for better appreciation of 3D morphology of the hip or for associated cartilage and labral lesions), cross-sectional imaging (CT or MR arthrogram) is recommended. Understand that there is no proven combination of test findings that identify internal impingement. This tends to cause pain at the back of the shoulder joint as well as sometimes at the front. The lack of a common biomechanical model is largely due to the limited patient population in which the syndrome is seen as well as the thousands of associated pathologic findings that have been reported. The material on this website is designed to support, not replace, the relationship that exists between ourselves and our patients. 2017 Dec;99-B(12):1577-1583. Decreased ability to perform activities of daily living and sports. Internal Impingement of the Shoulder - Physiopedia Internal Impingement of the Shoulder Online Course: Internal Shoulder Impingement Online Course: Distal Radius Fractures Programme Online Course: Early Management of Distal Radius Fractures with ORIF Introduction Internal impingement is a common cause of shoulder pain in overhead athletes. It was hypothesized that positive test results are pre Contributions of the serratus anterior muscle to the movement of the scapula (upward rotation, posterior tilt, external rotation and protraction of the scapula) during elevation. Neers Classification of Impingement identified four types of shoulder impingement identified below; Neer Classification of Subacromial Impingement. MORRISON D.S., FROGAMENI AD, WOODWORTH P., Non-operative treatment of subacromial impingement syndrome?, J Bone Joint Surg Am 1997. Pincer impingement. Acute hip pain red flag conditions include: In athletes, other causes of hip pain include inguinal pathology, adductor pathology and athletic pubalgia. However, it can be applied to the non-athletic population as well by incorporating activity-specific functional activities instead of sport-specific. They reported a sensitivity and specificity of 75.5% and 85% respectively, meaning a, NSAIDs (or other oral-anti-inflammatory meds), Partial thickness rotator cuff tear (PASTA-Partial articular supraspinatus tendon avulsion) compromises the integrity of the rotator cuff, Completion of rotator cuff tear by arthroscopic repair. [24][25] At the base of this abnormal scapular positioning lies the lack of neuromuscular control of the periscapular musculature as well as muscle imbalances between the rotator cuff and upward rotators of the scapula (serratus anterior, upper trap, lower trap). Intrinsic factors: (generally non-modifiable), Extrinsic factors: (potentially modifiable). Physical Therapy Reviews 2011;16:388-298. Acta Orthopaedica. Many other diagnostic labels have been proposed but it has been suggested that the term Subacromial Pain Syndrome (SAPS) best describes the pain thought to originate from structures lying between the acromion and the humeral head, most often associated with some degree of shoulder dysfunction,[23] but does not reflect many other causes of shoulder pain located outside the subacromial space. By lack of ligaments, the joint delegates the function of stability fully to the muscles that attach the scapula to the thorax. Primary cam morphology; bump, burden or bog-standard? In which phase of throwing does this pathologic process occur? In a study of high-level tennis players performing daily sleeper stretch exercises, patients were found to have significant increases in both internal rotation and total rotation, as well as a 38% decrease in the prevalence of shoulder problems. subacromial or "external" impingement which occurs on bursal side of rotator cuff, internal impingement covers a spectrum of injuries including, fraying of posterior rotator cuff (supraspinatus-infraspinatus interval), hypertrophy and scarring of posterior capsule glenoid, the inferior rotator cuff (infraspinatus, teres minor, subscapularis) balances the superior moment of the deltoid, the anterior cuff (subscapularis) balances the posterior moment of the posterior cuff (infraspinatus and teres minor), the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes, shoulder pain, sometimes loalized posteriorly, especially during late cocking and early acceleration, loss of > 20 of IR at 90 compared to contralateral shoulder, must stabilize the scapula to get true measure of glenohumeral rotation, often can demonstrate rotator cuff weakness, performed to test for partial suprapinsatus tears, performed by ranging shoulder in forward flexion, adduction and scapular retraction, positive when pain is reproduced on resistance, performed by bringing shoulder into maximum ER, abduction and extension, positive if posterior shoulder pain reproduced in this position and relieved when arm brought into neutral extension/flexion, can show pathology of the rotator cuff and/or labral pathology, partial articular-sided supraspinatus-infraspinatus tendon avulsion (PASTA), fraying, or tear, signal at greater tuberosity and/or posterosuperior labrum, ABER positioning reproduces position of impingement showing dynamic process on the humerus and glenoid sides, most internal impingement can be treated non-operatively, Operative treatment should only be considered if patient has failed adequate physical therapy for an extended period of time as results folliwing operative intervention are unpredictable, partial thickness rotator cuff tear (PASTA) that compromise the integrity of the rotator cuff, Arthroscopic vs mini-open rotator cuff and/or labral repair, partial tears >50% tendon thickness or full thickness tears, persistent posterior capsule contracture or anterior shoulder instability in addition to any of the above pathology, break from throwing until pain subsided, followed by supervised return to throwing focusing on proper mechanics, posterior capsular stretching program (i.e. The action of cocking can be summarised in three descriptive movements that all occur at the shoulder. The more external rotation (lay back) one goes into, the more internal impingement will arise The findings of magnetic resonance imaging of patients with internal impingement are usually more subtle. Ann Rheum Dis 1994;53:5258, Tyler T, Nicholas S, Lee S, Mullaney M, McHugh M. Correction of Posterior Shoulder Tightness is Associated with Symptom Resolution in Patients with Internal Impingement. MR arthrogram has typically been preferred over MRI because it has shown greater accuracy in identifying defects in the labrum and cartilage. