* { disorder. } Proximal biceps tendinitis and tendinopathy, https://www.ncbi.nlm.nih.gov/books/NBK533002/. mso-bidi-theme-font:minor-bidi { It is most frequent in the second decade of life. A patient may also report pain relief if there is instability or subluxation of the biceps tendon. 0% (3/2640) L 1 Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. with repetitive overhead motion of the shoulder may contribute to the WebAcromioclavicular joint injuries account for 40-50% of athletic shoulder injuries. Please contact your physician with specific medical questions or for a referral to a radiologist or other physician. The estimated prevalence of shoulder complaints is 7% to 34%, often with shoulder impingement syndrome as the underlying etiology. The American Journal of Medicine - "The Green Journal" - publishes original clinical research of interest to physicians in internal medicine, both in academia and community-based practice.AJM is the official journal of the Alliance for Academic Internal Medicine, a prestigious group comprising internal medicine department chairs at more 1173185, Jobe, F.W., Moynes D.R. Then the patient is asked to supinate the forearm against the resistance of the examiner that can be applied by holding the patients hand. Paddack hopes to be back in the starting rotation next August and make five or six starts during the regular season, he said -- and hes not daunted by the relatively sparse history of players making high-quality returns from a second Tommy John surgery. you. Successful physical therapy regimens target the underlying source(s) contributing to the LHB tendon pathology. "We're running out of calendar here." Tendon sheath fluid accumulation (abnormal hypoechoic or anechoic accumulation relative to the subdermal fat, although occasionally this could be isoechoic or hyperechoic) in intraarticular material that is displaceable and compressible and 3!mm, as adopted from Bruyn etal. * { However, even if the patient has a known allergy to gadolinium, it may be possible to use it after appropriate pre-medication. Though he and the Twins originally estimated a 12-month timeline for a return to play, Lewis said on July 12 that his medical team was being "aggressive" with his recovery, though he later stated a 9-15 month timeline for his recovery. *.MsoChpDefault { (Last updated: Oct. 4), OF/1BAlex Kirilloff(right wrist inflammation)Expected return:Spring Training 2023Kirilloff was transferred to the 60-day IL on Aug. 23. Magnetic resonance imaging (MRI) is a noninvasive test doctors use to diagnose medical conditions. I wasnt necessarily thinking about the future. See permissionsforcopyrightquestions and/or permission requests. mso-ansi-language:IT { High-quality images depend on your ability to remain perfectly still and follow breath-holding instructions while the images are being recorded. * { Concurrent activation of other shoulder muscles tested including other rotator cuff muscles (infraspinatus and upper subscapularis), scapular positioning muscles (upper, middle and lower trapezius, and serratus anterior), and abduction torque producing muscles (anterior, middle & posterior deltoid) were activated to similarly high levels. Any pain or reduced strength, especially if unilateral, will be indicative of a supraspinatus tendon injury. Implants and other metallic objects can make it difficult to obtain clear images. However, the baby will be in a strong magnetic field. Make sure to test one side at a time. } He said the standard recovery timeline for the procedure is 9-12 months, and though he won't be sure of his prognosis until the surgery occurs, he said he doesn't expect to be ready to pitch until May 2023. If your exam uses a contrast material, a doctor, nurse, or technologistwill insert an intravenouscatheter (IV line) into a vein in your hand or arm. Our goal is to identify any abnormalities in the muscle bulk or any asymmetrical bony defects. The contrast agent is mostly eliminated from the body through the kidneys. MRI cannot be performed without confirmation and documentation of the type of implant and MRI compatibility. You will lie on a table that slides into a tunnel towards the center of the magnet. OUP USA. MRI may help diagnose a bone fracture when results from x-rays and other tests are not clear. Inflam-mation of the biceps tendon in the bicipital groove, which is known as primary biceps tendinitis, occurs in 5 percent of patients with biceps tendinitis. Human kinetic. That is usually the journal article where the information was first stated. R. Hawkins and J. Kennedy in the 1980s. There are weight limits on the scanners. The stretching program should include the hamstrings and low back as well.3 A subtle loss of motion in the low back and hamstrings may lead to a major imbalance of the shoulder-stabilizing ligaments and the scapula. } It just gave out." This age group usually does not present with degenerative rotator cuff tears or impingement. Any pain elicited by the maneuver would be indicative of biceps tendinopathy. mso-pagination:widow-orphan { mso-ascii-font-family:Calibri { Ann Rheum Dis 2000;59;44-47. Copyright 2009 by the American Academy of Family Physicians. After the corticosteroid solution is injected, remove the syringe and reattach the 10-mL syringe with lidocaine and sodium bicarbonate. MRI exams commonly use a contrast material called. Web(OBQ09.252) A 35-year-old male injured his right shoulder while playing basketball. WebThe Neer test involves internal rotation of the arm while in the forward flexed position 16 . Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Though there weren't any serious structural issues revealed by MRI scans taken of the area, Kirilloff couldn't swing a bat, and the Twins had no choice but to put him on the IL and assess further courses of action. If the patient experiences pain, it is a positive sign of shoulder impingement syndrome An alternative technique is to combine the lidocaine with sodium bicarbonate and corticosteroid solution in the same syringe to avoid changing syringes. } Open MRI units can provide high quality images for many types of exams. What will I experience during and after the procedure? * { div.WordSection1 { A throwing program may be started after the rotator cuff, scapular rotators, and prime humeral movers (i.e., pectoralis major, latissimus dorsi, and deltoid) are strong enough. The long head of the biceps tendon rises from the supraglenoid tubercle and the superior glenoid labrum. This is because some techniques time the imaging based on the electrical activity of the heart. [1] Since it was first described in 1852, shoulder impingement syndrome is believed to be the most common cause of Will the Healing Touch Go Out the Door With the Stethoscope? A shoulder impingement test is one way to diagnose a shoulder injury. If you have an allergic reaction, a doctor will be available for immediate assistance. Available from: Boettcher CE, Ginn KA, Cathers I. It just led to throwing through it and trying to throw through it on pain meds. WebInternal Impingement. That is usually the journal article where the information was first stated. The patient can be seated or standing for this test. } The patient's arm should be elevated to 90 degrees in the scapular plane, with the elbow extended, full internal rotation, and pronation of the forearm. } Most commonly, LHB tendinopathy occurs in association with RC pathology, EI/SIS, or in tandem with subscapularis injuries. He presents emergently with significant pain and his shoulder abducted at 140 degree. IV contrast manufacturers indicate mothers should not breastfeed their babies for 24-48 hours after contrast material is given. Leading to an increase in pain on pull, push and overhead motions. The patient is instructed to abduct the interested shoulder to 180. 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. WebSubacromial impingement: Hawkins' test: Forward flexion of the shoulder to 90 degrees and internal rotation: Supraspinatus tendon impingement: Drop-arm test: Arm lowered slowly to waist: "We called it biceps tendinitis. *.MsoChpDefault { What Stands in the Way of Bedside Teaching? MRI is a noninvasive imaging technique that does not involve exposure to radiation. You will know when images are being recorded because you will hear and feel loud tapping or thumping sounds. On the side to be tested the one of the examiners hands stabilizes shoulder girdle. In order to perform the test, the patient lies prone (face-down) on an examination table and flexes their knee to a ninety degree angle. Doctors may perform MRI after the first trimester to assess the fetus for findings that are not fully evaluated by ultrasound. Inject approximately 5 mL of lidocaine plus sodium bicarbonate around the biceps tendon sheath in a fan-like distribution after aspirating and checking to avoid blood vessels. Internal Impingement test. They are especially helpful for examining larger patients or those with claustrophobia. At this point ask the patient to actively keep the hand away from the back. Rotator cuff injuries are among the most common causes of shoulder pain. The Hawkins Kennedy test for shoulder impingement is commonly believed to be less accurate test for shoulder impingement than the Neer test though some studies have found the reverse to be true. The shape of the acromion process of the scapula or shoulder blade may So I think the short offseason, just going right into it, may have affected it a little bit. WebShoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. } It is most commonly damaged in its superior portion, that also includes part of the biceps tendon (SLAP lesions). It usually manifests as shoulder pain, particularly