner and tell her she has a mark on her cheek. She will pull down the sun visor to use the mirror and be showered in rose petals and see your note.

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IDEA # 35
If your partner is going on a trip, pack a small present into the corner of her suitcase that she will find when she is away.

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IDEA # 36
When you and your partner are having an anniversary, buy two champagne glasses and get them engraved with your names and the date, for example:
Mal and Kate
7 May 2002
Go to the restaurant where you have made your reservations and request that when you and your partner arrive that your champagne be served in your special glasses. This will be a great surprise for your partner and a wonderful keepsake for you both.

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IDEA # 37
On a special occasion such as your partner's birthday, buy twenty-four red roses. Arrange to meet her at a specific spot in a shopping mall before going out for dinner. Get to the shopping mall early and position yourself around the corner from your meeting spot.

Ask a guy who is walking by whether he would mind helping you out. Give him a rose, point out your partner and ask him to walk up to her and say, "Happy Birthday Meagan" and give her the rose and then walk away. Repeat this with eleven other guys. Choose guys who are not too good looking and choose guys of different ages. A nice touch is to have the last rose delivered by a small child who could even by accompanied by his parents.

After the first twelve flowers have been delivered, approach your partner with the twelve remaining roses.

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IDEA # 38
Always listen for things that your partner reminisces about and jot them down somewhere. For example, perhaps she talks about the ice cream that she had from a particular shop when she was a little girl.

When a special occasion comes along, check your list of things that your partner talks about and try to recreate one of them, for example, visit the shop and buy a tub of ice cream making sure that the name of the shop is on the container.

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IDEA # 39
Create a love montage by collecting some photographs of you and your partner, some ticket stubs of places you have visited and any other small odds and ends that have special meaning to you both.

Take these items and get them professionally framed in a three dimensional montage. Alternatively, buy a frame and create a simple montage yourself.

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IDEA # 40
Buy an ornately carved wooden box which is lined with green or red felt. Find an old fashioned key and place it in the box.

Next, get a small gold plaque and have it engraved with the words
The Key To My Heart

Fix the plaque to the inside of the top of the box so that it can be read when the box is opened.

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IDEA # 41
Buy a tree with your partner and plant it in a special spot. Each year on your anniversary, have a glass of champagne next to your tree and talk about how your love and the tree have grown.

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IDEA # 42
If you shower first in the morning. Steam up the bathroom and write a message such as "Pete Loves Kathy" on the mirror for your partner to read when she uses the bathroom. This also works on car windows when it's cold.

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IDEA # 43
As a special gift, name a Star after your partner. A number of astronomical agencies allow individuals to name stars and you receive formal documentation identifying the star that you have named. See the following website for details:
http://www./gifts.htm

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IDEA # 44
Find a comic strip that relates to something that you and your partner have shared together, for example perhaps you both work in the same office and you find a Dilbert cartoon that relates to the politics at your workplace.

Enlarge the cartoon using a photocopier and use white-out to cover the cartoon text. Type up your own text that relates to you and your partner and paste it in the appropriate places and then photocopy the cartoon again so that it looks like your text was the actual text of the cartoon.

For an added touch, get your customized cartoon laminated before giving it to your partner.

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IDEA # 45
When you and your partner are enjoying a restful time away, organize to wake up early one morning and go to a scenic spot to watch the sun rise.

This may seem difficult but it is something which is definitely worth doing at least once. Seeing a new day being born is something really special to share with your partner.

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IDEA # 46
When you have access to a spa, create a romantic atmosphere by placing some candles around the tub and some rose petals floating on the surface of the water.

As your partner enjoys the water, serve champagne and chocolate covered strawberries before joining her.

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IDEA # 47
Create some love coupons that your partner can exchange for romantic favors.

For example you could have a coupon that reads

This coupon entitles the bearer to:
One Foot Massage.
Use by 07/08/2045

Use a date many years in the future if you want to suggest that you and your partner will always be together. Get 50 love coupons at this site: http://www./lovecoupons.htm

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IDEA # 48
On a warm summers night, organize a backyard picnic. Spread a picnic blanket on the ground and get together some snacks, chocolates and champagne. Lie down on the blanket with your partner and gaze up at the stars together.

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IDEA # 49
Next time it is raining really heavily, go for a walk with your partner. Forget the umbrellas and the raincoats. Run through the streets together, jump in puddles and get totally saturated.

Pick her up, twirl her around and kiss her while the rain falls. Taste the water off her face and hold her close.

When you get back home have a hot shower and then share a warm drink preferably in front of an open fire.

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IDEA # 50
Organize a hot air ballooning trip as a special surprise. Most trips begin with a glass of champagne before you float over the countryside with your partner.

101 ROMANTIC IDEAS (a)

2008-11-12T20:38:00.000-08:00

IDEA # 1
If your partner is going away for a few days, tell her that you are worried about her so you have organized a bodyguard to look after her. Then give her a small teddy bear.

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IDEA # 2

Buy a packet of glow in the dark stars and stick the stars on the roof above your bed to spell out a message such as "I Love You" When the lights go down, your message will be revealed!

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IDEA # 3

On a special occasion, buy your partner eleven real red roses and one artificial red rose. Place the artificial rose in the center of the bouquet.

Attach a card that says:

“I will love you until the last rose fades.”

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IDEA # 4

Buy the domain name of your partner's name if it is available for example www.TanyaJohnston.com. Create a web page containing a romantic poem and a picture of a rose. When your partner is surfing the web, casually ask whether she has ever checked to see whether her domain name is taken. Let her type it in to discover her page.

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IDEA # 5

Buy a stylish hand mirror and give it to your partner as a gift. Include a card in the box saying

“In this mirror you will see the image of
the most beautiful woman in the world.”

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IDEA # 6
Take a book that your partner is reading and using a pencil, underline letters in a section of the book she has yet to read to spell out a love letter. For example in the following exert from a novel, the underlined letters come together to spell out the secret message "I love you"

The palace was a labyrinth, their passage through it tortuous and interminable. Initially they passed from building to building under the sodden sky. Steve's feet ached; he might have laughed at himself, the tireless traveler, grown too soft from his months in the city to walk any proper distance. Abruptly the guards halted.

The underlined letters will make your partner curious and with a bit of luck she will write them down. Spend time to encode a proper message such as "Dear Belinda, I love you honey"

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IDEA # 7

Have flowers delivered to your partner's workplace. She will not only enjoy the flowers but will also receive comments and attention from her office mates which will add to her enjoyment.

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IDEA # 8
While walking with your partner on a weekend getaway, pick up a smooth stone and say that you're going to keep it as a special memento of your trip. Later, have a message such as

"I Love Rebecca"

engraved into the stone by a jeweler and give it to your partner.

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IDEA # 9
Drive into the country, find a grassy hill and lie with your partner and look up at the clouds.

Play the kid’s game of looking for shapes in the cloud formations.

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IDEA # 10
Get a piece of paper and some crayons. Draw a bright childlike picture with a smiley sun and two stick figures holding hands. Add labels with your two names pointing to the stick figures. Write "I Love You" inside a heart.

Next get a large formal envelope. Place your drawing inside and type up a formal address label of your partner's work such as:

For the immediate and urgent attention of:

Level 20
Collins & Smith Solicitors
New York

Mail it to your partner so she receives it in the middle of a busy day.

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IDEA # 11
Memorize one of Shakespeare's love sonnets and recite it to your partner when you are in a romantic setting like a botanical garden. Don't just suddenly start reciting poetry as this will just sound corny.

While you are cuddling your partner, ask in a joking manner, "So is now a good time to recite a love poem to you?" She will probably say yes, expecting you to come up with something of the "Roses are Red..." variety.

Instead, look into her eyes, smile and recite the sonnet while you gently stroke her face. Try the sonnet below. If this is too long, just memorize the first four lines and the last two.

Shakespeare Love Sonnet 18

Shall I compare thee to a summer's day?
Thou art more lovely and more temperate.
Rough winds do shake the darling buds of May,
And summer's lease hath all too short a date.
Sometime too hot the eye of heaven shines,
And often is his gold complexion dimmed,
And every fair from fair sometime declines,
By chance or nature's changing course untrimmed.
But thy eternal summer shall not fade,
Nor lose possession of that fair thou owest,
Nor shall Death brag thou wander'st in his shade
When in eternal lines to time thou grow'st.
So long as men can breathe, or eyes can see,
So long lives this, and this gives life to thee.

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IDEA # 12

If your partner has to work late, take a lunch box and fill it with some of her favorite things such as chocolates, herbal tea, cookies, a small teddy bear.

Next, get a piece of paper and write

"Michelle's Late Night Survival Pack"

Draw a big red cross below this and stick the paper to the top of the box. Tell your partner to open the box when things get really tough.

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IDEA # 13
If you are walking by a park, visit the swings and give your partner a ride. This will often bring back happy memories from her childhood.

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IDEA # 14
Leave a long stem rose where your partner will find it with a note on it saying:

"Thank you for coming into my life."

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IDEA # 15
If your partner is starting a new job, buy a copy of "The Sound Of Music" sound track. Tape the song, "I Have Confidence" onto a tape and add your own message at the end of the song saying,

"Good Luck honey, I have confidence in you."

Give the tape to your partner to play on the way to work in the car.

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IDEA # 16
Buy a small decorated cardboard box, a sheet of colored tissue paper, some massage oil and a blank card.

Line the box with the tissue paper. Place the massage oil in the box and write the following message on the card:

I know a great Masseur.
For an appointment ring:
(Your Phone Number)

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IDEA # 17
When your spouse has had a really long hard day, run a hot bath for her. Pour some fragrant bath oil into the tub and gently bathe her from head to toe. Carry her into the bedroom. Gently towel her dry and tuck her into a freshly made bed with a kiss on the forehead.

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IDEA # 18
For this idea you will need a portable CD player. If you and your partner have a favorite song, get a copy of it on CD and take it with you when you go away for a romantic weekend.

When you are in a romantic spot, ask your partner if she would like to dance. Place one earpiece in her ear and one in your own and enjoy your private dance floor.

This technique is particularly effective if the romantic spot you have chosen is somewhere where people would not normally dance, for example, the top of the Empire State building at sunset or on top of a mountain during a camping trip.

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IDEA # 19
If your partner has a pet that she adores, at Christmas, in addition to buying a gift for your partner, buy a small present for her pet.

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IDEA # 20
Go for a walk on the beach. Trace out the shape of a large love heart in the sand. Sit inside the heart and cuddle your partner as you watch the sun go down.

Rehabilitation program for the lower limb

2008-11-11T07:11:00.001-08:00

INTRODUCTION — Physical therapy, manual therapy, and exercises for the lower limb serve to restore strength, improve posture, and alleviate pain and disability in patients with lower extremity problems. These measures should be used in conjunction with principles of joint protection for the lower limb. (See "Joint protection program for the lower limb").

COGNITIVE-BEHAVIORAL THERAPY — This type of therapy should be considered if the clinician or therapist observes poor coping strategies, patient fear of disability, lack of motivation, or other self-defeating behavior. Several controlled studies have shown the value of this type of psychological counseling [1-3].

PHYSICAL THERAPY — Physical therapy modalities include heat, cold, ultrasound, and diathermy. The purpose of these treatments is to allow the patient to perform an exercise program; they should therefore be performed prior to each exercise session.

PRICE program — Acute injury is best managed with the PRICE program: protection; rest; ice; compression; and elevation. Protection includes reduced weight bearing with forearm canes or crutches. Shoe modification should be individualized with either soft insert appliances or molded shoes. If a stress fracture of the foot is suspected, a fracture shoe can provide temporary protection until the diagnosis is secure. Ice packs include frozen gel packs and frozen bags of peas. If many areas are involved, dishtowels can be moistened and frozen, then applied as needed. Ice should be applied for up to 20 minutes, and repeated every few hours.

Heat — Heat increases local blood flow, and can be used after the first few days following injury. A heating pad over a layer of plastic separating it from warm moist towels can be applied as moist heat for 20 minutes preceding exercise. Diathermy has little advantage over hot packs or moist heat.

Joint aspiration and injection — If synovitis/synovial effusion is present, joint aspiration and injection may result in a more rapid response to physical therapy and joint protection.

Ultrasound — Ultrasound requires expertise. This technique uses sound waves directed at specific tissues. As the sound waves penetrate the tissue, local temperature increases and tissue extensibility is enhanced. Ultrasound is used for local tendinitis, bursitis, fasciitis, muscle pain, or spasm. It is usually performed two or three times per week for two to four weeks. Acute inflammation is a contraindication to the use of ultrasound due to the focal increase in tissue temperature. Despite its frequent use, evidence from well controlled studies is mixed and inconclusive regarding the effectiveness of ultrasound in relieving pain, contributing to overall functional outcomes, or reducing treatment time or cost [4,5].

Extracorporeal shock wave therapy (ESWT) — There are conflicting data regarding the effectiveness of ESWT. Three sham-treatment controlled studies with random assignment were favorable [6-8], while three other studies reported no significant difference between treatment and sham-controlled groups [9-11]. The technique does have soft tissue adverse side effects that include causing hematomas and microfractures. It is possible that efficacy depends upon the type of ESWT device and treatment protocols.

MANUAL THERAPY — Manual therapy includes many techniques that are totally operator-dependent. Thus, little hard data can be applied to individual situations. Experience and availability within a given community will determine preference.

Diathermy, massage, and ultrasound require a significant other person and therefore should be reserved for complex chronic problems. Massage techniques can be taught in the office to the patient and his or her significant other. Similar to physical therapy, an exercise program should follow manual therapy.

Magnets imbedded in orthotics were found to be no better than sham magnets in a controlled study of patients with plantar heel pain of at least 30 days duration [12].

EXERCISE THERAPY — Exercises that provide stretching and strengthening are important for pain management, strength restoration, and safety in patients with lower extremity problems. In general, the tissue should be stretched before strengthened.

A graded exercise program should be individualized, depending upon pain severity, limitation of movement, and current strength. A home exercise program should have clearly defined goals, easily understood instructions, and should not require more than about 30 minutes duration for each session. In most cases, we ask the patient to perform a twice daily regimen [4]. The value of exercise in different disorders has been assessed and the following are illustrative results: Efficacy for osteoarthritis is supported by three controlled studies of strength-training [13-15]. Pain, walking time, gait, safety, and strength improved significantly in all three studies. However, synovial effusion increased in one study [13]. Patients who develop osteoarthritis of the patellofemoral joint do not seem to be significantly helped by treatment with a combination of physical therapy, quadriceps strengthening exercises, and patellar taping [16]. Non-weight-bearing stretching exercises specific to the plantar fascia is superior to weight-bearing Achilles tendon-stretching exercises [17] (See exercise 10 below).

Isotonic exercise is suggested for initial strengthening in patients with exercise-induced knee pain, and subsequent isokinetic exercise is suggested for improving joint stability or walking endurance [18].

Relaxation exercise can be performed when anxiety, tension, or pain limit exercise performance. These techniques include Yoga, breathing, audio tapes, and guided imagery. Self-help books are readily available.

A series of 11 exercises are presented here to stretch and strengthen the muscles of the lower extremity. The choice of exercise for individual patients is dependent upon the condition that is being treated. These exercises were selected for their ease of application and the author's experience. The snapping hip syndrome may be treated with the standing iliotibial band stretch (show picture 1). Fascia lata fasciitis may be treated with the sidelying iliotibial band stretch (show picture 2). Hamstring injuries may be treated with the posterior leg stretch-wall (show picture 3), posterior leg stretch-doorway (show picture 4), or supine leg stretch (show picture 5) (See "Evaluation of the adult patient with knee pain"). Myofascial knee pain may be treated with the hip flexor stretch (show picture 6). Quadriceps disuse atrophy, knee injuries, and the piriformis pain syndrome may be treated with resistive quadriceps strengthening (show picture 7). Sport centers often combine this with leg curls to strengthen the hamstring muscle group. Popliteal tendinitis (tennis leg) may be treated with the posterior leg stretch-wall (show picture 3). Plantar fasciitis may be treated with the calf-plantar fascia stretch (show picture 10) and toe curls (show picture 8). (See "Plantar fasciitis and other causes of heel and sole pain"). Running injuries may be treated with different exercises depending upon the area affected: a general exercise is the posterior leg stretch-wall (show picture 3); resistive quadriceps strengthening is used for knee injuries (show picture 7); foot/ankle circles are used for ankle sprains (show picture 9). Leg cramps may be treated with the posterior leg stretch-wall (show picture 3). (See "Nocturnal leg cramps, night starts, and nocturnal myoclonus"). Ankle tendinitis may be treated with foot/ankle circles (show picture 9), and the posterior leg stretch-wall (show picture 3). (See "Posterior ankle tendinopathies"). Achilles disorders may be treated with the posterior leg stretch-wall (show picture 3) and the calf-plantar fascia stretch (show picture 10). Metatarsalgia may be treated with toe curls (show picture 7), and toe towel curls (show picture 11). Adhesive capsulitis of the ankle, and plantar fasciitis may be treated with the calf-plantar fascia stretch (show picture 10).

SHOE MODIFICATION — Patients with metatarsalgia may benefit from adding rocker bars to the sole or from an orthotic. Structural disorders including pes planus, plantar fasciitis, bunions, and osteoarthritis of the midfoot may also improve with shoe modification. Patients who live or work on concrete flooring should change to running shoes, extra-depth shoes (see below), heat moldable shoes, or custom-made shoes. For dorsal exostoses, I teach the patient to mark the exostosis with lipstick, put on the shoe, then construct a bridge by applying adhesive-backed foam rubber strips (1/4 inch wide by 1 inch long) on either side of the lipstick mark inside the shoe or tongue. Elastic shoelaces should be used.

Extra-depth shoe — The extra-depth shoe is prescribed with the additional feature of the enlarged toe box. This shoe is helpful for patients with metatarsal and metatarsophalangeal joint difficulties, hammer toe, and rheumatoid or other inflammatory arthritides with forefoot deformity. Occupational therapists, orthopedists, or podiatrists are skilled in making the mold.

Running shoes — A running shoe has microcellular foam and a rigid forefoot. These are important differences from other sport shoes.

Orthoses — Orthoses can be used for a variety of purposes: to correct a leg length discrepancy; to correct foot/floor contact as in pronation/supination disorders; and to redistribute weightbearing patterns. Orthoses may be obtained over-the-counter or can be custom made.

RESOURCES — Resources for the professional include:

Carolyn Kisner, Lynn Allen Colby:Therapeutic Exercise: Foundations and Techniques. F A Davis Co; 4th edition, 2002.

William E Prentice, William Prentice: Rehabilitation Techniques for Sports Medicine and Athletic Training with Laboratory Manual and eSims Password Card. McGraw-Hill Humanities/Social Sciences/Languages; 4th edition; 2003

Steven B. Brotzman, Kevin E. Wilk: Clinical Orthopaedic Rehabilitation. Elsevier Science 2003

Anderson, BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed, WB Saunders Company, Philadelphia 1999.

Banwell, B, Hoehing, P. Physical interventions, exercise, and rehabilitation. In: Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd ed, Sheon, RP, Moskowitz, RW, Goldberg, VM (Eds), Williams & Wilkins, Baltimore, 1996.

REFERENCES

1. Savelkoul, M, de Witte, LP, Candel, MJ, et al. Effects of a coping intervention on patients with rheumatic diseases: results of a randomized controlled trial. Arthritis Rheum 2001; 45:69.
2. Barlow, JH, Turner, AP, Wright, CC. A randomized controlled study of the Arthritis Self-Management Programme in the UK. Health Educ Res 2000; 15:659.
3. Steultjens, MP, Dekker, J, Bijlsma, JW. Coping, pain, and disability in osteoarthritis: a longitudinal study. J Rheumatol 2001; 28:1068.
4. Downing, DS, Weinstein, A. Ultrasound therapy of subacromial bursitis: A double blind trial. Phys Ther 1986; 66:194.
5. Crawford, F, Snaith, M. How effective is therapeutic ultrasound in the treatment of heel pain?. Ann Rheum Dis 1996; 55:265.
6. Rompe, JD, Decking, J, Schoellner, C, Nafe, B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med 2003; 31:268.
7. Abt, T, Hopfenmuller, W, Mellerowicz, H. [Shock wave therapy for recalcitrant plantar fasciitis with heel spur: a prospective randomized placebo-controlled double-blind study]. Z Orthop Ihre Grenzgeb 2002; 140:548.
8. Hammer, DS, Adam, F, Kreutz, A, et al. Extracorporeal shock wave therapy (ESWT) in patients with chronic proximal plantar fasciitis: a 2-year follow-up. Foot Ankle Int 2003; 24:823.
9. Speed, CA, Nichols, D, Wies, J, et al. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res 2003; 21:937.
10. Haake, M, Buch, M, Schoellner, C, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ 2003; 327:75.
11. Buchbinder, R, Ptasznik, R, Gordon, J, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA 2002; 288:1364.
12. Winemiller, MH, Billow, RG, Laskowski, ER, Harmsen, WS. Effect of magnetic vs sham-magnetic insoles on plantar heel pain: a randomized controlled trial. JAMA 2003; 290:1474.
13. Rogind, H, Nielsen, BB, Jensen, B, et al. [A controlled trial of training in knee arthritis]. Ugeskr Laeger 2001; 163:3798.
14. Fransen, M, Crosbie, J, Edmonds, J. Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. J Rheumatol 2001; 28:156.
15. Petrella, RJ, Bartha, C. Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial. J Rheumatol 2000; 27:2215.
16. Quilty, B, Tucker, M, Campbell, R, Dieppe, P. Physiotherapy, including quadriceps exercises and patellar taping, for knee osteoarthritis with predominant patello-femoral joint involvement: randomized controlled trial. J Rheumatol 2003; 30:1311.
17. DiGiovanni, BF, Nawoczenski, DA, Lintal, ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003; 85-A:1270.
18. Huang, MH, Lin, YS, Yang, RC, Lee, CL. A comparison of various therapeutic exercises on the functional status of patients with knee osteoarthritis. Semin Arthritis Rheum 2003; 32:398.

