Watson AC, Jamieson RP, Mattin AC, Page RS. You may notice problems with Coracohumeral distances and correlation to arm rotation: An in vivo 3-dimensional biplane fluoroscopy study. For the hooked coracoid, the axis of the coracoid deviated posteriorly a few centimeters lateral to the base of the coracoid [9] (Figure 1C). During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. Friedman RJ, Bonutti PM, Genez B. Cine magnetic resonance imaging of the subcoracoid region. Although loculated, this distended subscapularis recess (asterisk) clearly demonstrates communication with the joint and the typical saddlebag appearance, and does not extend as far caudally as a subcoracoid bursa. Pearson correlation analysis was performed for coracohumeral distance and coracoglenoid angle, coracohumeral distance and coracohumeral angle, and coracoglenoid angle and coracohumeral angle. This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (, Magnetic Resonance Imaging, Rotator Cuff, Shoulder Impingement Syndrome, Coracohumeral distance, in axial T2-weighted FFE images (, Coracoglenoid angle, in axial T2-weighted FFE images (, Coracohumeral angle, in axial T2- weighted FFE images (, Medical Science Monitor : International Medical Journal of Experimental and Clinical Research, Brunkhorst JP, Giphart JE, LaPrade RF, Millett PJ. Identification of Diagnostic Magnetic Resonance Imaging Findings in 47 Shoulders with Subcoracoid Impingement Syndrome by Comparison with 100 Normal Shoulders. It is not uncommon for radiologists to confuse a distended subscapularis recess with the subcoracoid bursa. While the variability in the coracohumeral distance values between coracoid types was more prominent, there was no statistically significant difference due to less variability for coracoglenoid angle and coracohumeral angle values. A new approach uses coracohumeral angle to evaluate subcoracoid impingement. The subcoracoid bursa (SC) is separate and lies anterior to the subscapularis muscle and deep to the origins of the short head of the biceps tendon (SHB) and coracobrachialis (CB) muscles. There was a significant difference between normal and tendinosis groups (P=0.006) and between normal and tear groups (P=0.000) for coracoglenoid angle values. In pathologic situations such as trauma, arthritides or infection, a bursa becomes distended and fluid filled, and wall thickening may be observed in chronic cases. Authors Leonardo Osti 1 , Francesco Soldati , Angelo Del Buono , Leo Massari Affiliation 1 Unit of Arthroscopic and Sports Medicine, Hesperia Hospital, Modena, Italy. However, subcoracoid impingement is increasingly diagnosed in patients with anterior shoulder pain and tenderness [ 1 - 3 ]. An official website of the United States government. The presence of contrast filling the subcoracoid bursa has been described as an indirect sign of adhesive capsulitis on MR arthrography 15. Nevertheless, the results of our study are meaningful. ( A ) Flat coracoid. Because of its relative rarity in isolation and nonspecific presentation, diagnosis and management are often challenging for orthopaedic surgeons and their patients. We reviewed 13 consecutive patients suffering from this syndrome who underwent an arthroscopic treatment. FOIA Coracohumeral distance values were 213.5 mm. Oh JH, Song BW, Choi JA, et al. Before MeSH Clinical conditions that may cause changes in measurements of shoulder joints, such as tumors, shoulder surgery, osteoarthritis, inflammatory joint disease, hemophilic arthritis, pyrophosphate disease, and significant trauma (including fractures, dislocations and falling down), were excluded from the study. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process with different/possible . Am J Sports Med 2010; 38: 1687-1692, Meraj S, Bencardino JT, Steinbach L. Imaging of Cysts and Bursae about the Shoulder. 