Traditionally it was thought that supraspinatus was important for movement initiation and early abduction, while the deltoid muscle engaged from approximately 20 of abduction and carried the arm through to the full 180 of abduction. How many tendons and ligaments are in the shoulder? The demographic and morphological features of rotator cuff disease A comparison of asymptomatic and symptomatic shoulders. Did you find hard to remember anatomicalstructures? Imaging studies are indispensable for differential diagnosis. government site. The Treatment of Illnesses Arising in Pregnancy (issue 39/2017) until 10 December 2017. Normal appearance of the coracoacromial ligament. That is usually the journal article where the information was first stated. The glenohumeral, or shoulder, joint is a synovial joint that attaches the upper limb to the axial skeleton. Misdiagnoses, wrong indications (40%), and technical errors (40%) lead to persistent symptoms after subacromial decompression (38). Acting in conjunction with the pectoral girdle, the shoulder joint allows for a wide range of motion at the upper limb; flexion, extension, abduction, adduction, external/lateralrotation, internal/medialrotation and circumduction. With these mechanisms, wherein all the muscles about the joint are. To rehabilitate the patient with glenohumeral joint impingement requires a careful, systematic evaluation to identify the type of impingement and, more importantly, to determine the underlying cause of the impingement to ensure that an evidence-based nonoperative rehabilitation program can be developed. Glenohumeral and transverse humeral are capsular ligaments while coracohumeral is an accessory ligament. This joint is considered to be the most mobile and least stable joint in the body, and is the most commonly dislocated diarthrodial joint [1]. In a meta-analysis, Dong et al. The extrinsic compression theory postulates pressure damage due to pathological contact of the shoulder roof with the supraspinatus (SSP) tendon in subacromial impingement syndrome (5, e5). After thorough physical examination and ultrasonography, you order plain x-rays of the affected side and possibly local-anesthetic infiltration to clarify the diagnosis, followed by magnetic resonance imaging (MRI). internal rotators to cause posterior dislocations. It extends from the scapula to the humerus, enclosing the joint on all sides. The middle glenohumeral ligament (MGHL) attaches to the anterior aspect of the anatomic neck of the humerus, just medial to the lesser tuberosity. Secondary impingement results from a functional disturbance of centering of the humeral head, such as muscular imbalance, leading to an abnormal displacement of the center of rotation in elevation and thereby to soft tissue entrapment (1). Patients with shoulder impingement syndrome suffer from painful entrapment of soft tissue whenever they elevate the arm. Once the acute pain has been treated, emphasis is placed on physiotherapeutic measures for mobilization. One hand fixes the scapula while the other elevates and internally rotates the arm. The rotator cuff muscles are four muscles that form a musculotendinous unit around the shoulder joint. The acromiohumeral distance (AHD) is the distance, measured on the AP view, from the lower edge of the acromion to the humeral head; it is typically approximately 10 mm (714 mm) in men and 9.5 mm (712 mm) in women (1). On the pathophysiological level, it can have various functional, degenerative, and mechanical causes. c) The spur (red line) can also be seen on an anteroposterior (AP) shoulder x-ray. Limits external rotation and anterior translation of the humeral head. Palastanga, N., & Soames, R. (2012). All rights reserved. However more recent evidence has suggested that both muscles are activated through all parts of the abduction movement. Moor BK, Wieser K, Slankamenac K, Gerber C, Bouaicha S. Relationship of individual scapular anatomy and degenerative rotator cuff tears. There are four muscle groups in the shoulder: A bursa is a pillow-like sac filled with a small amount of fluid. Please select the answer that is most appropriate. According to some sources, the the overall strength of the capsule bears an inverse relationship to the patient's age; the older the patient, the weaker the Joint Capsule. Progressive resistance training in patients with shoulder impingement syndrome: A randomized controlled trial. von Eisenhart-Rothe R, Greiner S, Irlenbusch U, et al. A long acting local anesthetic infused around the nerves of the joint is often used with general anesthesia during surgery. The middle glenohumeral ligament attaches along the anterior glenoid margin of the scapula, just inferior to the superior GH ligament. The main exercises in this category are centered exercises to strengthen the rotator cuff and posture training to keep the spine erect and stabilize the scapula (29). As the shoulder impingement syndrome is a self-limiting illness, you examine the patient and then initiate conservative treatment with analgesics, physiotherapy, and physical treatment measures. The https:// ensures that you are connecting to the Joint Structure and Function: A Comprehensive Analysis. The aims of this study were to assess glenohumeral joint contact pressure, the impinged rotator cuff tendon area, and humeral head shift by inducing shoulder internal impingement in a cadaveric model of throwing in which The regular administration of anti-inflammatory drugs for 12 weeks to reduce pain is also important (23, e14), although the available evidence for this is currently on a low level (level III). Lessened peritendinous fat, indentation of a tendon by the coraco-acromial arch, and hyperintense signal are all indications of an impingement syndrome. The axillary capsule is formed by the inferior glenohumeral ligament and is best visualized on coronal images at the mid-glenoid level. The affected patients are generally over age 40 and suffer from persistent pain without any known preceding trauma. What test is useful in the diagnostic assessment of shoulder impingement syndrome? Each year, over 10,000 shoulder replacement surgeries are performed in the United States to relieve pain and improve function for shoulders that are severely damaged by glenohumeral arthritis. Hedtmann A. Weichteilerkrankungen der Schulter - Subakromialsyndrome. This provides for a greater range of motion available within the greater shoulder complex; The close-packed position of the glenohumeral joint is abduction and externalrotation, while open packed (resting) position is abduction (40-50) with horizontal adduction (30). The formal evidence level for the effectiveness of individual conservative treatment approaches is only moderate overall. Journal of Shoulder and Elbow Surgery. Magnetic resonance imaging reveals a type III acromion and a complete rupture of the supraspinatus tendon. Accessibility Learn more Severe muscle atrophy and fatty degeneration, Preoperative acromiohumeral distance (AHD) less than 7 mm, at 3 months, regardless of the size of the defect, in an elderly patient with a partial lesion, if there is a longstanding, severe tendon defect, in a young patient with a defect of traumatic origin, if the symptoms have been present for several months, if there is a documented lesion of the supraspinatus tendon, if there is marked restriction of glenohumeral movement, if the patient is young and has high functional requirements. Take the following custom quiz for a rotator cuff workout! Generally, complete recovery takes 4-6 months. Excessive stress on the shoulder must be avoided at every stage. Primary impingement. Primary impingement is the classic version and occurs without any other contributing pathology. 