Posterior ankle tendinopathies

2008-11-11T07:10:00.000-08:00

INTRODUCTION — Posterior ankle tendinopathies usually result from cumulative movement disorders or repetitive strain injuries. In some cases, subtle skeletal structural faults (such as limb length discrepancy) predispose to such disorders or injuries. It is therefore important to conduct a careful examination to detect these defects. (See "Evaluation for subtle structural defects of the lower limb").

Other factors can contribute to recurrent or perplexing lower limb distress. These include osteoporosis, spondyloarthritis and enthesitis of lower limb structures, improper footwear, prolonged standing on concrete floors, and structural disorders such as joint laxity or malalignment of the lower limbs.

This topic review will discuss tendinitis of the posterior ankle. Ankle sprains and other soft tissue disorders of the foot are discussed separately. (See "Ankle sprain" and see "Plantar fasciitis and other causes of heel and sole pain").

TENDINITIS OF THE ANKLE — Eleven muscles have tendons crossing the ankle (show figure 1 and show figure 2). Inflammation and degeneration of a tendon sheath (often referred to as peritendinitis and tendinosis, respectively) may result from repetitive activity or unaccustomed extraordinary work. In addition, improper footwear often causes injury to the extensor hallucis longus or Achilles tendon.

A chronic nonspecific tendinitis similar to that seen in de Quervain's tenosynovitis can affect several tendons of the ankle. Tenosynovitis involving the tibialis anterior, tibialis posterior, extensor digitorum longus, or fibularis (peroneal) tendons can occur where the tendons become angulated at the ankle; friction can then cause inflammation of the tendon sheath. A bulbous swelling often occurs distally to areas of constriction and is helpful in demonstrating points of constriction. Occasionally, there is an underlying systemic disorder such as rheumatoid arthritis, spondyloarthritis, and rarely oxalosis, xanthomas, giant cell tumors, or tuberculosis. (See "de Quervain's tenosynovitis" and see "Clinical features and management of ankle pain in the young athlete", section on peroneal tendon injuries).

The posterior tibial tendon typically is involved in a patient with a pronated flatfoot. The presenting complaints include an aching mild to moderate pain over the medial ankle and longitudinal arch with weightbearing. Several weeks of persistent pain often have passed before the patient decides to seek help. Tendinitis of the other tendons of the ankle may also develop slowly. Calcific tendinitis is the exception; onset of pain with this disorder is acute.

Physical examination in the patient with tendinitis often reveals a tubular swelling of the tendon sheath, tenderness, pain on passive stretching of the tendon, pain on active ankle movement, and normal findings with palpation of the ankle joint. Comparison with the uninvolved side is helpful.

Radiographic abnormalities in tendinitis are usually absent in plain x-rays. New bone formation over the posterior aspect of the medial malleolus can occur in some cases. Magnetic resonance imaging with a low-field-strength instrument gives excellent definition of tendinopathy with or without rupture, but may not provide a cost benefit. In a randomized controlled study of 500 persons with acute injury of the wrist, knee, or ankle, MRI did not expedite the workup or change treatment of wrist or ankle injuries when compared to plain radiography [2]. Ultrasound may be helpful in determining the extent of tendon injury [1].

Most cases of tendinitis can be treated by partial immobilization of the ankle with bandaging or an elastic support for three to six weeks, and home exercise therapy. Foot/ankle circles is a simple exercise to maintain range of motion and strength (show picture 1). These can be performed several times daily with increasing repetitions and intensity as healing progresses. Stretching and lengthening of the calf muscles and plantar fascia begin gently and continue as activity increases. Strengthening exercises are added as pain subsides. Massage of the involved tendon can improve tissue flexibility.

Complete immobilization in a walking cast boot for a brief period of time may be necessary in severe cases; nonsteroidal antiinflammatory drugs (NSAID) can be used for pain relief. Tendon sheath injection with a corticosteroid and anesthetic mixture may be used in select cases. When injections are performed, the needle must be kept parallel to the tendon in order to minimize the risk of injecting steroid directly into the tendon. Injection is only performed in nonathletes with palpable swelling at the site of injury. The risk of post injection tendon rupture is significant in young athletes. Following injection the patient gradully begins strengthening and stretching exercises.

To perform intralesional injection, prepare the area with soap and alcohol. Using the shortest needle that can reach the required depth, use the needle as a probe. A 1 inch No. 23 or No. 25 needle is inserted 1/4 to 1/2 inch deep parallel to the tendon and into the tendon sheath for deposition of the mixture of corticosteroid and local anesthetic (1 mL 1 percent lidocaine hydrochloride and 20 to 40 mg methylprednisolone or equivalent). The mixture will flocculate within the syringe. Repeated injections around the ankle should not be made, since this can result in tendon rupture.

POSTERIOR TIBIAL TENDINITIS — Researchers no longer describe posterior tibial tendinitis as an inflammatory condition but rather as a degenerative condition with a nonspecific reparative response to tissue injury characterized by mucinous degeneration, fibroblast hypercellularity, chondroid metaplasia, and neovascularization in some patients [3,4]. These pathologic changes result in marked disruption in collagen bundle structure and orientation, creating weakened tendons susceptible to injury.

Inflammation and dysfunction of the posterior tibial tendon presents with gradually increasing pain and swelling over the medial ankle and longitudinal arch. This disorder is important to recognize since longstanding inflammation can lead to tendon disruption and progressive flatfoot deformity if left untreated. Complete rupture of the posterior tibial tendon may be suspected by x-ray if a sag of the naviculocuneiform joint or mild subluxation of the talonavicular joint is evident.

Numerous risk factors have been identified including increasing age, pes planus, hypertension, diabetes mellitus, peritendinous injections and inflammatory arthropathies [5]. Middle aged women are commonly affected. The pathogenesis of idiopathic tibialis posterior tendinopathy remains unclear. Areas of the tendon with relatively poor vascularization are more vulnerable, particularly if they are close to the medial malleolus. Forces acting through this tendon are high and may be influenced by adverse biomechanics (eg, excessively pronation).

Treatment is similar to other forms of tendinitis and begins with rest, ice, compression, elevation, and gentle stretching. Nonsteroidal antiinflammatory medications (NSAID) may reduce pain and swelling. If symptoms have not resolved in ten to fourteen days and NSAIDs do not provide adequate pain relief, treatment with a tendon sheath injection, and possibly casting for a short time, followed by use of an orthosis, may be helpful. Passive stretching is performed with the forefoot rotated externally (ie, outward) from the neutral position, or in a circular manner. Walking in a figure eight can begin when tenderness and swelling have subsided. Surgical intervention is sometimes necessary [6].

ACHILLES TENDINITIS

Pathophysiology and risk factors — As with posterior tibial tendinitis, Achilles tendinitis appears to be a degenerative condition, rather than inflammatory [5,7]. Histopathological evaluation of Achilles tendon biopsies, obtained from regions showing pathology at surgery, reveals altered fiber structure and arrangement, focal variations in cellularity, extracellular glycosaminoglycans, neovascularization, and hyalinization, but no evidence of inflammatory cell infiltration [7]. Doppler studies have confirmed the presence of increased vascularity in symptomatic tendons [8].

Plantar flexor muscle weakness and increased dorsiflexion excursion appear to be intrinsic risk factors for the development of Achilles tendinitis [9]. A tight Achilles tendon may result from disuse, from complex factors associated with growth, or more often as a problem occurring in women who wear high-heeled shoes or individuals who wear boots with high heels. In addition, runners may develop microtearing due to accumulated impact loading, and local inflammation can be induced by calcific tendinitis, spondyloarthropathies, and use of fluoroquinolones [10].

Support for an association between fluoroquinolone use and Achilles tendinitis is provided by a population study of approximately 250,000 individuals [11]. The adjusted relative risk of tendinitis with the administration of a fluoroquinolone was 3.7, with the risk being particularly high with ofloxacin (relative risk of 10.1).

Affected patients present with pain over the heel. Dorsiflexion of the ankle increases the pain and tenderness and a tendon friction rub may be palpable. Bilateral involvement, in the absence of fluoroquinolone use, suggests a systemic rheumatic disease such as ankylosing spondylitis with peripheral arthritis, reactive arthritis (formerly Reiter's syndrome), or calcium apatite deposition disease.

Inflammation involving the Achilles tendon insertion can occur in association with spondyloarthritides (eg, ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, and psoriatic arthritis). (See appropriate topics). A tendon xanthoma, from hypercholesterolemia, can cause pain in the Achilles tendon without swelling.

Management — Gentle progressive stretching and lengthening exercises for the lower leg muscles are helpful, including the posterior leg stretch-wall (show picture 2), the posterior leg stretch-doorway (show picture 3), and the calf-plantar fascia stretch (show picture 4). Deep friction massage to the involved tendon may provide relief of pain and facilitate stretching. Achilles tendinitis in runners may respond to use of viscoelastic or other heel inserts to cushion and raise the heel, and a reduction in training level, especially on hills. If the disorder occurs in association with fluoroquinolone use, the antibiotic should be discontinued and another class of antimicrobial administered.

Several small randomized trials suggest eccentric exercise can reduce pain and improve function in patients with Achilles tendinitis, and many sports medicine specialists incorporate eccentric exercises into their treatment plan [5,12-15]. Eccentric loading exercises involve active lengthening (ie, the muscle is working while elongating) of the muscle tendon unit. A graded progressive program is recommended and is best supervised by an experienced therapist. The exercises may provide less benefit to sedentary patients [16].

Glyceryl trinitrate ointment applied to the skin overlying the Achilles tendon may be of some benefit. This was suggested in a randomized, placebo-controlled study in which 65 patients with noninsertional Achilles tendinopathy were randomly assigned to either apply the nitrate-containing patch (at a dosage of 1.25 mg per 24 hours) or an inert placebo [17]. Those who received the nitrate-containing patch had significantly less pain with activity.

Studies of chronic Achilles tendinopathy treatment using extracorporeal shock wave therapy have shown mixed results [18,19].

Corticosteroid injection for treatment of Achilles tendonitis is controversial [20]. It should only be considered in patients with ongoing symptoms despite rest, the use of corrective orthotics, and physical therapy. If local glucocorticoids are necessary, fluoroscopically guided peritendinous injection may offer an additional measure of safety. This was illustrated in a retrospective study of 43 patients who were injected with fluoroscopic guidance and were followed for at least two years [21]. Improvement occurred in 40 percent of patients; no major complications were noted.

In selected cases, refractory to other approaches, surgery such as percutaneous longitudinal tenotomy may be helpful [22]. Surgery may yield worse results in sedentary patients [23].

ACHILLES TENDON RUPTURE

History and examination — Rupture of the Achilles tendon may occur after abrupt calf muscle contraction. This typically occurs in men over the age of 30 who sporadically engage in sports and do not do a regular leg conditioning program. Fluoroquinolone antibiotic use has also been reported as a predisposing factor, particularly when combined with use of corticosteroids in people older than 60 years [10,24,25]. Genetic predisposition may also play a role [26].

The patient may note an audible snap, followed by pain in the calf as if struck with a baseball. Partial rupture, in contrast, may not have a well defined inciting event.

On physical examination, the patient may be unable to stand up on the toes. A positive Thompson test is further evidence of rupture (show figure 3). This test is performed with the patient kneeling on a chair and the feet hanging over the edge. When the examiner squeezes the calf muscle on the normal side, the foot responds with plantar flexion; on the side with a rupture, there is no foot response.

With partial rupture of the tendon there may still be substantial strength. A crescent sign due to blood tracking into the soft tissues may be seen beneath the malleolus or even into the foot or toes.

Management — Imaging is unnecessary in the case of obvious complete rupture. Discontinuity of tendon fibers and hypoechoic areas may be demonstrated by ultrasound in partial ruptures [27]. In one study, ultrasound was highly accurate in differentiating full from partial thickness tears [28].

Orthopedic consultation for immobilization or repair is necessary for patients with tendon rupture. Surgical end-to-end repair performed soon after the injury allows patients to return to their preinjury level of activity in over 90 percent of cases [29]. However, in one study of 25 elderly patients, only 9 had a complete recovery [30].

Nonoperative treatment appears to be associated with a higher risk of rerupture. This was illustrated in a 2004 systematic review that included 4 trials and a total of 356 patients in which operative and nonoperative treatment were compared [31]. Achilles tendon repair using an open operative technique had a significantly lower risk of subsequent rupture (relative risk 0.27, 95% CI 0.11-0.64). Infection, adhesions, and local nerve damage were more frequent in those who were operated upon. Patients have a more rapid rehabilitation when a functional brace is used rather than a cast for post operative immobilization.

The success of delayed surgery is less clear [32,33]. Extensive postoperative exercise rehabilitation may be needed.

REFERENCES

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2. Nikken, JJ, Oei, EH, Ginai, AZ, et al. Acute peripheral joint injury: cost and effectiveness of low-field-strength MR imaging--results of randomized controlled trial. Radiology 2005; 236:958.
3. Mosier, SM, Pomeroy, G, Manoli A, 2nd. Pathoanatomy and etiology of posterior tibial tendon dysfunction. Clin Orthop Relat Res 1999; :12.
4. Goncalves-Neto, J, Witzel, SS, Teodoro, WR, et al. Changes in collagen matrix composition in human posterior tibial tendon dysfunction. Joint Bone Spine 2002; 69:189.
5. Rees, JD, Wilson, AM, Wolman, RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford) 2006; 45:508.
6. Supple, KML, Hanft, FR, Murphy, BJ, et al. Posterior tibial tendon dysfunction. Semin Arthritis Rheum 1992; 22:106.
7. Movin, T, Gad, A, Reinholt, FP, Rolf, C. Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 1997; 68:170.
8. Knobloch, K, Kraemer, R, Lichtenberg, A, et al. Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med 2006; 34:92.
9. Mahieu, NN, Witvrouw, E, Stevens, V, et al. Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study. Am J Sports Med 2006; 34:226.
10. Ribard, P, Audisio, F, Kahn, et al. Seven cases of Achilles tendinitis including 3 complicated by rupture during fluoroquinolone therapy. J Rheumatol 1992; 19:1479.
11. van der Linden, PD, van de Lei, J, Nab, HW, et al. Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999; 48:433.
12. Roos, EM, Engstrom, M, Lagerquist, A, Soderberg, B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up. Scand J Med Sci Sports 2004; 14:286.
13. Ohberg, L, Lorentzon, R, Alfredson, H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med 2004; 38:8.
14. Silbernagel, KG, Thomee, R, Thomee, P, Karlsson, J. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 2001; 11:197.
15. Mafi, N, Lorentzon, R, Alfredson, H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001; 9:42.
16. Sayana, MK, Maffulli, N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 2007; 10:52.
17. Paoloni, JA, Appleyard, RC, Nelson, J, Murrell, GA Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am 2004; 86-A:916.
18. Furia, JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med 2006; 34:733.
19. Costa, ML, Shepstone, L, Donell, ST, Thomas, TL. Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial. Clin Orthop Relat Res 2005; 440:199.
20. Shrier, I, Matheson, GO, Kohl HW, 3rd. Achilles tendonitis: are corticosteroid injections useful or harmful?. Clin J Sport Med 1996; 6:245.
21. Gill, SS, Gelbke, MK, Mattson, SL, et al. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. A safety study. J Bone Joint Surg Am 2004; 86-A:802.
22. Maffulli, N, Testa, V, Capasso, G, Bifulco, G. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 1997; 25:835.
23. Maffulli, N, Testa, V, Capasso, G, et al. Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sport Med 2006; 16:123.
24. Harrell, RM. Fluoroquinolone-induced tendinopathy: what do we know?. South Med J 1999; 92:622.
25. van der, Linden PD, Sturkenboom, MC, Herings, RM, et al. Increased risk of Achilles tendon rupture with quinolone antibacterial use, especially in elderly patient taking oral corticosteroids. Arch Intern Med 2003; 163:1801.
26. Mokone, GG, Gajjar, M, September, AV, et al. The Guanine-thymine dinucleotide repeat polymorphism within the tenascin-C gene is associated with achilles tendon injuries. Am J Sports Med 2005; 33:1016.
27. Grassi, W, Filippucci, E, Farina, A, Cervini, C. Sonographic imaging of tendons. Arthritis Rheum 2000; 43:969.
28. Hartgerink, P, Fessell, DP, Jacobson, JA, van Holsbeeck, MT. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001; 220:406.
29. Soldatis, JJ, Goodfellow, DB, Wilber, JH. End-to-end operative repair of Achilles tendon rupture. Am J Sports Med 1997; 25:90.
30. Nestorson, J, Movin, T, Moller, M, Karlsson, J. Function after Achilles tendon rupture in the elderly: 25 patients older than 65 years followed for 3 years. Acta Orthop Scand 2000; 71:64.
31. Khan, RJ, Fick, D, Brammar, TJ, et al. Interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 2004; :CD003674.
32. Nellas, ZJ, Loder, BG, Wertheimer, SJ. Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft. J Foot Ankle Surg 1996; 35:144.
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Plantar fasciitis and other causes of heel and sole pain

2008-11-11T07:08:00.000-08:00

INTRODUCTION — Disorders of the ankle and foot, including ankle sprains, tendinitis, plantar fasciitis, and bursitis, usually occur in association with movement and result from trauma. In some cases, subtle skeletal structural faults (such as limb length discrepancy) predispose to these cumulative movement disorders or repetitive strain injuries. It is therefore important to conduct a careful examination to detect these defects. (See "Evaluation for subtle structural defects of the lower limb").

Other factors can contribute to recurrent or perplexing lower limb distress. These include stress fractures that occur due to osteoporosis, inflammatory arthritis due to rheumatoid arthritis, and the spondyloarthropathies which may also present with an enthesitis (inflammation at tendon insertions into bone), painful peripheral neuropathies (eg, associated with diabetes) that may also predispose to Charcot's joints, improper footwear, moving from a building with wood flooring to one with a concrete slab, prolonged standing, weakness and unsteadiness associated with the problems of ageing, and structural disorders such as joint laxity or malalignment of the lower limbs.

This topic review will discuss painful disorders of the foot. Tendinitis of the ankle and ankle sprains are discussed separately. (See "Posterior ankle tendinopathies" and see "Ankle sprain").

PLANTAR FASCIITIS — The predominant symptom of plantar fasciitis is pain in the plantar region of the foot that is worse when initiating walking. Plantar fasciitis is one of the most common causes of foot pain in adults estimated to be responsible for about one million patient visits to the doctor per year [1]. The peak incidence occurs between ages 40 and 60 years in the general population with a younger peak in runners [2,3]. It may be bilateral in up to a third of cases [2,4,5].

Heel spurs often coexist [6,7]; whether they have a causal role is unknown. They may represent a secondary response to an inflammatory reaction [2].

Anatomy — The deep plantar fascia (plantar aponeurosis) is a thick, pearly white tissue with longitudinal fibers intimately attached to the skin (show figure 1). The central portion is thickest and attaches to the medial process of the tuberosity of the calcaneus; distally it divides into five slips, one for each toe. The plantar fascia provides support; as the toes extend during the stance phase of gait, it is tightened by a windlass mechanism, resulting in elevation of the longitudinal arch, inversion of the hindfoot, and a resultant external rotation of the leg [8].

Etiology — The etiology is poorly understood and is probably multifactorial. Possible risk factors for the development of plantar fasciitis include obesity, prolonged standing or jumping, flat feet, reduced ankle dorsiflexion, and heel spurs [3,5,7,9-11]. There is a high incidence in runners, suggesting that plantar fasciitis, at least in this population, is due to an injury caused by repetitive microtrauma [12]. In this group, the following have been proposed as risk factors [13-16]: Excessive training (particularly a sudden increase in the distance run) Faulty running shoes Running on unyielding surfaces Flat feet (pes planus or pronated ankles) Limited ankle dorsiflexion (eg due to a shortened Achilles tendon) Pes cavus (high-arched) foot

However, evidence of an association for most of these factors is limited or absent [14].

