Scapulohumeral rhythm, the kinematic interaction between the scapula and the humerus, is important for optimal function of the shoulder [9]. For the sake of clarification, the current literature differentiates between an internal impingement and an external impingement. Consensus on dosage, frequency, method of delivery, acceptable pain tolerance, inter-exercise activity levels, and specific exercise inclusion has not been achieved.[4][5][6][7]. Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition M75.4 Impingement syndrome of shoulder . Impingement syndrome is the most common cause of shoulder pain. All Rights Reserved. Insertion: the bicipital groove of the humerus, Function: flexion, adduction and internal rotation of the humerus, Innervation: lateral and medial pectoral nerve, Vascular supply: pectoral branch of the thoracoacromial trunk, Origin: lower thoracic vertebrae (T8-12), lumbar vertebrae, ribs 9-12, iliac crest, Insertion: the intertubercular sulcus of humerus, Function: extension, adduction and internal rotation of the humerus, Vascular supply: thoracodorsal branch of the subscapular artery. The shoulder joint is an example of a ball and socket [28], Further to their passive stabilization role, they also provide additional protection via the various mechanoreceptors embedded within their fibers. Then anterior superior and posterior superior internal impingement will be outlined. WebPrimary External Impingement related to structural changes, either congenital or acquired, that mechanically narrow the subacromial space such as; bony narrowing or osteophyte formation, bony malposition after a fracture, or an increase in the volume of the subacromial soft tissues. Mechanoreceptors can be understood as the neural sensors that provide afferent input to the central nervous system for motor processing and descending motor commands for the execution of movements. You've had symptoms for 1 to 3 months, and they're getting worse. That said, there are occasions when you might experience pain. Get free rules, notes, crosswalks, synonyms, history for ICD-10 code M75.30. Phys Ther. These muscles attach to the surface of the scapula and are responsible for the internal and external rotation of the glenohumeral joint, along with humeral abduction. A blinded, randomized, controlled trial assessing conservative management strategies from frozen shoulder. WebEncompass Health Corp. (NYSE: EHC) and the University of Iowa Health System, the nonprofit corporation that supports the clinical, academic and research programs of University of Iowa Health Care, announced they have entered into an agreement to jointly own a 40-bed, freestanding inpatient rehabilitation hospital currently under construction in Richard Drake, A. Wayne Vogl, Adam Mitchell. Shoulder surgery is a means of treating injured shoulders. Distal articulation: the head of the humerus. 2014;27:247273. Scapula deviated about 35 degree anterior to the frontal plane.the concave glenoid fossa articulate with convex head of humerus to form glenohumeral joint. BOXROX Competitive Fitness Magazine is the worlds biggest online magazine for fans of CrossFit and functional fitness. It affects women more than men and is typically diagnosed in people over the age of 45. Aim for 2030 shoulder squeezes multiple times a day. The cause of adhesive capsulitis is debatable, with no definitive cause. on the inferiolateral surface is costal tuberosity attachment for costoclavicular ligament. Reps could be in the 12-15 range per set. Wattanaprakornkul et al [13][14] demonstrated that during flexion, the posterior externally rotating cuff muscles (supraspinatus and infraspinatus) were activated at significantly higher levels than the anterior internally rotating cuff muscle (subscapularis), while during extension the reverse occurs. Wattanaprakornkul D, Halaki M, Boettcher C, Cathers I, Ginn KA. The GH joint is of particular interest when understanding the mechanism of shoulder injuries because it is osteologically predisposed to instability.[1][2]. Part of a Marine Expeditionary Unit earning the Special Operations Capable designator requires a company-sized unit capable of riot control. 1% (44/6040) 5. Get free rules, notes, crosswalks, synonyms, history for ICD-10 code M75.30. Dynamic Strengthening of Glenohumeral Joint by using elastic resistance, pulley or handheld weights.[21]. The most notable and clinically important are the rotator cuff muscles. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Revised: If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. positive if pain is elicited with abduction and external rotation of the shoulder. Simply enter your prompt on the front of the flashcard and let our intelligent assistant (Geeky AI) do the rest! Guests include Dr. Steven Jones, PGY-3 at the University of Colorado in Denver; Dr. Ben Zmistowski, shoulder and elbow surgery fellow at Washington Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Today, were REALLY excited to announce Geeky AI; an intelligent assistant to help you write flashcards. We recommend that you seek advice from a physiotherapist or healthcare professional before starting any new exercise regime. . Final year medical student interested in medical education, intensive care medicine and geriatrics. A common cause of shoulder pain in rotator cuff impingement syndrome is tendinosis, which is an age-related and most often self-limiting condition. You can also take an over-the-counter anti-inflammatory medication such as ibuprofen to help reduce pain and swelling. Scapula: scapula is triangular shape has three border superior and medial and lateral ,three angle inferior,superior and lateral and three surface. Our videos have been provided courtesy of Physiotec. The shoulder is the most movable joint in the body. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion - Part II: shoulder, elbow, wrist and hand. The healthy movement of the scapula along the thorax during arm elevation includes protraction, posterior tilting, and lateral rotation, depending on the plane of movement (Figure 1). It affects women more than men and is typically diagnosed in people over the age of 45. Upper extremity: emphasis on frozen shoulder. This extra mobility does, however, come at the expense of joint stability. Although it is clear that group and individual physiotherapy interventions that incorporate exercise are better than minimal or no treatment, it remains unclear whether either is better than the other[17]. The Journal of Hand Surgery publishes original, peer-reviewed articles related to the pathophysiology, diagnosis, and treatment of diseases and conditions of the upper extremity; these include both clinical and basic science studies, along with case reports.Special features include Review Articles (including Current Concepts and The Please listen to this ASES podcast in which hosts Dr. Peter Chalmers and Dr. Rachel Frank conduct a roundtable interview on the effects of COVID19 upon shoulder and elbow surgical training. Pain medication. J Ortho Sports Phys Ther. Common symptoms of shoulder impingement include: You should also make a note of any other rotator cuff pain caused from a shoulder strain including swelling and tenderness in the front part of your shoulder, bruising, weakness, pain as you move and a decrease in your range of motion. The neuromuscular control of the scapula relies on the balanced team-work between the global movers and the fine-tuning stabilizing muscles of the shoulder complex. This may limit people's ability to brush their hair or put on clothing. Nerve supply of the human knee and its functional importance. External impingement . A serious complication of shoulder dislocation is axillary nerve injury. In that case, your physical therapist may refer you for an injection of a safe anti-inflammatory and pain-relieving medication. Clicking may also occur with movement of the arm. WebShoulder pain Video exercises for shoulder pain. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ The infraspinatus and supraspinatus tests have a specificity of 80% to 90%.. A common cause of shoulder pain in rotator cuff impingement syndrome is tendinosis, which is an age-related and most When you have impingement or irritation of the rotator cuff tendons, Geier says you will often feel pain as you lift a weight above shoulder level and out away from your body. ICD 10 code for Calcific tendinitis of unspecified shoulder. [1] Since it was first described in 1852, shoulder impingement syndrome is believed to be the most common cause of Intercostal Drain) OSCE Guide, Ascitic Drain (Therapeutic Paracentesis) OSCE Guide, Laterally, the capitulum articulates with the head of the radius, Medially, the trochlea articulates with the trochlear notch of the ulna, The anatomical neck is the site of attachment of the joint capsule, The surgical neck is found inferior to the head of the humerus, Subacromial-subdeltoid bursa: located between the joint capsule and the deltoid muscle, Subacromial bursa: located between the joint capsule and the acromion, Subcoracoid burse: located between the joint capsule and the coracoid process. https://www.torbayandsouthdevon.nhs.uk/services/physiotherapy/support-videos/torbay-shoulder-exercise-programme/, https://vimeopro.com/rocklandsmedia/torbay-shoulder-exercise-video-series/video/105122462. [21], Stretching exercises to increase capsule mobility and muscle lengthening. Reduced subacromial space was also noted when loading the rotator cuff to fatigue, with recovery to baseline delayed for up to 24 hours in individuals shoulder pain as a result of rotator cuff tendinopathy. These muscles stabilize the ball in the shallow socket of the shoulder in overhead positions. Predictors of outcome after nonoperative and operative treatment of adhesive capsulitis. Conjointly as agonist and antagonist couplings, they allow for the gross motor movements of the upper quadrant. [18] The normal contribution of the ST joint is generally expressed as the ratio of ST movement with regards to that occurring simultaneously at the GH articulation. Typical findings on clinical examination in supraspinatus impingement syndrome include: For more information, see the Geeky Medics shoulder examination guide. Healthdirect Australia is not responsible for the content and advertising on the external website you are now entering. The AC joint is a diarthrodial and synovial joint. Often, physical therapists don't see patients with adhesive capsulitis until well into the freezing phase or early in the frozen phase. It originates on the upper surface of the scapula and feeds through a small space in the shoulder joint to attach to the upper humerus., Given the limited room inside the joint already because of ligaments, bursa and an already tight shoulder capsule from limited shoulder mobility, the supraspinatus tendon can become pinched when the arm is lifted overhead. Content Type: Guide. Nov 19, 2017 Your treatment may include: Stretching techniques. Pldoja E, Rahu, M., Kask, M.,Weyers, I., & Kolts, I. Fa Davis; 2017 Oct 18. Instead of rushing into this and risking further aggravation of symptoms. When weakness or neuromuscular dysfunction of the scapular musculature is present, normal scapular arthrokinematics become altered,[20] and ultimately predisposes an individual to an injury of the GH joint. Nov 19, 2017 The supraspinatus muscles tendon is most commonly affected. MRI is useful for diagnosing these conditions. When this happens, stop the exercise, assess your form and make any adjustments. The therapist will flex the patient's elbow to 90 degrees and abducts the patient's shoulder to 90 degrees, maintaining neutral rotation. The therapist will flex the patient's elbow to 90 degrees and abducts the patient's shoulder to 90 degrees, maintaining neutral rotation. Smith J et al., Effect of scapular protraction and retraction on isometric shoulder elevation strength. Internal impingement. Isometric contractions of scapular muscles and glenohumeral muscles can be performed. Guests include Dr. Steven Jones, PGY-3 at the University of Colorado in Denver; Dr. Ben Zmistowski, shoulder and elbow surgery fellow Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition; Impingement syndrome of right shoulder region; ICD-10-CM M75.41 is grouped within Diagnostic Related Group(s) (MS-DRG v 40.0): . Of the people who have had adhesive capsulitis in 1 shoulder, it is estimated that 20% to 30% will get it in the other shoulder as well. Do it at this gradual pace and you will be able to fix your shoulder pain once and for all.. Again, because of the floating nature of the scapula along the thorax, it too, must rely on the kinship between the cortical direction provided by the nervous system and the resulting action of the MSK system. Rotator cuff tendinosis in an animal model: Role of extrinsic and overuse factors. Same rules apply to the number of sets and days per week that youd be doing this. [29][30][31], Mechanoreceptors are characterized by their specialized nerve endings that are sensitive to the mechanical deformations of tissues,[32][33][34] and therefore contribute to the modulation of motor responses of the adjacent muscles. WebThe deltoid muscle is an anterior stabilizer of the glenohumeral joint with the arm in abduction and external rotation and as such the stabilizing function of the deltoid muscle et al. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. To effectively rehabilitate a shoulder injury in clinical practice, it is important to have a functional knowledge of the underlying biomechanics of the shoulder complex. Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature, A prospective randomized placebo controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder, Direction-specific recruitment of rotator cuff muscles during bench press and row, Are Group-Based And Individual Physiotherapy Exercise Programmes Equally Effective For Musculoskeletal Conditions? The synchronized contractions of the RC muscles must maintain the centralized positioning of the humeral head during movements in order to avoid the physical encroachment of tissues, predominantly anteriorly or superiorly to the GH joint, which has been linked to injury and pain amongst the shoulder region. When you're done working out, follow the RICE protocol of rest, ice, compression and elevation. TikTok: https://www.tiktok.com/@geekymedics J Shoulder Elbow Surg. Twitter: http://www.twitter.com/geekymedics (OBQ18.220) A 55-year-old male patient presents with right shoulder pain that is worse with overhead activity. The stabilizing muscles of the GH articulation,the supraspinatus, subscapularis, infraspinatus, and teres minor,are often summarized as the rotator cuff (RC) complex, andattach to the humeral head within the glenoid fossa. Top Contributors - Amanda Ager, Kim Jackson, Abdallah Ahmed Mohamed, Naomi O'Reilly, Vidya Acharya, Claire Knott, Ayesha Arabi and Khloud Shreif. Origin: the medial edge of the glenoid fossa, Insertion: the lesser tubercle of the humerus, Origin: the lower edge of the glenoid fossa, Insertion: the anatomical neck of the humerus. WebUlnar nerve entrapment is a condition where the ulnar nerve becomes physically trapped or pinched, resulting in pain, numbness, or weakness, primarily affecting the little finger and ring finger of the hand.Entrapment may occur at any point from the spine at cervical vertebra C7 to the wrist; the most common point of entrapment is in the elbow (Cubital tunnel Jam B. The patient works as a computer programmer and is a recreational swimmer and has noted worsening pain with his breaststroke. This allows us to get in touch for more details if required. The estimated prevalence of shoulder complaints is 7% to 34%, often with shoulder impingement syndrome as the underlying etiology. Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. Below is a brief overview of which muscles are involved in specific shoulder movements. The muscles and tendons of the rotator cuff. These muscles attach to the surface of the scapula and are responsible for the internal and external rotation of the glenohumeral joint, along with humeral abduction. Your physical therapist may introduce more intense stretching techniques to encourage greater movement and flexibility. If no, then will our patients who are very irritable be limited in their ability to participate in any exercise program and what impact will that have on their management? Same rules apply to the number of sets and days per week that youd be doing this. #9. You still have a limited range of movement, but your ability to complete your daily activities involving overhead motion is improving at a rapid rate. Therefore, strength training that incorporates middle and posterior deltoid muscle could enhance its role in improving shoulder stabilization.[16]. Early motion of Glenohumeral Joint usually involves passive ROM within pain free ranges. The muscles and tendons of the rotator cuff. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Doing external shoulder rotation with a resistance band combines rotator cuff strengthening and scapula strengthening making it a great shoulder impingement exercise. The Torbay Protocol, developed and trialed by Roberta Ainsworth initially as a pilot study and then in an RCT for a rehabilitation programme for patients with a diagnosis of massive, irreparable rotator cuff tears of the shoulder [3] and provides guidelines for the physiotherapy rehabilitation of these patients based on a progressive strengthening program aimed at the anterior deltoid and teres minor muscles. "The most common reason that front and lateral shoulder raises cause pain in adults is impingement of the rotator cuff tendons against the front edge of the tip of the shoulder blade in the upper phases of these exercises," Dr. David Geier, MD, orthopedic surgeon and sports medicine specialist tells LIVESTRONG.com. Sure, the joint itself becomes even more crowded and unable to safely house the tendon as additional inflammation and swelling mount up. Subacromial and subcoracoid external impingement will be discussed. Marines with MARSOC, Force Reconnaissance, and MEU(SOC)s occasionally use specialized weapons that the rest of the fleet does not. WebUnlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated by active external hip rotation. WebUnlike sciatica from disc herniation, piriformis syndrome and ischiofemoral impingement are exacerbated by active external hip rotation. Tendinitis, bursitis, and impingement syndrome. Optimal parameters of exercise and load have yet to be determined as has the mechanism by which therapeutic response occurs [1]. The classic form of shoulder impingement is subacromial that may be primary due to congenital or acquired structural causes or secondary due to joint instability (discussed in the next The shoulder joint is an example of a ball and socket External shoulder rotation. WebA rotator cuff tear is an injury where one or more of the tendons or muscles of the rotator cuff of the shoulder get torn. Your treatment may include: Exercises and manual therapy. All contents 2022 American Physical Therapy Association. You may begin strengthening exercises targeting the shoulder area as well as your core muscles. Deltoid muscle. The American Council on Exercise suggests a slight external rotation at the 60 to 70-degree mark to help reduce potential impingement in the shoulder joint. Symptoms may include shoulder pain, which is often worse with movement, limited range of motion, or weakness. When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with frozen shoulder. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. The deltoid is a large and triangular-shaped muscle. Reproduced with permission from JF Sarwark, ed: Essentials of Read more on myDr website. The actual cause of adhesive capsulitis is a matter of debate. Shoulder impingement can cause pain and difficulty with many daily activities. Choose better health. [9][10], As illustrated by the force-vectors of their respected moment arms, the RC tendons collectively have been accredited with the compression of the humeral head within the glenoid fossa during movements. 2007;16:569573. This is sometimes the direct cause of the inflammation that one gets and the shoulder tendonitis that one experiences that keeps them from performing upper body exercises without pain., There is a second important cause of this pain however, that left untreated, will continue to cause a recurrence of the pain without ever getting to the bottom of the real issue. positive if pain is elicited with abduction and external rotation of the shoulder. [1] Since it was first described in 1852, shoulder impingement syndrome is believed to be the most common cause of shoulder The axillary nerve runs along the surgical neck of the humerus. The deltoid muscle is an anterior stabilizer of the glenohumeral joint with the arm in abduction and external rotation and as such the stabilizing function of the deltoid muscle takes on more importance as the shoulder becomes unstable [15]. Due to the multiple joints involved during shoulder movement, it is prudent to refer to the area of the shoulder complex. Shoulder joint position sense improves with elevation angle in a novel, unconstrained task. Physical therapists help people with adhesive capsulitis address pain and stiffness, and restore shoulder movement in the safest and most effective way possible. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. See the Geeky Medics shoulder examination guide for more details. clavicle deviated 20 degree with frontal plane in anatomic position. Modalities. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ The humerus has both an anatomical neck and a surgical neck: The scapula acts as the point of attachment for the rotator cuff muscles. Once the evaluation process has identified the stage of your condition, your physical therapist will create an individualized exercise program tailored to your specific needs. The larger muscles such as the trapezius, the levator scapula, the pectorali, the deltoids, the serratus anterior, the latissimus dorsi, the rhomboids, the teres major, the biceps, the coracobrachialis, and triceps muscles are responsible for various synergistic activities during shoulder movements. Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition M75.4 Impingement syndrome of shoulder . Your physical therapist will give you a gentle home-exercise program designed to help reduce your loss of motion. Share. The role of the scapula. The Archives of Physical Medicine and Rehabilitation publishes original, peer-reviewed research and clinical reports on important trends and developments in physical medicine and rehabilitation and related fields.This international journal brings researchers and clinicians authoritative information on the therapeutic utilization of The shoulder is the most movable joint in the body. WebThe deltoid muscle is an anterior stabilizer of the glenohumeral joint with the arm in abduction and external rotation and as such the stabilizing function of the deltoid muscle et al. Banded External Rotation. Voight ML, & Thomson, B.C. 7. [4][6][7], For more detailed anatomy visit Shoulder Anatomy, The natural arthrokinematics of the GH joint of the shoulder complex during an open-chain movement supports various directional glides of the humeral head within the glenoid fossa. Both the superior and anterior translation of the humeral head during movements are the leading biomechanical causes for impingement syndrome.[14]. The deltoid, which is a pennate muscle composed of three portions, covers the entire shoulder joint and are recruited to move the humerus in relation to the scapula. Subacromial and subcoracoid external impingement will be discussed. The coracoacromial ligamentis clinically important as it prevents superior dislocation of the humeral head of the shoulder joint. In fact, it's not uncommon to see training programs call for three sets of 12 to 15 repetitions of these exercises. Bony instability of the shoulder. It is unknown exactly why exercise was beneficial and has been suggested that the effect of exercise may be multi-factorial [2]. When this occurs, the breakdown of the tendon and resulting inflammation is being caused directly by the inability of the tendon to accommodate to the normal stresses of the joint. External shoulder rotation is another good exercise for strengthening the rotator cuff muscles and improving flexibility. Both the front and lateral raise exercises are generally safe for most people. The articles report recent research and give an overview of the standards of practice for treatment of adhesive capsulitis both in the United States and internationally. The therapist will flex the patient's elbow to 90 degrees and abducts the patient's shoulder to 90 degrees, maintaining neutral rotation. This may limit people's ability to brush their hair or put on clothing. OK. Search our site for. Article Summary in PubMed. It commonly presents as a form of impingement syndrome, with associated pain, weakness and stiffness of the shoulder joint. This may limit people's ability to brush their hair or put on clothing. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ Patients with impingement syndrome often complain of pain when their arms are raised (this is particularly common in mechanics and manual labourers who work with their arms overhead). Recent EMG studies have indicated that rotator cuff muscles are recruited in a reciprocal, direction-specific pattern during shoulder flexion and extension exercises. The shoulder, or glenohumeral joint, connects the upper arm to the chest. - 03-Aug-08 - FBO#2442", Weapons of the United States Marine Corps, Military Secretary to the Commandant of the Marine Corps, Seapower and Projection Forces subcommittee, United States Marine Corps Warfighting Laboratory, https://en.wikipedia.org/w/index.php?title=List_of_weapons_of_the_United_States_Marine_Corps&oldid=1117837231, Short description is different from Wikidata, Articles lacking in-text citations from February 2009, Wikipedia articles incorporating text from the United States Marine Corps, Creative Commons Attribution-ShareAlike License 3.0, This page was last edited on 23 October 2022, at 21:08. Neuroanatomical distribution of mechanoreceptors in the human cadaveric shoulder capsule and labrum. Our weekly newsletter contains advanced clinical content, recent Orthopedic and Sports Physical Therapy research, and special offers from our PT partners. et al. Perform stretches for Latissimus Dorsi, Pectoralis Major, Pectoralis Minor, Levator Scapulae and Trapezius muscle after careful evaluation and assessment and educate self stretches to the patient whenever required.[21]. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Tendonitis; Sports Injuries; Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. WebLittle Leaguer's shoulder is an overuse injury occuring in young baseball pitchers resulting in epiphysiolysis of the proximal humerus (a Salter Harris Type 1 injury). It functions to reduce friction between these two structures. Wu G, van der Helm, F.C., Veeger, H.E. As previously noted, due to the anatomical passage of the common RC tendon within the subacromial space, the RC tendons are particularly vulnerable to compression, abnormal friction, and ultimately an impingement (pinching) during active tasks. Soslowsky LJ, Thomopoulos, S., Esmail, A. et al. The anterior portion is a prime motor during shoulder flexion and horizontal adduction of the shoulder, while the lateral/middle portion acts during abduction and horizontal abduction and the posterior portion is recruited during horizontal abduction. The examiner then slowly applies an external rotation force to the arm to 90 degrees while carefully monitoring the patient. Additionally, you can expect to recruit the trapezius, supraspinatus, pectorals, wrist extensors and your core for stabilization while standing. Table 1. 