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. [18], The lateral centre-edge angle (LCEA) measures femoral head bony coverage by the acetabulum. Extrinsic mechanisms: External to the tendons. Parts of these guidelines are backed by evidence, but many of the treatments discussed have not been validated with medical research, so until that research is conducted these guidelines may provide a foundational starting point for clinicians treating internal impingement. [23], The Dutch Orthopaedic Association Guidelines arise the use of ultrasounds the most valuable and cost-effective diagnostic imaging if the first period of conservative treatment fails, which they recommend can be combined with conventional radiography of the shoulder to determine osteoarthritis, osseous abnormalities, and presence/absence of calcium deposits. That is usually the journal article where the information was first stated. FADDIR is an acronym for Flexion Adduction Internal Rotation. This remained the dominant theory for injury to structures within the subacromial space for the past 40 years and has been the rationale to guide clinical tests, conservative treatment, surgical procedures and rehabilitation protocols,[2] however the validity of this model of acromial impingement has been challenged from both a theoretical and practical perspective throughout the last decade, with suggestions that the use of SIS terminology can potentially contribute to negative expectations of physiotherapy and conservative treatment for patients, which may compromise outcome, often resulting in an increased incidence for surgery.[22][2][3][22]. 2016 Jan 20;98(2):135-41. Full Disclaimer, The word impingement basically means 'rubbing' or 'catching' of structures. It is the impingement of the rotator cuff (muscles and. There are a variety of shoulder conditions that can initially be confused with subacromial pain syndrome [34]. [5] A review of the literature does show several common symptoms that most internal impingement patients seem to share. When refering to evidence in academic writing, you should always try to reference the primary (original) source. 2000;31:285293. Non-surgical management of this shoulder classification is quite good, you only need to prescribe a minimum number of exercises (quality over quantity!). It's location is the anterior side of the ankle in the talocrural joint. NSAIDS and steroid injection: To help facilitate the decrease in inflammation, NSAIDs such as ibuprofen can be helpful, as can a steroid injection into the joint such as Kenalog. It may also show up tears in the rotator cuff. Acetabular labral tears of the hip: Examination and diagnostic challenges, Efficacy of adding a physiotherapy rehabilitation programme to arthroscopic management of femoroacetabular impingement syndrome: a randomised controlled trial (FAIR). internal impingement shoulder physiopedia. J Anat 1930; 64: 288-302. (OBQ09.142) [55] (Level of evidence 3b), A combination of physical therapy and surgical treatment would give better clinical results than physical therapy alone. Leroux J-L, Codine P, Thomas E, Pocholle M, Mailhe D, Blotman F. Isokinetic evaluation of rotational strength in normal shoulders and shoulders with impingement syndrome. It occurs when the shoulder is abducted and externally rotated ( ABER position ). Level of Evidence 1, ALGUNAEE M, GALVIN R, FAHEY T, Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. When evaluating a patient with suspected internal impingement syndrome, it is very important to get a thorough history, as it is an important element of the clinical diagnosis. In most cases Physiopedia articles are a secondary source and so should not be used as references. In 2008, Cools, et al. [8] It is important, before treatment is undertaken, to rule out other anterior instability pathology, including SLAP lesions, labral tears, and partial rotator cuff tears. The full treatment protocol can be viewed here. The brace did modify the kinematics of patients with FAI by limiting movements that were associated with hip impingement (flexion, internal rotation and adduction of the hip) during common activities (squat, stair climbing and stair descending). When Internal shoulder impingement (also known as thrower's shoulder) occurs, the tendons of the rotator cuff, most commonly the supraspinatus tendon,. Journal of Orthopaedic and Sports Physical Therapy. First the best fit circle for the inferior and medial margins of femoral head is drawn. Mobility and contributions of the cervical spine, thoracic spine and thoracic cage mobility. [46] Surgery should only be considered if the patient does not respond to exhaustive non-operative treatment. [8] suggested that articular cartilage may be the main site of inflammation and degeneration in hips with FAI and that if OA progresses, metabolic activity spreads to the labrum and synovium and labrum. The home exercise sheets provided to patients in the physiotherapy group can be viewed here in PDF format. To challenge the functional deficit of the patient, a minimum of a 12-week period is recommended. Impingement has been described as a group of symptoms rather than a specific diagnosis. Moderate pain during exercise, no loss of strength and no limitation in movement. Ostor AJ, Richards CA, Prevost AT, Speed CA, Hazleman BL: Diagnosis and relation to general health of shoulder disorders presenting to primary care. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Diamond LE, Dobson FL, Bennell KL, Wrigley TV, Hodges PW, Hinman RS. It is basically a generic term that encompasses pain associated with any lesion within a structure or structures within the Subacromial Space. High-Intensity Shoulder Abduction Exercise in Subacromial Pain Syndrome. Researchers are still trying to ascertain the best approach to managing this condition: Arthroscopy is the most common surgical procedure for FAI discussed in the literature and typically involves: Surgical complications are a recommended area of future research to help inform the clinical decision-making process.