Plantar fasciitis is common among ballet dancers [17] and those performing dance aerobic exercise. Stress applied to the Achilles tendon, either due to muscle contraction or passive stretching, results in increased tension in the plantar fascia [18]. Decreased knee extension, as may occur with tight hamstring muscles, causes an increase in loading of the forefoot when walking [19]; this could in turn increase the stress on the plantar fascia.

Plantar fasciitis usually occurs as an isolated problem but may be associated with systemic rheumatic diseases particularly reactive arthritis and the spondyloarthritites. Plantar fasciitis has been reported in association with fibromyalgia [20], fluoride used for the treatment of osteoporosis [21], and may be the presenting symptom in patients with nutritional osteomalacia [22].

Pathology — The site of abnormality is typically near the origin of the plantar fascia at the medial tuberosity of the calcaneum. Specimens of plantar fascia obtained during surgery for plantar fasciitis reveal a spectrum of changes, ranging from degeneration of the fibrous tissue, to fibroblastic proliferation, with or without evidence of chronic inflammation [23-25].

Diagnosis — A hallmark for diagnosis of plantar fasciitis is local point tenderness. This is best elicited by the examiner dorsiflexing the patient's toes with one hand in order to pull the plantar fascia taut, and then palpating with the thumb or index finger of the other hand along the fascia from the heel to the forefoot (show picture 1). Points of discrete tenderness can be found and marked for possible later injection.

Laboratory testing is not helpful in the diagnosis of plantar fasciitis. Tests for inflammation (eg, erythrocyte sedimentation rate and C-reactive protein) will be normal unless there is coexistent inflammatory disease.

Radiographic studies may be required to establish the diagnosis when this is in doubt in patients with persistent plantar pain. The primary goal of radiography is to rule out other disorders, especially calcaneal stress fractures. Lateral and axial radiographs are the appropriate views due to the myriad of diagnostic possibilities. The presence of heel spurs is of no diagnostic value in either ruling in or ruling out plantar fasciitis. In one study, 85 percent of 27 patients with plantar fasciitis and 46 percent of 79 controls had calcaneal spurs detected on plain non-weight bearing lateral X-Rays read by a radiologist blinded to the clinical diagnosis [26]. On the other hand, increased plantar fascia thickness and fat pad abnormalities detected in the same X-Rays had a sensitivity of 85 percent and specificity of 95 percent for plantar fasciitis.

The soft tissue may be evaluated with magnetic resonance imaging (MRI) in cases resistant to treatment [27]. Features suggestive of plantar fasciitis are thickening of the plantar fascia and increased signal on delayed (T2) and short tau inversion recovery (STIR) images [28]. Technetium scintigraphy has also been successful in localizing the inflammatory focus and ruling out stress fracture [29].

Ultrasonography of the foot may also be useful in detecting plantar fascial thickening, hypoechogenicity at the insertion upon the calcaneus, blurring of the boundary between fascia and surrounding tissues, and decreased echogenicity suggestive of edema [30,31]. The sensitivity and specificity of ultrasonography for the diagnosis of plantar fasciitis was 80 percent and 88.5 percent respectively in a study of 77 patients and a similar number of asymptomatic controls [32]. Doppler ultrasound may improve the value of this technique and provide additional information on local hyperemia [33].

Differential diagnosis — Plantar heel pain and pain in the sole of the foot may be induced by a number of other disorders. These include the following [34-36]: Rupture of the plantar fascia — Rupture of the plantar fascia generally follows physical activity and has a sudden onset, unlike the more gradual appearance of the pain of plantar fasciitis. Examination of the affected foot may reveal a loss of height of the arch and there may be visible swelling or ecchymosis present. Nerve pain due to entrapment — Entrapment of the posterior tibial nerve as it courses beneath the medial malleolus can cause pain, paresthesia, and numbness on the sole of the foot. Percussion tenderness over the posterior tibial nerve in the tarsal tunnel is characteristically found. (See "Overview of lower extremity peripheral nerve syndromes", section on Tarsal tunnel syndrome). Compression or trauma to branches of the posterior tibial nerve, particularly the medial calcaneal branch or to the nerve supplying the abductor digiti quinti can also cause pain in the heel. Bone pain — Pain arising from the calcaneus may also be associated with exacerbation during weight bearing. Pain caused by a neoplasm or infection is typically constant or characterized by nocturnal worsening. Stress fractures should be considered if there has been an increase in physical activity. While plain radiographs may be diagnostic, early changes with infection, tumor, and stress fracture are better differentiated by MRI. (See "Cancer pain syndromes", and see "Diagnosis of osteomyelitis in adults", and see "Overview of stress fractures").

Other causes of calcaneal bone pain are Paget's disease, which is generally apparent on plain radiographs with coarsened trabecular bone and may be accompanied by an elevated serum alkaline phosphatase. (See "Clinical manifestations and diagnosis of Paget's disease of bone"). Tendinitis of the posterior tibialis or flexor digitorum longus tendons — These typically have an insidious onset with pain and tenderness along the course of the tendons and tendon sheaths. Subtle changes in the position of bones of the midfoot may be indicative of tendon rupture. (See "Posterior ankle tendinopathies"). Reactive arthritis and other spondyloarthritides — Asymmetric involvement and a propensity for the joints and entheses of the lower extremities are frequently seen in the spondyloarthritides. Back pain with inflammatory features (eg, night pain, prolonged morning stiffness) is frequently present in patients with ankylosing spondylitis, while a prior history of enterocolitis or genitourinary infection is suggestive of reactive arthritis. (See "Reactive arthritis: Definition; diagnosis; and management" and see "Calcaneal periostitis" below). Painful heel pad syndrome — The painful heel pad syndrome most often occurs in marathon runners. It is thought to result from disruption of the fibrous septae that compartmentalize the fat in the heel pad. Pain is localized to the heel pad; the plantar fascia is not tender and pain is not accentuated as the examiner dorsiflexes the toes. Insertion of heel cups [37] and "plastizote" that is individually molded to the patient's heel may be useful [38]. Atrophy of the heel pad — Atrophy of the heel pad occurs in the elderly. Palpation reveals bony prominence without the padding usually afforded by subcutaneous fat. Unlike pain due to plantar fasciitis, pain due to atrophy of the heel pad is absent in the morning and develops and worsens during weight bearing throughout the day. Piezogenic papules — Piezogenic papules are herniations of fat that occur as painful papules at the medial inferior border of the heel. They may be noted only upon weightbearing and are an uncommon cause of painful heels. Weight reduction, use of felt padding, and cushion-soled or crepe-soled shoes may provide relief [39]. Sarcoidosis — Heel pain has been reported to occur in sarcoidosis [40]. The combination of erythema nodosum, hilar adenopathy, migratory polyarthralgias, and fever is referred to as Lofgren's syndrome, and is typically seen in patients with sarcoidosis. (See "Erythema nodosum").

Treatment

Conservative therapy — Treatment of obesity, symptomatic flat feet, and systemic inflammation should be undertaken when these conditions are present. Others should begin with conservative therapy including measures to relieve pain, alterations in their shoes or habits, and exercise therapy. It should be noted there are limited data for the effectiveness of most of these modalities in the treatment of plantar fasciitis [34,41]. Rest and icing may give initial pain relief. Nonsteroidal antiinflammatory drugs (NSAIDs) are often used. A well-designed but small trial that randomly assigned 29 patients to NSAID or placebo reported a non-significant trend toward improved pain and disability in the NSAID group [42]. Use for longer than two or three weeks should be reserved for patients with systemic inflammation. There are conflicting reports on the benefit of resting padded foot splints [43-46]; these splints can usually be purchased in pharmacies that feature orthopedic supplies (show picture 2). The splints are worn at night to keep the ankle in the neutral position with or without dorsiflexion of the metatartophalangeal joints during sleep. A clinical trial reported they were of similar effectiveness to custom-fitted orthotics (see below) although there was better compliance and fewer side effects reported with orthoses use [47]. Prefabricated silicone heel inserts combined with stretching exercises (see below) may be of value [48]. Felt pads or rubber heel cups appear to be less effective than silicone inserts and magnetic insoles have not been found to provide additional benefit compared with nonmagnetic insoles [49,50]. Wearing slippers or going barefoot may aggravate symptoms or result in a recurrence of symptoms. Thus, the first step out of bed should be made with a supportive shoe or sandal on. Patients who work or reside in buildings with concrete floors should use cushion-soled or crepe-soled shoes. Excessive heel impact from jumping, excessive heel impact during walking, or use of a trampoline should be avoided. Athletic shoes, arch supporting shoes (particularly those with an extra-long counter, which is the firm part of the shoe that surrounds the heel), or shoes with rigid shanks (usually a metal insert into the sole of the shoe) may be helpful. Shoes with these features can be found in stores featuring work shoes or "orthopedic shoes". Exercises may be beneficial although evidence is limited. (See "Joint protection program for the lower limb" and see "Rehabilitation program for the lower limb"). Home exercises include the calf-plantar fascia stretch (show picture 3), foot/ankle circles (show picture 4), toe curls (show picture 5), and toe towel curls (show picture 6). One unblinded trial noted that non-weight bearing stretching exercises specific to the plantar fascia were more beneficial in the short term than weight-bearing Achilles tendon-stretching exercises [51], although the method of analysis may have biased towards this result. At two-year follow up there were no differences between groups [52]. Another placebo-controlled trial found no significant differences in pain and function in those who undertook a two-week calf muscle stretching program compared to those who did not [53]. Ultrasound therapy, ice massage, and deep friction massage may be used prior to exercise although their effectiveness is unknown. Tape support of the affected plantar surface, a technique referred to as low-Dye taping may be beneficial to some patients particularly for first-step pain [54,55]. Four strips of tape are applied as illustrated in the figure (show figure 2). The tape should not be applied too tightly and use of hypoallergenic tape is recommended to avoid allergic reactions [55].

If these inexpensive and noninvasive measures fail to bring about improvement within two to three weeks, the following may be considered: The points of tenderness along the plantar fascia may be injected with a corticosteroid/local anesthetic mixture (show picture 7). Injections may provide short-term, temporary pain relief. In a randomized placebo-controlled study, significantly less pain was noted in patients who received a single corticosteroid injection, a difference that was significant at one month, but not at three or six months [56]. An alternative, possibly less painful approach, a medial injection, may also provide significant benefit [57]. One of the authors (RS) injects into a minimum of three tender locations along the fascia while the other author (RB) uses a single injection directed to the site of maximal tenderness. The utility of using ultrasound to guide placement of the injection remains uncertain. Two randomised trials have found pain relief from ultrasound-guided injection was no different to blind injection [58,59] although one trial reported a lower recurrence rate [59].

Corticosteroid injection should be used judiciously since repeated injection may cause heel pad atrophy [60]. It may also predispose to plantar fascia rupture [61,62] although evidence for this is limited and non-conclusive. One study reported a series of 37 patients with a presumptive diagnosis of plantar fascia rupture, all of whom had had a prior episode of plantar fasciitis treated with corticosteroid injection into the calcaneal origin of the fascia [61]. In another study of 765 patients with plantar fasciitis, 43 of 51 patients with plantar fascia rupture had received one or more corticosteroid injections although the number of patients without plantar fascial rupture who received one or more corticosteroid injections was not reported [62].

A randomised trial of corticosteroid injection compared to extracorporeal shock wave therapy (see "Shock wave therapy" below) in 132 patients found that after three months there was significantly less pain in those who received the injection (mean differences in visual analog pain of 1.48 versus 3.69, respectively) [63]. Custom-fabricated inserts, usually provided by podiatrists, include inserted orthoses with foam rubber raised arches and rubber or tub heels, and molded ankle-foot orthoses. The efficacy of foot orthoses remains controversial, and there are considerable variations in the prescribing habits of podiatrists, orthopedists, and prosthetists [64-66]. Any advantage of customized orthotics over prefabricated ones must be weighed against a substantial difference in cost, estimated to be approximately two to six-fold more for the customized version [65]. A short walking cast is used by some orthopedists although again there are no published trials of this treatment approach. Iontophoresis with 0.4 percent dexamethasone (six sessions over two weeks) provided moderate initial relief of plantar pain in a small, randomized placebo-controlled trial in runners with plantar fasciitis although this effect was not maintained at 4 weeks [67]. In another small study, low-Dye taping combined with iontophoresis with a 5 percent solution of acetic acid was superior to taping and iontophoresis with 0.4 percent dexamethasone but no different to taping and iontophoresis with placebo [68].

Shock wave therapy — The effectiveness of extracorporeal shock wave therapy for plantar fasciitis has been more extensively studied than any other single treatment modality. As of April 2007, at least 14 randomised controlled trials that have compared shock wave therapy with either placebo or sub-therapeutic doses of shock waves have been published in English language journals [69-71]. These trials have been of variable methodological quality and have reported conflicting results. A systematic review published in 2005 included 11 trials and performed a pooled analysis of data from 6 trials involving 897 patients [69]. The authors concluded there was no clinically important benefit of shock wave therapy despite a small statistically significant benefit in morning pain of less than 0.5 cm on a 10 cm visual analogue scale. No statistically significant benefit was observed in a sensitivity analysis that only included high-quality trials.

There is ongoing clinical uncertainty about the effectiveness of shock wave therapy; opinions are highly polarized, fuelled by the lack of convergence of findings from randomised evaluations. Explanations that have been put forward to explain the differing results include variation in methodological quality, the different types of equipment that have been used to generate the shock waves, different delivery methods and different doses. Duration of symptoms has not been found to influence response to treatment [72,73]. An association between therapeutic response and the amount of the shock wave energy applied was noted in one study [71]. The major reported adverse effect is transient pain at the time of treatment.

Botulinum toxin injection — A single small double-blind placebo-controlled trial in 27 patients with unilateral or bilateral plantar fasciitis assessed the effect of two injections of botulinum toxin (40 units); one into the foot near the calcaneal tuberosity and the other in the arch (30 units) [74]. Feet injected with botulinum toxin had more improvement in pain and tenderness at 3 and 8 weeks than those injected with saline solution (placebo) although effect sizes were not reported. Further trials are needed before considering this treatment approach for usual care. (See "Botulinum toxins for chronic pain and headache").

Complementary therapies — Topical application of wheatgrass cream twice daily for 6 weeks was ineffective in a recent randomised double-blind placebo-controlled trial involving 80 participants [75]. Other trials of complementary therapies are expected.

Radiotherapy — Radiation therapy is sometimes used in Europe to treat chronic plantar fasciitis that is unresponsive to more conservative approaches [76]. Its effectiveness has not been assessed in randomised controlled trials and whether there is a long term increased risk of carcinogenesis is unknown. Because of concern about the possibility of late onset hematopoietic malignancy, radiation therapy is seldom used to treat plantar fasciitis in other parts of the world.

A survey of German radiation treatment institutions found that 81 percent provided radiation therapy for heel pain associated with calcaneal spurs [76]. There was wide variation in the amount of radiation delivered per session (median 1 Gy) and the total amount of radiation (median 6 Gy). Retrospective review of the outcomes of a single course of therapy in 7947 patients at 76 centers found that complete pain relief lasting at least 3 months occurred in 25 to 100 percent of patients (median 70 percent) and was not related to the dose of radiation delivered. Approximately 15 percent of treatment courses resulted in no pain relief.

Surgical therapy — It is estimated that 2 to 5 percent of patients with plantar fasciitis undergo surgical procedures [2,4,12,77] although the rate may be much lower. As an example, a report of the surgical experience at the Mayo Clinic found that only 16 operations had been performed during a twelve year study period [78].

While numerous surgical procedures have been described, none have been assessed in controlled trials. Favorable outcomes are reported in more than 75 percent of published case series although recovery time may be prolonged and persistent pain is not uncommon. Variations of open or closed partial of complete plantar fascia release with or without calcaneal spur resection, excision of abnormal tissue and nerve decompression have been described. Exostoses (bony projections) in runners and dancers may also improve with surgery [79].

In comparison to open release, closed procedures may allow more rapid recovery and resumption of usual activities [80,81]. In an uncontrolled series of 16 runners and 10 walkers with refractory plantar fasciitis, uniportal plantar fasciotomy gave good or excellent results provided the patient's body mass index was less than 27 [82]. Runners in this series required a mean of 2.6 months before returning to jogging.

Potential complications of surgery include transient heel pad swelling, calcaneal fracture injury to the posterior tibial nerve or its branches and flattening of the longitudinal arch with resultant midtarsal pain.

Cryosurgery — Promising results have recently been observed in a single study that used percutaneous cryosurgery, a minimally invasive technique for freezing tissue, to treat plantar fasciitis in 59 patients [83]. The effectiveness of this technique needs to be assessed in controlled trials.

Prevention — The efficacy of preventive strategies such as stretching exercises and controlling the intensity of running (eg distance, frequency and duration) in specifically preventing plantar fasciitis is unknown [84]. Footwear designed to maximize shock absorption may also be of value [85].

Prognosis — The outcome for patients with plantar fasciitis is generally favorable; approximately 80 percent of patients have complete resolution of pain within one year [4,77,86,87]. The favorable natural history of this benign condition should be borne in mind when weighing the potential benefits and risks of unproven and sometimes costly treatments.

Summary and recommendations — Plantar fasciitis is a painful disorder that is associated with degenerative and sometimes chronic inflammatory changes in the affected tissue. It has a good prognosis and patients can be informed that with conservative treatment 80 percent have complete resolution within a year. Although many types of treatments have been used for this disorder, few have been rigorously validated in clinical trials. Based upon the data presented earlier in this review, the following initial conservative interventions are recommended (see "Conservative therapy" above): Stretching exercises for the calf muscles and the plantar fascia, which the patient can perform at home Avoiding the use of flat shoes and bare-foot walking Using prefabricated, over-the-counter, silicone heel shoe inserts (arch supports and/or heel cups) Decreasing physical activities that are suggested by the medical history to be causative or aggravating (eg, excessive running, dancing, or jumping) Prescribing or recommending a short-term (two to three weeks) trial of NSAIDs is reasonable, but long-term use should be reserved for patients with known systemic rheumatic disease Injecting the tender areas of the plantar region with glucocorticoids and a local anesthetic.

If the treatments above have not produced sufficient improvement, more costly therapies can be considered although these remain unproven: Molded shoe inserts (orthotics) Night splints Immobilization with a cast Extracorporeal shock wave therapy

Surgery is generally reserved for those patients who do not respond to at least six to 12 months of conservative therapy.

OTHER CAUSES OF HEEL PAIN — A variety of other disorders may cause heel pain.

Haglund's syndrome — A prominent enlarged bony posterior superior calcaneal tubercle sometimes causes compression of soft tissue and foot pain (which may be due in part to a retrocalcaneal bursitis) in the posterior area of the heel over the bony prominence, above the site of attachment of the Achilles tendon [88]. The cause is usually a combination of developmental problems and altered foot dynamics including a more vertical pitch of the posterior portion of the calcaneus.

Patients with this disorder come to the physician due to an inability to wear shoes comfortably. A 2 to 3 mm bony extrusion is visible and palpable. The overlying skin may contain an area of erythema and swelling.

Nonoperative treatment of Haglund's syndrome includes a well-fitted heel cup, a laced or strapped shoe that reduces heel counter friction, and heel padding to raise the heel. A "V" cutout heel counter to decompress the bursa may be used if bursitis is present and persistent; incising the heel counter with a deep "V" will provide less friction. Surgical excision should be considered if the exostosis is large and symptoms persist [89]. Although calcaneal ostectomy provided good to excellent results in a series of 39 feet that were operated upon, six of 36 patients said they would not recommend the surgery to others, mainly due to the prolonged time to recover from the operation [90].

Calcaneal periostitis — Calcaneal periostitis may result from trauma, reactive arthritis, ankylosing spondylitis, psoriatic arthritis, or rheumatoid arthritis [91]. Pain is usually bilateral, along the lateral and plantar aspect of the heels, worse in the morning upon arising, and often accompanied by morning stiffness. Tenderness is diffusely present along the plantar aspect of the heel and midfoot, and along the lateral border of the heels.

Bilateral involvement should alert to the possibility of a coexistent systemic rheumatic disease. Fluffy calcific deposition of the plantar aspect of the heel on a lateral radiograph is suggestive of reactive arthritis.

Management includes use of NSAIDs for pain and inflammation; the resulting painful heel may have to be raised one to two cm with a heel lift for relief. Treatment of the underlying disease process will often be helpful.