1. proximal clavivle articulates with sternum and cartilage of 1st rib. Steuri R, Sattelmayer M, Elsig S, et al. Even with the closest attention to detail, surgical complications may occur. Internal rotation is primarily performed by the subscapularis and teres major muscles. A multiplicity of potential etiologies makes the diagnosis more difficult; it is established by the history and physical examination and can be confirmed with x-ray, ultrasonography, and magnetic resonance imaging. . It becomes stretched, and least supported, when the arm is abducted. Extending only at its medial margin, where the fibers protrude by around 1 cm. Before Another study has shown that 16% of the population has shoulder pain in one month (e1). Arises from the glenoid and inserts on the humerus just beyond the lesser tuberosity. Patients treated with cortisone injections, compared to untreated controls, have significantly better pain relief (SMD: -0.65 [-1.04; -0,26]) and joint mobility (SMD: -0,56 [-1,06; -0,05]) (e15). All four muscles are firmly attached around the joint in such a way that they form a sleeve (rotator capsule). An SMD of +/-0.2, +/-0.5, or +/-0.8 is conventionally said to correspond to a weak, intermediate, or strong effect, respectively. FOIA The impingement hypothesis assumes a pathophysiological mechanism in which different structures of the shoulder joint come into mechanical conflict (1). 23, 5, 26 With . Possible causes of motion loss include: The doctor will first obtain a history of the patient's symptoms and health over the past several years. Impingement-associated entities such as bursitis and tendon changes or ruptures are visualized in standard tomographic planes with a 512 MHz linear transducer. 3 In medical texts we usually begin with a description of the pathogenesis of diseases and proceed to their clinical picture. The pain is commonly present at night, and interferes with sleep. Instead the surrounding shoulder muscles and ligamentous structures offer the joint security; the capsule, ligaments and tendons of the rotator cuff muscles. The glenohumeral joint is the most commonly dislocated joint, attributed to the much larger articular surface area of the humeral head and the smaller, shallow glenoid fossa. Patients report pain on elevating the arm between 70 and 120 (the painful arc), on forced movement above the head, and when lying on the affected side (1). Last reviewed: September 26, 2022 Shoulder pain is the third most common musculoskeletal complaint in orthopedic practice (e1), and impingement syndrome is one of the more common underlying diagnoses (e2). Tashjian RZ. The concavity of the fossa is less acute than the convexity of the humeral head, meaning that the articular surfaces are not fully congruent. Neurologic complications after total shoulder arthroplasty. Ligaments. Edinburgh: Churchill Livingstone. Surgical complications are rare. The transverse humeral ligament extends horizontally between the tubercles of the humerus. Exercises for this purpose can be carried out with an elastic latex band or a pulley. Humeral Avulsion of the Glenohumeral Ligament (HAGL) is an injury to the inferior glenohumeral ligament causing instability and/or pain and a missed cause of recurrent shoulder instability. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Dimitrios Mytilinaios MD, PhD Donigan JA, Wolf BR. These three views enable the display of the bony structures so that the physician can assess the state of the coraco-acromial arch, the acromioclavicular joint, the centering of the head of the humerus, the greater tubercle, arthritic changes, and normal anatomic variants. A. coracoacromial ligament B. coracohumeral ligament C. superior glenohumeral ligament D. trapezoid ligament. Recurrent traumatic instability typically produces symptoms when the arm is placed in positions . Read more. The correct etiologic diagnosis and choice of treatment are essential for a good outcome. The site is secure. Full recovery usually takes 4-6 months. . More than 4.1 million of these visits were for rotator cuff problems. The subacromial bursa and the subdeltoid bursa (under the deltoid muscle) are often considered as one structure. In fact, it is the most mobile joint of the human body. 2002 Dec;32(12):605-12. The loose inferior capsule forms a fold when the arm is in the anatomical position. Soft-tissue debridement and tenotomy of the long tendon of the biceps is an option for elderly patients and for those who have irreparable defects with a high-lying humeral head, but without glenohumeral arthritis and with intact function of the joint (36). Forward and upward movement of the humerus on the glenoid in the sagittal plane. Distalization and medialization of the center of rotation of the shoulder puts the deltoid muscle under tension and thereby restores shoulder function. Nyffeler RW, Werner CM, Sukthankar A, Schmid MR, Gerber C. Association of a large lateral extension of the acromion with rotator cuff tears. It stabilizes the anterior capsule, limiting externalrotation, particularly when the arm is in an abducted position (45o 60o abduction). Dehlinger F, Ambacher T. Die Kalkschulter. Corticosteroid injections (cortisone shots) may be recommended for more severe cases that do not respond to NSAIDS. Glucosamine and chondroitin are non-prescription supplements that may help neutralize the destructive enzymes associated with osteoarthritis. Neer CS. Muscles and tendons work together in the shoulder to provide the "dynamic" stability of the shoulder. Jump straight into the anatomy of the glenohumeral joint with this integrated quiz: Explore our video tutorials, quizzes, articles and atlas images of glenohumeral joint for a full understanding of its anatomy. The relation between these two entities is a controversial matter (4). Gray's Anatomy (41tst ed.). The closed packed position of the GH Joint is Abduction and External Rotation. You can even add and remove individual muscles if you like. know what forms of treatment are suitable. Helps to support the weight of the resting arm against gravity. Amsterdam, The Netherlands: Elsevier. Atlas of Human Anatomy (7th ed.). There are many treatment options for shoulder arthritis, ranging from pain medications and exercises for mild cases, to surgical procedures for severe cases. Pain and tenderness in the front of your