2009;2 (1): 51-5. Muscles Ligaments Tendons J. Learn more about navigating our updated article layout. Additional comprehensive studies are required that involve evaluations on different plans and that include dynamic imaging and correlation of MRI arthrography. Int Orthop. Figures 15 and 16 demonstrate loose bodies within the subscapularis recess and biceps tendon sheath, which communicate with the shoulder joint normally. There was a significant difference between type A and C coracoid for coracohumeral distance values (P=0.012), but no significant difference was found between other coracoid groups (P>0.05). Ethics Committee approval was obtained from Kirikkale University Faculty of Medicine (date: 08.05.2018, number: 10/02). Coracoglenoid angle, in axial T2-weighted FFE images ( white*; coracoid distal tip). Tears of the subscapularis tendon constitute 3137% of all repaired rotator cuff tendons [1012]. The supra-acromial and coracoclavicular bursae have been described as locations of calcific tendonitis 2, but are not as frequently identified as sources of pathology on MRI as the other bursae, which are more intimately related to the rotator cuff. The results of measurement of coracohumeral distance, coracoglenoid angle, and coracohumeral angle in the subscapularis tendon pathologies are shown in Table 3. In the development of subcoracoid impingement, studies on the variabilities of coracoid morphology, coracohumeral distance, and coracoglenoid angle have been published [1,37,9,10]. Impingement of the subcoracoid space is a poorly understood pathologic cause of anterior shoulder pain. Distention of the subcoracoid bursa has also been recognized in subcoracoid impingement and rotator interval tears, and may be associated with other pathology of the rotator interval such as adhesive capsulitis. 2006;186 (1): 242-6. A total of 200 patients (87 males with mean age of 51.115.2 years and 113 females with mean age of 52.610.7 years) undergoing shoulder MRI were included in this retrospective study. Coracoglenoid angle values decreased in type C coracoid but the variability was not more than 2 and no statistically significant difference was observed. Bennett WF. Our results suggest that type C coracoid is an especially important predisposing factor in subcoracoid impingement development. The discrepancy between these numbers has not been explained, but it has been speculated that significant bursal distension may disrupt normal barriers between the bursae5. A normal coracohumeral distance measures 8-11mm, with an average value of 5.5mm in symptomatic individuals 8,9. Tendons, ligaments, and capsule of the rotator cuff: gross and microscopic anatom. One possibility is that the rotator cuff tear has altered the joint space, resulting in new patterns of impingement. The small subacromial fluid collection (arrowheads) did not communicate with the subcoracoid bursa, and there was no full thickness rotator cuff tear. Imaging of the Bursae. We explain what to expect and whether there are any dietary restrictions before coming in for your imaging test or procedure. Osti L, Soldati F, Del Buono A, Massari L. Subkorakoid impingement and subscapularis tendon: is there any truth? -, Osti L, Soldati F, Del Buono A, Massari L. Subkorakoid impingement and subscapularis tendon: is there any truth? However, variabilities of coracoglenoid angle and coracohumeral angle between coracoid and subscapularis tendon groups are valuable for future studies. Received 2018 Jun 1; Accepted 2018 Aug 1. Arrigoni P, Brady PC, Burkhart SS. The amount of fluid within the subcoracoid bursa has not been directly correlated with degree of patients symptoms, but it has been suggested that larger amounts of fluid within the bursa correlate with the presence of a full thickness rotator cuff tear4. In subscapularis normal tendon subjects, orthopedic examination results were selected from those with no evidence of subcoracoid impingement. Generating an ePub file may take a long time, please be patient. We predict that type C coracoid from coracoid types is an especially effective factor in subcoracoid impingement. In the subscapularis tendon tears, the coracohumeral distance narrowed and the mean value was 6 mm. However, if subcoracoid im-pingement was the referring di agnosis, prospective MRI evalua tion more often was correct (n = 7 [three true-negatives, two true-positives, two false-negatives]). In our study, type A coracoid was the most frequent type, and type C coracoid was less frequent in the normal tendon group; type C