Calcaneal spurs — Calcaneal spurs can develop on the plantar tuberosity and extend across the entire width of the calcaneus. The apex of the spur is embedded in the plantar fascia. Heel spurs are typically asymptomatic (show radiograph 1); pain occurs when the apex is angled downward by depression of the long arch. An acutely painful heel spur may also be seen in certain systemic diseases, such as ankylosing spondylitis, reactive arthritis, or rheumatoid arthritis.

Conservative treatment includes a cutout heel pad or a custom-made orthotic. Surgery usually is needed if the prominence is palpable with only a thin amount of natural heel pad intervening between the spur and skin. MRI may be useful if surgery is being considered; it may delineate other factors responsible for the pain, particularly if the spur is not palpable and the diagnosis is in doubt.

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Overview of running injuries of the lower extremity

2008-11-11T07:07:00.000-08:00

INTRODUCTION — Running is one of the most popular forms of exercise, with approximately 30 to 40 million Americans participating regularly [1-3]. Benefits include improved cardiopulmonary function, reduced risk of obesity and osteoporosis, and enhanced mental health. (See "Overview of the risks and benefits of exercise" and see "Exercise and fitness in the prevention of cardiovascular disease").

Running is not without risk; approximately 35 to 45 percent of participants suffer a running-related injury every year [4]. Since the forces associated with running are largely absorbed by the lower extremity, the majority of injuries occur in the foot and leg. These include intra- and periarticular hip and knee injuries, stress fractures of the tibia, fibula and foot, tendonitis, heel pain, and plantar fasciitis. An overview of lower extremity injuries due to running is presented here.

GENERAL ISSUES — Most running injuries have an insidious onset and are not associated with specific trauma.

Risk factors — Some people beginning a conditioning program are at higher risk of injury. Army recruits represent one group that has been studied to identify potential risk factors. Poor physical fitness, extremes of flexibility (high or low), a prior sedentary lifestyle, and tobacco use are among the factors that increase the risk of exercise related injuries [5]. Malalignment problems such as genu varum, patellar deviations, tibial torsions, and foot pronation may result in overuse injuries.

Among female recreational runners, increasing age may be a risk factors for a new injury. This was illustrated in a study of 844 runners training for a 10 km race [6]. Age greater than 50 years in women was a risk factor and age less than 31 was protective against new injury.

Prior injuries and incomplete rehabilitation may also increase the risk of injury. In the study previously cited [6], one-half of the participants who reported a new injury had previously been injured; 42 percent of these runners reported that they were not completely rehabilitated on starting the 13 week training program. An injury rate of 29.5 percent was recorded across all training clinics surveyed. The knee was the most common site of injury. Every injured runner seeking medical attention should be closely questioned about injury history.

Prevention — Several interventions for prevention of initial or recurrent running related injuries have been evaluated.

Stretching — Traditionally, poor flexibility has been associated with an increased risk of injury. Improved passive and active range of motion can be expected from both passive and active muscle stretching [7]. However, controlled trials have not proven that stretching decreases injury rates. As examples: A trial that randomly assigned 421 runners to an educational intervention regarding warm-up, cool-down, and stretching before and after running did not result in any important difference in the rates of running related injuries between the control and intervention groups (4.9 and 5.5 injuries per 1000 hours of running, respectively) [8]. Another controlled study of the effect of stretching on injury among 901 military recruits revealed no difference in rates of injury; however, the incidence of muscle/tendon injuries and low back pain were significantly lower in the stretching group [9].

A year 2004 meta-analysis by the US Centers for Disease Control and Prevention concluded that there was no statistically significant decrease in risk of total injuries among those who stretched before exercising (OR 0.93, 95% CI 0.78-1.11) [10]. As a result it was concluded that there is insufficient evidence to either encourage or discourage the practice of routine stretching before or after exercise to prevent injury among competitive or recreational athletes.

Distance — Running injuries of the lower extremity are primarily due to training errors and the accumulation of excessive mileage [11]. Reducing the weekly running distance and decreasing the amount of hard surface running may therefore be reasonable suggestions in patients with recurrent running-related injuries. Among 580 habitual runners, running 64.0 km (40 miles) or more per week was the most important predictor of injury for men (odds ratio = 2.9) [12]. Risk also was associated with having had a previous injury in the past year (odds ratio = 2.7), and with having been a runner for less than three years (odds ratio = 2.2).

Footwear — Proper shoe fit and recognition of excessive shoe wear are also important factors in preventing injury. Since the foot often widens with age, shoe size should be reexamined at each time of purchase. Width should be determined while standing. Women, in particular, should be sure that the heel provides adequate support since women's heels typically are much narrower than those of men. The microcellular foam insoles and cushioning may appear normal but can be worn out. New shoes lose approximately 40 percent of their cushioning after running between 250 and 500 miles [13]. The American Podiatric Medical Association recommends running shoes be changed every 350 to 500 miles [14].

Orthoses — Orthoses can be helpful for runners with excessive pronation, leg length discrepancy, patellofemoral disorders, plantar fasciitis, Achilles tendinitis, and shin splints. In one study, most runners preferred a flexible orthosis [15]; however, some practitioners suggest a semiflexible orthosis [16]. For many runners, over the counter orthoses are adequate. Other runners require orthoses which are fabricated from a mold of the patient's feet; podiatrists or orthopedists then send the mold to an orthotist who fabricates the orthotic insert. (See "Rehabilitation program for the lower limb").

Soft insoles — Stress fractures of the tibia may occur in approximately 30 percent of some high-risk groups, such as military recruits undergoing basic training [17]. Systematic reviews of the usefulness of "shock absorbing" soft insoles concluded that the use of this type of orthotic device reduced the risk of stress fracture in "at-risk" individuals (eg, military recruits) [18,19]. Conflicting data exist on the benefit of insoles in running shoes (in contrast to military boots); these are generally designed with built-in shock-absorbing insoles [20].

Ankle braces — Prevention of ankle sprains through the use of ankle braces may also be recommended, particularly for those with histories of prior ankle injuries. A systematic review included 14 randomized trials of external ankle support for mostly active and young individuals [21]. Primary and secondary prevention with semi-rigid braces, air-filled removable casts, and high top shoes were evaluated. A substantial reduction in risk of ankle sprain was seen in those using external support (relative risk 0.53, 95 percent confidence interval 0.40 to 0.69). In addition, the use of pneumatic braces in the rehabilitation of tibial stress fractures significantly reduces the time to recommencing training (weighted mean difference -42.6 days, 95 percent confidence interval -55.8 to -29.4 days) [18].

Evaluation — The general evaluation of the injured runner, independent of a specific evaluation of the site of injury, should include: Information related to training patterns Running experience Weekly mileage Inspection of shoe wear Musculoskeletal examination with an evaluation of the runner's gait and joint alignment, muscle strength, balance and flexibility, and palpation of the soft tissues

Prompt diagnosis in sports medicine is increasingly relying upon magnetic resonance imaging (MRI) for differentiating many lower limb injuries. Where available, MRI may be used to assess runners with injuries of the navicular and tibia for stress fractures and shin splints (see "Shin splints syndrome" below) [22,23]; MRI may also be valuable for unexplained hip and groin pain [24].

Training — A sports therapist can work with the injured athlete to maintain cardiorespiratory endurance during rehabilitation, helping to find an activity that is aerobic in nature, that can be performed at least three times per week for no less than 20 minutes and with a heart rate that is elevated to at least 60 percent of the maximum predicted rate. As healing allows, training can progress to interval, continuous, and full speed play [25].

Treatment — Absolute rest from running, or at least a reduction in pace and running mileage, is the basis of an effective treatment plan for most running-related injuries. Runners can frequently maintain cardiovascular fitness through alternate non-impact activities, like bicycling or swimming. Identifying biomechanical stresses and correcting them is also essential. Although experimental data suggests that active warm-up may be protective against muscle strain injury, the results of clinical research are equivocal [26].

As previously mentioned, a review of proper footwear selection and the use of orthotics for some conditions can be helpful. The use of non-prescription strength doses of nonsteroidal antiinflammatory drugs and acetaminophen may alleviate acute pain. Surgery may be beneficial in selected cases.

FOOT INJURY — Mechanical factors, such as overpronation due to pes planus deformity and microtrauma due to overuse (which may cause stress fractures), are the most important elements associated with foot and ankle injury due to running. The exact site of the pain may help establish the diagnosis (show figure 1A-1C).

Forefoot — Pain in the forefoot may be caused by a stress fracture, arthritis, bursitis, or a neuroma. Stress fracture pain is often felt as a sharp, localized discomfort over a bony surface. Pain over the first metatarsal joint may be due to an underlying osteoarthritis or bursitis involving the first metatarsal phalangeal joint. Hyperextension injury (turf toe) and hallux valgus are other causes of pain at the base of the great toe.

Morton's neuroma is associated with pain and dysesthesia usually felt in the interspace between the third and fourth toes [27] (show figure 2). The diagnosis can be confirmed by noting a clicking sensation (Mulder's sign) when palpating this interspace while simultaneously squeezing all the metatarsal joints. An Intermetatarsal bursitis can cause a similar pain. (See "Nerve entrapment syndromes of the leg and foot" and see "Bursitis: An overview of clinical manifestations, diagnosis, and management").

Midfoot and hindfoot — Although the midfoot is a less common site for pain due to running, pain in this region may be due to stress fracture or plantar fasciitis, which results from an abnormally structured medial arch. These anomalies cause excess mechanical stress (overpronation) to the plantar fascia and its site of insertion into the os calcis.

Overall, plantar fasciitis is one of the most common causes of foot pain in adults. Heel spurs frequently coexist with this condition, representing a secondary response to inflammation [28]. A detailed discussion of the clinical characteristics, diagnosis, and treatment of plantar fasciitis is presented separately. (See "Plantar fasciitis and other causes of heel and sole pain").

ANKLE INJURY — Ankle pain due to running may be the result of sprains, tendonitis, or bursitis involving adjacent structures (show figure 3 and show figure 4).

Sprains — Ankle sprains result from the stretching or tearing of ankle ligaments following inversion or eversion injuries. The ligamentous structures of the medial side of the ankle are much less commonly affected than those of the lateral side, since inversion injury is more common than eversion.

Pain is increased upon ankle inversion with all lateral ankle sprains; the examiner can palpate for tenderness and often determine which portion of the ligament is involved. In contrast, the pain of a medial (deltoid) ligament sprain is accentuated by gentle eversion of the ankle. (See "Ankle sprain" for a detailed discussion concerning the clinical characteristics and treatment of ankle sprains).

Tendonitis — Tendonitis of the ankle area is common since eleven muscles have tendons which cross the ankle. Inflammation and degeneration of a tendon sheath may result from repetitive activity or unaccustomed extraordinary work. In addition, improper footwear often causes injury to the extensor hallucis longus or Achilles tendon.

Tenosynovitis involving the tibialis anterior, tibialis posterior, extensor digitorum longus, or peroneal tendons can occur where the tendons become angulated at the ankle; friction can then cause inflammation of the tendon sheath. A bulbous swelling may occur distally to areas of constriction and is helpful in demonstrating points of constriction.

The posterior tibial tendon is typically involved in a patient with a pronated flat foot. The presenting complaints include an aching mild to moderate pain over the medial ankle and longitudinal arch with weightbearing. Several weeks of persistent pain often have occurred before the patient decides to seek help.

With tendinitis, physical examination frequently reveals tubular swelling of the tendon sheath, tenderness, pain on passive stretching of the tendon and active ankle movement, and normal palpation of the ankle joint. Comparison of findings with the uninvolved side is helpful. (See "Posterior ankle tendinopathies", for a review of the clinical manifestations and treatment of ankle tendinitis).

Achilles tendonitis — Achilles tendonitis is the most common form of tendonitis observed in runners. It can be severe and has been reported to force up to 16 percent of runners to stop running indefinitely [29]. Training errors, such as inappropriate increases in mileage, pace, or hill running, may cause tendon microtears and secondary inflammation.

Affected patients present with pain over the heel. Dorsiflexion of the ankle increases the pain, and a tendon friction rub may be palpable. Pain is noted on palpation of the tendon; there may be soft tissue swelling, redness, and warmth which may involve the adjacent retrocalcaneal bursa.

Treatment options include a rehabilitation regimen, use of topical nitrate ointment. Local injection of glucocorticoids near the tendon may be considered in some cases. Longitudinal tendonotomy may be beneficial for those with refractory tendinitis.(See "Posterior ankle tendinopathies", for a detailed discussion concerning Achilles tendonitis).

The presentation and/or treatment of retrocalcaneal bursitis is similar to Achilles tendinitis; however, those with bursitis may also improve with the addition of a firm "heel cup", which is an orthotic device added to stiffen a shoe's heel counter. (See "Bursitis: An overview of clinical manifestations, diagnosis, and management").

Achilles tendon rupture — Rupture of the Achilles tendon may occur after abrupt calf muscle contraction. This typically occurs in men over the age of 40 who engage sporadically in sports and do not perform a regular leg conditioning program. The patient may note an audible snap, followed by pain in the calf as if struck with a baseball.

On physical examination, the patient may be unable to stand up on the toes. A positive Thompson test (show figure 5) is further evidence of rupture. This test is performed with the patient kneeling on a chair or lying prone on an examination table and the feet hanging over the edge. When the examiner squeezes the calf muscle on the normal side, the foot responds with plantar flexion; on the affected side, there is no foot response.

Urgent orthopedic consultation for immobilization or repair is necessary for patients with tendon rupture. Surgical end-to-end repair performed soon after the injury allows patients to return to their preinjury level of activity in over 90 percent of cases [30]. Percutaneous repair has become an increasingly popular alternative to open repair [31,32]. The success of delayed surgery is less clear; use of allografts and Marlex mesh are under investigation in these cases [33,34]. Extensive postoperative exercise rehabilitation is needed [3].

DISTAL TIBIA-FIBULA INJURY — The causes of pain in the distal tibia-fibula region include the shin splints syndrome (eg, medial tibial stress syndrome), stress fractures, and the exertional compartment syndrome.

Shin splints syndrome — Shin splints syndrome or medial tibial stress syndrome is applied to a complex of pain and discomfort in the lower leg occurring after repetitive overuse. Tibial stress reactions result from a progressive process of injury; it begins with periosteal edema, which leads to marrow involvement, and may culminate in a cortical stress fracture.

Symptoms — Discomfort may emanate from a number of areas (show figure 6 and show figure 1C). These include [35,36]: Lower half of the posteromedial border of the tibia Anterior tibial compartment (containing the tibialis anterior and extensor hallucis longus muscles) Tibia Interosseous membrane region of the foreleg

Patients typically complain of a dull ache followed by a gradually worsening pain. The symptoms are at first relieved by rest, but later become continuous. Accompanying numbness, or loss of sensation over the fourth toe may be noted. The pain usually is confined to the posteromedial portion of the leg, although the site of involvement may be more diffuse; it is much less localized than the pain of stress fractures.

Physical examination — Tenderness can usually be elicited over symptomatic sites during physical examination. Mild swelling and induration may also be evident at the site of tenderness. Sensory or motor nerve deficits suggest a compartment syndrome rather than shin splints (see "Exertional compartment syndrome" below) [36].

Diagnosis — The diagnosis of shin splints syndrome is predominantly clinical and is based upon the history and physical examination. The main diagnostic dilemma often revolves around distinguishing this disorder from a stress fracture. Imaging studies may be necessary in order to make this distinction: Plain films are normal in patients with shin splints syndrome, but may also be normal in those with stress fractures; the latter does not usually produce radiographic changes for two to three weeks, at which time periosteal changes may be seen. Callus formation is typically not apparent until at least four to six weeks after injury (see "Stress fracture" below). Technetium bone scans may show changes within a few days of the injury in patients with either disorder. There often is increased uptake focally in the area of a stress fracture (show bone scan); uptake in patients with shin splints syndrome is less localized and is usually longitudinal involving the posteromedial tibia cortex. Fat-suppressed MRI may be useful in discriminating between stress fracture and shin splints. This was illustrated in a study of twenty-two athletes who had pain in the middle or distal part of their leg during or after sports activity [23]. Result of MRI were compared to those of serial radiographs. Stress fractures were diagnosed when consecutive radiographs showed local periosteal reaction or a fracture line, and shin splints were diagnosed in all the other cases.

In all eight patients with stress fractures, an abnormally wide region of high signal localized to the bone marrow was noted in the coronal fat-suppressed MRI scan. The MRI changes were present prior to periosteal changes on plain radiographs. None of 11 patients with shin splints had this type of bone marrow signal. Instead there were narrower linear high signal areas noted either along the medial posterior surface of the tibia or along the medial bone marrow adjacent to the cortical bone.

Periostitis (often evident on triple phase bone scan or MRI), tears of musculotendinous structures, or ischemic compartment syndromes are additional important diagnostic considerations. Pain out of proportion to the clinical findings is suggestive of a compartment syndrome (see below).

Treatment — RICE is an acronym for the usual care of injuries such as shin splints syndrome that stands for Rest, Ice, Compression of injured tissue, and Elevation. Leg elevation and application of ice packs for 15 minutes at a time are initial treatment measures. Brief rest usually allows the pain to subside, at which time activity may be resumed.

Stretching (lengthening) followed by strengthening exercises directed to the musculature of the involved site of the leg are helpful. (See "Rehabilitation program for the lower limb"). Pelvic, spinal, and lower extremity structure and alignment should be checked for imbalances if the injury is recurrent. (See "Evaluation for subtle structural defects of the lower limb"). Manual techniques such as massage, myofascial release, and pressure applied to trigger/tender points have also been helpful.

The runner should decrease weekly mileage, avoid hard surface running, and shorten the running stride to reduce impact. Changing to shoes with waffle soles and using orthoses with alteration of the heel counter (the hind part of the shoe surrounding the heel) may also be useful in some cases.

Stress fracture — Stress fractures most commonly involve the lower third of the tibia but can also occur in the metatarsals, tarsals, fibula, and sesamoid bones of the foot (show figure 7, show figure 8, show figure 6 and show figure 1C). The etiology is multifactorial, including increased mileage, excessive shoe wear, and running on hard surfaces. In general, stress fractures should be considered an overuse injury to bone. (See "Stress fractures of the tibia and fibula").

In the female runner, components of the "female athlete triad", defined as disordered eating, amenorrhea, and osteoporosis, may be present [37]. A retrospective study of female track-and-field athletes found that those with a history of oligomenorrhea and restrictive eating patterns were six to eight times more likely to suffer a stress fracture [38]. However, measurement of bone turnover is not clinically useful in predicting the likelihood of such fractures [39].

Symptoms — Similar to patients with shin splint syndrome, patients with stress fractures often complain of increasing pain during exercise that subsides with rest. Pain is focal, sharp and exacerbated by weight bearing, and may be referred to sites distant from the fracture. With increasing severity, the pain occurs earlier in the exercise regimen. Some stress fractures, however, may be asymptomatic.

Physical examination — Tenderness and pain is well localized on physical examination. There may be localized swelling without erythema. An intermittent or complete ischemic compartment syndrome should be excluded if pain is out of proportion to the clinical findings.

Diagnosis — Plain radiographs (show radiograph 1) , bone scintigraphy (show bone scan), or magnetic resonance imaging may confirm the diagnosis of stress fracture, although radiographs are often unremarkable in the first two or three weeks following the injury.

Depending on the medical resources available, either triple phase bone scan with technetium or MRI should be considered, but only if pain is severe or longer than 10 days in duration. One study found that MR imaging was more accurate than bone scintigraphy in correlating the degree of bone involvement with clinical symptoms [40]. By comparison, a prospective study evaluating magnetic resonance imaging versus two-phase bone scintigraphy in patients with radiographically negative stress related bone injury found scintigraphy was the superior imaging modality (100 percent sensitivity and specificity) [41].

Treatment — Treatment measures include rest, substitution of sports such as swimming, stretching and strengthening exercises, gentler training, and monitored return to running. (See "Rehabilitation program for the lower limb"). Six weeks of rest is usually sufficient in mild cases. Crutches may be needed if ordinary walking is painful. A fracture shoe is very helpful in cases of metatarsal (March) stress fracture.

As with shin splints syndrome, abnormal biomechanical factors should be recognized and modified. (See "Evaluation for subtle structural defects of the lower limb"). Orthoses are of uncertain value with stress fractures, although there are many anecdotal reports of benefit.

Exertional compartment syndrome — Compartment syndromes are due to increased tissue pressure within a closed muscle compartment that compromises local circulation and neuromuscular function. They require both a constricting envelope (a constricting fascia or cast) and an increase in volume (eg, due to blood, swelling).

Muscle compartments — The leg has four fascial compartments, each enclosed in a constricting fascia (show figure 9) [2]: The anterior tibial compartment contains the tibialis anterior and the extensor hallucis longus muscles. The deep posterior compartment contains the tibialis posterior muscle, the flexor digitorum longus, and the flexor hallucis longus muscles. The lateral compartment contains the fibularis (peroneus) longus and fibularis (peroneus) brevis muscles. The superficial posterior compartment contains the soleus muscle and the two heads of the gastrocnemius muscle.