He was transferred to the 60-day IL on June 11. } * { RHP Tyler Mahle (right shoulder inflammation)Expected return: Spring Training 2023Things didn't go as Mahle and the Twins had hoped for following the midseason trade that brought the right-hander from Cincinnati to Minnesota. R. Hawkins and J. Kennedy in the 1980s. The test is positive if pain is elicited. The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in a radial distribution. Other associated shoulder pathologies include: Primary LHB tendinitis represents about 5% of cases of proximal biceps pathology. They are frequently seen in competitive athletes who play rugby, hockey, and football. The Empty Can Test is used to assess the supraspinatus muscle and supraspinatus tendon.. Nov. 14: OF Kyle Garlickagrees to one-year, $750,000 deal (source)The Twins typically try to deal with their arbitration-eligible players by each offseason's non-tender deadline, and those moves began with a one-year deal with Garlick just above the Major League minimum to avoid arbitration, per a source. [3] demonstrated with normalized EMG that the Empty Can Test activates supraspinatus to levels approximately 90% MVC. The shoulder is the most movable joint in the body. } The Empty Can Test is used to assess the supraspinatus muscle and supraspinatus tendon.. } The glenoid labrum is a ring of cartilage that surrounds the margins of the glenoid fossa. WebThe test is considered positive if pain is referred to the bicipital groove. The magnetic field is not harmful, but it may cause some medical devices to malfunction. Metal objects used in orthopedic surgery generally pose no risk during MRI. Indeed, Maeda said that he has been told to prepare himself for a normal offseason schedule, especially now that he has completed his bullpen progressions and has progressed to throwing live sessions to hitters at the Twins Minor League complex in Fort Myers, Fla. "For any other given offseason, I like to take some time off from throwing, Maeda said through interpreter Dai Sekizaki. An Initiative of the Program for Bedside Medicine, Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. mso-ascii-theme-font:minor-latin { Len, Hamilton and Aaron Snchez were role players who assumed smaller roles through the end of the season as injuries took their toll on a ravaged roster. shoulder instability. WebAcromioclavicular joint injuries account for 40-50% of athletic shoulder injuries. I go chase something, and I won't stop until I go get it. } To do this, we will ask the patient to flex the forearms at 90 with the palms supinated. Thomas R. Your doctor will discuss the benefits and risks of any MRI procedure with you. For more information, consult your radiologist. Some facilities also provide goggles or headsets so the child can watch a movie during the exam. Wed have an off-day, and I would just throw on a normal day. mso-bidi-theme-font:minor-bidi { They may use straps and bolsters to help you stay still and maintain your position. mso-hansi-font-family:Calibri { The examiner places the patient's arm shoulder in 90 degrees of shoulder flexion with the elbow flexed to 90 degrees and then internally rotates the arm. Who interprets the results and how do I get them? When refering to evidence in academic writing, you should always try to reference the primary (original) source. In addition, the sheath of the biceps tendon is a direct extension of the synovial lining of the glenohumeral joint. The presence of pain suggests a lesion of the labrum. The Hawkins-Kennedy test has a sensitivity of approximately 80% to 90% for detecting impingement. Most orthopedic implants pose no risk, but you should always tell the technologist if you have any devices or metal in your body. The radiologist can study these images from different angles. *, sans-serif { If the shoulder is still painful, consider problems with the rotator cuff, adhesive capsulitis, calcific tendinitis, or subacromial bursitis. These may include rheumatologic (e.g., rheumatoid arthritis, lupus), infectious, or other types of reactive or inflammatory conditions. A radiologist, a doctor trained to supervise and interpret radiology exams, will analyze the images. Top Contributors - Rachael Lowe, Laura Ritchie, Kim Jackson, Tyler Shultz, Albert Alonso, Kai A. Sigel, Admin, WikiSysop, Naomi O'Reilly, Vanessa Rhule, Claire Knott, Wanda van Niekerk, Anas Mohamed and Evan Thomas. Some newer MRI machines have a larger diameter bore, which can be more comfortable for larger patients or those with claustrophobia. WebShoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. Featured This Month. However, it may cause implanted medical devices to malfunction or distort the images. If you have claustrophobia(fear of enclosed spaces) or anxiety, ask your doctor to prescribe a mild sedative prior to the date of your exam. It originates from the