coracoid was seen more frequently in the tendinosis and tear groups. Quantitative measurement of humero-acromial, humero-coracoid, and coracoclavicular intervals for the diagnosis of subacromial and subcoracoid impingement of shoulder joint. -. Impingement of the subcoracoid space is a poorly understood pathologic cause of anterior shoulder pain. Skeletal Radiol.1996;25:5137, Horwitz T, Tocantins LM. -, Kleist KD, Freehill MQ, Hamilton L, et al. Wynell-Mayow W, Chong CC, Musbahi O, Ibrahim E. JSES Int. Freehill MQ. Bookshelf 50816 cases. Isolated subacromial bursitis should be considered a diagnosis of exclusion after all other associated pathology has been ruled out. 1998;21(5):54548. Contributed by Mourad Kerdjoudj. The mechanism is increased with activities involving adduction, internal rotation, and forward flexion because the position decreases coracohumeral distance and impinges the intervening soft-tissue structures [ 4 - 6 ]. All MRI examinations were performed using surface coils by 1.5 Tesla (T) MRI systems (Philips MRI Systems, Achiava Release 3,2 Level 2013-10-21, Philips Medical Systems Nederland B.V.). Coracohumeral distance, coracoglenoid angle, and coracohumeral angle values were compared with post hoc Tukey test among the subscapularis tendon pathologies. The subscapularis tendon is thickened and displays abnormal intrasubstance bright signal in T2WI most likely partial tear. A statistically insignificant increase in coracohumeral angle values was found in the subscapularis tendon pathologies. This bursa does not normally communicate with the glenohumeral joint but may communicate with the subacromial bursa [ 1 ]. There was a negative correlation between coracohumeral distance and coracohumeral angle (R=-0.668 P=0.000) and between coracoglenoid angle and coracohumeral angle (R=-0.605 P=0.000). Identification of a fluid-filled subcoracoid bursa should thus prompt a diligent search for associated pathology of the shoulder. Since most arthrograms these days are performed in conjunction with MRI, this is not usually a significant problem, as MRI will reveal the status of the rotator cuff. [16]. Venous vascular malformation - thigh. Neither the subacromial nor the subcoracoid bursa should communicate with the joint under normal circumstances. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Abdrabou A, Subcoracoid impingement. CHD coracohumeral distance; CGA coracoglenoid angle; CHA coracohumeral angle. Angled or elongated coracoid type and calcification of the subscapularis tendon are among the idiopathic causes [17]. Nair AV, Rao SN, Kumaran CK, Kochukunju BV. Hekimoglu et al. Coracohumeral angle, in axial T2- weighted FFE images (white*; coracoid distal tip). Careers. A statistically insignificant increase in coracohumeral angle was noted. In many studies, a coracohumeral distance below 6 mm is considered to be significant for subcoracoid impingement in partial and full-thickness tears of subscapularis tendon [8]. No communication between subcoracoid and subacromial bursae. A statistically insignificant increase in coracohumeral angle was noted. 2021 Dec;29(6):367-375. doi: 10.1080/10669817.2021.1950300. There was a statistically significant difference in coracohumeral distance (P=0.000) and coracoglenoid angle (P=0.000), but there was no significant difference in coracohumeral angle (P=0.06). Okoro T, Reddy VR, Pimpelnarkar A. Coracoid impingement syndrome: A literature review. An early anatomic study identified the subcoracoid bursa in nearly 90% of gross specimens, and in 11% of those, there was a normal communication between the subcoracoid bursa and the subacromial/subdeltoid bursa 3. Direct MR visualization of rotator interval tears is acknowledged to be difficult5 and published illustrations are rare 13,14, but subcoracoid effusions have been reported in association with rotator interval tears5. Cetinkaya M, Ataoglu MB, Ozer M, Ayanoglu T, Kanatli U. Arthroscopy. Correctly identifying the subcoracoid bursa and its relationship to other bursae in the shoulder should prompt the MRI radiologist to search for specific associated abnormalities. (12c) A more lateral sagittal image demonstrates the distended subcoracoid bursa (arrowheads). AJR Am J Roentgenol. It extends caudal to the tendon of the coracobrachialis and the short head of the biceps. Giaroli EL, Major NM, Lemley DE, Lee J. Coracohumeral interval imaging in subcoracoid impingement syndrome on MRI. Limitations of the study are as follow. Report problem with Case; Contact user; 2007;16(2):24550. Giaroli et al. Correlation analysis among coracohumeral distance, coracoglenoid angle and coracohumeral angle. The aim of this study was to investigate the effects of coracoid morphology, coracohumeral distance, coracoglenoid angle, and coracohumeral angle variabilities on subcoracoid impingement development using magnetic resonance imaging (MRI). subscapularis tearing secondary to impingement technique resect posterolateral coracoid to create 7 mm clearance between coracoid and subscapularis if significant subscapularis tendon tear then repair open coracoplasty indications symptoms refractory to conservative treatment subscapularis tearing secondary to impingement technique Coracohumeral interval imaging in subcoracoid impingement syndrome on MRI. Distension of the subcoracoid bursa can be an isolated finding, but more frequently it is a marker of significant pathology elsewhere in the shoulder. The results measurement of coracohumeral distance, coracoglenoid angle and coracohumeral angle in the subscapularis tendon pathologies. Kim TK, Rauh PB, McFarland EG. Watson et al. Indeed this bursa is actually a recess of the joint, alternatively referred to as the subscapularis recess. For binary comparisons, Tukey post hoc analysis was done. Dugarte AJ, Davis RJ, Lynch TS, et al. Subcoracoid impingement has also been suggested as a cause of subcoracoid bursal distention5,7. The https:// ensures that you are connecting to the Coracohumeral distance, coracoglenoid angle, and coracohumeral angle values were compared with post hoc Tukey test among the types of coracoids. Curr Rev Musculoskelet Med. All measurements were calculated T2-weighted FFE-weighted sequences on axial plane by an expert musculoskeletal radiologist with at least 10 years of experience (NA). The subacromial bursa and the subcoracoid bursa do not communicate with the joint under normal circumstances. There is a notable absence of loose bodies in a distended non-communicating subcoracoid bursa (figure 16b). Surgeons often refer to the coracoid process as the "lighthouse of the. Disclaimer, National Library of Medicine Share Add to . American Journal of Roentgenology 2010;195: 567-576, Kim HJ, Han TI, Lee KW, et al. 2019 Aug;43(8):1909-1916. doi: 10.1007/s00264-018-4078-5. Prevalence of subscapularis tears and accuracy of shoulder ultrasound in pre-operative diagnosis. Coracohumeral angle, in axial T2- weighted FFE images ( white*; coracoid distal tip). Coracoid morphology and subscapularis tendon were evaluated. For coracoid morphology, the shape of the coracoid was determined according to whether it was straight or not, any osteophyte included, and whether it was curved. Type C coracoid was more frequent in the tendinosis and tendon tear groups. HHS Vulnerability Disclosure, Help The most valuable data of this study was the narrowed coracohumeral distance measurement. (17a) A fat-suppressed proton density-weighted axial image reveals a degenerated and medially dislocated long biceps tendon (arrow), providing presumptive evidence of a rotator interval injury. (14b) A sagittal fat-suppressed image confirms the fluid in the subscapularis recess (asterisk) decompressing out into the subcoracoid bursa (arrowheads). Coracoglenoid angle, in axial T2-weighted. P<0.05 was considered statistically significant. 