Compartment syndromes may occur acutely or chronically.

Acute compartment syndrome — An acute syndrome can be induced by limb trauma, drug and alcohol abuse, limb surgery, and limb ischemia. Recognition of this syndrome is important to avoid significant or total loss of neuromuscular function in the affected limb [42].

Increased pain in the anterior compartment following passive flexion of the toes is an early sign of an acute compartment syndrome. Pain, pallor, and pulseless paralysis are late hallmarks of the serious ischemic, posttraumatic syndromes.

Patients with an acute compartmental syndrome may require urgent fasciotomy to alleviate neurovascular symptoms. The outcome is excellent, with more than 90 percent of patients able to return to sports.

Chronic compartment syndrome — A chronic syndrome, resulting from repetitive use, is often confused with other injuries, such as shin splints. Recognition of a chronic compartment syndrome is important since management differs from other lower extremity injuries. Long term neuromuscular sequelae are unlikely in patients with the chronic syndrome unless diabetes or alcohol dependency coexist.

Chronic compartment syndromes may involve the gluteal or quadriceps femoris muscles as well as the lower leg. Exercise normally increases muscle volume and blood flow; further exercise may lead to increased compartment pressure and decreased blood flow.

Patients complain of aching or cramping of the leg in the anatomic distribution of the compartment within 10 to 30 minutes of exercise. There is usually a return to normal function between episodes. Diagnosis — A chronic compartment syndrome may be suspected and differentiated from shin splints when conservative therapy fails to provide relief from recurrent pain with exercise. There may be no diagnostic signs at rest.

Elevated compartment pressure is a confirmatory diagnostic finding for acute or chronic compartment syndromes; pressures are usually >20 mmHg. Pre- and post-exercise compartment pressures can be determined in patients suspected of having a chronic syndrome by using a wick catheter inserted into the suspected compartment [43-45]. Similarly, the central plantar compartment pressure can be determined if a compartment syndrome in the foot is suspected [46,47]. Pre- and post-exercise magnetic resonance imaging using a radiopharmaceutical agent (methoxy isobutyl isonitrile) has also been used to demonstrate and document the location of a chronic compartment syndrome [48]. Treatment — As with the acute syndromes, surgery is also the only effective treatment for chronic compartment syndromes, although the situation in these cases is not urgent [49,50]. Stretching and conditioning exercise should be tried. (See "Rehabilitation program for the lower limb"). One study performed outpatient fasciotomy using local anesthesia in 70 patients with chronic compartment syndromes [49]. Over 90 percent were cured or had significant improvement in symptoms or function at a median follow-up of 4.5 months. The median time to unassisted walking and resumption of conditioned running was 2 and 21 days, respectively.

KNEE PAIN — The knee is the most common site for running injuries. The repetitive stress of running may cause knee pain due to overuse or by activation of a previously dormant knee injury involving the patellofemoral joint, menisci, or soft tissue structures surrounding the knee (show figure 10).

The evaluation of the patient with knee pain commonly involves knee radiographs; these should include weight-bearing anterior and posterior views, a lateral view with the knee in 45 degrees of flexion, and tangential and skyline views of the patella [40]. Magnetic resonance imaging should be considered in the evaluation of persistent knee pain due to a suspected intraarticular process, such as a meniscal injury.

Patellofemoral pain — The patellofemoral pain syndrome has been observed in approximately 25 percent of runners attending a sports medicine clinic [51,52]. It is also referred to as patellofemoral dysfunction or chondromalacia patellae. (See "Evaluation of the adult patient with knee pain").

The pain in this syndrome is attributed to a combination of overtraining and anatomical/biomechanical forces. During the running gait cycle, both ground reaction forces and body impact must be absorbed by the musculoskeletal system. This results in forces equivalent to two to six times body weight being absorbed across the lower extremity [53,54].

Patellofemoral pain is more commonly observed in women because they possess a wider pelvis, thereby increasing femoral anteversion, genu varum, tibial torsion and foot overpronation. Other anatomic variables which enhance the risk for this syndrome include instability of the patella, excessive tightness of the lateral retinaculum, and weakness of the vastus medialis muscle [55].

Symptoms — The pain is described as a diffuse anterior knee discomfort, which is exacerbated by exercise, climbing stairs, or sitting with the knee in a flexed position for an extended period of time. With running, there may be a sense of popping, catching, or the knee giving way.

Physical examination — Physical examination reveals pain with compression of the patella or with forced extension of the knee. The patella may track abnormally within the patellar groove causing crepitation or there may be lateral subluxation (show radiograph 2). The quadriceps and hamstring muscles may atrophy and lose flexibility.

Treatment — Physical therapy is the mainstay of treatment. Patella stabilization braces are often helpful. This is usually a self-limited condition, lasting from months to a few years, with the pain improving slowly as fibrocartilage replaces the degenerating surface of the patella. (See "Evaluation for subtle structural defects of the lower limb" and see "Patellofemoral pain syndrome").

The importance of conservative management was highlighted in a study of 40 young women with patellofemoral pain syndrome [56]. No significant differences were found between the most symptomatic knee and the least symptomatic knee, nor between patients and controls with regard to leg alignment, Q-angle, and leg-heel alignment. Pain was associated with increased activity, suggesting that chronic overloading and temporary overuse of the patellofemoral joint, rather than malalignment, contributed to patellofemoral pain.

Iliotibial band syndrome — The iliotibial band consists of connective tissue that runs from the ilium to the fibula. In patients with this syndrome, an aching or burning pain is felt at the site where the band courses over the lateral femoral condyle and, occasionally, the pain radiates up the thigh toward the hip. There may also be an abnormal shortened iliotibial tract. The tightness of the iliotibial band can be tested for by having the patient lie on the side with the involved side up. The examiner lowers the straight involved leg forward and downward noting any discomfort, tautness, and tenderness, when compared to the uninvolved leg. Risk factors include a varus alignment of the knee, excessive running mileage, worn shoes, or continuous running on uneven terrain [57]. The role of hip abductor weakness which has been noted in runners with this injury is uncertain, but the weakness typically improves with rehabilitation [58].

The treatment of iliotibial band syndrome includes rest, NSAIDs, stretching, physical therapy, and attention to contributing factors, such as shoes, techniques and running surface. Local corticosteroid injection into the areas of tenderness can be helpful, but the patient must refrain from running for at least two weeks following the injection. Anecdotally, some patients have found relief with the use of a pull-on knee sleeve, possible due to a decrease in knee flexion. Rarely, in selected patients, surgical release of the iliotibial band may be beneficial.

PELVIC AND HIP PAIN — Exacerbation of an underlying hip joint disease, such as osteoarthritis, may become apparent, particularly in the older runner or with increases in mileage. Pubic ramus stress fractures may also present with groin pain [59]. Muscle overuse injuries, such as proximal hamstring tendonitis and groin strains, are common in runners. Other lesions, such as acetabular labral tears, hip capsule laxity and instability, chondral lesions, osteonecrosis, ligamentum teres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies may be found on MRI or by hip arthroscopy [24].

MUSCLE STRAIN AND TEARS — Injuries to muscle may present in one of four broad clinical categories [60]: Acute Chronic Acute exacerbation of a chronic problem Subclinical alteration of function

Most injuries result in partial disruption of muscle fibers in certain muscle groups; these most commonly include the hamstring, rectus femoris, gastrocnemius, and adductor longus muscles [61]. Symptoms consisting of focal pain and limited flexibility develop acutely or insidiously. A localized hematoma may develop at the site of a sizable muscle tear.

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Nerve entrapment syndromes of the leg and foot

2008-11-11T07:06:00.000-08:00

INTRODUCTION — Increased pressure on a nerve as it traverses a closed space causes an entrapment neuropathy. The mechanism of nerve damage is not completely understood but includes pressure, friction and ischemia. There are three major manifestations of nerve entrapment: Pain Paresthesia Weakness distal to the site of entrapment

The entrapment syndromes that involve the leg and foot are discussed here. Entrapment syndromes of the elbow, forearm, shoulder, and neck are discussed separately. (See "Overview of the nerve entrapment syndromes").

RISK FACTORS — There are several risk factors for the development of lower extremity entrapment neuropathies: Peroneal palsy (foot drop) may result from occupations requiring crouching, squatting, or kneeling (eg, agriculturalists, miners, shoe salesmen). Increased pressure at the popliteal fossa may occur in those who tilt back in chairs. The tarsal tunnel syndrome may result from the use of shoes with an improper arch support. Kneeling with the toes flexed inside tight shoes may cause interdigital nerve injury (eg, in electricians or carpet layers).

Nerves that previously have been affected by another process such as diabetes or alcoholism seem to be more susceptible to entrapment syndromes.

TARSAL TUNNEL SYNDROME — Tarsal tunnel syndrome refers to an entrapment neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel beneath the flexor retinaculum on the medial side of the ankle (show figure 1) [1]. Beneath this retinaculum (or laciniate ligament) lies a tunnel containing the tendons of the flexor digitorum longus and flexor hallucis longus muscles, the vascular bundle, the posterior tibial nerve, and the medial and lateral plantar nerves [2].

Etiology — The most common cause of tarsal tunnel syndrome is a fracture or dislocation involving the talus, calcaneus, or medial malleolus [2]. In these cases, scar tissue, bone or cartilage fragments, or bony spurs may be found compressing the nerve. Etiologies other than injury include rheumatoid arthritis, other causes of inflammation, and tumors [3-5]. As an example, any disorder that results in tenosynovitis of one or more of the tendons within the tarsal tunnel can cause a compression neuropathy.

Pronation related to loss of the plantar arch is another risk factor. I have seen many elderly patients with flatfeet develop the syndrome when going barefoot around the house; slippers with arches or wedges are helpful in this situation [6]. In addition, increased tibial nerve tension in an unstable foot (thereby increasing the risk of the syndrome) may occur during eversion, dorsiflexion, combined dorsiflexion-eversion, and cyclical load with increasing internal rotation [7].

Increases in pressure within the tarsal tunnel occur when the foot is placed in maximal eversion or inversion, as was illustrated in a study in 10 cadavers [8]. This may provide an explanation for the clinical observation of aggravation of symptoms in these positions and improvement of symptoms with neutral immobilization in some patients with tarsal tunnel syndrome. (See "Joint protection program for the lower limb".)

Clinical manifestations — Patients with tarsal tunnel syndrome typically present with aching, burning, numbness, and tingling involving the plantar surface of the foot, the distal foot, the toes, and occasionally the heel. The pain may radiate up to the calf or higher [9]. The discomfort is often most aggravating at night, may be worse after standing, and sometimes leads to the desire to remove the shoes, even while driving. Bilateral involvement is more common when the syndrome is due to systemic inflammation. Any nocturnal foot symptoms and foot pain that radiates out to the toes should suggest an entrapment neuropathy [10,11].

Physical examination seldom reveals swelling or atrophy. Sensory nerve loss is variable and often absent. The Tinel sign and the dorsiflexion-eversion test are useful in assessing for posterior tibial nerve compression.

Tinel test — The Tinel's test (sign), in which the nerve is tapped with a finger or reflex hammer at the flexor retinaculum posterior and inferior to the medial malleolus often reproduces the symptoms. Tapping must be performed over the entire course of the posterior tibial nerve or one of its branches. Firm rolling pressure across the nerve occasionally may be required to reproduce the symptoms. A tourniquet applied just above the ankle can reproduce the symptoms by creating venous engorgement of the tarsal tunnel.

The dorsiflexion-eversion test — the dorsiflexion-eversion test, is a physical examination maneuver in which the tibial nerve is compressed as it runs beneath the flexor retinaculum behind the medial malleolus. In this test, the ankle is passively maximally everted and dorsiflexed while all of the metatarsophalangeal joints are maximally dorsiflexed; the position is maintained for five to 10 seconds. The diagnostic and prognostic value of this test was illustrated by a study in which it was performed on fifty normal volunteers (100 feet) and on 37 patients (44 feet) whose signs and symptoms were correlated with surgical findings [12]. The major findings were as follows: Signs and symptoms of tarsal tunnel syndrome were intensified or induced by the maneuver in fifteen of the twenty feet of the patients who reported numbness, in 15 of the 17 feet of those who reported pain alone, and in six of the seven feet of those who had combined numbness and pain. Local tenderness was intensified in 42 of 43 feet, and it was induced in one foot in which it had been previously absent. A Tinel sign (see "Tinel test" above) became more pronounced in forty-one feet, and the sign was induced in three feet in which it had been absent previously. Intraoperative observation confirmed that the tibial nerve was stretched and compressed beneath the laciniate ligament when the ankle was dorsiflexed, the heel was everted, and the toes were dorsiflexed. Among those who underwent decompressive surgery, preoperative signs and symptoms disappeared a mean of approximately 3 months after the operation, and they could not be induced by repeating the test except in three patients, all of whom had tarsal tunnel syndrome subsequent to a fracture of the calcaneus. In the normal volunteers, no symptoms or signs could be induced by the test.

Thus the physical examination maneuver was positive in 36/44 (82 percent) of symptomatic feet and in none of the 100 controls. When combined with a Tinel test over the posterior tibial nerve, performed at the same examination, the dorsiflexion-eversion test appears to be both sensitive and specific for the tarsal tunnel syndrome.

Children rarely may develop the tarsal tunnel syndrome. Their symptoms differ from those of adults: Night pain is less common Involvement is unilateral rather than bilateral The symptoms most typically include burning pain in the sole of the foot while walking, or recurrent spontaneous sudden sharp pain in the foot.

Paresthesias in the sole of the foot of affected children result when the nerve is percussed behind the medial malleolus. Children often walk with the affected foot in supination, allowing only the lateral border of the sole to contact the ground [13]. I have never seen a child with a tarsal tunnel syndrome and some neurologic and neurosurgical textbooks doubt that it exists.

Diagnosis — The diagnosis of tarsal tunnel syndrome is usually suspected from the history and physical examination, and may be by benefit resulting from conservative treatment. Then if symptoms persist imaging with MRI and electrodiagnostic tests are warranted. Radiographs are useful to detect bony abnormality. Electrodiagnostic testing, particularly nerve conduction studies (NCS), may be useful in assessing the severity of nerve compression.

Magnetic resonance imaging — High resolution MRI can demonstrate the contents of the tarsal tunnel and other soft tissue compartments of the ankle [14-17]. As an example, in one study of 40 feet in 33 patients with tarsal tunnel syndrome, the surgical findings in 19 patients confirmed MRI findings of tenosynovitis, dilated veins or varicosities, fracture or soft tissue injuries, or fibrous scars. Normal findings were also noted in six feet [14]. However, conservative measures should precede imaging studies and electrodiagnostic testing in most cases, unless there has been a recent injury or the symptoms continue to be disabling after all conservative measures have failed.

Electrodiagnostic studies — The tibial nerve conduction velocity normally is 49.9 ± 5.1 milliseconds, and latency from the malleolus to the abductor hallucis muscle is 4.4 ± 0.9 milliseconds. Prolonged latency in excess of 6.1 milliseconds for the medial plantar nerve, and 6.7 milliseconds for the lateral plantar nerve, is suggestive of disease [2,18,19]. However, normal values do not exclude the syndrome, particularly early in its course [19]. In addition, outcome does not necessarily correlate with abnormalities seen on nerve conduction studies.

In one study of electrodiagnostic studies on 111 feet with tarsal tunnel syndrome, distal motor latency (DML) was abnormal in 74 percent (82/111 feet); sensory conduction velocity (SCV) was abnormal from the big toe in 82 percent; from the 5th toe in 73 percent; only 7 percent had normal electrodiagnostic findings in this series [20].

The cost of these studies is prohibitive for the uninsured. Electromyography (EMG) does not contribute useful information beyond what nerve conduction studies provide; abnormalities in the EMG are rare in these patients in my experience.

Laboratory testing — Tarsal tunnel syndrome most often occurs in the absence of inflammatory rheumatic disease. However, if other features are suggestive, an erythrocyte sedimentation rate and tests for rheumatic disease, including rheumatoid factor and antinuclear antibody, should be performed.

Differential diagnosis — A peripheral neuropathy may present similarly to the tarsal tunnel syndrome, although reflexes are more likely to be diminished in the former. Complex regional pain syndrome (reflex sympathetic dystrophy), sciatica, and compartment syndromes should also be considered in the differential, but generally have other characteristic features. (See "Etiology, clinical manifestations, and diagnosis of complex regional pain syndrome in adults", see "Approach to the diagnosis and evaluation of low back pain in adults", and see "Overview of running injuries of the lower extremity").

Management — Nonoperative treatment of tarsal tunnel syndrome includes use of proper shoes (at least a one inch heel and cushioned sole if the flooring is concrete) and slippers, arch supports when indicated, ensuring proper gait and stride, orthoses if significant pronation is present, and nonsteroidal antiinflammatory drugs (NSAIDs). Patients should avoid the use of flat slippers or "deck" shoes.

Local injection — A corticosteroid–local anesthetic mixture injected in a fan-like pattern once or twice into the region inferior and posterior to the medial malleolus provides relief in most persistent cases; relief of pain with this procedure is also useful in confirming the diagnosis [21]. The mixture should include 20 mg methylprednisolone mixed with 1 percent procaine or lidocaine hydrochloride. Care should be taken not to inject the nerve.

Some practitioners report only a 30 percent response to corticosteroid injection and recommend decompression surgery [9].

Decompression surgery — The results of decompression surgery of the tarsal tunnel have been mixed. Examples include the following: A retrospective study of 30 patients (32 feet) with tarsal tunnel syndrome, reported that only 44 percent benefited from surgery [22]. Only 5 patients felt complete relief; those who had a mass lesion such as a ganglion cyst, an accessory navicular bone, or a medial talocalcaneal coalition seemed more likely to have a positive result, leading the authors to suggest that surgery be restricted to patients who have an associated lesion near or within the tarsal tunnel. In addition, 18 feet had electrodiagnostic studies suggestive of a tarsal tunnel syndrome in this report; however, the result had no relation to surgical outcome. Findings of varicosities, tight retinaculum, and synovitis, were similarly not well correlated with outcome. A second study of tarsal tunnel surgery found similar results [23]. Operative treatment in 45 patients (50 feet) was most successful in those with a tumor or talocalcaneal coalition. In contrast, patients with idiopathic and traumatic cases had the worst outcome. Results were best in those who had surgery within ten months after the onset of symptoms. A third study of tarsal tunnel surgery in 34 patients (37 feet) also found that outcomes were influenced by multiple characteristics, including fibrosis around the nerve, the preoperative severity of the condition, a history of sprained ankle, the duration of illness, and the demands of work [24]. More favorable results were observed with a short history of illness, the presence of a ganglion, no history of sprains, and light work demands. In addition, measurement of the terminal latency of the medial plantar nerve was valuable in assessing recovery in this [24] and other studies [25]. To ensure a complete release, division of the deep portion of the abductor hallucis fascia appears to be important [26]. In a fourth study, the results of surgery in 66 feet, all with positive electrodiagnostic studies, had improvement scores as follows [27]: preoperative MFS (Maryland Foot Scores) scores obtained preoperatively, were 61/100 (average), and postoperative MFS scores were 80/100 (average). Postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores were 80/100 (average). Patients with symptoms less than one year had postoperative MFS/AOFAS scores significantly higher (better) than those with symptoms greater than one year. The most common surgical findings included arterial vascular leashes indenting the nerve and scarring about the nerve. Varicosities and space occupying lesions were present also. The outcome of surgery was not affected by the presence or absence of trauma.

Endoscopic surgery has been proposed to lessen the patient trauma and hasten recovery [28]. Results of this procedure are preliminary at this point. Use of a radial forearm freeflap to cover the nerve was successful in two patients who had failed to benefit from standard decompressive surgery [29] Some surgeons use a posterior tibial nerve block preceding surgery; pain relief is said to be a predictor of a good surgical outcome.

Surgery for tarsal tunnel of longstanding duration may still be helpful. In one study of 18 patients with disease duration of 5 or more years, decompression resulted in total pain relief in 11 of 18 [24].

Summary — Patients with symptoms of tarsal tunnel syndrome and no history of trauma should be given a trial of conservative therapy, including NSAIDs, shoe modification, and in some cases orthotics. If the patient does not respond, corticosteroid injection may provide some relief and can be useful diagnostically. Those that continue to be symptomatic should have further diagnostic testing, including nerve conduction studies and/or MRI. Patients with mass lesions seen on MRI are more likely to benefit from tarsal tunnel surgery.

Local or systemic underlying disorders causing tarsal tunnel or similar symptomatic syndromes must be considered if symptoms persist despite therapy. These include vascular disease with venous stasis, diabetes mellitus with neuropathy, rheumatoid arthritis, myxedema, pregnancy, and amyloidosis [18,30]. However, one study suggests that surgery may provide significant pain relief for those with tarsal tunnel and diabetic neuropathy [30]. Fibromyalgia and tophaceous gout may also be present in patients with persistent symptoms; the former is a predictor of a poor surgical outcome in my experience.