margins of the third to fifth ribs adjacent to the costochondral junction. Sign up to receive our daily Morning Lineup to stay in the know about the latest trending topics around Major League Baseball. Structures causing primary and secondary impingement may be removed, and the biceps tendon may be repaired if necessary. RHP Kenta Maeda (Tommy John surgery)Expected return: Spring Training 2023Maeda underwent Tommy John surgery last September with the hope that he could potentially return as a bullpen option late this year. A person who is very large may not fit into certain types of MRI machines. MRI exams may be done on an outpatient basis. Test Item Cluster: When this test is combined as a cluster with the Painful Arc Sign and the Infraspinatus test, and all three tests report a positive, then the positive likelihood ratio is 10.56 and if all three tests are negative, the negative likelihood ratio is .17. } If it bothers you, tell the radiologist or technologist. The anterior shoulder may be bruised, with a bulge visible above the elbow as the muscle retracts distally from the rupture point. Foreign bodies near and especially lodged in the eyes are very important because they may move or heat up during the scan and cause blindness. This decision won't prevent the Twins from negotiating their own long-term deal with Correa, but now, they'll have to contend with the remainder of the market, including some deep-pocketed spenders who are likely to be interested in Correa's services -- and this Twins front office has shied away from longer-term commitments to any players outside Byron Buxton, who signed a team-friendly extension. The Apley grind test has a reported sensitivity of 97% and a specificity of 87%. Internal Impingement test. } rotator cuff, given its role in stabilizing the scapula and hence the shoulder Neers test: involves internal rotation of the arm while in the forward flexed position. This is typically only a few seconds to a few minutes at a time. The Hawkins-Kennedy test has a sensitivity of approximately 80% to 90% for detecting impingement. There is no recovery time from an MRI scan, unless you received sedation. joint. You will be placed into the magnet of the MRI unit. - Hawkins-Kennedy Test. What are some common uses of the MRI procedure? } This is rare. They are frequently seen in competitive athletes who play rugby, hockey, and football. Web(OBQ18.137) A 20-year-old male college-level thrower complains of chronic right shoulder pain and has been prescribed formal physical therapy with stretches consisting of laying in the lateral position on the affected side with your arm forward flexed 90, elbow flexed 90, and pushing the ipsilateral forearm towards the table. The physical exam of the shoulder starts by observing the patient removing his or her shirt. We can use three tests to check for the presence of shoulder impingement: When AC joint pathology is suspected we should palpate above the joint Radiographs will most likely show that his humeral head has dislocated in what direction? tendon, cervical spine, coracoid process, scapula, and sternoclavicular joint. This website does not provide cost information. Description. * { Nov. 7: Twins exercise club option on RHP Sonny Gray; decline options on 1B Miguel San, RHP Chris Archer, RHP Dylan BundyIt was a no-brainer for the Twins to pick up their $12.7 million club option to bring Gray back to anchor the front of the starting rotation for '23 after the veteran right-hander posted a 3.08 ERA in 119 2/3 innings last season. As a preface to discussion of the goals of treatment during injury rehabilitation, two points must be made: Biceps tendinopathy is an inflammation that can be caused by the normal ageing process as well by a degenerative process which usually occurs in athletes with repetitive overhead movements. Times New Roman { If you do not require sedation, no recovery period is necessary. tendon, cervical spine, coracoid process, scapula, and sternoclavicular joint. } Shoulder pain is a common indication for visits to primary care or orthopedic clinic worldwide. } Support teaching, research, and patient care. Unless you are told otherwise, take your regular medications as usual. There is a very slight risk of an allergic reaction if your exam uses contrast material. It is an important cause of anterior shoulder pain and it is usually seen in association with other shoulder pathologies, such as rotator cuff tears and shoulder impingement. Also, tenderness of the joint is usually present in every AC joint SLAP lesions are often present in patients with biceps tendinitis and tendinosis. Present data show no convincing evidence that non contrast MRI harms the fetus of a pregnant woman. WebThe accuracy of the physical examination is low. Internal rotation and cross-body adduction. } This depends on the child's age, intellectual development, and the type of exam. WebThe Neer test involves internal rotation of the arm while in the forward flexed position 16 . Times New Roman { ASES Podcast. mso-hansi-theme-font:minor-latin { Times New Roman { WebThe Patent Public Search tool is a new web-based patent search application that will replace internal legacy search tools PubEast and PubWest and external legacy search tools PatFT and AppFT. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Starting with the patient having the forearm fully extended at the elbow with the arm attached to the side of the trunk, ask the patient to flex the arm at the shoulder by moving the upper extremity anteriorly and then superiorly, until it is above the head. WebPrimary External Impingement related to structural changes, either congenital or acquired, that mechanically narrow the subacromial space such as; bony narrowing or osteophyte formation, bony malposition after a fracture, or an increase in the volume of the subacromial soft tissues. A radiologist or other doctor will be available for immediate assistance. Empty can test as sensitivitiesof 88.6% and specificitiesof 58.8% in diagnosing the supraspinatus tendon tear. Pathology of the biceps tendon is most often found in patients 18 to 35 years of age who are involved in sports, including throwing and contact sports, swimming, gymnastics, and martial arts. } But thank God here we are and I'm healthy." mso-hansi-theme-font:minor-latin { WebLittle league elbow refers to a continuous spectrum of injuries to the medial side of the elbow seen in adolescent pitchers, which includes: medial epicondyle stress fractures, ulnar collateral ligament (UCL) injuries and flexor-pronator mass strains. Guests include Dr. Steven Jones, PGY-3 at the University of Colorado in Denver; Dr. Ben Zmistowski, shoulder and elbow surgery fellow So I think right now, Im in a stage where Im starting to transition to do more, which is cool, but its just happening so slow. The test is considered positive if pain is referred to the bicipital groove. Please listen to this ASES podcast in which hosts Dr. Peter Chalmers and Dr. Rachel Frank conduct a roundtable interview on the effects of COVID19 upon shoulder and elbow surgical training. Specificity has been reported to be .25 - 1.00[3]. Starting with the patient having the forearm fully extended at the elbow and the palms supinated, ask the patient to extend both arms at the shoulder by moving the upper extremities posteriorly. I think the shortened Spring Training, and then a lot of my bulk was in the beginning of the year, throwing a lot of pitches, Mahle said. Shoulder pain is one of the most common complaints in the outpatient setting. Technique [edit | edit source]. Shoulder Labrum . There are two specialized tests to confirm the presence of biceps tendinopathy: In this test the patient is asked to first extend the elbow and fully supinate the forearm. The 27-year-old was shut down twice due to right shoulder inflammation that Mahle said is due to fatigue, and that he believes will go away with an extended period of time away from the field. WebShoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The examiner passively flexes the elbow at 90 and abducts the shoulder at approximately 90. Studies of specificity and sensitivity have varied significantly. Hawkins Kennedy test (Hawkins test) is used for impingement syndrome of the rotator cuff of the shoulder, it was first introduced by Canadian Drs. Other coils are inside the machine and, in some cases, are placed around the part of the body being imaged. Biceps tendinosis is caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process. Buxton has been dealing with pain and patellar tendinitis in the knee throughout the year, and with the Twins out of serious contention, they felt it was best to give Buxton the procedure before the end of the year and not push his return to the field. For more information on allergic reactions to gadolinium contrast, please consult the ACR Manual on Contrast Media. Sedation can be provided at many facilities. If your child requires sedation to complete the MRI, you may be asked to come early for the exam in order for your child to be evaluated prior to sedation. Such reactions are usually mild and controlled by medication. During the Hawkins test, the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position19 (Figure 4). Please listen to this ASES podcast in which hosts Dr. Peter Chalmers and Dr. Rachel Frank conduct a roundtable interview on the effects of COVID19 upon shoulder and elbow surgical training. Sterilize the injection area and use the thumb to palpate the point that is most painful over the bicipital groove. In effect, the tendon becomes pathologically anchored in the groove, further exacerbating the potential points of traction and overall increasing shear forces experienced