[15]. Impingement generally occurs at the coracoacromial space secondary to anterior translation of the humeral head as opposed to the Subacromial space that is seen in primary impingement. Surgical criteria for femoroacetabular impingement syndrome: a scoping review, https://www.youtube.com/watch?v=iE9cgvI7OKw. Providing a more detailed assessment of cam morphologies and associated pathophysiology. Compression injuries e.g. [7], Other frequently used questionnaires to determine the progression of symptoms such as pain, disability and other outcomes=. This usually occurs at 90 degrees abduction and external rotation. Journal of Athletic Training. Rehabbing the GIRD component: Started immediately upon 1st treatment and continue throughout. There may also be shoulder instability as a result of the damage done to the labrum. On exam, he has a 30 degree internal rotation deficit and is diagnosed with internal impingement. [11], Patients treated for symptomatic FAI syndrome frequently report improvement in their symptoms and are able to return to their usual activities. Disabilities of the Arm, Shoulder and Hand (, TTP (tender to palpation) posterior shoulder/joint line, involved shoulder usually has increased muscle bulk and lies lower than unaffected shoulder, abnormal scapulothoracic rhythm/scapular movement, decreased GH internal rotation: 10-15 degrees, increased GH external rotation: 10-15 degrees, Posterior Impingement Sign: Meister et al. 765777. The Physio Channel. Casartelli NC, Maffiuletti NA, Bizzini M, Kelly BT, Naal FD, Leunig M. The management of symptomatic femoroacetabular impingement: what is the rationale for non-surgical treatment? Functional rehabilitation plan: Designed to prepare the athlete to return to full athletic activity. That is usually the journal article where the information was first stated. The load on the tendon (shear or compressive forces). also reported that malpositioning of the arm relative to the glenoid bone during throwing motions can also lead to impingement of the rotator cuff tendons between the glenolabral complex and the humeral head. 1990;72-a:13341343. The three recommended views are:[44], The size of the subacromial space can also be measured. Next, the angle between two lines drawn from the centre of the circle is measured: one line runs vertically along the longitudinal axis of the pelvis and the other line runs to the lateral acetabular rim. Treatment during these sessions consisted of education, manual therapy (mandatory release of key trigger points, optional lumbar mobilisation) and, starting at 6-8 weeks post-surgery, functional and sport-specific drills. A non-athlete may also not need to progress all the way to phase 3, which will depend on the activity level they wish to return to. The scapulothoracic articulation is a prime example of the dynamic stability of the human body. Cochrane Database Syst Rev. A recent study has found that interventions focusing on the scapular can improve short-term shoulder pain and function. ; Educate all caregivers on proper UL handling during . Dunn lateral view shows the deformity present on the anterolateral side. Strengthening exercises are continued and plyometrics are initiated using both hands and limiting external rotation at first, progressing to one-handed drills and gradually working into increasing velocity and resistance. Internal impingement This occurs predominantly in athletes where throwing is the main part of the sport, e.g. (OBQ11.140) How do you manage GIRD (GH internal rotation deficit): Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. 2009 Nov; 90(11): 1898-903. If the timing of the movement is correct, this external rotation of the humerus during elevation permits the avoidance of the compression of the greater tuberosity against the subacromial structures. The 'impingement' lesions on the labrum and rotator cuff are known as 'kissing lesions'. J Bone Joint Surg Am. J Sci Med Sport. This laxity allows for increased anterior humeral head translation. The body of the giant was packed and loaded into a helicopter, and transferred to a secret location in the USA for. 2012. distraction, AP glides) and trigger point work, For patients who do not improve with core treatment components above. Image showing how the rotator cuff gets 'pinched' (impinged) between the glenoid labrum and the humeral head in full abduction and external rotation. Tight posterior GH capsule: The posterior-inferior GH joint capsule is hypothesized to become hypertrophied in the follow-through tensile motion of throwing. In-fact, the condition is sometimes called "The Throwers Shoulder" and is also seen in the "Swimmer's Shoulder". Posterosuperior impingement, also known as internal impingement, is a relatively uncommon form of shoulder impingement primarily involving the infraspinatus tendon and the posterosuperior glenoid labrum. Ach Phys Med Rehabil 2012, 93(2): 229-36, Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK. Am J Sports Med. 2000;30(3):126-137 (Level of evidence 1b), Kuhn JE. (2000) 30:126-137, Muraki T, Aoki M, Izumi T, Fujii M, Hidaka E, Miyamoto S. Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study. Secondary impingement in the shoulder. DE BIE R.A., BASTIANENEN C.H.G. Arthroscopic subacromial decompression - Dr Terry Hammond.dv Available from: Shoulder Arthroscopic Subacromial Decompression - Dr. Tony Jabbour Available from: YELDAN I., CETIN E., OZDINCLER A.R. Dijkstra HP, Ardern CL, Serner A, Mosler AB, Weir A, Roberts NW, Mc Auliffe S, Oke JL, Khan KM, Clarke M, Glyn-Jones S. Chopra A, Grainger AJ, Dube B, Evans R, Hodgson R, Conroy J, Macdonald D, Robinson P. Reiman MP, Thorborg K, Goode AP, Cook CE, Weir A, Hlmich P. Diagnostic Accuracy of Imaging Modalities and Injection Techniques for the Diagnosis of Femoroacetabular Impingement/Labral Tear: A Systematic Review With Meta-analysis. 2008;54(3):15970. His velocity has decreased over the past 2 months. Cross-body ADDuction at various degrees of elevation (also targeting various portions of the posterior capsule), with or without posterior glides. Asia Pac J Sports Med Arthrosc Rehabil Technol. [26], The Subacromial Space measures between 2 and 17 millimeters depending on the arm position and contains the following anatomical structures: [9][3][27]. 2009;18:138-160 (Level of evidence 1a), Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Occupations that require repeated overhead lifting or work at or above shoulder height are also at risk of rotator cuff impingement. Arthroscopy 2003;19:64161, Burkhart SS, et al. pathologic micromotion of the humeral head allows the rotator cuff to become impinged between the humral head and glenoid. [23] [24]Subacromial pain syndrome is poorly understood despite being a commonly diagnoses. The hip (acetabulofemoral joint) is a synovial joint formed between the femur and acetabulum of the pelvis. ; Nonoperative Management of Secondary Shoulder Impingement Syndrome; Journal of Orthopaedic & Sport Physical Therapy; Volume 17-5;1993, Ulrich J. Spiegl et al., Symptomatic Internal Impingement of the Shoulder in Overhead Athletes, Sports Med Arthrosc Rev Volume 22, Number 2, June 2014. [23], The treatment depends on age, activity level and general health of the patient. Radiology. (2009) 37:2222-2227, Cools AM, Declercq G, Cagnie B, Cambier D, Witvrouw E. Internal Impingement in the Tennis Player: Rehabilitation Guidelines. Improve dynamic stability-restoration muscle balance: Strengthening exercises: Target all shoulder and scapular musculature. Orthop Traumatol Surg Res. AP x-rays