INTERDIGITAL PLANTAR (MORTON'S) NEUROMA — Entrapment neuropathy, with or without an associated plantar neuroma, often develops between the third and fourth toes on the plantar surface of the foot (show figure 2). Anastomoses of the medial and lateral plantar nerves occur in this area. A neuropathy in this location is commonly called a Morton's neuroma. Similar involvement of other interdigital plantar nerves may also occur.

Etiology — Possible causes of neuropathy in this area include excessive mobility of the fourth metatarsal, nerve impingement between flattened metatarsal heads, or compression of the nerve as it is angulated over the transverse tarsal ligament. Chronic compression leads to neuroma formation. Similar signs and symptoms may be induced by an intermetatarsal bursitis rather than a neuroma since the neurovascular bundle lies close to the bursa [31]. (See "Bursitis: An overview of clinical manifestations, diagnosis, and management").

Clinical manifestations — Symptoms of a Morton's neuroma include hyperesthesia of the toes, numbness and tingling, and aching and burning in the distal forefoot. Pain radiates forward from the metatarsal heads to the third and fourth toes. It is aggravated by walking on hard surfaces and wearing tight or high-heeled shoes. The pain frequently persists for some time after cessation of weight bearing. Symptoms are unilateral in 85 percent of cases.

Physical examination reveals tenderness in the plantar aspect of the distal foot over the third and fourth metatarsals; compressing the forefoot reproduces the symptoms. The tenderness is occasionally aggravated by direct pressure to the plantar aspect of the third and fourth metatarsophalangeal joints; pressure may be applied by squeezing the metatarsal heads together with one hand, and simultaneously compressing the involved web space with the thumb and index finger of the opposite hand [32]. There should be a concomitant sensation of burning distally.

Diagnosis — The diagnosis of a Morton's neuroma is often clinical. Radiography may reveal lateral toe deviation, a faintly radiopaque shadow, and rarely, notching of the adjacent bone. Other procedures used include ultrasonography, computed tomography, MRI, and nerve conduction testing.

Of these modalities, MRI is the most effective to diagnose a Morton's neuroma. In one report, for example, MRI findings in 17 feet with suggestive symptoms of neuroma were corroborated by surgical findings [33]. In another study, a change in clinical diagnosis as well as in treatment plans occurred after MRI in 28 and 57 percent of feet initially thought to harbor a neuroma, respectively [34].

Resected nerves have no pathognomonic changes, although in one study of surgical specimens from patients with symptoms of intermetatarsal neuroma and plantar nerves obtained at autopsy the largest diameter nerves were surgical specimens while the smallest were from the autopsy group [35]. Nerve swelling was calculated to have a sensitivity of 78 percent and specificity of 80 percent. This provides some support for the usefulness of MRI assessment of nerve size as a confirmatory test.

Treatment — Conservative treatment should precede expensive diagnostic procedures; this involves decreasing stresses at the metatarsal heads with the use of a metatarsal support, metatarsal bar, or a comma-shaped metatarsal shoe insert. External appliances should be placed on both shoes so that the patient walks evenly, even when symptoms are unilateral. A broad-toed shoe that allows spreading of the metatarsal heads or an extra-depth shoe is helpful.

Injection of a local anesthetic–corticosteroid injection into the site of compression can be beneficial [32,36]; methylprednisolone 20 mg (0.5 mL) mixed with 0.5 mL 1 percent lidocaine should suffice. The injection should precede consideration for surgery since an intermetatarsal bursitis is common, and the injection and use of proper shoes may provide a cure. When the neuroma is evident, injection may only provide transient benefit.

Surgical removal of the neuroma and nerve may be required in those who are resistant to nonoperative therapy [37]; patients still benefit from wearing adapted shoes after surgery. In one post-operative study of 31 patients, for example, only 30 percent had no restrictions in the choice of their shoes at long term follow-up [38]. Others report surgical success rates of up to 80 to 90 percent [32,38,39].

OTHER ENTRAPMENT NEUROPATHIES OF THE LOWER EXTREMITY — Entrapment neuropathies also may occur in other areas of the lower extremity.

Anterior tarsal tunnel syndrome — Anterior tarsal tunnel syndrome results from entrapment of the deep peroneal nerve beneath the inferior extensor retinaculum at the anterior aspect of the tarsal tunnel [40]. Symptoms include paresthesias on the dorsum of the foot and often in the great toe. The discomfort is increased at night.

Relief following local infiltration with corticosteroids, along with an avoidance of boots, high-heeled shoes, or tight lacing, is helpful and confirms the diagnosis [41]. Surgical decompression is often necessary when the entrapment follows a crush injury [42].

Traumatic prepatellar neuralgia — Traumatic prepatellar neuralgia follows trauma to the anterior patella; it may be preceded by transient prepatellar swelling. Patients typically present a few weeks after the injury with exquisite tenderness over the medial outer border of the patella at the site of emergence of the neurovascular bundle; even slight stroking is exquisitely painful [6,43].

The diagnosis of this disorder is based upon clinical features. Tapping over the nerve (Tinel's sign) is positive when the paresthesia is reproduced or accentuated.

Treatment of traumatic prepatellar neuralgia with a local anesthetic or corticosteroid injection into the point of maximum tenderness is usually helpful [44]. Local application of capsaicin cream may also provide pain relief. Surgical excision of the subcutaneous tissue in the tender area can provide complete relief if necessary [43].

Compression of the common peroneal nerve — Foot-drop with an inability to dorsiflex the foot often results from peroneal nerve stretching forces during contact sports, or from compression due to crossing the leg, hanging the leg over a constricting rigid object, or from direct trauma. A tight boot or cast may also cause sensory or motor peroneal nerve loss, and a partial or complete foot-drop. Nerve conduction measurement can localize the site of entrapment, and distinguish peroneal nerve injury from other etiologies of foot-drop including mononeuritis, sciatica, and heavy metal poisoning.

Management of common peroneal nerve compression consists of primary treatment of the injury, use of a posterior foot-drop splint until active movement has recovered, physical therapy progressing from passive range of movement to passive assistive, active, and active resistant exercise under supervision with a physical therapist. Walking is particularly important therapy.

Approximately one-third of patients recover without surgery [45]. However, surgical consultation should not be delayed if no progress or worsening occurs within two months following the injury. In one study, for example, surgical decompression or interfascicular graft repair resulted in benefit in 97 percent of patients who had surgery at 2 months after the injury, compared to only 38 percent of those who had surgery 4 to 8 months after onset [25]. Less successful results are associated with increasing lengths of the interfascicular graft [45]. A constricting band often is found at the level of the fibular head and at the proximal origin of the peroneus longus muscle.

Joplin's neuroma — Perineural fibrosis of the plantar digital nerve may follow a bunionectomy or trauma to the first metatarsophalangeal joint. This results in pain and paresthesia at the plantar aspect of the first metatarsophalangeal joint of the great toe. A Hoffman-Tinel test may be positive beneath the first metatarsophalangeal joint. Relief occurs with foot rest or removal of the shoe. Surgical excision of the nerve may be necessary.

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39. Dereymaeker, G, Schroven, I, Steenwerckx, A, Stuer, P. Results of excision of the interdigital nerve in the treatment of Morton's metatarsalgia. Acta Orthop Belg 1996; 62:22.
40. Akyuz, G, Us, O, Turan, B, et al. Anterior tarsal tunnel syndrome. Electromyogr Clin Neurophysiol 2000; 40:123.
41. Gessini, L, Jandolo, B, Pietrangeli, A. The anterior tarsal syndrome. Report of four cases. J Bone Joint Surg Am 1984; 66:786.
42. Dellon, AL. Deep peroneal nerve entrapment on the dorsum of the foot. Foot Ankle 1990; 11:73.
43. Ikpeme, JO, Gray, C. Traumatic prepatellar neuralgia. Injury 1995; 26:225.
44. Gordon, GC. Traumatic prepatellar neuralgia. J Bone Joint Surg 1952; 34B:41.
45. Kim, DH, Kline, DG. Management and results of peroneal nerve lesions. Neurosurgery 1996; 39:312.

Hallux valgus deformity (bunion)

2008-11-11T07:02:00.000-08:00

INTRODUCTION — Valgus malformation of the great toe, commonly known as a bunion, is a very common and potentially painful and debilitating condition of unclear etiology. This topic review will provide an overview of the relevant anatomy, pathophysiology, diagnosis, and management of hallux valgus. Toe and foot injuries are discussed elsewhere. (See "Toe fractures" and see "Metatarsal shaft fractures").

RELEVANT ANATOMY AND BIOMECHANICS

Basic forefoot anatomy — By convention, toes and their respective metatarsals are numbered from one (great toe) through five (little toe). The great toe has two phalanges, while the second through fifth toes typically have three (show figure 1, show figure 2 and show figure 3). Tendons and ligaments insert at the bases of each phalanx. The digital artery and nerve pass together along each side of each toe deep to the plantar surface.

Definitions Hallux valgus deformity — This deformity is defined as a lateral deviation of the hallux (great toe) on the first metatarsal (show figure 4). The deviation of the hallux occurs primarily in the transverse plane. The deformity often also involves rotation of the toe in the frontal plane causing the nail to face medially (ie, pronation). These two deviations have led to the use of different terms to describe the deformity. In orthopedic texts, it is often called "hallux valgus" (HV) whereas many podiatry texts prefer the term "hallux abductovalgus (HAV)." The public is more familiar with the expression "bunion." Hallux abductus (or hallux valgus) angle — The angle created by the bisection of the longitudinal axis of the hallux and the longitudinal axis of the first metatarsal (show figure 4) (show radiograph 1). Historically an HA angle of greater than 15 degrees was considered abnormal, but such deformities are not always symptomatic, and some cases of an HA angle greater than 15 degrees occur naturally due to the shape of the articular surfaces involved [1,2]. Contemporary research suggests an HA angle of 20 degrees or greater is abnormal [3]. Intermetatarsal (IM) angle — The angle determined by the bisection of the longitudinal axes of the first and second metatarsals (show figure 4). An IM angle less than 9 degrees is considered normal. Ray — The forefoot consists of five longitudinal projections, called rays, which are comprised of the metatarsal and its respective phalanges, and the bones aligned with and proximal to the metatarsal, such as the cuneiforms or cuboid bones. Hallux valgus involves the first ray.

First ray anatomy — No muscles originate on the first metatarsal and insert into the phalanx to directly stabilize the first metatarsophalangeal (MTP) joint. The abductor and adductor hallucis muscles pass medially and laterally to the MTP joint respectively, but they are located nearer to the plantar surface (show figure 5). Thus, any force pushing the proximal phalanx laterally, or the metatarsal head medially, is relatively unrestrained and can create a valgus deformity.

The first metatarsal is held in alignment by a splinting action of the abductor hallucis muscle medially and by the lateral pull of the peroneus longus acting at the base of the metatarsal [4]. Movement at the first MTP joint in the transverse plane is prevented by collateral ligaments running from the metatarsal epicondyles, distally and plantarly, to the proximal phalanx.

Pathophysiology of HV deformity — The metatarsocuneiform joint has a sinusoidal curve allowing medial-dorsal and plantar-lateral movements. Increased pressure under the head of the first metatarsal (for example, due to increased subtalar pronation or a congenital plantar-flexed first ray) will force the metatarsal to move medial-dorsally. This movement increases the HA and IM angles and places the metatarsal more medial relative to its proximal phalanx. As muscle action stabilizes the joint during gait, pressure from the proximal phalanx on the lateral aspect of the metatarsal head pushes the metatarsal more medially, further increasing the HA angle.

As the first metatarsal moves medially and the hallux moves laterally, the medial capsule and medial collateral ligament come under chronic strain and eventually rupture. The medial movement of the metatarsal forces the abductor hallucis muscle beneath the metatarsal. From this position it acts solely as a plantar-flexor of the proximal phalanx, thereby contributing to the valgus rotation seen with HV deformity. Eventually, without medial stabilizing structures, the lateral joint capsule and collateral ligaments tighten and the adductor hallucis muscle acts unopposed, exacerbating the deformity [5].

Since not all cases of HV deformity become severe, there may be a threshold up to which the forces deforming the joint can be opposed by other anatomic structures. When forces greater than the threshold occur, the joint becomes deformed. It is possible that such progression occurs rapidly rather than worsening steadily over several years [1,2,6].

PREVALENCE — Many studies have tried to determine the prevalence of hallux valgus (HV) deformity. Approximately 4 to 44 percent of women and 2 to 22 percent of men have HV deformity, depending upon the method of measurement and the population studied [7-14]. The prevalence is greater among shod compared with barefoot populations, although the condition is still found twice as often in women than men in non-shod populations [15-17].

ETIOLOGY — Many theories have been proposed, but the precise etiology of hallux valgus (HV) deformity is unknown [18]. Most likely, HV deformity is multifactorial in origin and includes such factors as: abnormal foot mechanics affecting the first ray [5,19-23], abnormal first metatarsophalangeal anatomy [24-27], joint hypermobility [28,29], and genetic influences [4]. HV is also associated with conditions such as inflammatory joint disease [30-32].

Since HV deformity occurs primarily in shod populations, affecting women in particular, poor footwear has frequently been cited as a cause. The fact that some women wear footwear that compresses their toes significantly without detrimental effects, while some men suffer from marked HV deformity despite the use of sensible footwear, leads many to think that footwear probably exacerbates underlying bony or mechanical abnormalities rather than acting as a primary factor.

DIAGNOSIS — Although hallux valgus (HV) is easily recognized by clinical examination, x-rays may be necessary to determine the presence of damage to the articular surfaces of the first metatarsophalangeal (MTP) joint. Surgeons use radiographs to assess the severity of the deformity and select the appropriate procedure.

Associated findings — HV can lead to a number of painful complications in or around the first MTP joint, including [33-35]: Inflammation of a medial bursa protecting the joint (most common) Degeneration of the crista on the plantar surface of the metatarsal head, caused by erosion as the metatarsal moves over the sesamoids Entrapment of the medial dorsal cutaneous nerve as it passes through the enlarged bunion area Hammertoe deformity of the second toe, caused by destabilizing pressure from the laterally deviated great toe Central metatarsalgia, caused by the patient's chronic shifting of weight from an unstable first ray onto the central rays Degeneration of the cartilage covering the metatarsal head Synovitis of the MTP joint

Hyperkeratosis may also occur as a result of altered weight-bearing forces and can cause marked discomfort. Assessment of HV to determine the factors causing patient discomfort is important, as it will help to determine the appropriate treatment.

TREATMENT — Hundreds of studies have been published assessing numerous conservative and surgical treatments for hallux valgus (HV) deformity. Overall, there is little evidence that conservative treatments are useful. Nevertheless, we agree with the American College of Foot and Ankle Surgeons and suggest that patients make use of conservative therapies before surgical referral is made [36].

Patients with severe pain or dysfunction and those whose symptoms do not improve under a conservative regimen should be referred to a foot surgeon.

Conservative management — A systematic review identified only three randomized trials conducted on conservative treatments in adults [37]. Nevertheless, we suggest the following nonoperative treatments be considered to alleviate symptoms and possibly to help prevent progression of HV deformity [36]: Shoe modification: wide, low-heeled shoes, or specially altered shoes with increased medial pocket for the first metatarsophalangeal (MTP) joint to minimize deforming forces Orthoses to improve support and alignment Night splinting to improve toe alignment Stretching to maintain joint mobility Medial bunion pads to prevent irritation Ice applied after activity to reduce inflammation Analgesics: acetaminophen or NSAIDs

Orthoses — In the treatment of HV deformity, orthoses are used to improve foot mechanics (eg, reducing abnormal subtalar joint pronation) and to prevent abnormal forces from acting on the first ray complex. It is hoped that orthoses might prevent deterioration of the HV angle and relieve pain by improving joint function. Orthoses need to be worn in a well-fitting, low-heeled, fastening shoe, and this type of shoe may itself influence joint position and discomfort.

In subjects with rheumatoid arthritis (RA), orthoses have been shown to prevent progression of HV deformity compared with controls with RA and placebo orthoses [38]. The Hallux abductus (HA) angle progressed in 10 percent of the treatment group compared with 25 percent of the control group (adjusted odds ratio = 0.27) [38]. In the same study, however, measures of pain, disability, and function of the foot showed little difference between patients wearing orthoses and those wearing placebo devices. Furthermore, the majority of patients in the trial were male, and these results may not apply to women, who comprise the majority of patients with HV deformity.

When orthoses were compared with no treatment in patients with painful, mild-to-moderate HV deformity, patients wearing orthoses reported improved pain scores after six months, but these improvements were not maintained thereafter [39]. At one year, only the global assessment score remained better in the orthosis group (46 percent better than one year ago versus 24 percent; 11 percent worse than one year ago versus 34 percent). In the same study, surgery (chevron osteotomy) outperformed orthoses for all outcomes. The study did not evaluate HA angle progression.

Splinting — Splints can be used to place the toe in a corrected position in the hope of enabling soft tissue adaptation and delaying rupture of the medial joint capsule and collateral ligament. The most common devices used are night splints, which realign the hallux while non-weight-bearing (show picture 1). Wedges placed between the first and second toe and attached with adhesive strapping can also used.

Night splints were ineffective in reducing pain associated with HV deformity in one small randomized trial [40]. Progression of the deformity did not occur in the treatment or the control group over the six-month trial duration. Night splints were more effective in reducing deformity and pain than a toe separator, but they were less effective than exercises, in one very small study [41]. However, the mean decrease in HA angle was approximately 2 degrees, which was within the range of measurement error.

Other — Marigold ointment was reported to be effective in reducing pain, soft tissue swelling, and the HA angle when applied to the bunion area over an eight-week period [42].

Surgery — Referral for surgical repair is based primarily upon patient symptoms (eg, pain, difficulty with ambulation); neither clinical nor radiographic appearance play a significant role. Patients with severe pain or dysfunction and those whose symptoms do not improve under a conservative treatment regimen should be referred to a foot surgeon. (See "Conservative management" above).

Approximately 150 surgical procedures for the correction of HV deformity have been described. All involve one of the following basic approaches: Fusing the metatarsophalangeal (MTP) joint or the metatarsocuneiform joint in a corrected position (arthrodesis) Removing the joint or replacing the joint with an implant (arthroplasty) Cutting the first metatarsal and realigning the bone in a less adducted position (osteotomy) Removing the prominent side of the metatarsal head (bunionectomy) Mobilizing soft tissue to pull the bones into a corrected position

There are many retrospective studies but very few prospective, randomized trials evaluating these procedures. A systematic review identified 15 randomized trials concerned with surgical correction of the deformity [37]. Although patient satisfaction with surgical correction ranges from 50 to 90 percent, the trend is toward greater satisfaction as surgical techniques have improved.

Both orthopedic and podiatric specialist foot surgeons, as well as non-specialists, perform operations to repair HV deformity. No study has compared the results of surgery based on who performed the procedure. Nevertheless, we suggest patients be referred to a foot surgery specialist with experience repairing HV deformity.

Patient satisfaction — Patient satisfaction does not appear to correlate with surgical outcome as determined by radiographic parameters (ie, HA and IM angles) [43]. Some patients have a misapprehension that the hallux should be straight after the operation. Others may be under the mistaken impression that they will be able to fit into narrower shoes postoperatively and can be dissatisfied if this expectation is not met.

Managing patient expectations is important. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months [44]. Most will remain unable to fit into narrower shoes. One study found that only 2 of 52 patients could wear smaller shoes after their procedure, despite a postoperative reduction in foot width [45].

Arthrodesis — Fusion of the first MTP joint is rarely performed, unless there is severe degeneration of the joint and good function is unlikely to be regained were only joint position corrected. The procedure is usually reserved for older patients. Walking on a fused MTP joint alters foot mechanics during gait and can cause secondary hyperkeratoses to develop.

A study of 81 patients treated with first MTP arthrodesis reported success in relieving joint pain, improving walking distance, and improving appearance after a minimum follow-up of 24 months [46].

Fusion at the metatarsocuneiform joint is called the Lapidus procedure and is used when the mobility of the first ray is excessive. A study of 87 patients, found that the Lapidus procedure combined with a soft tissue correction was successful in reducing the HA and IM angles, as well as improving the American Orthopaedic Foot and Ankle Society (AOFAS) functional score [47]. Eighty-four percent of patients considered the surgery satisfactory.

Arthroplasty — A comparison of arthrodesis with Keller's arthroplasty found that 75 percent of the arthroplasty patients were completely satisfied postoperatively, and that 88 percent experienced complete pain relief [46]. However, 12 percent experienced worse pain after the surgery. The authors also found the response to surgery could be prolonged, with some patients needing up to 30 months before manifesting improvement. Overall, little difference in outcomes was found between the arthroplasty and arthrodesis groups.