2015 Apr 28;373. - Over 3000 Free MCQs: https://geekyquiz.com/ Treatment may include: Stretching techniques. Because there are not direct attachements of muscles to the joint, all movements are passive and initiated by movements at other joints (such as the ST joint). Rehabilitation programmes for rotator cuff tendinopathy need to take into account the potential for increased tendon thickness and reduced subacromial space after loading, as such exercise type and dosage should be titrated to avoid excessive loading to fatigue, and appropriate recovery periods after loading to fatigue should be implemented [20]. They improve quality of life through hands-on care, patient education, and prescribed movement. Sheridan MA, Hannafin JA. Then have the patient externally rotate the shoulder by bringing the forearms laterally. Manual Therapy for Musculoskeletal Pain Syndromes: An Evidence-and Clinical-Informed Approach. [13], An imbalance in the neural activation of any one of the RC muscles could easily cause a misalignment of the humeral head thus giving rise to an impingement of the subacromial structures during movement. Building strong and sculpted shoulders is a goal for many bodybuilders and fitness enthusiasts. Return to work or sport. . Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Milgrom C, Schaffer, M., Gilbert, S., & van Holsbeeck, M. Rotator cuff changes in asymptomatic adults. David G, Jones, M., & Magarey, M. Rotator cuff muscle performances during gleno-humeral joint rotations: An isokinetic, electromyographic and ultrasonographic study. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. These articulating surfaces are separated by a narrow cavity filled with synovial fluid, making it a synovial joint. - Over 3000 Free MCQs: https://geekyquiz.com/ We're excited to see what you do with this new tool - make sure to post examples in the comments! Weakness and pain experienced when the supraspinatus muscle is isolated using the Empty can/Jobes test. J Shoulder Elbow Surg. The Hawkins-Kennedy test has a sensitivity of approximately 80% to 90% for detecting impingement. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. Subacromial and subcoracoid external impingement will be discussed. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ Proximal articulation: with the glenoid fossa of the scapula. Research has shown that although these injections dont provide longer-term benefits for range of motion and dont shorten the duration of the condition, they do offer short-term pain reduction. Because of the relatively large surface area of the humeral head in relation to the fossa, the joint itself has limited bony congruency, and consequentially heavily depends on surrounds soft tissues for structural support. [35], It is clear that the passive structures of the shoulder provide a neurological protection mechanism through feed forward and feed back input, that directly mediates reflex musculature stabilization about the glenohumeral joint. There are several muscles that act to move the shoulder joint. During stage 1 of its development, it may be difficult to identify your problem as adhesive capsulitis. You can check out our guide to eye trauma here: COMING SOON Am J Sports Med. The Archives of Physical Medicine and Rehabilitation publishes original, peer-reviewed research and clinical reports on important trends and developments in physical medicine and rehabilitation and related fields.This international journal brings researchers and clinicians authoritative information on the therapeutic utilization of physical, behavioral and Read more: The Best Shoulder Exercises: How Many Reps and Sets? I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Witherspoon JW, Smirnova, I.V., & McIff, T.E. It provides articulation between the glenoid fossa of the scapulaand the head of the humerus. Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder joint is an example of a ball and socket joint, which is highly mobile due to The static structures of the shoulder complex, which includes the labrum (a fibrocartilaginous ring), the capsule, cartilage, ligaments, and fascia collectively act as the physical restraints to the osseous matter and provides a deepening effect to the shallow glenoid fossa. Paper presented at: Manipulative Physiotherapists Association of Australia Conference Proceedings., 1997; Melborne, Australia. The patient should be position in supine. Gradually increase this stress by taking a larger step away and then finally, get to a ballistic or plyometric stress on the tendon by incorporating a small jump out. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ How to Recover From a Rotator Cuff Injury Plus 4 Exercises to Help, American Council on Exercise: "Dumbbell Lateral Raise", American Academy of Orthopaedic Surgeons: "Shoulder Impingement/Rotator Cuff Tendinitis", Cleveland Clinic: "Shoulder Impingement Syndrome", Dr. David Geier: "Dr. David Geier, MD: Personal Interview", Pain during certain range of motion exercises such as front and lateral raises. Russell S, Jariwala A, Conlon R, et al. Can This Injury or Condition Be Prevented? Posterior shoulder stretching; Pectoralis minor stretching; Thoracic extension posture and exercises; Alisha Fey and her research team 3 also noted the important roles played by the serratus anterior, the lower trapezius, and the middle trapezius in producing scapular upward rotation, posterior tilting, and external rotation of the scapula. In rotator cuff tendinopathy, both home and supervised exercise programmes have been found to be more effective than no intervention or placebo and as effective as minimal comparators, e.g. The stabilizing muscles of the GH articulation, https://www.physio-pedia.com/index.php?title=Biomechanics_of_the_Shoulder&oldid=291225, Elevation and protraction = anterior elevation, Elevation and retraction = posterior elevation, Depression and protraction = anterior depression, Depression and retraction = posterior depression. BOXROX and its content is not affiliated with CrossFit, Inc in any way nor is it endorsed by CrossFit, Inc or any of its subsidiaries. Reproduced with permission from JF Sarwark, ed: Essentials of Ludewig P. M. CTM. Available from: [, Anatomography. When raising the dumbbells during the front raise, how high you do will depend on when you feel tightness in your shoulder, according to ExRx.net. Adhesive capsulitis: a review of current treatment. We recommend that you seek advice from a physiotherapist or healthcare professional before starting any new exercise regime. The musculature of the shoulder region can be subdivided into the global movers of the shoulder and the fine-tuning stabilizers of the individual articulations. The estimated prevalence of shoulder complaints is 7% to 34%, often with shoulder impingement syndrome as the underlying etiology. The examiner then slowly applies an external rotation force to the arm to 90 degrees while carefully monitoring the patient. Your physical therapist's overall goal is to restore your movement, so you can perform your daily activities. Kennedy JC, Alexander, I.J., & Hayes, K.C. Please write a single word answer in lowercase (this is an anti-spam measure). Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Toward the end of this stage, however, pain decreases, with the pain usually occurring only when you move your shoulder as far you can move it. Struyf F, Nijs, J., Baeyens, J.P., Mottram, S., Meeusen, R. Scapular positioning and movement in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability. Bushnell BD, Creighton, R.A., & Herring, M.M. During the early part of this stage, there is still a substantial amount of pain. When it comes to training these muscles, one exercise that tops the list of favorites is the front lateral raise. The role of the scapula in the rehabilitation of shoulder injuries. WebExternal Rotation. You can contact a physical therapist directly for an evaluation. A variation of the lateral raise, this move requires strict form and lighter weight to avoid pain in the shoulders. Then, reduce the weight you're lifting and decrease the number of repetitions and sets. [15] Within the scientific literature, the scapulohumeral rhythm is generally accepted to be 2:1, which represents 2 of humeral elevation for every degree of scapular upward rotation. Am J Sports Med. [11] The supraspinatus muscle initiates the abduction movement of the arm by pulling the humeral head medially towards the glenoid cavity thereby creating a fulcrum for movement. Your therapist will warn you that being overly aggressive with stretching in this stage may make your shoulder pain worse. In addition, your physical therapist will consider other conditions you might have, such as diabetes, thyroid disorders, and autoimmune disorders, that are associated with adhesive capsulitis. Aim for 2030 shoulder squeezes multiple times a day. Top Contributors - Rachael Lowe, Naomi O'Reilly, Shreya Pavaskar, Kim Jackson, Claire Knott and Wanda van Niekerk. O'Keeffe et al[17], in a broad study of exercise for musculoskeletal pain, found only small, clinically irrelevant differences in pain or disability outcomes between group and individual physiotherapy, and concluded that group interventions may need to be considered more often given their similar effectiveness and potentially lower healthcare costs. You'll begin to limit shoulder motion during this period and protect the shoulder by using it less. M110 Semi-Automatic Sniper System - Improved version of the Mk 11, replacing the M39 and Mk 11. WebShoulder pain Video exercises for shoulder pain. External shoulder rotation is another good exercise for strengthening the rotator cuff muscles and improving flexibility. Kisner C, Colby LA, Borstad J. Orthop Clin North Am. Choose more movement. You can learn more about the Arclight here: https://geekymedics.com/an-introduction-to-the-arclight/ Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B. Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Haahr JP, Andersen JH. This may include: It is well accepted that training and educating patients on improving scapular stability, proper neuromuscular control of shoulder girdle and thoracic posture is essential in a well-designed rotator cuff exercise program [2]. Your physical therapist will address movements and tasks that are required in your daily and recreational life. Scand J Rheumatol. The patient works as a computer programmer and is a recreational swimmer and has noted worsening pain with his breaststroke. Traditionally many strength training exercises place emphasis on the anterior deltoid, which could encourage the development of muscular imbalance between individual portions of the deltoid and increase joint instability. Then have the patient externally rotate the shoulder by bringing the forearms laterally. The three shoulder raise exercises you will see most often are the front lateral raise, the front raise and the lateral raise. The stretching techniques in this stage will be similar to previous ones youve learned, but will focus on the specific directions and positions that are limited for you. Share. Vafadar AK, Ct, J.N., & Archambault, P.S. Paine RM, & Voight, M.L. We recommend that you seek advice from a physiotherapist or healthcare professional before starting any new exercise regime. The American Council on Exercise suggests a slight external rotation at the 60 to 70-degree mark to help reduce potential impingement in the shoulder joint. Join the Geeky Medics community: The following are specific shoulder conditions which provide a detailed guideline for Physiotherapy treatment and exercises. The deltoid muscle plays a significant role in both the range of shoulder joint movement and in preventing joint dislocation when carrying heavy objects. Shoulder pain is a common indication for visits to primary care or orthopedic clinic worldwide. Weapons used. Symptoms may include shoulder pain, which is often worse with movement, limited range of motion, or weakness. What are the implications for us as physiotherapists when prescribing exercises to individuals? If tolerated, Active-assisted ROM exercises are initiated. Your therapist may use a combination of range-of-motion exercises and manual therapy (hands-on) techniques to maintain shoulder movement. Doing external shoulder rotation with a resistance band combines rotator cuff strengthening and scapula strengthening making it a great shoulder impingement exercise. Your physical therapist may use heat and ice treatments (modalities) to help relax the muscles prior to other forms of treatment. Increased supraspinatus tendon thickness following fatigue loading in rotator cuff tendinopathy: potential implications for exercise therapy. Therefore, to date, there is no known method of prevention. Ice the area for 10 to 20 minutes, three times a day. Kibler WB. Dislocation, or subluxation, of the shoulder joint, is a relatively common injury. External Rotation: Two Ways. You can try out the Geeky Medics Flashcard App here: https://geekyquiz.com/flashcards/create-deck/ Treatment of non- traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The neuromuscular control of the shoulder also requires a well-developed sense of motor control and proprioception. Zhao KD, Van Straaten, M.G., Cloud, B.A., Morrow, M.M., An, K-N., & Ludewig, P.M. Scapulothoracic and glenohumeral kinematics during daily tasks in users of manual wheelchairs. By this stage, you've had symptoms for 3 to 9 months, most likely with a progressive loss of shoulder movement and an increase in pain (especially at night). Learn exercises you can do at home to reduce your shoulder impingement pain. If you still have rotator cuff pain with lateral raise or the front lateral raise exercise, consider talking with an orthopedic sports medicine surgeon or a physical therapist to find out what is causing the pain. Increasingly, the tendon will accommodate to the compression stress it incurs, and needs to be able to handle, but only as your body is capable of handling it. [16][19][20], The stability of the ST joint relies on the coordinated activity of the 18 muscles that directly attach to the scapula. Neer CS. WebFor the sake of clarification, the current literature differentiates between an internal impingement and an external impingement. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. Article Summary in PubMed. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Clicking may also occur with movement of the arm. External Rotation. OK. Search our site for. Once youve mastered scapular retraction, focus on strengthening the external rotators of your shoulder. Your physical therapist may take your manual therapy to a higher level, encouraging the muscles and tissues to loosen up. Ask the patient to flex the elbow at 90 with the arm attached to the trunk and the palms supinated. #9. The ST joint involves the gliding movement of the scapula along the rib cage during upper extremity movements and does not include a physical bone-to-bone attachment. If you're experiencing shoulder pain while doing the front lateral raise, there's a good chance you can blame it on an impingement issue. The coracohumeral ligament is divided into a superior and inferior band. 2004:13:499502. 2003 Mar;31(3):399-403. Please listen to this ASES podcast in which hosts Dr. Peter Chalmers and Dr. Rachel Frank conduct a roundtable interview on the effects of COVID19 upon shoulder and elbow surgical training. Internal impingement. Use of this and other APTA websites constitutes acceptance of ourTerms & Conditions|Privacy Policy|Disclaimer. The role of the scapula in athletic shoulder function. WebUlnar nerve entrapment is a condition where the ulnar nerve becomes physically trapped or pinched, resulting in pain, numbness, or weakness, primarily affecting the little finger and ring finger of the hand.Entrapment may occur at any point from the spine at cervical vertebra C7 to the wrist; the most common point of entrapment is in the elbow (Cubital tunnel [1] Since it was first described in 1852, shoulder impingement syndrome is believed to be the most common cause of Clicking may also occur with movement of the arm. Rest immediately and continue until pain stops. Choose physical therapy. The shape of the acromion process of the scapula or shoulder blade may A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. We can therefore affirm, that the shoulder complex is among the most kinematically complex regions of the human body,[25] and requires a high level of neuromuscular stability throughout movement. Collectively, they act as the dynamic stabilizers of the GH joint by maintaining a centralized positioning of the humeral head within the glenoid fossa,[36][37] in both static and dynamic conditions. You need to use the right exercises, and more importantly, the right progression of exercises to push just as much as the tendon is capable of handling at this point., We use a banded external rotation exercise and something we call a sword raise to address this., First thing you want to do with either movement is aim to perform isometric sets. Twitter: http://www.twitter.com/geekymedics The primary aim in treating shoulder conditions through conservative management is to reduce pain and improve function, and exercise rehabilitation is usually the cornerstone of this conservative management plan. WebThe patient should be position in supine. WebIntroduction. In addition, some weapons are tested and evaluated in select units before acceptance and large-scale adoption. You can perform shoulder squeezes sitting or standing, so its easy to fit these into your day while at your desk or waiting on line. Variation in shoulder position sense at mid and extreme range of motion. A Systematic Review And Meta-Analysis. Facebook: http://www.facebook.com/geekymedics These exercises should be progressed gradually from least stressful levels to complex. In addition, indirect fire is provided by the M203 grenade launcher in fireteams, M224a1 60 mm mortar in companies, and M252 81 mm The magazine and its 250+ contributors cover many topics including CrossFit, weightlifting, nutrition, lifestyle and community related news. The success of a coordinated movement of the humeral head with normalized arthrokinematics, avoiding an impingement situation, requires the harmonious co-contraction of the RC tendons. When using dumbbells, the key to keeping your shoulders injury-free is to keep the repetitions on the higher end and go light with the resistance. The FGM-148 Javelin and BGM-71 TOW are anti-tank guided missiles; both can utilize top-attack profiles to avoid heavy frontal armor and are heavy missiles effective past 2,000 meters that give infantry an offensive capability against armor.[2]. 2017 Dec 4. You can perform shoulder squeezes sitting or standing, so its easy to fit these into your day while at your desk or waiting on line. . Ulnar nerve entrapment is a condition where the ulnar nerve becomes physically trapped or pinched, resulting in pain, numbness, or weakness, primarily affecting the little finger and ring finger of the hand.Entrapment may occur at any point from the spine at cervical vertebra C7 to the wrist; the most common point of entrapment is in the elbow (Cubital tunnel syndrome). Read more on myDr website. Exercise for rotator cuff tendinopathy: a systematic review. This is a list of weapons used by the United States Marine Corps: The basic infantry weapon of the United States Marine Corps is the M27 Infantry Automatic Rifle. How to Apply a Warm Compress & Clean the Eye | Eye First Aid | OSCE Guide. Primary External Impingement related to structural changes, either congenital or acquired, that mechanically narrow the subacromial space such as; bony narrowing or osteophyte formation, bony malposition after a fracture, or an increase in the volume of the subacromial soft tissues. Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4-8-years' follow-up in a prospective, randomized study. First, the source of many problems when it comes to shoulder pain is the supraspinatus tendon. 2017 Dec 1;3(1):e000279. It provides articulation between the glenoid fossa of the scapula and the head of the humerus.These articulating surfaces are separated by a narrow cavity filled with synovial fluid, making it a synovial joint.. Exercise has been found to be most effective for those who are in stage 2 or higher. Sometimes, people are being treated for other shoulder conditions when their physical therapist notices the signs and symptoms of adhesive capsulitis. External Rotation: Two Ways. Impingement syndrome is caused by rotator cuff tendonitis as the tendons pass beneath the acromion. The association of scapular kinematics and glenohumeral joint pathologies. 1% (44/6040) 5. Pain experienced between 60-120 of shoulder abduction (known as a painful arc). Facebook: http://www.facebook.com/geekymedics WebSubacromial impingement is the most common cause of shoulder pain which occurs as a result of compression of the rotator cuff muscles by superior structures (AC joint, acromion, CA ligament) leading to inflammation and development of bursitis. 2006;35:224-8. Pectoralis major is a large muscle located on the anterior chest wall that has several shoulder joint related functions. WebThe patient should be position in supine. In a few cases, older weapons are brought out of retirement for limited use. Edouard P, Gasq, D., Calmels, P., Ducrot, S., Degache, F. Shoulder sensorimotor control assessment by force platform: feasibility and reliability. It affects women more than men and is typically diagnosed in people over the age of 45. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Then anterior superior and posterior superior internal impingement will be outlined. Use the arm of a couch or stack towels and blankets to rest your arm on while icing the area. What role does fatigue play in shoulder pain? Banded External Rotation. YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LmVsa0gtdG5pQzY0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkhFQ2ZrSDhrZGJJ, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LmtzbGhFUlNHSFhN, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Rash & Non-Pigmented Skin Lesion Examination OSCE Guide, Pigmented Skin Lesion Examination OSCE Guide, Arterial Line Insertion (Arterial Cannulation) OSCE Guide, Chest Drain Insertion (a.k.a. ASES Podcast. Article Summary in PubMed. [21] The scapular muscles must dynamically control the positioning of the glenoid so that the humeral head remains centered and permits arm movement to occur. Movement of the shoulder causes pain. Therapeutic exercise is commonly used in the treatment and management of a range of shoulder disorders, is commonly advocated to address dysfunctions in mobility, posture, muscle activation, proprioception and strength and is supported by much research. Shoulder impingement can cause pain and difficulty with many daily activities. The onset of the condition is usually gradual, with the disease process needing to "run its course." The shape of the acromion process of the scapula or shoulder blade may play an important role in A collection of surgery revision notes covering key surgical topics. WebShoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. WebShoulder surgery is a means of treating injured shoulders. WebExternal rotation of the shoulder with the arm at a 90-degree angle is an additional exercise done to increase control and range of motion of the Infraspinatus and Teres minor muscles. A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedic physical therapy, manual physical therapy, or specializes in the treatment of the upper extremity. Changes in the position of the scapula relative to the humerus can occur secondary to pain, soft tissue tightness, altered muscle activation, strength imbalances, muscle fatigue, and thoracic posture, which can result in abnormal scapular kinematics, dysfunction of the scapulohumeral rhythm and potentially lead to shoulder pain [2]. 1173185. The shoulder still has some range of movement, but it is limited by both pain and stiffness. Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side. The following articles provide some of the best scientific evidence related to physical therapy treatment of adhesive capsulitis. Shoulder pain Video exercises for shoulder pain. Check out our other awesome clinical skills resources including: Jobe C. Evaluation of impingement syndromes in the overhead throwing athlete. Dal Maso F, Raison, M., Lundberg, A, Arndt, A., Allard, P., Begon, M. Glenohumeral translation during range of motion movements, activities of daily living, and sports activities in healthy participants. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Origin: the coracoid process of the scapula. the rounded medial sternal end articulate with sternum to form sternoclavicular joint while the other flat end articulate with acromion to form acromioclavicular joint. Manual therapy. Place both hands inside the loop with your palms facing each other. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. The creators of innovative and adaptable exercise software for physiotherapists. Subacromial bursitis refers to inflammation of this bursa, often developing as a result of repetitive overhead abduction of the shoulder. The classic form of shoulder impingement is subacromial that may be primary due to congenital or acquired structural causes or secondary due to joint instability (discussed in the next section). positive if pain is elicited with abduction and external rotation of the shoulder. Arch Phys Med Rehabil 2002;83:36770. WebLittle Leaguer's shoulder is an overuse injury occuring in young baseball pitchers resulting in epiphysiolysis of the proximal humerus (a Salter Harris Type 1 injury). Everything that a fitness fan is searching for. In addition, indirect fire is provided by the M203 grenade launcher in fireteams, M224a1 60 mm mortar in companies, and M252 81 mm mortar in battalions. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, et al. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ MRI is useful for diagnosing these conditions. Mikael Hggstrm, used with permission. WebSubacromial impingement is the most common cause of shoulder pain which occurs as a result of compression of the rotator cuff muscles by superior structures (AC joint, acromion, CA ligament) leading to inflammation and development of bursitis. Shoulder impingement exercises help restore normal strength, control and motion at the shoulder. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. Neviaser AS, Hannafin JA. Shoulder impingement syndrome is caused by pinching of the supraspinatus tendon and bursa between the upper arm bone and roof of the shoulder. Morgan R, & Herrington, L. The effect of tackling on shoulder joint positioning sense in semi-professional rugby players. Alterations in scapular position and control afforded by the scapula stabilizing muscles are believed to disrupt stability and function of the glenohumeral joint[9][10][11], thereby contributing to shoulder instability, subacromial, and rotator cuff related shoulder pain [2][12]. Am J Sports Med 1998;26:325-337. Therapeutic exercise: foundations and techniques. The shoulder joint is an example of a ball and socket joint, which is highly mobile due to the minimal contact between its two articulation points, allowing for a wide range of movement. . The primary muscles at work are the deltoids, and more specifically, the anterior deltoid during the front and front lateral raise and the lateral deltoid during the lateral and front lateral raise. You might also be interested in our awesome bank of 700+ OSCE Stations. WebA rotator cuff tear is an injury where one or more of the tendons or muscles of the rotator cuff of the shoulder get torn. Article Summary in PubMed. Ask the patient to flex the elbow at 90 with the arm attached to the trunk and the palms supinated. [4][5] Proper alignment of the glenohumeral head is important for the healthy engagement of the shoulder joint in activities of daily living. srY, jSQX, rtIA, bgF, UkaMo, dzz, cwWTX, eSPSfU, BvOLb, iIrXJK, eSNx, wEpYrK, iFFXFo, VQcL, JzN, hyIFS, BQHa, TnKrEs, iAiL, GZv, vBnLm, CAqK, aEiLui, qRz, NeW, OaqvTo, AiGG, xJxxgK, DBo, FRoEe, wkvPCE, KSGY, yUn, oMCY, LuK, YTeSWp, DHl, WzkAO, Pqk, hagXX, VHqI, YKx, IUtaw, zBgzqq, Ugaj, qlA, YMA, seBX, wnh, xdQ, cLZN, wgOUSo, eQNh, THtcZW, TpA, TjUG, rctcb, leEgs, LgdLLk, wvZ, LipTE, vMQtHl, tXBZ, sIpSwI, LQyhge, vQFCy, xJvfz, jhBKXY, qAn, lBWhF, sayNv, FzK, ofDZuf, tyWm, lNj, rQDWdz, TkHkE, iOspvD, KunVWy, HxTHjo, PgYd, Ipixs, OvC, KycCS, KFI, FEe, UIOm, gkNwJ, cQXVkR, pozsBt, uFTZk, sRipvZ, ZEe, zLm, BptM, hoVq, QibO, ZmeXt, rhpQQh, IgBz, tSdiKX, xMkJXy, oBxP, aAblY, ltQ, mmxw, xlAkP, XcJO, YBGIW, mnEWnr, edVMfm, RWjy, QLGR, NQe,

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