of the pelvis and lateral x-rays of the femoral neck are recommended initially for suspected FAI syndrome. The American Journal of Sports Medicine. Regenerative medicine in rotator cuff injuries. (2010) 38:2, Drakos M, Rudzki J, Allen A, Potter H, Altchek D. Internal Impingement of the Shoulder in the Overhead Athlete. Rotator cuff (particularly the external rotators - infraspinatus and teres minor), All aspects of the trapezius muscle (upper/middle/lower), A generalized and global approach for scapular muscles, to encourage proper performance and timing of scapular upward rotation, external rotation and posterior tilting during elevation. Coracoacromial Arch, composed of the Acromion, Coracoid Process and Coracoacromial Ligaments, Tendons of the Rotator Cuff; Supraspinatus, Infraspinatus, Teres Minor and Subscapularis, Tendon of the Long Head of Biceps Brachii, Tendon histology (quality of the tendons), Loss of control of the humeral head (GH instabilities), Loss of scapular control (scapular instabilities). In addition, physical therapy modalities such as electrogalvanic stimulation, ultrasound treatment and transverse friction massages can be helpful. Anterior or posterior capsular pathologies, Chondromalacia of the posterosuperior humeral head. technique. Subcoracoid Impingement Pain in the shoulder caused by contact between the rotator cuff and the coracoid process. British Journal of Sports Medicine. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. 2009; 31(11): 935940 (Level of evidence 1b), Ron Diercks, Carel Bron, Oscar Dorrestijn, Carel Meskers, Ren Naber, Tjerk de Ruiter; Guideline for diagnosis and treatment of subacromial pain syndrome; Pages 314-322 | Received 23 Jan 2014, Accepted 04 Mar 2014, Published online: 21 May 2014;JournalActaOrthopaedica Volume 85, 2014, Bang MD, Deyle GD. A baseball pitcher has aching pain in the posterior shoulder after throwing. Mihata T, Gates J, McGarry M, Lee J, Kinoshita M, Lee T. Effect of Rotator Cuff Muscle Imbalance on Forceful Internal Impingement and Peel-Back of the Superior Labrum: A Cadaveric Study. Comparative reliability and diagnostic performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance arthrography for the evaluation of internal derangement of the hip. Sleep stretch (targeting the posterior capsule). [17] Most recently a value of 60 has been proposed as a definition of cam morphology. [1][2][3] SIS has been viewed as symptomatic irritation of the subacromial structures between the coracoacromial arch and the humeral head during elevation of the arm above the shoulder/head [1] and as reflected by the literature is considered by many to be one of the most common causes of shoulder pain. The catching of the affected structures may be structural and/or functional in etiology 2. Adam Smithson. A study of 420 scapulas. The underside of the rotator cuff tendons impinges against the glenoid labrum. That is usually the journal article where the information was first stated. At this stage, the syndrome could be possibly reversible. Ther., 2011. BioMed Res Int. Anterior internal impingement of the shoulder in rugby players and other overhead athletes. Fluid around tendons and in the joint could also point to impingement. Repeated loading of the labrum leads to upregulation of nociceptive receptors in that structure through the production of neurotransmitters such as substance P. Radiological findings of FAI-associated morphologies among subjects with affected siblings, Higher instances of cam morphology in men and pincer morphology in women, Exposure to repetitive and often supraphysiologic hip rotation and hip flexion during development in childhood and adolescence (e.g. Lewis J. Subacromial Impingement Syndrome: A Musculoskeletal Condition or a Clinical Illusion? Original Editor - Joshua Caldwell, Phillip Williams, Gary Diekhoff, Bryan McAdams as part of the Texas State University Evidence-based Practice Project, Top Contributors - Joshua Caldwell, Phillip Williams, Gary Diekhoff, Bryan McAdams, Rachael Lowe, Kim Jackson, Admin, Evi Jacobs, Mandeepa Kumawat, Deborah Huart, Fasuba Ayobami, Tarina van der Stockt, Katherine Knight, Naomi O'Reilly, WikiSysop, Jess Bell, George Prudden, Simisola Ajeyalemi, Wanda van Niekerk, Robin Tacchetti, Jeremy Brady and Jelle Habay, Internal impingement is a common cause of shoulder pain in overhead athletes. This page addresses the condition known as the following: There has been huge debate in relation to the diagnostic labelling of non-traumatic shoulder pain related to the structures of the subacromial space. Edema and/or hemorrhage may be present. Impingement may occur when the rotator cuff and other subacromial structures become encroached between the greater tuberosity and the coracoacromial arch. sleeper stretches), rotator cuff strength balancing, scapular stabilization, kinetic chain coordination, outcomes correlated with compliance to therapy regimen, perform meticulous exam under anesthesia to assess range of motion, diagnostic arthroscopy intra-articular and subacromial, arthroscopic shaver to debride loose tissue edges, allows accelerated rehab and return to throwing, arthroscopic has advantage of addressing labral and other intra-articular pathology, bursectomy performed to visualize bursal-side of tendon, acromioplasty is not indicated if no bursal-sided pathology seen, abrasive preparation of the greater tuberosity footprint, pulley technique utilizing suture anchors to reduce tendon to tuberosity, will functionally shorten the tendon length, complete partial tear followed by anatomic repair technique, prepare glenoid rim and repair of unstable labral tear, cautery wand or arthroscopic shaver to release synovium and capsular tissues, done adjunctively with the above procedures, Progression to full-thickness rotator cuff tear, small risk of partial tears treated with debridement alone, worse rates following rotator cuff repairs in throwing athletes, at risk during posterior release at the inferior border of infraspinatus, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. A randomized controlled trial. (2009) 14:375-380, Robert C. Manske, Meggan Grant-Nierman,Brennen Lucas. It is also prudent to look at the endurance of the deep neck flexors and thoracic extension muscles. [48]Special attention should be paid to correction of GIRD through the sleeper stretch which allows posterior capsular stretching. The anterior impingement syndrome of the ankle is a strangulation that can be caused by soft tissue, like the joint capsule or scar tissue, and hard tissue which refers to bone tissue. Anterior Impingement (AI) Often know as "athlete's ankle" or "footballer's ankle" is caused by repeated dorsiflexion, microtrauma, and repeated inversion injury causing damage to anteromedial structures such as the articular cartilage. 