A small study comparing distal metatarsal osteotomy with Keller's arthroplasty found larger residual HA and IM angles in the arthroplasty group, but overall satisfaction and pain relief did not differ significantly [48].

Osteotomy — The cut made in the bone during an osteotomy varies in shape and position, depending upon the surgical strategy. As an example, a straight cut is used in the Wilson osteotomy whereas a wedge-shaped cut is used in the chevron osteotomy. The cut may be made near the neck of the metatarsal (distal osteotomy) or near the base (proximal osteotomy). Although a greater degree of correction is possible through proximal osteotomies, these procedures require larger dissections and have higher complication rates. Generally, the surgeon tries to minimize metatarsal shortening and to maintain the metatarsal's plantar-flexed position.

The chevron osteotomy has been evaluated most often through randomized, controlled trials. A study of 209 patients comparing chevron osteotomy to treatment with orthosis and to no treatment found that osteotomy outperformed nonoperative alternatives [39]. At 12-month follow-up, the HA and IM angles in the osteotomy group were at normal values, and 80 percent of patients were satisfied with their treatment. Nevertheless, 61.5 percent of these surgical patients still had "moderate" footwear problems, and half had experienced some pain in the previous six months. Over the 12-month follow-up period, the surgery group also had the highest costs for foot care and took the greatest number of sick days.

Although a comparison between distal metatarsal osteotomy and Keller's arthroplasty reported better radiological outcomes in the osteotomy group, patient satisfaction scores were similar [48]. The authors commented that 60 percent of the patients were over 60 years old and that good surgical outcomes can be achieved in older patients.

Proximal osteotomy appears to be more effective at correcting both the HA and IM angles but results in a shorter metatarsal and higher complication rates [43]. Patient satisfaction with each procedure was 97 percent.

Soft tissue procedure — No study has evaluated soft issue procedures to correct HV deformity independently. One small study compared chevron-Akin osteotomy to a distal soft tissue reconstruction-Akin osteotomy [49]. Although the soft tissue reconstruction did not correct the HA and IM angles as well as the osteotomy alone, patient satisfaction did not differ significantly.
A larger study compared the chevron osteotomy with the chevron plus adductor tenotomy and found no significant difference in patient satisfaction and little difference in mechanical correction [50].

SUMMARY AND RECOMMENDATIONS — Hallux valgus (HV) deformity (ie, bunion) is a very common, potentially debilitating deformity consisting of lateral deviation of the hallux on the first metatarsal. The etiology is unknown. The deformity is more common among women and shod populations. A detailed description of the relevant anatomy, biomechanics, and pathophysiology is found above. (See "Relevant anatomy and biomechanics" above). Important aspects of diagnosis and management are summarized below. Although HV is easily recognized by clinical examination, x-rays may be necessary to determine the presence of articular damage. Neither radiographic nor clinical appearance provide the basis for surgical referral, which is determined by patient pain and disability. (See "Diagnosis" above). There is little evidence that conservative treatments are useful in the treatment of HV. Nevertheless, we suggest patients without debilitating symptoms avail themselves of conservative therapies before being referred for surgery (Grade 2C). Possible treatments include:

- Shoe modification: wide, low-heeled shoes, or specially altered shoes with increased medial pocket for first metatarsophalangeal (MTP) joint to minimize deforming forces
- Orthoses to improve support and alignment
- Night splinting to improve toe alignment
- Stretching to maintain joint mobility
- Medial bunion pads to prevent irritation
- Ice applied after activity to reduce inflammation
- Analgesics: acetaminophen or NSAIDs. (See "Conservative management" above).
We recommend patients with severe pain or dysfunction and those whose symptoms do not improve under a conservative treatment regimen be referred for surgical repair (Grade 1B). Approximately 150 surgical procedures for the correction of HV deformity have been described. Few prospective, randomized trials evaluating these procedures have been performed. Both orthopedic and podiatric specialist foot surgeons, as well as non-specialists, perform operations to repair HV deformity. Patients should be referred to a foot surgery specialist with experience repairing HV deformity. (See "Surgery" above). Managing patient expectations about surgery is important. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months. Most patients will remain unable to fit into narrower shoes. (See "Patient satisfaction" above).

Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Hardy, RH, Clapham, JC. Observations on hallux valgus; based on a controlled series. J Bone Joint Surg Br 1951; 33-B:376.
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14. Benvenuti, F, Ferrucci, L, Guralnik, JM, et al. Foot pain and disability in older persons: an epidemiologic survey. J Am Geriatr Soc 1995; 43:479.
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17. Sim-Fook, L, Hodgson, AR. A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J Bone Joint Surg Am 1958; 40-A:1058.
18. Wilson, DW. Hallux valgus and rigidus. In: The Foot, volume 1, Helal, B, Wilson, D (Eds), Churchill Livingstone, New York 1988. p.411.
19. Root, ML, Orien, WP, Weed, JH. Forefoot deformity caused by abnormal subtalar joint pronation. In: Normal and Abnormal Functions of the Foot, Clinical Biomechanics, volume 2, Root, ML, Orien, WP, Weed, JH (Eds), Clinical Biomechanics Corporation, Los Angeles 1977. p.376.
20. La Reaux, RL, Lee, BR. Metatarsus adductus and hallux abducto valgus: their correlation. J Foot Surg 1987; 26:304.
21. Griffiths, TA, Palladino, SJ. Metatarsus adductus and selected radiographic measurements of the first ray in normal feet. J Am Podiatr Med Assoc 1992; 82:616.
22. Faber, FW, Kleinrensink, GJ, Verhoog, MW, et al. Mobility of the first tarsometatarsal joint in relation to hallux valgus deformity: anatomical and biomechanical aspects. Foot Ankle Int 1999; 20:651.
23. Fritz, GR, Prieskorn, D. First metatarsocuneiform motion: a radiographic and statistical analysis. Foot Ankle Int 1995; 16:117.
24. Brahm, SM. Shape of the first metatarsal head in hallux rigidus and hallux valgus. J Am Podiatr Med Assoc 1988; 78:300.
25. Ferrari, J, Malone-Lee, J. The shape of the metatarsal head as a cause of hallux abductovalgus. Foot Ankle Int 2002; 23:236.
26. Cralley, JC, McGonagle, W, Fitch, K. The role of adductor hallucis in bunion deformity: Part I. J Am Podiatry Assoc 1976; 66:910.
27. Bozant, JG, Serletic, DR, Phillips, RD. Tibialis posterior tendon associated with hallux abducto valgus. A preliminary study. J Am Podiatr Med Assoc 1994; 84:19.
28. Carl, A, Ross, S, Evanski, P, Waugh, T. Hypermobility in hallux valgus. Foot Ankle 1988; 8:264.
29. McNerney, JE, Johnston, WB. Generalized ligamentous laxity, hallux abducto valgus and the first metatarsocuneiform joint. J Am Podiatry Assoc 1979; 69:69.
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33. Jahss, M. Disorders of the hallux and first ray. In: Disorders of the foot and ankle. Medical and surgical management, Jahss, M (Ed), WB Saunders and Company, Philadelphia 1991. p.946.
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39. Torkki, M, Malmivaara, A, Seitsalo, S, et al. Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial. JAMA 2001; 285:2474.
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42. Khan, MT. The podiatric treatment of hallux abducto valgus and its associated condition, bunion, with Tagetes patula. J Pharm Pharmacol 1996; 48:768.
43. Resch, S, Stenstom, D, Jonsson, K, Reynisson, K. Results after chevron osteotomy and proximal osteotomy for hallux valgus: a prospective, randomised study. The Foot 1993; 3:91.
44. Klosok, JK, Pring, DJ, Jessop, JH, Maffulli, N. Chevron or Wilson metatarsal osteotomy for hallux valgus. A prospective randomised trial. J Bone Joint Surg Br 1993; 75:825.
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47. Faber, FW, Mulder, PG, Verhaar, JA. Role of first ray hypermobility in the outcome of the Hohmann and the Lapidus procedure. A prospective, randomized trial involving one hundred and one feet. J Bone Joint Surg Am 2004; 86-A:486.
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49. Basile, A, Battaglia, A, Campi, A. Comparison of chevron-Akin osteotomy and distal soft tissue reconstruction-Akin osteotomy for correction of mild hallux valgus. J Foot Ankle Surg 2000; 6:156.
50. Resch, S, Stenstrom, A, Reynisson, K, Jonsson, K. Chevron osteotomy for hallux valgus not improved by additional adductor tenotomy. A prospective, randomized study of 84 patients. Acta Orthop Scand 1994; 65:541.

Evaluation for subtle structural defects of the lower limb

2008-11-11T06:59:00.000-08:00

INTRODUCTION — Subtle structural defects of the lower limb often predispose or contribute to the development of cumulative movement disorders or repetitive strain injuries [1]. Careful examination to detect these defects should be part of the management of patients with disorders such as tendinitis, bursitis, stress fractures, compartment syndromes, and plantar fasciitis. (See appropriate topic reviews).

Long distance runners, for example, may have complaints that result from the accumulated impact loading of this activity [2-4]. These problems are often related to biomechanical overuse in patients with minor structural disorders. Malalignments with mechanical disadvantages, muscle contractures, and the use of untrained muscles may lead to biomechanical failure [3].

Lateral asymmetry is a common cause for many regional pain disorders and may predispose to sport injury and other lower limb pain and injury. Features include facial asymmetry, scoliosis, a short leg, and flat feet

A careful examination includes evaluation of the appearance of the lower extremity when the patient is standing, walking, rising, sitting, and lying. It also includes evaluation of the patient's shoes.

STANDING EXAMINATION — Congenital abnormalities of alignment and joint mobility may be evident while the patient is standing with the feet slightly apart and parallel (pointing directly forward). Genu recurvatum — Excessive backward motion during active knee extension may be an isolated finding or part of generalized multidirectional joint instability. Hyperextension of the knee, excessive backward knee joint mobility, or patella alta (a high-riding patella) can contribute to recurrent knee dislocation. In severe cases, leg braces may be required. The hypermobility syndrome should be considered if knee pain, knee hyperextensibility, and flat feet are present (show picture 2). (See "Clinical manifestations and treatment of the hypermobility syndrome"). Joint hypermobility — Children with hypermobility may have joint pain. This was illustrated in a study of juvenile hypermobility syndrome in 125 children (64 females) who had hypermobile joins and pain that had been present for longer than three months [5]. Hypermobility had only been recognized as a possible cause of joint complaint in 10 percent. The average age at onset of symptoms was 6.2 years and age at diagnosis 9.0 year, indicating a two- to three-year delay in diagnosis.

The major presenting complaint was arthralgia in 74 percent, abnormal gait in 10 percent, apparent joint deformity in 10 percent, and back pain in 6 percent. Mean age at first walking was 15.0 months; 48 percent were considered "clumsy" and 36 percent as having poor coordination in early childhood. Twelve percent had "clicky" hips at birth and 4 percent actual congenitally dislocatable hips. Other features that were noted in association with joint hypermobility were: recurrent joint sprains (20 percent) and actual subluxation/dislocation of joints (10 percent); problems with handwriting tasks (40 percent), major limitations of school-based physical education activities (48 percent), other physical activities (67 percent). Easy bruising and significant periods of schooling missed because of symptoms were also noted in many children. Abnormal patellar alignment — Patellar alignment should be viewed in relation to the tibial tubercle. From the frontal aspect, the patellae may point away from the midline, denoting lateral patellar subluxation ("grasshopper eye patellae"); this often occurs in association with chondromalacia patellae [6]. External rotational malalignment with inwardly pointing patellae may predispose to patellofemoral subluxation [7]. (See "Evaluation of the adult patient with knee pain").

The clinical significance of abnormal patellar alignment is uncertain. Many people with such subtle abnormalities are asymptomatic. The lack of an association between patellar alignment problems and anterior knee pain was illustrated in two studies. In one of these studies of 40 young women who had patellofemoral pain syndrome, no significant differences were found between the most symptomatic knee and the least symptomatic knee, nor between patients and controls with regard to leg alignment, Q-angle, and leg-heel alignment [8]. Pain was associated with increased activity, suggesting that chronic overloading and temporary overuse of the patellofemoral joint, rather than malalignment, contributed to patellofemoral pain.

In the second study of 33 patients with patellofemoral pain and matched controls, no difference was found in measures of patellar tilt, superior migration of the patella, or patellar facet angle at rest or with quadriceps contraction [9].

However, malformations or degenerative changes of the patella can lead to patellofemoral pain. Arthroscopy with debridement is necessary in some cases. However, I advise patients to first try a short arc resistance quadriceps exercise under the supervision of a therapist or trainer. Miserable malalignment syndrome — The so called miserable malalignment syndrome is a constellation of excessive femoral anteversion, excessive tibial outward rotation, and patellofemoral pain. When evaluating patients with patellofemoral pain, it is important to assess the rotational profiles of the femur and tibia. Although an uncommon cause for patellofemoral pain, treatment has been proposed consisting of ipsilateral outward femoral osteotomy and inward tibial osteotomy. A series study of 27 limbs in 14 patients reported a satisfactory five year outcome in all operated patients [10]. Genu varum (bowleg) or genu valgum (knock-knee) — The terms varus and valgus refer to inward or outward deviation of the foreleg from the midline, respectively. However, discussions in the literature have emphasized that these commonly used terms are inaccurate and inadequate [11]. Thus, it is usually best to add additional descriptions (eg, bowleg, knock-knee) when defining changes related to these anatomic deviations.

Genu valgum is common in children and often resolves spontaneously. However, it may predispose to lateral patellar dislocation or displacement, and later in life to osteoarthritis. (See "Risk factors for and possible causes of osteoarthritis"). If present at age six or older, gait may be impaired. Bracing and strength training can sometimes improve the angulation or at least prevent it from worsening. Surgical revision with osteotomy during childhood has been suggested for children [12]. Some adults may also benefit from osteotomy if they have not developed advanced osteoarthritis of both lateral and medial compartments of the knee.

When painful genu valgum or genu varum (less commonly) occurs in an adolescent, rickets should be a consideration. Although rare in developed countries, rickets still occurs in rural and third world populations [13,14]. Toe deformities — Toe deformities such as hallux valgus and metatarsus primus varus of the first toe (the first metatarsus is shortened and deviated to the midline, and the toe is rotated slightly medially as noted by the slant of the toe nail) are evident during the standing examination. Toe crowding should also be observed.

WALKING EXAMINATION — The patient should be observed while walking toward and away from you with the legs uncovered. The feet may point away 30 degrees from the midline. Deformities such as a short leg, osteoarthritis of a hip, leg torsions, genu recurvatum, flatfeet, or neurologic disturbances may become apparent during this examination.

Pes planus (flatfoot) may give rise to knee region discomfort. The flatfoot is accompanied by pronation, a tilting outward of the foot, and valgus deviation of the heel (show picture 3). This can be seen best by inspecting the foot from behind the standing patient.

From the frontal view, a line carried from the midpoint of the patella down the anterior spine of the lower tibia should project forward through the web between the second and third toes. The heel should be aligned parallel to the longitudinal axis of the distal tibia when viewed posteriorly. The plane of the metatarsal heads should be perpendicular to the heel [2].

SITTING AND RISING EXAMINATION — The patient should be observed while rising from a seated position without the use of hands for assistance. This is a simple test of the integrity and strength of the quadriceps extensor mechanism, but may also suggest knee disorders located in the patellofemoral region or primary muscle disease. Lateral patellar displacement or subluxation may be observed as the seated patient straightens the knee and the patella moves outward instead of straight upward; this is often called the "J" sign. The laterally tilted patella should be manually correctable when the patient is lying supine. In addition, the patella should be displaceable medially about 1 cm from its resting position when the knee is flexed to 30 degrees. Inability to perform these maneuvers suggests that the lateral patellar retinaculum is abnormally tight; these patients may benefit from stretching exercises [15]. (See "Rehabilitation program for the lower limb"). Surgical release of the tight tissue or other plastic repair may be required in persistent problems. Inspection of the foot while the patient is seated includes noting presence of a normal arch, forefoot width, and the presence of calluses and other dermatologic features.

SUPINE EXAMINATION — The examiner can determine the rigidity or softness of the plantar fascia with the patient lying supine. The toes are grasped and dorsiflexed with one hand, while the other hand palpates the plantar aspect of the foot, particularly the bands compressing the plantar fascia. Only by examining many normal feet can the physician become familiar with the pathologic tightly bound plantar fascia. A tear of the plantar fascia should be suspected if the banded fascia is not palpable.

SHOE INSPECTION — Proper shoes should provide support and comfort (proper fit) for the weightbearing foot, with room for the toes to extend fully and to broaden out during weightbearing. Proper fit is determined by having foot size measured while standing. Callus formation at the lateral and medial borders of the metatarsals 1 and 5 suggest too wide a shoe. Palpate the foot in the shoe while the patient stands and note where the tip of the toes lie in the shoe, gaping at the ankle or heel; note heel wear. Improper shoes can cause or exacerbate lower limb disorders, including hallux valgus, hammer toes, hard corns, and plantar keratoses.

How long can a runner run in a pair of shoes before they wear out? A computational finite element analysis (FEA) was made of the stress distribution in the heelpad and a running shoe midsole, using heelpad properties deduced from published force-deflection data, and measured foam properties [16]. Measurements of plantar pressure distribution in running shoes confirmed the FEA. The peak plantar pressure increased on average by 100 percent after 500 km run. Scanning electron microscopy shows that structural damage (wrinkling of faces and some holes) occurred in the foam after 750 km run. Fatigue of the foam reduces heelstrike cushioning, and is a possible cause of running injuries.

Leather soles were meant to be used on wood floors. Newer microcellular foam shock absorbing material used in most exercise and walking shoes is preferred for walking and standing on concrete. The role of shoe sole materials on balance and vertical impact in sports were tested in a randomized, crossover trial of ethyl-vinyl acetate foams of varying thickness [17]. All of the currently available shoes were found to be too soft and thick, suggesting that further improvements in shoes is required.

Shoe modification can be helpful for dorsal exostoses, metatarsalgia, bunions, painful flat feet, and plantar fasciitis. (See "Rehabilitation program for the lower limb").

REFERENCES

1. Sheon, RP, Moskowitz, RW, Goldberg, VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd ed, Williams Wilkins, Baltimore, 1996.
2. James, SJ, Bates, BT, Osternig, LR. Injuries to runners. Am J Sports Med 1978; 6:40.
3. Baugher, WH, Balady, GJ, Warren, RF, Marshall, JL. Injuries of the musculoskeletal system in runners. Contemp Orthop 1979; 1:46.
4. Brady, DM. Running injuries. Clinical Symposium (CIBA) 1980; 32:2.
5. Adib, N, Davies, K, Grahame, R, et al. Joint hypermobility syndrome in childhood. A not so benign multisystem disorder? Rheumatology (Oxford) 2005; 44:744.
6. Dehaven, KE, Dolan, WA, Mayer, PJ. Chondromalacia patellae and the painful knee. Am Fam Physician 1980; 21:117.
7. Cooke, TDV, Chir, B, Price, N, et al. The inwardly pointing knee: An unrecognized problem of external rotational malalignment. Clin Orthop 1990; 260:56.
8. Thomee, R, Renstrom, P, Karlsson, J, Grimby, G. Patellofemoral pain syndrome in young women. I. A clinical analysis of alignment, pain parameters, common symptoms and functional activity level. Scand J Med Sci Sports 1995; 5:237.
9. Laprade, J, Culham, E. Radiographic measures in subjects who are asymptomatic and subjects with patellofemoral pain syndrome. Clin Orthop Relat Res 2003; :172.
10. Bruce, WD, Stevens, PM. Surgical correction of miserable malalignment syndrome. J Pediatr Orthop 2004; 24:392.
11. Houston, CS, Swischuk, LE. Varus and valgus - no wonder they are confused. N Engl J Med 1980; 302:471.
12. Pretkiewicz-Abacjew, E. Knock knee and the gait of six-year-old children. J Sports Med Phys Fitness 2003; 43:156.
13. Mallet, E, Gaudelus, J, Reinert, P, et al. [Symptomatic rickets in adolescents]. Arch Pediatr 2004; 11:871.
14. Kabir, ML, Rahman, M, Talukder, K, et al. Rickets among children of a coastal area of Bangladesh. Mymensingh Med J 2004; 13:53.
15. Post, WR, Fulkerson, JP. Anterior knee pain: A symptom, not a diagnosis. Bull Rheum Dis 1993; 42:5.
16. Verdejo, R, Mills, NJ. Heel-shoe interactions and the durability of EVA foam running-shoe midsoles. J Biomech 2004; 37:1379.
17. Robbins, S, Waked, E. Balance and vertical impact in sports: Role of shoe sole materials. Arch Phys Med Rehabil 1997; 78:463.