shoulder. The diagnostic sensitivity of physical examination is 90%. In a very limited number of cases, the MGHL can cause abrasion on the upper edge of the subscapularis causing persistent pain symptoms for patients. Introduction to the musculoskeletal system, Nerves, vessels and lymphatics of the abdomen, Nerves, vessels and lymphatics of the pelvis, Infratemporal region and pterygopalatine fossa, Meninges, ventricular system and subarachnoid space, Synovial ball and socket joint; multiaxial, Glenoid fossa of scapula, head of humerus; glenoid labrum, Superior glenohumeral, middle glenohumeral, inferior glenohumeral, coracohumeral, transverse humeral, Subscapular nerve (joint); suprascapular nerve, axillary nerve, lateral pectoral nerve (joint capsule), Anterior and posterior circumflex humeral, circumflex scapular and suprascapular arteries, Flexion, extension, abduction, adduction, external/lateral rotation, internal/medial rotation and circumduction, Pectoralis major, deltoid, coracobrachialis, long head of biceps brachii, Latissimus dorsi, teres major, pectoralis major, deltoid, long head of triceps brachii, Coracobrachialis, pectoralis major, latissimus dorsi, teres major, Subscapularis, teres major, latissimus dorsi, pectoralis major, deltoid. Clinically Oriented Anatomy (7th ed.). Humeral Avulsion of the Glenohumeral Ligament (HAGL) is an injury to the inferior glenohumeral ligament causing instability and/or pain and a missed cause of recurrent shoulder instability. It is advisable to favor the affected arm in the acute phase, avoiding overhead movement, rapid movement, and heavy mechanical loading of the joint. the labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament is the most common "normal" variation. These regional blocks will provide several hours of pain relief even after a patient has emerged from general anesthesia. Schulte-Altedorneburg G, Gebhard M, Wohlgemuth WA, et al. tightness leads to internal impingement and increased shear forces on superior labrum (linked to SLAP lesions) anterior band IGHL. Limits external rotation and inferior translation of the humeral head. Is there evidence in favor of surgical interventions for the subacromial impingement syndrome? In what circumstances is surgery for impingement syndrome not indicated? Impingement may occur as a result of loss of competency of the rotator cuff. Adduction is produced by the pectoralis major, latissimus dorsi and teres major muscles. Yang JL, Chen SY, Hsieh CL, Lin JJ. The main lateral rotators are the infraspinatus and teres minor muscles, with help from the posterior fibers of the deltoid muscle. Glenoid bone loss is often visible on the backside of the joint. Der Unfallchirurg. It also transmits loads across the scapula. inferior direction, even though the coracohumeral ligament is much more robust than the superior glenohumeral ligament. The Noted Anatomist. Most individuals have less pain at night or at rest in the first 2-4 weeks after surgery. Alteration of this regular scapulohumeral movement pattern results in shoulder injuries, pain and impingement. Another series of intra-articular injections should be performed. For unreconstructable superior defects of the rotator cuff, centering can be improved by a superior capsular reconstruction with auto- or allografting. Register now Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. Finally, the mechanical stresses of everyday life are carefully analyzed: individual movements carried out at work and in sporting activities are examined and improved. especially in the early stages or with concomitant shoulder pathologies such as rotator cuff impingement, bursitis, and labral pathology which may present with overlapping clinical features. Loss of motion is another common symptom. An all-or-nothing rule has been proposed: in patients with painful AC joint arthritis documented by clinical testing and radiological confirmation of active inflammation, the joint should be resected in an open or arthroscopic procedure, along with 34 mm of the acromion and of the clavicle. Runs laterally from the coracoid process to the humerus, covering the superior Glenohumeral Ligament and blending with the Superior Joint Capsule and Supraspinatus Tendon superiorly. Vol 5: pp53-61, 1996. Cortisone can be injected in targeted fashion, together with a local anesthetic, in the subacromial space or the glenohumeral joint. and transmitted securely. Subacromial impingement syndrome is often associated with rotator cuff ruptures. Decellularized subcutis or skin (of animal or human origin) can now be used for tendon augmentation. 82-A: pp 26-34, 2000. The condition should ideally be diagnosed as early as possible, and intensive functional rehabilitation of the shoulder girdle including the scapular muscles should be started in order to restore muscle balance. Holschen M, Agneskirchner JD. What does the inside of the shoulder look like? (Watch, 1992). In like fashion, internal impingement of the glenohumeral joint is an exaggeration of a normally occurring event that becomes abnormal or symptomatic when it is performed with increased force or increased frequency. Determining the Resting Position of the Glenohumeral Joint: A Cadaver Study. Inferior Glenohumeral Ligament: limits external rotation and superior and anterior translation of the humeral head (anterior portion); limits internal rotation and anterior translation. From: Habermeyer P: Schulterchirurgie, 4th ed., 2010 (1). Damage to the cartilage surfaces of the glenohumeral joint (the shoulder's "ball-and-socket" structure) is the primary cause of shoulder arthritis. In the previous studies, there have been noted abnormalities after the total hip arthroplasty, proximal femoral osteotomy . Levangie PK, Norkin CC. Impingement or pinching is the primary cause of pain. Over time, current advances in materials and techniques should improve these percentages even more. Stretch your arm . The glenohumeral (GH) joint is a true synovial ball-and-socket style diarthrodial joint that is responsible for connecting the upper extremity to the trunk. will also be available for a limited time. The glenohumeral joint is a load-bearing joint. Surgery is indicated if the patient is suffering from pain and a disturbing loss of function; age plays a steadily less important role. Instead, joint security is provided entirely by the soft tissue structures; the fibrous capsule, ligaments, shoulder muscles and their tendons. These compounds, which are available separately or in combination, have been shown to decrease arthritis pain in some clinical trials; however, more research is needed to evaluate the full extent of their effectiveness. The risk that the patient will develop a rotator cuff lesion is higher if the CSA exceeds 35, while the risk of shoulder arthritis is higher if the CSA is less than or equal to 35 (9). Gartsmann GM, Roddey TS, Hammerman SM. Nagerl H, Kubein-Meesenburg D, Cotta H, Fanghanel J, Kirsch S. Biomechanical principles in diarthroses and synarthroses II: The humerus articulation as a ball-and-socket joint. With x-ray, the doctor can see structural changes that indicate arthritis, such as: Other imaging techniques used to make the diagnosis include: Mild glenohumeral arthritis is often manageable with a regimen of: Mild to moderate glenohumeral arthritis pain is often effectively controlled by using any one or a combination of the following treatments: When severe shoulder arthritis pain is unmanageable with non-operative measures, surgical treatment may be recommended. Several bones and a network of soft tissue (ligaments, tendons, and muscles), work together to produce shoulder movement. This review is based on pertinent literature retrieved by a selective search of the Medline database. [ 1] Neer describes the following 3 stages in the spectrum of rotator cuff impingement: Stage 1, commonly affecting patients younger than 25 years, is depicted by acute inflammation, edema, and. Saltychev M, Aarimaa V, Virolainen P, Laimi K. Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Humeral Avulsion Glenohumeral Ligament (HAGL). The labrum acts to deepen the glenoid fossa slightly, it is triangular in shape and thicker anteriorly than inferiorly. Because of this mobility-stability compromise, the shoulder joint is one of the most frequently injured joints of the body. The most common clinical diagnoses are rotator cuff defects (85%) and/or impingement syndromes (74%) (e2). The initial treatment is conservative, e.g., with nonsteroidal anti-inflammatory drugs, infiltrations, and patient exercises. Thomazeau H, Rolland Y, Lucas C, Duval JM, Langlais F. Atrophy of the supraspinatus belly Assessment by MRI in 55 patients with rotator cuff pathology. Clavicular stability is preserved by the coracoclavicular ligaments and also, if the arthroscopic technique is used, by the cranial and posterior ligaments of the AC joint. When is rotator cuff reconstruction absolutely indicated? Up to 30% of persons over age 70 have a total defect, but 75% of such cases are asymptomatic (e3). More importantly, it holds the humerus securely to the glenoid, almost as if suction were involved. Reading time: 15 minutes. Treatment of acute shoulder syndrome with flurbiprofen. 2022 The glenohumeral (GH) joint is a true . The tendon is well preserved, without retraction or fatty degeneration. The reported sensitivity and specificity of noncontrast MRI are 92% and 93%, respectively (17). It is usually due to a defect of the rotator cuff and/or an impingement syndrome. A randomized trial showed no difference in the functional outcome of bursectomy with and without additional acromioplasty, but the acromion type and the nature of symptoms did have an effect on the outcome (32 34). Positive when pain arises on maximal internal rotation of the arm in 90 of anteversion with the elbow flexed. This creates a bone-on-bone environment, which encourages the body to produce osteophytes (bone spurs). Origin: lateral border of the coracoid process. Translated from the original German by Ethan Taub, M.D. Matsen (28) has pointed out the value of the exercise program devised by the physiotherapist Sarah Jacksin (box 3). Pain from bone-on-bone rubbing within the joint is the most common symptom of glenohumeral arthritis. Limiting factors for reconstruction include tissue quality, defect size, and fatty degeneration of the musculature. This enables better detection of additional damage within the joint cavity, e.g., partial supraspinatus lesions or biceps tendon abnormalities (15). https://www.sciencedirect.com/science/article/abs/pii/S0030589808000461?via%3Dihub, https://www.physio-pedia.com/index.php?title=Glenohumeral_Joint&oldid=278612. Persons who are out of condition should improve their overall fitness by training in endurance sports. For posterosuperior defects, the tendons of the latissimus dorsi and teres major muscles are used; for anterior/anterosuperior defects, the pectoralis major tendon is used. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. fracture or dislocation of GH Joint. Elevation of the humerus on the glenoid in the scapular plane, which is midway between the coronal and sagittal planes. They report pain on elevating the arm, on forced movement above the head, and when lying on the affected side. This is a synovial fold of the bursa that may cause clicking and subacromial impingement pain with bursitis. Correspondence (letter to the editor): Motion Sequence Disrupted, Correspondence (letter to the editor): If Possible Treat Without Surgery, Correspondence (letter to the editor): Dont Forget Radiotherapy. The glenohumeral joint is a load-bearing joint with a wide range of motion ( e4 ). What finding is not typical of impingement syndrome? This CME unit can be accessed until 4 February 2018, and earlier CME units until the dates indicated: Fitness to Drive in Cardiovascular Disease (Issue 41/2017) until 7 January 2018. A high AI is also a risk factor for rotator cuff lesions. 33, 248. Daghir AA, Sookur PA, Shah S, Watson M. Dynamic ultrasound of the subacromial-subdeltoid bursa in patients with shoulder impingement: a comparison with normal volunteers. This article will discuss the anatomy and function of the glenohumeral joint. Which ligament, immediately superior to the glenohumeral joint, can be an area of impingement? They may also serve as building blocks for new cartilage formation. Richards, J. Anastasopoulos PP, Alexiadis G, Spyridonos S, Fandridis E. Latissimus dorsi transfer in posterior irreparable rotator cuff tears. HHS Vulnerability Disclosure, Help Ogilvie-Harris DJ, Wiley AM, Sattarian J. Harrison AK, Flatow EL. The rotator cuff centers the head of the humerus in the glenoid cavity. The glenohumeral joint is innervated by the subscapular nerve (C5-C6), a branch of the posterior cord of brachial plexus. Subacromial impingement syndrome. After debridement of the bone adjacent to the tendon, the tendon is repositioned with a transosseous technique or with so-called suture anchor systems, with a closure that is as free of tension as possible. Together these joints can change the position of the glenoid fossa, relative to the chest wall. Grounded on academic literature and research, validated by experts, and trusted by more than 2 million users. In contrast, the intrinsic compression theory postulates degenerative processes in the SSP tendon itself, leading to defects. It covers the intertubercular sulcus and the long head tendon of the biceps brachii muscle, preventing displacement of the tendon from the sulcus. A radiological study of the critical shoulder angle. between the glenoid cavity of the scapula and the head of the humerus; colloquially called the shoulder joint). Specifically, it is the head of the humerus that contacts the glenoid cavity (or fossa) of the scapula. Participants in the CME program can manage their CME points with their 15-digit uniform CME number (einheitliche Fortbildungsnummer, EFN). The glenohumeral joint is a ball and socket joint that includes a complex, dynamic, articulation between the glenoid of the scapula and the proximal humerus. AC, acromioclavicular; CAL, coraco-acromial ligament. The subacromial impingement syndrome has both primary and secondary forms. They also resist anterior translation of the humeral head. In subacromial impingement syndrome, elevation of the arm leads to an abnormal contact between the rotator cuff and the roof of the shoulder (figure 2). An abnormally low AHD on the AP view indicates a defect of more than one rotator cuff tendon (16). A systematic review. Early superficial chondral wear of the inferior portions of the glenohumeral joint. Bursae (plural) reduce friction and allow smooth gliding between two firm structures, like bone and tendon or bone and muscle. There are still no valid measuring instruments or prospective studies showing which patients stand to benefit from conservative treatment or from surgery (19 21). Sterile precautions and informed consent, with special mention of the risk of infection and other side effects including diabetes mellitus, are very important. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. In the shoulder joint, the ligaments play a key role in stabilising the bony structures. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. This bursa serves to allow the rotator cuff to slide easily beneath the deltoid muscle. Those who suffer from shoulder arthritis typically report an increase in pain over several years. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Which of the following measures plays no role in the conservative treatment of impingement syndrome? These techniques are not supported by extensive evidence and are therefore only performed for special indications in shoulder centers. Introduction. The glenohumeral joint is the articulation between the spherical head of the humerus and the concave glenoid fossa of the scapula. All content published on Kenhub is reviewed by medical and anatomy experts. The other authors state that they have no conflict of interest. Anatomical overview of the shoulder (left, above), showing the mechanism of subacromial impingement with painful entrapment of soft tissues (arrows, right, above) on elevation of the arm, due to pathological contact of the humeral head with the roof of the shoulder joint, particularly the anterolateral portion of the acromion (below). An official website of the United States government. Pure Spin of the Humerus on Glenoid (Posterior Spin when following greater tuberosity), Pure Spin of the Humerus on Glenoid (Anterior Spin when following greater tuberosity). The medial attachment of the joint capsule is the glenoid and the labrum. Patient gymnastics are initially combined with stretching and swinging exercises and with passive movement. What are the chances I may require a second shoulder arthroplasty? Information about our response to the Coronavirus (COVID-19), Shoulder, Knee, Elbow Surgery & Sports Medicine, Complex Shoulder, Complex Knee & Sports Surgery, Complex Knee, Shoulder & Sports Medicine Specialist, Shoulder, Hip, Knee & Sports Medicine Specialist, Complex Knee, Complex Shoulder, Hip and Sports Medicine, Shoulder, Knee, Elbow & Hip Preservation Surgery, Trauma (such as a fracture or dislocation), Chronic rotator cuff tears in which the head of the, Post-surgical changes that can be a result of over-tightening during instability surgery, To provide a smooth, slick surface for easy movement, To be a shock absorber and protect the underlying bone, To help stabilize the joint by improving the fit of the bones, To act as a spacer and improve contact between the articular cartilage surfaces. These are the supraspinatus, infraspinatus, teres minor and subscapularis muscles. Urwin M, Symmons D, Allison T, et al. the glenohumeral joint contact pressure and the functional area of rotator cuff tendons through internal impingement. With the arm in a resting position the inferior and anterior portions of the capsule are lax, while the superior portion is taut. Systematic review: nonoperative and operative treatments for rotator cuff tears. Pain on abduction, with extended elbow, in the scapular plane between 60 and 120 indicates pathology in the subacromial space. Together these three are known as the climbing muscles, as they are powerful adductors, alternatively they can lift the trunk up towards a fixed arm. Ellman H. Arthroscopic subacromial decompression: analysis of one- to three-year results. Lynch NM, Cofield RH, Silbert PL, Hermann RC. Kloth JK, Zeifang F, Weber MA. It acts to limit inferior translation and excessive externalrotation of the humerus. Bursitis is characterized ultrasonographically by an anechoic effusion and a thickened bursa wall; initial tendon changes display high echogenicity and thickening, especially of the SSP tendon (13, 14). Limits external rotation and superior and anterior translation of the humeral head (anterior portion); Limits internal rotation and anterior translation (posterior portion). Journal of Bone and Joint Surgery. Trauma, repetitive motions or frequent dislocations of the shoulder joint as a child or as an adult can lead to this condition. Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2014). Shoulder arthroplasty is a complex procedure, which requires a great amount of cutting of deep tissues and bone. This article has been certified by the North Rhine Academy for Postgraduate and Continuing Medical Education. The middle glenohumeral ligament (MGHL) typically contributes partially to the anterior stability of the shoulder. Repeat a few times. Symptoms of shoulder impingement syndrome include: Pain when your arms are extended above your head. de Jesus JO, Parker L, Frangos AJ, Nazarian LN. CME points of the Medical Associations can be acquired only through the Internet, not by mail or fax, by the use of the German version of the CME questionnaire. 3. the only bony connection between the humerus and axial skeleton. Although impingement signs are present, they result from a primary problem somewhere else, commonly in the scapular or humeral control or stabilizer muscles. The subdeltoid-subacromial (SASD) bursa is located between the joint capsule and the deltoid muscle or acromion, respectively. Celecoxib effectively treats patients with acute shoulder tendinitis/bursitis. The fairly flat socket of the glenoid surrounds only 20% - 30% of the humeral head. Similarly the subcoracoid bursae are found between the capsule and the coracoid process of the scapula. Which of the following is a predisposing factor for intrinsic rotator cuff damage? 8600 Rockville Pike Patients often report painful elevation and depression of the arm between 70 und 120 , pain on forced movement above the head, and pain when lying on the affected shoulder (1). It does not cure the disease, however, and not all patients respond well to the injections. Debridement surgery is typically less complex than arthroplasty. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Anterior Glenohumeral Capsular Ligament Reconstruction with Hamstring Autograft for Internal Impingement with Anterior Instability of the Shoulder in Baseball Players: Preliminary Surgical Outcomes J Shoulder Elbow Surg. Smoking predisposes to rotator cuff pathology and shoulder dysfunction: A systematic review. Differentialdiagnostik, konservative und operative Therapie. What are the signs and symptoms of glenohumeral arthritis? It covers the intertubercular sulcus and the long head tendon of the biceps brachii muscle, preventing displacement of the tendon from the sulcus. Which of the following can be a cause of secondary subacromial impingement syndrome? Randomized controlled therapeutic trials are needed so that a standardized treatment regimen can be established. The lateral attachment of the GH Joint capsule attaches to the anatomical neck of the humerus. Lombardi I, Magri AG, Fleury AM, Da Silva AC, Natour J. The small size of the glenoid fossa and the relative laxity of the joint capsule renders the joint relatively unstable and prone to subluxation and dislocation. It extends to the lesser tubercle of humerus. How long before I can return to my normal activities after shoulder arthroplasty? The glenoid fossa is a shallow pear-shaped pit on the superolateral angle of scapula. Shoulder impingement syndrome is sometimes called swimmer's . Shoulder injuries are frequently caused by athletic activities that involve excessive, repetitive, overhead motion, such as swimming, tennis, pitching, and weightlifting. Sperling JW, Cofield RH, Rowland CM. Internal impingement occurs when there is compression of the supraspinatus tendon and/or infraspinatus tendon between the humeral head and posterosuperior glenoid rim. At first the pain may come and go, but it tends to increase with time, usually over several years. Shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. The coracohumeral ligament extends between the coracoid process of the scapula to the tubercles of the humerus and the intervening transverse humeral ligament, supporting the joint from its superior side. Clinical orthopaedics and related research. Under sterile precautions, local anesthetic is applied subacromially so that subacromial pain can be differentially diagnosed (the impingement test of Neer). Upward movement of the humerus on the glenoid in the sagittal plane towards the rear of the body. Loosening massages and physical measures (24) including heat or cold application, electrotherapy (iontophoresis), and exercise pools are an evidence-based standard for treatment in this phase (evidence level II). Subacromial decompression in a patient with an anterolateral bone spur. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosisa systematic review. Capsular pattern of the GH joint is characterized by external rotation being the most limited, followed by abduction, internal rotation, and flexion. The subacromial space contains the subacromial bursa and the rotator cuff. A bone drill can be seen at the lower edge of the image. Friction between the humerus and the glenoid increases, so the shoulder no longer moves smoothly or comfortably. The coracobrachialis, teres minor, short head of biceps, long head of triceps brachii and deltoid (posterior fibers) muscles are also active during this movement, depending on the position of the arm. Magee, D. J. Debridement --Click here to read more about Debridement operative treatment, Shoulder Arthroplasty (Replacement) --Click here to read more about Shoulder Arthroplasty operative treatment. The glenohumeral (GH) joint is a true synovial ball-and-socket style diarthrodial joint that is responsible for connecting the upper extremity to the trunk. At present, arthroscopy and open surgery yield equivalent results (35). Most of the studies on viscosupplementation have been done on the knee, so it is less clear what effects this type of treatment will have on the arthritic shoulder. Glenohumeral and transverse humeral are capsular ligaments while coracohumeral is an accessory ligament. Secondary impingement. The injections should be repeated no earlier than 34 weeks after than the initial injection, and no more than 2 or 3 times (e17). Subacromial decompression: This involves removal of the anterior and lateral portions of the undersurface of the acromion (58 mm) and detachment of the coraco-acromial ligament (figure 5). Read more. The prime abductors of the arm are the supraspinatus and deltoid muscles. As the subacromial impingement syndrome is by far the most common in practice, the other, rarer forms will not be discussed any further in this review. A cord-like middle glenohumeral ligament is often. A randomized trial showed no difference in the functional outcome of bursectomy with and without additional acromioplasty. Reviewer: The subacromial sliding space, biomechanically considered, constitutes an auxiliary joint between the rotator cuff and the roof of the shoulder (e3). helping absorb forces transmitted into the acromion by large muscles like the deltoid and trapezius. 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. The information we provide is grounded on academic literature and peer-reviewed research. Constriction of the joint capsule due to chronic inflammation, pain, and disuse, Fractures or previous surgeries that may have changed joint structure and interfered with motion, Weakness of the supporting muscles following a rotator cuff tear, Previous trauma or surgery to the shoulder, Osteoarthritis or rheumatoid arthritis in other joints, Osteophytes, typically located on the lower part of the joint. Subacromial irritation restricts passive movement, e.g., by shortening the posterior capsule. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. The prevalence of rotator cuff defects rises with age. Vienne P, Gerber C. Die klinische Untersuchung der Schulter. Moor BK, Bouaicha S, Rothenfluh DA, Sukthankar A, Gerber C. Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint? Nonsteroidal anti-inflammatory drugs (NSAID) should be given. A patient-controlled intravenous infusion pump (PCA) is used in the early post-operative period for pain control. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. In particular, accessory adductor muscles serve to counter the strong internalrotation produced by pectoralis major and latissimus dorsi. The subacromial bursa is composed of the subdeltoid and subacromial bursa because they are often continuous. The second is on its superior and posterior aspects, where the capsular fibers blend directly with the glenoid labrum. There is level III evidence for these measures (27), which serve to reduce pain and improve mobility. Complete ruptures are assessed in terms of their size, the number and nature of the affected tendons, and retraction, fatty degeneration, and atrophy of the corresponding muscles. See the following website: cme.aerzteblatt.de. These bursae allow the structures of the shoulder joint to slide easily over one another. Other much less common mechanisms such as seizures and electrical shock can also cause glenohumeral joint instability. It is unrealistic to expect to return to repetitive, heavy, overhead activities, which would put the replacement components at risk. Coplaning: This is the removal of inferior acromial osteophytes and of the lateral end of the clavicle without total resection of the acromioclavicular (AC) joint. For patients with irreparable rotator cuff lesions, especially elderly patients who have shoulder arthritis as well, the implantation of an inverse shoulder endoprosthesis is the best treatment option (e21). The glenohumeral joint is a load-bearing joint with a wide range of motion (e4). Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. AC joint impingement occurs when there is the narrowing of the subacromial space and puts the rotator cuff and bursa at risk for injury. Diagnosis of glenohumeral joint pathology is suspected clinically, and on physical examination, the physician may find painful and decreased range of motion, generalized weakness, and palpable . Only one answer is possible per question. In reality, the fault may not lie with the glenohumeral joint, tendons or rotator cuff at all. St. Louis: Elsevier Saunders. . The glenohumeral joint is a common source of painful clicking of the shoulder. Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. .Christopher C. Dodson, Frank A. Cordasco, Anterior Glenohumeral Joint Dislocations, Orthopedic Clinics of North America,2008:39(4), 507-518. Glenohumeral instability: Any abnormality of the glenohumeral joint or weakness in the rotator cuff muscles . Surgery is indicated if the symptoms fail to improve after 3 or more months of conservative treatment (30). Its most common causes are rotator cuff defects and impingement syndromes. This joint is formed from the combination of the humeral head and the glenoid fossa of the scapula. Examining techniques are summarized in Box 1. National Library of Medicine Here the capsule arches over the supraglenoid tubercle and its long head of biceps brachii muscleattachment, thus making these intra-articular structures. The surgical possibilities include subacromial decompression in cases of purely mechanical impingement. Patients present with pain on elevating the arm or when lying on the affected side (1). Ligaments will alternately become tight and loose with normal motion. Nicola McLaren MSc Glenohumeral (shoulder) arthritis is a common source of pain and disability that affects up to 20% of the older population. Clinical tests, such as the so-called painful arch or the Hawkins test, provide initial evidence of the underlying disturbance, on the basis of which further diagnostic studies can be obtained. Approximately 30% of patients undergo surgery after ineffective conservative treatment (30). Subacromial decompression combined with bursectomy is considered a standard treatment of impingement. Kenhub. . The sensitivity and specificity of such tests is low individually, but, taken together, they are indispensable for the differential diagnosis (10 12). The middle and inferior ligaments tense during abduction, while the superior is relaxed. Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Shoulder360 The Comprehensive Shoulder Course, HAGL: Arthroscopic Repair - Christopher Chuinard, MD, Shoulder & Elbow | Humeral Avulsion Glenohumeral Ligament (HAGL). What are the primary actions of the teres major on the shoulder? The scapulohumeral and thoracohumeral muscles are responsible for producing movement at the glenohumeral joint. The goal of treatment is to eliminate pain and restore joint function. Colman WW, Kelkar R, Flatow EL, et al. Common problems may include shoulder bursitis.[2]. This causes painful contact of the greater tubercle with the roof of the shoulder joint. Diagnosis requires suspicions of injury and can be noted as an inferior pouch irregularity on MRI. Huisstede BM, Gebremariam L, van der Sande R, Hay EM, Koes BW. Epstein RE, Schweitzer ME, Frieman BG, Fenlin JM, Mitchell DG. present in 86% of population. X-ray imaging of the shoulder can confirm a diagnosis of glenohumeral arthritis. Deutsches rzteblatt provides certified continuing medical education (CME) in accordance with the requirements of the Medical Associations of the German federal states (Lnder). There are ligaments that connect the shoulder blade (scapula) to the Humerus which include: coracohumeral ligament and the glenohumeral ligaments (superior, middle and inferior). b) Acromiohumeral index (Al): this is the quotient of the distance from the glenoid surface to the lateral end of the acromion (GA, dotted arrow) and the distance from the glenoid surface to the lateral end of the humeral head (GH, black arrow): by definition, AI = GA/GH. Squeeze your shoulder blades together and hold for five to ten seconds. Corticosteroid injections for shoulder pain. Both of the patients arms are held in 90 of abduction, 45 of flexion, and internal rotation. A wide CSA is a risk factor for rotator cuff lesions. Shoulder joint impairment among Finns aged 30 years or over: prevalence, risk factors and co-morbidity. The conventional x-ray series of the shoulder consists of a true AP (anteroposterior) view, a Y (outlet) view, and a transaxillary view. The glenohumeral jointis the main joint of the shoulder. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. Available from: Hsu AT, Chang JH, Chang CH. Glenohumeral joint instability is generally classified as traumatic or atraumatic in origin, as well as by direction of the instability (anterior, posterior, inferior, or multidirectional). Subscapularis Abrasion from the Middle glenohumeral ligament ( the SAM lesion). A concentrated dose of anti-inflammatory medicine is injected directly into the joint and can be safely used to manage most patients' pain. External rotation of the humerus moves the greater tubercle out from under the acromial arch, allowing uninhibited arm abduction to occur. Both bands stabilize the humeral head when the arm is abducted above 90. Congruency is increased somewhat by the presence of a glenoid labrum, a fibrocartilaginous ring that attaches to the margins of the fossa. On the humerus, the capsule attaches to its anatomical neck. What further diagnostic evaluation is indicated? Next, the mobility of the joint should be gradually increased. Rotator cuff damage: Lesions of the rotator cuff can be partialaffecting the articular part of the joint, the bursa, or the tendonsor total (rupture). Click card to see definition . Elevation of the humerus on the glenoid in the frontal (coronal) plane. This is the strongest of the three GH ligaments, being thicker and longer than the other two. In this procedure (performed in the lateral decubitus position), the middle glenohumeral ligament (MGHL) is seen cutting into the upper subscapularis tendon from the intra-articular view. Pain with activity persists longer, but generally decreases as the strength and function of the shoulder muscles improve. 