2011 Mar; 6(1): 5158, Chlodwig Kirchhoff & Andreas B. Imhoff, Posterosuperior and anterosuperior impingement of the shoulder in overhead athletesevolving concepts,: 20 March 2010, Heijden van der GJ, Leffers P, Bouter LM. This can cause reactive tendinopathy or a tendon dysrepair (causing a painful response to movement). It's also known as impingement syndrome or swimmer's shoulder, since it's common in swimmers. Ultrasound and arthrography are being used when rotator cuff tears are suspected or in complex cases. The vast majority of the studies (92%) in this scoping review included diagnostic imaging as a criterion, yet there is currently no consensus on specific imaging modalities or cut-off values to determine when surgery is indicated. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.[35]. There are four phases involved in throwing. Non-operative management of secondary shoulder impingement syndrome. [53] Exercise therapy is a vital part of treatment for subacromial impingement but results showed no significant difference between home-based exercises and clinical exercise. 1173185, Mechanism of Injury / Pathological Process, Surgery with a Post-Operative Physiotherapy Programme, Personalised Hip Therapy - The UK FASHIoN Trial. 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. [57] (Level of Evidence 2b), The motions of the rotator cuff that are emphasized for strengthening are internal rotation, external rotation and abduction. The main symptom patients with internal impingement usually complain of is pain. [31] Peak incidence occurs during the sixth decade of life. Change to the actual size of structures within the space (tendons of the RC muscles, subacromial bursae, for example). [9] It is thought that numerous underlying pathologies may cause impingement symptoms. These definitions and descriptions of SIS are based on a hypothesis that acromial irritation leads to external abrasion of the bursa, rotator cuff or other structures within the subacromial space. Current concepts in the rehabilitation of the overhead throwing athlete. Phys Ther. BMC Musculoskelet Disord. a Trillat osteotomy of the coracoid for the treatment of anterior instability. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Hamstring Strain - Physiopedia www.physio-pedia.com. J Bone Joint Surg Am. The femoral head glides anteriorly into the acetabulum and increases joint loading. [2] However, the long-term prognosis is not known, nor is it known if treatment of FAI syndrome prevents the development of hip OA. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. [26], Thoracic and cervicothoracic manipulation: spinal manipulations can be used to improve mobility in these regions and have proven therapeutic short and long term effects. [19] In general, two pathological mechanisms in the possible aetiology of internal impingement have been described: Anterior GH instability: Jobe et al. (2009) 91:2719-2718, Jobe C, Coen M, Screnar P. Evaluation of Impingement Syndromes in the Overhead-Throwing Athlete. Med Sci Sports Exerc. SLAP Lesions: Although the validity of physical examination tests used to detect SLAP lesions is controversial, the fact that these lesions are a common finding with internal impingement warrants the need to perform at least some combination of the following tests: Laxity of the anterior GH joint capsule: The following have proven diagnostic accuracy: Generally (+) but may be (-), Conservative management of internal impingement is an appropriate initial approach, particularly in patients who do not report an acute traumatic event. Available from: Chinzei N, Hashimoto S, Fujishiro T, Hayashi S, Kanzaki N, Uchida S, Kuroda R, Kurosaka M. Inflammation and Degeneration in Cartilage Samples from Patients with Femoroacetabular Impingement. Anatomical, biomechanical, and pathological reasons for developing internal impingement What do athlete's that have internal impingement feel? KHAN Y, NAGY MT, MALAL J, WASEEM M, The painful shoulder: shoulder impingement syndrome. Intrinsic Mechanisms: What can affect the size of the content of the subacromial space? The #1 test to perform to diagnose internal impingement What else you should look for on examination to develop the best treatment program The topic is so big, I need to break it down into 2 parts. Scand J Med Sci Sports. SAPS is the most common disorder of the shoulder[29], accounting for anywhere between 44% to 65% of all complaints of shoulder pain, [30] with the incidence increasing with age. Shoulder Pain: Can One Label Satisfy Everyone and Everything? Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Grade IV, end range, dorsal-glide mobilizations are performed with thepatient supine with shoulder placed into 90 abduction, and either in neutral or end range internal rotation of the humerus (refer to pictures). The Physician and Sportsmedicine. Non-surgical treatment[6][7][14]. High-energy extracorporeal shockwave therapy (ESWT) is more effective than low-energy ESWT, ESWT is not recommended in the acute phase. 2014;2014:129515. This prospective study introduces a new sign to differentiate between outlet impingement and non-outlet (intra-articular) causes of shoulder pain in patients with positive impingement sign: the internal rotation resistance strength test (IRRST). [5][6][7][8] This ultimately leads to impingement of the rotator cuff tendons (supraspinatus/infraspinatus) and the glenoid labrum. Cortisone is often used because of its anti-inflammatory and pain-reducing effect, but this is controversial depending on the structure involved and should not be utilised in tendon related pain. 79(5): 732 (Level of evidence 2b). Exercise in the treatment of rotator cuff impingement: A systematic review and synthesized evidence-based rehabilitation protocol. This is called a tendonitis. Matthew J. Siskosky and Neal S. ElAttrache Internal impingement is a condition that can cause significant disability to the elite throwing athlete. [47], There is no convincing evidence that surgical treatment is more effective than conservative treatment and surgery should only be considered when the conservative treatments fail to reduce the pain or restore function. American Journal of Sports Medicine. Stage I (early): Shoulder stiffness and a prolonged warm-up period; discomfort in throwers occur in the late-cocking and early acceleration phases of throwing; no pain is reported with activities of daily living. Musculoskeletal Science and Practice. The effectiveness of low-level laser therapy on shoulder function in subacromial impingement syndrome. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. The scapula is a flat blade lying along the thoracic wall. Hip-specific and functional lower limb strengthening: deep hip external rotators, abductors and flexors in the transverse, frontal and sagittal planes for improvement of dynamic stability. (2010) 38:114-120, Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Stretching techniques that focus on increasing posterior shoulder soft tissue flexibility are commonly incorporated into prevention and treatment programs for the overhead athlete. [23], There is strong evidence that supervised non-operative rehabilitation decreases pain in the shoulder and increases function. However, non-elite athletes, as well as non-athletes may also be affected by internal impingement. Lin DJ, Wong TT, Kazam JK. [4], There is a good clinical-radiological association between subacromial pain syndrome and findings on ultrasound. Infraspinatus/teres minor re-education (addressing imbalances, strength, neuromuscular control and muscular recruitment & en. Sometimes, sports-specific techniques are useful, particularly for strengthening the throwing motion, the serving motion or swimming motions. If further assessment is required (e.g. Archives of Physical Medicine and Rehabilitation. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. reported that scapular retractor muscle fatigue led to an overall decrease in force production of the rotator cuff muscles as well as the decreased strength of the scapular stabilizers. Training within the patient's normal sport environment started at 10-12 weeks post-surgery. original editor - joshua caldwell, phillip williams, gary diekhoff, bryan mcadams as part of the texas state university evidence-based practice project. hockey, basketball or football). [14] Smithson[14] suggests that a cluster of tests could be studied to develop a clinical prediction rule to achieve both high specificity and sensitivity and thus a more accurate diagnosis in a clinical setting. Cam impingement. Isotonic (fixed-weight) exercises are preferable to variable weight exercises. A contributing factor to GIRD has been theorized to be the thickening of the posterior GH capsule, limiting the overall range of internal rotation of the GH joint. Lack of extensibility of external rotator muscles (infraspinatus/teres minor). Morrison DS, Greenbaum BS, Einhorn A. 2017 Sep;45(11):2665-2677. [24], While it is accepted that multiple factors are involved in the pathology, several unresolved issues remain such as: which subacromial structure is first engaged by pathology, and what are the pain-generating mechanisms? Abduction: The movement of bringing your arms up from your side to clap above your head. J Orthop Sports Phys Ther. Rehabilitacion (Madr). Shoulder subluxation:. Magnetic resonance imaging has been used frequently to diagnose pathologic conditions of the shoulder. JBJS. [28] Non-operative treatment should, therefore, be attempted first, assuming there is no tear that requires surgery. In many situations, the diagnosis of internal impingement is made through the physical examination along with MRI[29] and radiographs. BMC Musculoskeletal Disorders. Subjects in the physiotherapy treatment group attended one pre-operative and six post-operative 30-minute sessions with a physiotherapist. . Br J Sports Med. It protects the humeral head and subacromial structures from direct trauma and superior dislocation of the humeral head. Available from: RegencyMarketing. This is a fat pad within the shoulder to allow tendons and muscles to glide over bones easily. Murphy NJ, Eyles J, Bennell KL, Bohensky M, Burns A, Callaghan FM et al. tape thigh into external rotation and abduction, For the purposes of the FASHIoN trial, group treatments could be included but only in addition to the core components, Based on the findings of the treating physiotherapist, pathology/symptoms that were felt to be affecting the FAI could also be treated. Increased Laxity - A patient with isolated internal impingement may have an increase in global laxity or an increase in anterior laxity alone of the dominant shoulder. Reduction of the subacromial space - reflect on why is this occurring. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Journal of Orthopaedic Surgery. They suggest that where reliable ultrasound is not available or inconclusive, then MRI of the shoulder is indicated and should be used in patients who are eligible for surgical repair of a rotator cuff tear to assess the degree of retraction and atrophied fatty infiltration. [5] This is characterized by Scapular malposition, a prominent Inferior medial border, Coracoid pain, and scapular dysKinesia, all of which can be picked up in the basic examination during palpation and observation of the scapula. Bennell KL, Spiers L, Takla A, O'Donnell J, Kasza J, Hunter DJ, Hinman RS. What Is Internal Shoulder Impingement? Osseous changes of the inferior acromioclavicular joint or the coracoacromial ligament may also affect the subacromial space. pudendal nerve, scrotum, labia major. Log In Sign up Features Features Courses Eportfolio Then press down on arm while patient attempts to maintain position testing for weakness or pain. Impingement is not a diagnosis - it is a mechanism. In fact, some authors have identified internal impingement as the leading cause of rotator cuff lesions in athletes. investigated the ability to detect articular-sided rotator cuff tears and posterior labral lesions. (2000) 35:293-299, Cools, A.M., et al. Realize that this protocol is geared toward the athletic population. The rotator cuff stabilizes the shoulder against the action of the prime movers to prevent excessive anterior, posterior, superior, or inferior humeral head translation.[13]. Internal impingement is usually diagnosed on clinical examination. It is an injury that is frequently seen in athletes such as swimmers or baseball pitchers. 19. There are 3 main mechanisms that can affect the distance/space of the subacromial space (acromio-humeral distance). [45]The sleeper stretch is performed with the patient lying on their injured side with the shoulder in 90 forward flexion, the scapula manually fixed into retraction, while glenohumeral internal rotation is performed passively. [45] The diagnostic accuracy of ultrasound is considered good and comparable to that of conventional MRI for identification and quantification of complete (full-thickness) rotator cuff injuries. 2013 Apr 30;4:CD007427, Alexander L. Lazarides et al., Rotator cuff tears in young patients: a differentdisease than rotator cuff tears in elderlypatients, journal of Shoulder and elbow surgery, 2015, R. Michael Greiwe and Christopher S. Ahmad, Management of the Throwing Shoulder: Cuff, Labrum and Internal Impingement, Department of Orthopaedic Surgery, Bang M, Deyle G. Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome. Casartelli NC, Bizzini M, Maiuletti NA, Sutter R, Pfirrmann CW, Leunig M, Naal FD. The pain is a result of inflammation and irritation to the tendons which are being impinged. During arm elevation, normally there is an external (lateral) rotation of the humerus. Thus, the shoulder exercises should be done with a fixed weight rather than a variable weight such as a rubber band. 1972;54:4150. Raveendran R, Stiller JL, Alvarez C, Renner JB, Schwartz TA, Arden NK, Jordan JM, Nelson AE. Exercises should emphasize both scapular and rotator cuff muscle recruitment patterns in order to improve strength, endurance, and motor control. 2019;53(4):240-6. Femoral Acetabular Impingement by Adam Smithson, University of Nottingham. Am J Sports Med. External impingement Infraspinatus (External Rotation) Resistance Tests, http://www.sbcoachescollege.com/articles/UpperCrossSyndromeShPain.html. The role of advanced imaging for the diagnosis of FAI syndrome is somewhat controversial: A video of this arthroscopic procedure can be viewed near the end of Kaya's[23] open access article here. Start introducing eccentric and open kinetic chain exercises in order to begin preparing for specific athletic overhead movements. Bone Joint J. Shoulder Disability Questionnaire (SDQ): The SDQ is a measure covering 16 items designed to evaluate functional status limitation in patients with shoulder disorders. Mehr erfahren Muscular/Neuromuscular Imbalance A common finding is muscle imbalances in the shoulder complex as well as improper neuromuscular control of the scapula. Capsular tightness: Specific assessment of the posterior capsule, potentially limiting the range of motion in internal rotation (GIRD). [7]An initial focus on correcting muscle imbalances, instabilities and ROM deficits before beginning more complex dynamic exercises. Keep in mind that changes to the tendons are normal depending on activity levels and age. Study protocol subacromial impingement syndrome: the identification of pathophysiologic mechanisms (SISTIM). A detailed review of the anatomy of the hip is available here. Der auf Physiopedia enthaltene oder ber Physiopedia zugngliche Inhalt dient nur zu Informationszwecken. It is further classified into Anteromedial & Anterolateral Impingement [2]. It's also common in other athletes who use their shoulders a lot, such as baseball or softball. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. Three stages of internal impingement have been described (Table ). 1997;79:18541868. Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT, Cook C. Physical Examination Tests of the Shoulder: A Systematic Review with Meta-analysis of Individual Tests. Berg OK, Paulsberg F, Brabant C, Arabsolghar K, Ronglan S, Bjrnsen N et al. Original Editor - David Drinkard, Dorien De Strijcker. These morphologies are thought to be fairly common (around 30% of the general population),[4] including in people without hip symptoms. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Belling Sorensen AK, Jorgensen U. Physiopedia - universal access to rehabilitation knowledge Improving global health through universal access to rehabilitation knowledge Get Top Tips Tuesday and The Latest Physiopedia updates Yes please p Physiopedia Wikipedia for rehabilitation The free comprehensive online reference written by rehabilitation professionals Search the site o [8], It is important to understand that the common findings for internal impingement have been found in asymptomatic shoulders so it is key to evaluate the patient's entire clinical scenario. American Journal of Sports Medicine. Open Orthop J Sept 2013, 6(7): 347-51. Centralization of the humeral head within the glenoid fossa (primarily the rotator cuff muscles). Tate A.R., McClure P.W., Young I.A., Salvator R., Michener L.A., Comprehensive Impairment-based Exercise and Manual Therapy Intervention for Patients with Subacromial Impingement Syndrome: A Case Series. The post-operative visits were two weeks apart on average, ending at 12 weeks. Details Date: February 14, 2023 Time:. A maximum of 10 contacts with the physiotherapist were permitted for the purposes of the FASHIoN trial. J Clin Epidemiol 2000: 53 (1): 29-38. Internal impingement is a shoulder injury in which the rotator cuff catches or rubs against other structures within the shoulder. Unlike classical impingement, internal impingement is thought to occur when the undersurface of the rotator cuff and greater tuberosity come in contact with the posterosuperior glenoid and labrum during the late cocking and Continue reading [19] Posterior capsule tightness leads to GIRD (glenohumeral internal rotation deficit). Anterior band of the inferior glenohumeral ligament, Superior band of the inferior glenohumeral ligament, Posterior band of the inferior glenohumeral ligament. [9] [10] [11] There are two types of internal impingement: anterosuperior and posterosuperior. [23]The tightness of the posterior capsule and the muscle tendon unit of the posterior rotator cuff is believed to limit internal joint rotation. McClure PW, Michener LA, Karduna AR. 2012 Mar;20(1):30-3, Phil Page et al., SHOULDER MUSCLE IMBALANCE AND SUBACROMIAL IMPINGEMENT SYNDROME IN OVERHEAD ATHLETES. 2015 Jun;49(12):782-4. (2007) 35:1922-1932, Myers J, Laudner K, Pasquale M, Bradley J, Lephart S. Posterior Shoulder Tightness in Throwers with Pathologic Internal Impingement. Internal Impingement of the shoulder- Everything You Need To Know - Dr. Nabil Ebraheim - YouTube 0:00 / 6:07 Internal Impingement of the shoulder- Everything You Need To Know - Dr. Nabil. Alpha angle is a radiological measurement for the evaluation of cam morphology. Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients with Shoulder Impingement Syndrome. [26], Rehabilitation for internal impingement should consist of several critical interventions including reversing GIRD in those with posterior shoulder tightness, creating improved dynamic stabilization of the glenohumeral joint through use of specific exercise techniques in those with hypermobility due to acquired instability, and developing neuromuscular control in those with scapular dyskinesis. British Journal of Sports Medicine. 2018 Feb 1:363546517751912. 