Ankle sprain

2008-11-11T06:56:00.000-08:00

INTRODUCTION — Ankle injuries are among the most common injuries presenting to primary care offices and emergency departments [1]. Patients with ankle sprains (stretching, partial rupture, or complete rupture of at least one ligament) constitute a large percentage of these injuries.

Ankle ligaments provide mechanical stability, proprioceptive information, and directed motion for the joint. Recurrent ankle sprains can lead to functional instability and loss of normal ankle kinematics and proprioception, which can result in recurrent injury, chronic instability, early degenerative bony changes, and chronic pain [2]. Acute ankle sprains can result in lost days of work and inability to participate in sports.

This topic review will discuss ankle sprains. Ankle fractures are discussed elsewhere. (See "Overview of ankle fractures").

CLASSIFICATION OF ANKLE SPRAINS

Location — The mechanism of injury determines the location of the sprain.

Lateral ankle sprain — The most common mechanism of ankle injury is inversion of the plantar-flexed foot, which causes damage to the lateral ligament complex of the ankle. This ligament complex consists of the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament (show figure 1). The ligaments within this complex are injured in a predictable sequence as forces increase.

The anterior talofibular ligament is the first or only ligament to be injured in the majority of ankle sprains. Stronger forces lead to combined ruptures of the anterior talofibular ligament and the calcaneofibular ligament, which can result in significant ankle joint instability. Isolated injury of the calcaneofibular ligament is uncommon. Yet stronger forces result in injury to all three ligaments. Such injuries, while uncommon, are more debilitating and more commonly associated with significant nerve injury [3].

Medial ankle sprain — The medial deltoid ligament complex (show figure 2) is the strongest of the ankle ligaments and is infrequently injured. Forced eversion of the ankle can cause damage to this structure but more commonly results in an avulsion fracture of the medial malleolus because of the strength of the deltoid ligament.

Syndesmotic sprain (high ankle sprain) — Dorsiflexion and/or eversion of the ankle may cause sprain of the syndesmotic structures, which include the anterior tibiofibular, posterior tibiofibular, and transverse tibiofibular ligaments, and the interosseous membrane (show figure 3). These structures are critical to ankle stability. Syndesmotic ligament injuries contribute to chronic ankle instability and are more likely to result in recurrent ankle sprain and the formation of heterotopic ossification [4]. Syndesmosis sprains range from 1 to 11 percent of all ankle sprains, with a higher rate of injury occurring in contact sports [5].

Grading — Ankle sprains have traditionally been classified based upon clinical signs and functional loss from grade I to grade III: A grade I sprain results from mild stretching of a ligament with microscopic tears. Patients have mild swelling and tenderness. There is no joint instability on examination, and the patient is able to bear weight and ambulate with minimal pain. Due to their benign nature, these injuries are not frequently seen in the office. A grade II sprain is a more severe injury involving an incomplete tear of a ligament. Patients have moderate pain, swelling, tenderness, and ecchymosis. There is mild to moderate joint instability on exam with some restriction of the range of motion and loss of function. Weight bearing and ambulation are painful. A grade III sprain involves a complete tear of a ligament. Patients have severe pain, swelling, tenderness, and ecchymosis. There is significant mechanical instability on exam and significant loss of function and motion. Patients are unable to bear weight or ambulate.

Although higher grade sprains involve more severe injuries to ligaments, the time for healing is not always proportional to the grade of the sprain.

CLINICAL EVALUATION

History — Evaluation of an injured ankle requires a careful history. It is important to determine: The mechanism of injury in order to direct the rest of the examination Whether or not the patient could walk after the injury in order to help stratify risk of fracture Whether or not the ankle had been previously injured, as people who sprain ankles are more likely to reinjure the same ankle; a study in basketball players found repeat ankle injuries almost five times as likely as primary injuries [6].

Physical examination — Physical examination of the ankle includes inspection, palpation, determination of weight-bearing ability, and injury-specific physical diagnostic tests. Look for swelling and ecchymosis. Palpate the entire fibula (a syndesmotic injury may be associated with a fracture of the proximal fibula — a Maisonneuve fracture), the distal tibia, the foot, and the Achilles tendon. The Thompson test should be performed if any tenderness or a tissue deficit is detected while palpating the Achilles tendon. (See "Posterior ankle tendinopathies").

Check for tenderness in the areas required for the Ottawa ankle rules (posterior edge or tip of the lateral malleolus; posterior edge or tip of the medial malleolus; base of the fifth metatarsal; navicular bone). (See "Ottawa ankle rules" below).

Tenderness of the distal tibia or fibula may represent fracture associated with inversion or eversion injuries (see "Ottawa ankle rules" below). Tenderness over the ligamentous structures is a non-specific finding but often indicates injury.

An eversion or hyperdorsiflexion injury associated with tenderness at the distal tibiofibular joint (show picture 1) without significant swelling may suggest a syndesmosis sprain.

Effusion and pain on palpation of the talocrural joint line (show picture 2) may suggest a fracture of the osteochondral talar dome resulting from direct trauma between the talus and the fibula or tibia. Check for pain on gentle passive inversion and eversion of the ankle. In lateral ankle sprains, pain is increased with forced ankle inversion, while the pain of a medial (deltoid) ligament sprain is accentuated by eversion of the ankle. Perform specific examination maneuvers (described below) including the squeeze test, the external rotation stress test, the anterior drawer test, and the talar tilt test.

If there is no swelling or ecchymosis, physical examination maneuvers do not elicit pain, and the Ottawa ankle criteria for imaging are not met (see "Ottawa ankle rules" below), there is unlikely to be structural damage.

Squeeze test — The squeeze test consists of compression of the fibula against the tibia at the mid-calf level. This maneuver elicits pain in the region of the anterior tibiofibular ligament (anterior to the lateral malleolus and proximal to the ankle joint) when a syndesmotic sprain has occurred (show picture 3).

External rotation stress test — The external rotation stress test can also help identify a syndesmotic sprain (show picture 4). The physician stabilizes the leg proximal to the ankle joint while grasping the plantar aspect of the foot and rotating the foot externally relative to the tibia. The test is positive if pain is elicited in the region of the anterior tibiofibular ligament (anterior to the lateral malleolus and proximal to the ankle joint).

Anterior drawer test — The anterior drawer test detects excessive anterior displacement of the talus on the tibia. If the anterior talofibular lateral ligament is torn by an inversion stress, the talus will sublux anteriorly and laterally out of the mortise. The test is performed with the patient's foot in the neutral position (slightly plantar flexed and inverted). The lower leg is stabilized by the examiner with one hand, and with the opposite hand, the examiner grasps the heel while the patient's foot rests on the anterior aspect of the examiner's arm. An anterior force is gently but steadily applied to the heel while holding the distal anterior leg fixed (show picture 5). The amount of movement should be compared to the uninjured side to determine joint laxity. This test has limited usefulness in the acute setting because pain, swelling, and muscle spasm may limit mobility of the joint and interfere with the test's reliability. It is a more helpful test in the evaluation of chronic ankle instability.

Talar tilt test — The talar tilt test detects excessive ankle inversion. If the ligamentous tear extends posteriorly into the calcaneofibular portion of the lateral ligament, the lateral ankle is unstable and talar tilt occurs. With the ankle in the neutral position, gentle inversion force is applied to the affected ankle, and the degree of inversion is observed and compared to the uninjured side (show picture 6). As with the anterior drawer test, this maneuver is of limited usefulness in the acute injury when pain, swelling, and muscle spasm are present, and it may be more important in evaluating chronic ankle instability.

Deferred exam — Deferred examination may improve the diagnosis of ligamentous injuries and instability. One study of 160 consecutive patients with inversion injuries found that performing a physical examination five days after the injury improved the accuracy of diagnosing ligament rupture [7]. The positive predictive value for ligament rupture of the triad of pain on palpation of the anterior talofibular ligament, lateral discoloration due to hematoma, and a positive anterior drawer sign was 95 percent.

Despite this, most patients with acute ankle injuries can be appropriately managed and triaged without performing a deferred examination.

RADIOGRAPHY

Imaging modality — Malleolar fractures, distal fibula fractures, talar dome fractures, and syndesmosis separation may be diagnosed with plain x-ray. If indicated, anteroposterior, lateral, and mortise x-rays should be obtained.

Stress radiography (obtaining plain films while performing a talar tilt or anterior drawer stress maneuver) is sometimes considered; however, it is rarely if ever clinically helpful [8].

In the setting of acute injury, magnetic resonance imaging (MRI) has no advantage over plain x-ray [9]. However, MRI should be considered in ankle sprains that are still painful after six to eight weeks of standard therapy. MRI can detect talar dome fractures and may be used to confirm suspected syndesmosis injury.

Selection of patients — While not well studied in the primary care setting, it is estimated that fracture of the ankle or midfoot occurs in less than 15 percent of patients presenting to an emergency department with an acute ankle sprain [10-14]. The Ottawa ankle rules were developed in an effort to reduce the number of unnecessary radiographs in such patients [15].

Ottawa ankle rules — The Ottawa ankle rules were developed, tested, and validated in adult patients presenting to the emergency department with acute ankle injuries. Although their use specifically in the primary care setting has not been assessed, the rules have demonstrated excellent results in both pediatric and adult emergency department patient populations.

A systematic review of 27 studies including 15,581 patients found that the Ottawa ankle rules were highly sensitive (96.4 to 99.6 percent) for excluding ankle fracture [16]. Specificity was modest and varied widely (10 to 79 percent), but the rules were purposely calibrated for high sensitivity at the expense of specificity. Less than 2 percent of patients who were negative for fracture according to the rules actually had a fracture. It was estimated that use of these rules in the emergency department for patients presenting with an acute ankle sprain would reduce the number of unnecessary radiographs by 30 to 40 percent. (See "Evaluation of foot and ankle pain in the young athlete", section on Radiologic evaluation).

Clinicians should remember that although multiple systematic reviews have found the Ottawa ankle rules to perform extremely well, as with any guidelines there are specific circumstances when clinical judgement should supersede them. As an example, patients with diminished peripheral sensation, such as diabetics, or intoxicated patients may need radiographs regardless of the Ottawa criteria. Missed fractures are a significant cause for litigation in the United States.

The rules are as follows (show figure 4):

An ankle series is only indicated for patients who have pain in the malleolar zone and Have bone tenderness at the posterior edge or tip of the lateral or medial malleolus

or
Are unable to bear weight both immediately after the injury and for four steps in the emergency department or doctor's office.

A foot series is only indicated for patients who have pain in the midfoot zone and Have bone tenderness at the base of the fifth metatarsal or at the navicular

or
Are unable to bear weight both immediately after the injury and for four steps in the emergency department or doctor's office.

The following apply to the use of the Ottawa ankle rules: If the patient can transfer weight twice to each foot (four steps), he or she is considered able to bear weight even if he or she limps. Palpate the distal 6 cm of the posterior edge of the fibula when assessing for bone tenderness.

A web teaching program for the rules is available online at: www.ohri.ca/programs/clinical_epidemiology/OHDEC/ankle_rule/default.asp

TREATMENT

Immediate therapy — All lateral ankle ligament sprains can be treated in a similar fashion. Initial management goals are to limit inflammation and swelling and to maintain range of motion. Early treatment includes RICE (rest, ice, compression, elevation) and early mobilization: Rest is achieved by limiting weight bearing by having patients use crutches until they are able to walk with a normal gait. Cryotherapy applied as ice or cold water immersion is recommended for 15 to 20 minutes every two to three hours for the first 48 hours or until swelling is improved, whichever comes first [17]. Compression to control and decrease swelling should be applied early, usually with an elastic bandage or a padded, contoured semi-rigid ankle brace (eg, Aircast). An elastic bandage is wrapped from the toes to the calf, with extra compression around the ankle provided by a "U" shaped piece of felt. One small trial showed improvement in ankle joint function at both 10 days and one month among patients using the Aircast compared with a standard elastic bandage [18]. The injured ankle should be kept elevated above the level of the heart to further alleviate swelling. Nonsteroidal antiinflammatory drugs (NSAIDs) are recommended, but one NSAID has not been shown in good studies to be better than another. NSAIDs have been found to be superior to placebo [19,20]; however, they have not been compared with non-NSAID analgesics such as acetaminophen, so it is not clear that the antiinflammatory effect itself is important. From the beginning, exercises including plantar flexion, dorsiflexion, and foot circles (show figure 5) should be done to maintain range of motion. Ankle splints or braces can limit extremes of joint motion and allow early weight bearing while protecting against reinjury (see "Splints and braces" below). The issue of whether severe ankle sprains should be immobilized with a plaster cast or ankle boot is discussed below (see "Immobilization" below).

Rehabilitation — Functional rehabilitation is of primary importance in aiding return to activity and preventing chronic instability. Early functional rehabilitation includes range of motion exercises (Achilles tendon stretch, foot circles (show figure 5), alphabet exercises [have the patient trace letters in the air with his big toe]), muscle strengthening exercises (isometric and isotonic plantar flexion, dorsiflexion, inversion, eversion, toe curls (show picture 7) and marble pickups, heel walks and toe walks), and proceeds to proprioceptive training (circular wobble board and walking on different surfaces) and activity-specific training (walk-jog, jog-run) [21,22].

In most patients, functional rehabilitation should begin on the day of injury and continue until the patient has returned to pain-free activity. The rehabilitation program should take several weeks in order for the ankle to strengthen and to limit the chance of reinjury. In a study of active-duty marines with grade II ankle sprains, those undergoing a structured rehabilitation program returned to duty up to several months earlier than those without rehabilitation [23].

Whether patients with severe sprains should have their ankle immobilized for a period of time prior to rehabilitation is controversial (see "Immobilization" below).

Splints and braces — During functional rehabilitation, it may be of benefit to use splints, braces, elastic bandages, or taping to try to reduce instability, protect the ankle from further injury, and to limit swelling.

A systematic review of nine randomized and quasi-randomized controlled trials that evaluated strategies for treatment of acute lateral ankle ligament injuries using different methods of ankle support during functional rehabilitation reported the following results [24]: Lace-up ankle supports were superior to semi-rigid ankle supports, elastic bandages, and tape in preventing persistent swelling. Semi-rigid ankle supports (show table 1) resulted in quicker return to work, quicker return to sports, and less instability at short-term follow-up than elastic bandages. Tape caused more skin irritation than elastic bandages.

Immobilization — Although patients with ankle sprains are sometimes treated with immobilization with a plaster cast or with a rigid boot prior to functional rehabilitation, most patients do not require immobilization.

A systematic review of 21 randomized and quasi-randomized trials found that functional rehabilitation was superior to immobilization on seven outcome measures: more patients returned to sport in the long term (RR 1.86, 95% CI 1.22-2.86); the time taken to return to work was shorter (4.9 days, CI 1.5-8.3); more patients had returned to work at short-term follow-up (RR 5.75, CI 1.01-32.71); the time taken to return to work was shorter (8.2 days, CI 6.3-10.2); fewer patients suffered from persistent swelling at short-term follow-up (RR 1.74, CI 1.17-2.59); fewer patients suffered from objective instability as tested by stress x-ray (2.60, CI 1.24-3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, CI 1.09-3.07) [25]. The systematic review found that many trials were of poor quality, and there was variety among the functional treatments evaluated. In a separate analysis of the higher quality trials, the only significant result was that patients treated with functional rehabilitation returned to work sooner than those treated with immobilization (12.9 days, CI 7.1-18.7).

The treatment of Grade III ankle sprains, in particular, remains controversial. The systematic review discussed above did not stratify patients to look at a subset of patients with more severe ankle injuries. One of the trials included in the systematic review assigned 80 patients with grade III lateral ligament ruptures to immobilization in a plaster cast or early mobilization with a stabilizing orthosis. Patients treated with early mobilization resumed work and sports earlier than immobilized patients, and there were no differences in ankle stability or symptoms during activity after one year of follow-up. Given these results, it appears likely that early functional rehabilitation is superior to immobilization even in patients with Grade III ankle sprains.

Surgery — Surgical repair of ruptured ankle ligaments is sometimes considered in patients with ankle sprains. A meta-analysis that looked at controlled trials of surgery for acute ruptures of lateral ankle ligaments found that compared with functional treatment, patients treated with surgery were significantly less likely to experience giving-way of the ankle (relative risk 0.23, 95% CI 0.17-0.31) [26]. A subsequent systematic review concluded that there were methodologic flaws in all trials making it impossible to determine the relative effectiveness of surgical and conservative treatment for sprains of the lateral ankle ligaments [27].

A subsequent prospective trial of therapy for lateral ankle ligament rupture allocated 185 patients to surgery and 203 patients to functional treatment based upon the week in which they presented [28]. After a median follow-up of eight years, fewer patients treated surgically than with functional treatment reported residual pain (16 versus 25 percent), symptoms of giving-way (20 versus 32 percent), and recurrent sprains (22 versus 34 percent). There was no difference in the percent of patients with worsening radiographic evidence of joint degeneration. At follow-up, patients treated surgically were less likely to have a positive anterior drawer test (30 versus 54 percent); however, this was assessed by clinicians who knew how the patients had been treated. Thus, there were no blinded objective assessments in this trial that demonstrated superiority of surgery.

Based on these results, it is unclear whether patients with acute ankle sprains would benefit from surgery. Given costs and operative risks, it is unlikely that most patients with mild or moderate ankle sprains will be treated surgically. It may be reasonable to consider surgery in some patients with severe sprains who are engaged in professional sports or other activities that are likely to impose repeated large stresses on the ankle joint.

Although many experts conclude that delayed operative reconstruction of injured ligaments achieves results similar to that with acute repair [26], we are not aware of any head-to-head trials that examine this issue.

Other therapy — Neither ultrasound therapy [29], low-level laser therapy [30], or hyperbaric oxygen therapy [31] appear to be effective in the treatment of ankle sprains.

REFERRAL — Indications for referral to an orthopedic surgeon include: Fracture Dislocation or subluxation Syndesmosis injury Tendon rupture Wound penetrating into the joint Uncertain diagnosis

Patients with neurovascular compromise (distal findings of decreased sensation, motion, or circulation) require emergent evaluation.

PREVENTION — Options for primary or secondary prevention of ankle injuries include external ankle supports such as semi-rigid orthoses (show table 1), lace up supports, and high-top shoes, taping, stretching, strengthening, and proprioceptive ankle training using a wobble board.

A systematic review of 14 randomized trials concluded that patients treated with external ankle supports had a reduced risk of sprain (RR 0.53, 95% CI 0.40-0.69); however, the protective effect of high-top shoes, in particular, has not been established [32]. The reduction in risk was greater for those with a previous ankle sprain than in primary prevention. External supports did not appear to alter the severity of ankle sprains that did occur or change the incidence of other leg injuries. The authors concluded that further research was needed comparing various external ankle supports and on interventions such as taping, strengthening, and proprioceptive training.

A meta-analysis of eight studies that looked at prevention of ankle sprains found variability in study methodology and design, but concluded that while ankle braces and taping both appeared to be somewhat effective, braces appeared to be superior to taping [33]. Proprioceptive training appeared to be equally effective in primary and secondary prevention of ankle injuries.

Athletes may have concerns about decreased performance with external ankle supports. A study that looked at running and jumping performance found differing results depending on the specific brace or method (such as taping) used, but in no case did a support decrease performance by more than 5 percent [34].

Two randomized controlled trials conducted with high school and young adult athletes found that proprioceptive balance training reduced the incidence of ankle sprains among players with prior ankle sprains [35,36].

SUMMARY AND RECOMMENDATIONS — The mechanism of most ankle sprains is an inversion injury to the lateral ligaments of the ankle.

For patients presenting with an acute ankle injury: Perform a careful history to determine the mechanism of injury (to direct the examination), whether the patient could walk after the injury (important for the Ottawa ankle rules), and whether the ankle had been previously injured (patients with a history of ankle sprains are at increased risk for new sprains). Perform a careful physical examination, with particular attention to the areas covered by the Ottawa ankle rules (see "Ottawa ankle rules" above). To rule out an ankle fracture, obtain anteroposterior, lateral, and mortise plain films of the ankle, if indicated by the Ottawa ankle rules (see "Ottawa ankle rules" above). Start functional rehabilitation with rest, ice, compression, elevation (RICE), early mobilization, and support orthosis with early weight bearing. Referral to a physical therapist for advanced functional rehabilitation may be helpful. Patients with a positive squeeze test or positive external rotation stress test may have a syndesmosis injury. Syndesmosis injury can be confirmed with MRI. Patients with a syndesmosis injury should be referred to an orthopedic surgeon.

For patients with persistent symptoms: Consider obtaining an MRI in patients with symptoms that persist for more than six to eight weeks to rule out conditions such as talar dome fractures or syndesmosis injury. Consider referral to an orthopedic surgeon for patients with chronic ankle instability.

For prevention of reinjury in patients with a history of ankle sprain: Institute proprioceptive balance board training, possibly under the guidance of a physical therapist.

REFERENCES

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