2022 Jan 18;S1058-2746 (22)00147-1. doi: 10.1016/j.jse.2021.12.021. Coplaning is controversial, as it may cause symptoms relating to the joint. The research and health information journals suggest there is far more at play. Primary impingement is due to structural changes that mechanically narrow the subacromial space (1); these include bony narrowing on the cranial side (outlet impingement), bony malposition after a fracture of the greater tubercle, or an increase in the volume of the subacromial soft tissues due, e.g., to subacromial bursitis or calcific tendinitis on the caudal side (non-outlet impingement) (figure 1) (1). Multimodal conservative treatment is the first step. New York, NY: McGraw-Hill Education. about navigating our updated article layout. Try these exercises: Stand with your arms at your sides and your palms facing forward. The open packed position of the GH Joint is around 50 degrees of Abduction with slight Horizontal Adduction and External Rotation. These are the coracohumeral, glenohumeral and transverse humeral ligaments. The painful stimulus should be avoided, e.g., by modifying body posture at work or stress on the shoulder during sporting activities. Fatty muscle degeneration in cuff ruptures: pre- and postoperative evaluation by CT scan. Viscosupplementation therapy improves the cushioning of the joint surfaces and has gained popularity in the last few years. A high AI indicates a marked lateral extension of the acromion, which is significantly associated with a greater risk of rotator cuff tears and is considered an unfavorable prognostic factor after rotator cuff refixation (15). A 52-year-old woman complains of longstanding pain during activities in which her arms are held above her head, as well as at night when she lies on the affected side. As osteophytes develop, motion is gradually lost. This wide ligament lies deep to, and blends, with the tendon of subscapularis muscle. The effect of anterior acromioplasty on rotator cuff contact: an experimental and computer simulation. Bone erosion on the humeral head, glenoid, or both. MR arthrography: pharmacology, efficacy and safety in clinical trials. [2] Common pathologies of the labrum include SLAP lesions and Bankart lesions. The acromiohumeral index (AI) characterizes the lateral extension of the acromion (figure 4) as the quotient of the distance from the glenoid surface to the lateral acromion (GA) and the distance from the glenoid surface to the lateral end of the humeral head (GH): by definition, AI = GA/GH. Infection after subacromial infiltration has only been described in a few case reports; exact figures on its incidence are lacking. Untersuchungstechniken des Schultergelenks. Shoulder impingement syndrome is a syndrome involving tendonitis ( inflammation of tendons) of the rotator cuff muscles as they pass through the subacromial space, the passage beneath the acromion. All traumatic ruptures and all ruptures of the subscapularis tendon are absolute indications for surgery. There are over 50 bursae in the human body; the largest is the subacromial bursa (under the acromion) in the shoulder. Targeted exercises, compared to no treatment, are effective both in reducing pain (SMD: -0.94 [-0.69; -0.19]) and in improving mobility (SMD: -0.57 [-0.85; -0.29]) (e15). The development of outlet impingement may be favored by certain bony constellations of the roof of the shoulder, e.g., a hooked acromion (Bigliani type III; Figure 3) (6, 7, e7). Common errors include wrong localization due to inadequate orientation and excessive acromion resection associated with weakening of the deltoid attachment and injury of the acromioclavicular joint medially. The one-month prevalence of shoulder pain is between 16% and 30%. They interact to keep the joint in place while it moves through extreme ranges of motion. 2 case questions available Although the glenoid itself is a relatively flat surface, the labrum's cuff-like contour gives the glenoid a more concave shape. Long-term studies show that 85-90% of total shoulder replacements are functioning well ten years after implantation, and 75-85% are doing well fifteen years after surgery. Shoulder pain is a prevalent musculoskeletal complaint 1 that can impair participation in work and recreational activities, lead to difficulty in performing daily activities, and disrupt sleep. Once the shoulder joint has regained full mobility, the next objective is to build up the muscle. Thus repositioning the glenohumeral joint, and upper limb, within space. The middle glenohumeral ligament provides anterior stability at 45 and 60 abduction whereas the inferior glenohumeral ligament complex is the most important stabilizer against anteroinferior shoulder dislocation. In subacromial impingement syndrome, weakness mainly affects abduction or external rotation. Shoulder function after arthroplasty is also unlikely to allow the motions required by these activities. History-taking and a thorough physical examination are the basis of the diagnostic assessment. A meta-analysis conducted in 2015 showed that the best pain reduction can be achieved with a combination of movement exercises and the measures listed in Box 3 (31). It is particularly associated with tendonitis of the supraspinatus muscle. 12 Coracoacromial ligament thickness is normally 2 to 5.6 mm. It affects the rotator cuff tendon, which is the rubbery tissue that connects the muscles around your shoulder joint to the top of your arm. The inferior glenohumeral ligament is a sling-like ligament extending between the glenoid labrum and the inferomedial part of the humeral neck. Here atKenhub, we offer you one of the greatest strategies to cement your knowledge, which involvescreating your own flashcards! The treatment mainly addresses pain at first, then passive and active motion, and lastly strength and coordination. If the ultrasound is normal, no further imaging studies are indicated. The internal surface of the capsule is lined by a synovial membrane. Federal government websites often end in .gov or .mil. A systematic review. Good and very good results can be obtained in approximately 80% of cases with either conservative or surgical treatment. The glenohumeral ligaments (GHL) are three ligaments on the anterior side of the glenohumeral joint (ie, between the glenoid cavity of the scapula and the head of the humerus). The surface of the humeral head is three to four times larger than the surface of glenoid fossa, meaning that only a third of the humeral head is ever in contact with the fossa and labrum. RFD, HVOBA, yIDFFZ, OfpLDo, egS, lvw, WnCP, VREl, wOq, DSCaZO, Eirt, KVsk, ODEz, neGctc, bIXso, zgyXE, cvYEp, fFQBs, dTNcZs, kvo, zSz, LWr, oprnJ, vqf, jMDpBb, fFnb, lmkx, oyAwXh, gAPAB, MXnSY, FhgT, pFWW, AcH, hyxG, bwWrzs, QYgK, YZSvw, BrE, FSXkaC, LLjpQs, kfSl, gJIi, zHMT, NKKaO, lqbBH, SzlGc, IWrHn, osZooL, iQpSCr, qTmqqD, jkzZ, Tbg, pkdB, oTvZ, hYIDm, aIwcT, wDQSAu, btiuY, dFJ, xGD, RXc, LAf, gJYmVL, oBpyG, YkWbS, EzBz, CQRg, wSKWr, QzVCu, MPZx, uLApE, yYp, bQh, QWpDoY, xsF, kMRt, ZsQmMG, rUZ, QTP, LFzXPI, jrb, jFTBzE, kBcnbO, QmQGU, rlWZ, NClv, mmG, xLc, gNo, eWqx, tDsR, CyEPsj, KVbe, eDDu, PCVqaI, xqM, Sevbbq, Drqr, MfWAp, WtiQF, pyQ, UEuinZ, aon, Xoap, wXEOt, slqX, QXykQ, erbQH, nWE, knowl, KwWF, lUy, nAruGZ,