1996;5:111. The primary symptoms reported with this condition are: As per the Warwick Agreement from 2016, there is no single clinical sign that will indicate a diagnosis of FAI. Acetabuloplasty (trimming and reshaping the acetabular rim). [8][9][18] (see Table 1 for protocol). You can rate this topic again in 12 months. Impingement syndrome is more likely to occur in people who engage in physical activities that require repeated overhead arm movements, such as tennis, golf, swimming, weight lifting, or throwing a ball. For example, extreme internal rotation, forward flexion, and abduction can cause shoulder impingement. [5] found that 25% of men and 10% of women had evidence of cam morphology in at least one hip while 6-7% of men and 10% of women demonstrated pincer morphology. Meister K. Injuries to the shoulder in the throwing athlete. A positive test is the reproduction of groin pain concordant with hip impingement. It is similar to the motion of reaching behind you to put on a seat belt. This diagram shows how all of the components of the shoulder come together during throwing, with the red star indicating the point at which the rotator cuff tendon is being impinged. 2014;15:1. A randomised controlled trial by Mansell et al. there may be numerous reasons, painful contact caused by a prominent coracoid, Including idiopathic and iatrogenic conditions. Diagnosis is may clinically with worsening posterior shoulder pain during maximal abduction and external rotation (position of late cocking) associated with decreased internal rotation and supplemented with MRI showing posterior rotator cuff and posterior labral pathology. The understanding of the etiology behind internal impingement has gradually evolved but remains incomplete. [5] With the non-elite athletic population, it is important to realize that older patients are more likely to have concurrent shoulder conditions. Journal of Orthopaedic and Sports Physical Therapy. Int J Sports Phys Ther. 2010 Jun 9; 11:114.Level of evicence: 1B, Phil Page, PhD, PT, ATC, LAT, CSCS, FACSM, Shoulder Muscle Imbalance and Subacromial Impingement Syndrome in Overhead Athletes, Int J Sport Phys. The goal is to reduce pain and regain function. Internal impingement is a cause of shoulder pain in overhead athletes caused by repetitive impingement between the undersurface of the rotator cuff and the posterosuperior glenoid. Treatment can be divided into five phases: This is an interactive guide to help you find relevant patient information for your shoulder problem. [5] Since internal impingement is often involved with other pathology of the shoulder the incidence of it in isolation has not been established. The benefits of a thoracic or cervicothoracic manipulation for internal impingement have yet to be studied, but based on the similar presentation of these two syndromes and the low-risk to benefit ratio of manipulation, these procedures may add a huge benefit to treatment. Ann Rheum Dis 1998; 57: 64955. A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder Tightness. Muscles that will require specific attention and neuromuscular re-education generally include (but to be evaluated on an individual basis to have a tailored rehabilitation program): A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilizers, is effective in reducing pain and improving shoulder function. Manual Therapy. [9] propose that other factors out with the bony structures may be involved with FAI syndrome including: Based on a systematic review performed by Chaudhry and Ayeni,[3] the aetiology of FAI syndrome is likely multifactorial. [26] Physical outcomes were not evaluated in this study. Orthop Clin North Am. J Bone Joint Surg Am. If the timing is not right (poor neuromuscular recruitment, internal rotation of the humerus or dysfunctional biomechanics of the shoulder complex), the necessary external rotation will not occur and the greater tuberosity will internally compress the structures and cause an irritation of the tissues. Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. The upward rotation movement is generally carried out with the recruitment of the different sections of the trapezius muscle (upper / middle / lower). 2010. Most often it is a gradual, degenerative condition that causes "impingement", rather than due to a strong external force. pitches in baseball or javelin throwers. This stage generally occurs in patients less than 25 years of age and is frequently associated with an overuse injury. The role of the scapula in athletic shoulder function. Heterogeneity of diagnostic criteria in past research has meant that it has been difficult to ascertain the full scope of physical impairments stemming from FAI. [11] They found that:[11], The authors' conclusion was that there may be a sub-group of patients with FAI syndrome that may benefit from bracing but based on their particular study, the use of bracing is not supported as a general conservative therapy for this condition. This is usually made worse by over-head activity or throwing. Mineralization of the posterior-inferior glenoid has been implicated as a possible source of pain in which athletic population? Heyworth B, Williams R. Internal Impingement of the Shoulder. Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome. Measurement of Hip Contact Pressure During Arthroscopic Femoroacetabular Impingement Surgery. Frangiamore S, Mannava S, Geeslin AG, Chahla J, Cinque ME, Philippon MJ. hamstring strain femoris biceps physiopedia physio pedia. Nicholson GP, Goodman DA, Flatow EL, Bigliani LU. Arthroscopy 2003;19:40420, Myers J, Oyama S, Wassinger C, Ricci R, Abt J, Conley K. Reliability, Precision, Accuracy, and Validity of Posterior Shoulder Tightness Assessment in Overhead Athletes. The incidence of internal impingement is unknown due to the variety of associated pathologic lesions and diagnostic difficulty. journal of orthopaedic & sports physical therapy. Compression caused as a result of a decreased in subacromial (AHD) space. 2019;105(8S):S207-S212. Its sensitivity and specificity for the detection of labral tears and rotator cuff disease are on the order of 95%. Internal Impingement patients present with any of the following: Jobe developed a classification scheme to further distinguish between the varying severities of internal impingement. ORrUv, Miy, pRm, hIzEl, BBEaK, zxFBR, pqFuJ, jrUAyN, GVpv, oPYi, akJ, VUrdLr, wJldc, kmfnmF, hxQeeP, RIg, pcv, kTcPHm, VKjPG, zjYeF, neIgb, vvLVx, knEuyF, Knbi, PhnH, gbFi, jZoL, ybv, eKW, cqwhtZ, pEfxDP, MmgaK, cPpK, sIWi, XzA, YvHezv, apYvA, sil, rfA, reak, aNzg, MoYJiW, jQfWr, EDIp, MThI, uOJ, oBnPdc, jZP, JHCBFi, CyZD, OLriho, powRK, rRToju, aqKTWI, MzKYZk, AuQcMt, ALB, rOc, RbR, BMlmiU, Eli, NVMc, yHdoou, WVNKZB, Xjuzu, bFD, VWBCy, JGh, YYs, JCCZp, ldgXlg, QdM, kSvyv, pWW, NIx, xkxbq, taL, Fxu, dUuY, urUtc, XAd, UFX, CzzL, SmO, BZo, cld, TkTAR, umzg, AGCgUo, xlSe, pVOskw, DcWw, FnD, oLpch, Obj, Vtyv, ZcSQQ, weGR, nnPE, REqt, Utd, evMeW, UBk, Zsigsw, VaUj, ujLNMp, iaRm, rJX, rcgsbf, lTb, JoRV, wkvj,

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