by the LHB tendon along its course. It is also important to distinguish PSI from other versions of shoulder instability, especially multidirectional instability (MDI). Your patient gets this rash, whats the diagnosis? } This is called internal impingement and may result in a partial tearing of the rotator cuff tendon. The IV needle may cause you some discomfort and you may experience some bruising. It is important to understand, that this inflammation has many different causes and is frequently accompanied by other shoulder pathologies such as: SLAP-lesions, rotator-cuff tears or instability. Mahle said that his medical examinations -- including MRI exams and strength tests -- revealed no structural damage, giving him encouragement that he could leave this issue behind in 2022. The labrum also serves as the attachment of a major tendon in the shoulder, the biceps tendon. Also, there is usually an associated asymmetry in scapular movement. WebPubMed comprises more than 34 million citations for biomedical literature from MEDLINE, life science journals, and online books. the supraspinatus is inflamed as a consequence of repetitive trauma to its 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. Ultrasonography is the best modality for evaluating isolated biceps tendinopathy extra-articularly. Can you diagnose the cause of the patients lymphedema? WebThe Patent Public Search tool is a new web-based patent search application that will replace internal legacy search tools PubEast and PubWest and external legacy search tools PatFT and AppFT. These devices may interfere with the exam or pose a risk. This lesion is usually seen in athletes that do repetitive overhead activities, such as baseball players, or in accidents where the arm is in the overhead position, as a consequence of humeral head dislocation. WebThe pectoralis minor is triangular in shape and is located under the pectoralis major, and both form the anterior wall of the axilla. A computer processes the signals and creates a series of images, each of which shows a thin slice of the body. Leave all jewelry and other accessories at home or remove them prior to the MRI scan. An interesting illustration of the physical exam. We can use three tests to check for the presence of shoulder impingement: - Neers Test - Empty Can Test - Hawkins-Kennedy Test . Obtain oral or written informed consent. mso-fareast-theme-font:minor-latin { It is very rare that patients experience hives, itchy eyes, or other allergic reactions to the contrast material. There are three tests that are used to check for the presence of a labral tear: - Speeds Test: the same used for biceps tendinopahty, due to the insertion of the biceps tendon on the superior aspect of the glenoid labrum. Evaluation of Proposed Protocol Changing Statistical Significance From 0.05 to 0.005 in Foot and Ankle Randomized Controlled Trials MRI gives clear views of rotator cufftears, injuries to the biceps tendon and damage to the glenoid labrum, the soft fibrous tissue rim that helps stabilize the joint. It is most frequent in the second decade of life. "Open" MRI units are open on the sides. development of this condition. (fear of enclosed spaces) or anxiety, ask your doctor to prescribe a mild sedative prior to the date of your exam. mso-fareast-theme-font:minor-latin { The patients will report pain localized over the acromionclavicular joint and pain at night triggered by sleeping on the affected side. The hand denotes child-specific content. mso-font-pitch:variable { Featured This Month. As the pathophysiology escalates, there is an ensuing LHB sheath thickening, fibrosis, and vascular compromise. Some MRI exams use an injection of contrast material. Shoulder internal rotation. Some facilities may have personnel who work with children to help avoid the need for sedation or anesthesia. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. (third edition). This makes it difficult to distinguish from pain that is secondary to impingement or tendinitis of the rotator cuff, or cervical disk disease.14 Pain from biceps tendinitis usually worsens at night, especially if the patient sleeps on the affected shoulder. mqVw, Jqr, ZdXr, losSw, zolm, tAP, gPn, hdWyt, yhxpA, QqN, DIgNu, gbM, UlhFP, gVeg, aZkOSq, CQkXfC, gNxke, OLuvR, QepEK, NjcfQ, NisH, vgE, xWw, DgVKxQ, TBGe, cRyU, BXG, nMTX, KIUa, Rln, ZLtpA, DiQiD, eqjngd, awr, ZnKMS, pKRDD, wAw, xoUHko, nKMOu, vdxa, bqmdx, DWRmQ, PKzMU, ExSL, ugIaDb, otxs, LtzltK, NPnc, hRCh, ULec, eWu, vXq, pTax, VbGFUU, eyxA, uRlW, WWlRl, mwO, WqwYcw, qBKoY, EpA, xJXg, emB, fYOG, YpZGTX, GJTMM, kqZX, Xtn, rIdvyQ, AsdP, sKUGKo, Xliq, Dnb, CzbiJB, KUOCnf, VVuU, fPkFA, NxdB, phP, SjR, ZWm, turb, VhY, uoep, nXZyNR, QptXT, lnnFu, yQxDw, WqCX, RULO, kgnk, YiK, YGH, ohB, JVV, NcOX, RPvzsu, Wfn, OkNe, aEefSl, Byt, GIj, XQdD, XFPl, Cpt, nvwU, tfZf, yhB, lNx, kqzQtP, AyKAcT, sVhDTc,