8600 Rockville Pike There were For subscapularis tendinosis and tear pathologies in the normal tendon of cases, we observed a narrowed coracohumeral distance and a decreased coracoglenoid angle, as well as an increase in coracohumeral angle. There was a negative correlation between coracohumeral distance and coracohumeral angle (R=0.668 P=0.000) and between coracoglenoid angle and coracohumeral angle (R=0.605 P=0.000). If the patients palm is placed below the outer part of the gluteal muscle on the same side, the movement factor may also be inhibited. Narrow coracohumeral distance measures 6.5 mm (Normal > 10 mm).The subscapularis tendon is thickened and displays abnormal intrasubstance bright signal in T2WI most likely partial tear. Kragh J, Jr, Doukas WC, Basamania CJ. Subcoracoid impingement syndrome is the cause of anterior shoulder pain, first reported by Gerber et al. Imaging parameters were as follows: field of view, 1820 cm; matrix, 256182 pixels; slice thickness, 4 mm; section gap, 0.3 mm. Coracohumeral distances and correlation to arm rotation: An. eCollection 2022 May. The separate subcoracoid bursa (arrowheads) has an elongated configuration tracking inferior to the subscapularis recess, along the anterior inferior margin of the subscapularis tendon and deep to the coracobrachialis muscle and tendon (CB). Clinical presentation sharing sensitive information, make sure youre on a federal Radiologists often mistake a distended subscapularis recess for a distended subcoracoid bursa. All MRI studies were performed with standard positioning. Adhesive capsulitis of the shoulder: MR arthrography. Epub 2016 Dec 8. Clinical presentation Patients present with anterior shoulder p. Int Orthop. Determining the coracoid type is important for subcoracoid impingement due to the narrowing of the coracohumeral space [1,6,9,10]. The subacromial bursa and the subscapularis recess are in close proximity; both track anterior to the subscapularis muscle and deep to the coracoid process, separated only by a thin fibrous band. Radiology care teams at Ascension sites of care provide convenient imaging tests and quickly share results with you and your doctor. There was no significant difference among subscapularis tendon groups for coracohumeral angle. [10] used a coracoglenoid angle measurement on different planes and found a positive correlation between the coracohumeral distance and the coracoglenoid angle. [16] described an increased subcoracoid area after decompression surgery in symptomatic patients. Data are expressed as mean standard deviation (SD) or median (range). All MRI studies were static and used no special patient positioning technique. For binary comparisons, Tukey post hoc analysis was done. At the level of the glenoid, the next sagittal image demonstrates contrast within the subscapularis recess (asterisk) and the subcoracoid bursa (arrowheads) outlining the superior portion of the subscapularis musculotendinous junction (SSc). The site is secure. Relationship between narrowed coracohumeral distance and subscapularis tears. Mild amount of fluid surrounding the tendon of long head of biceps muscle (tendinitis). Subcoracoid impingement Last revised by Dr Henry Knipe on 15 Mar 2022 Edit article Citation, DOI & article data Subcoracoid impingement is an unusual form of shoulder impingement and results from narrowing of the coracohumeral interval (space between the tip of the coracoid and the humerus ). There is no study on coracohumeral angle measurement in the literature. 2022 Sep;14(3):441-449. doi: 10.4055/cios21261. Check for errors and try again. It is essential to properly distinguish these two potential spaces about the shoulder, since fluid within the subcoracoid bursa is considered pathologic, while the fluid in the subscapularis recess is due to a normal communication with the glenohumeral joint. Identification of a fluid-filled subcoracoid bursa should thus prompt a diligent search for associated pathology of the shoulder. Charry FB, Martnez MJL, Rozo L, Jurgensen F, Guerrero-Henriquez J. J Man Manip Ther. A small amount of fluid within the subscapularis recess is indicated (asterisk). Find the code on the page and enter it above. Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: A statistical analysis of sixty cases. MRI subcoracoid impingement diagnoses were falsely positive. (13b) A fat-suppressed proton density-weighted axial image demonstrates a partial thickness subscapularis tendon tear (arrow), and a narrowed coracohumeral distance (dotted line, measuring 3mm). Garofalo R, Conti M, Massazza G, et al. The results are expressed as meanstandard deviation (SD); CHD coracohumeral distance; CGA coracoglenoid angle; CHA coracohumeral angle. The coracoid impingement of the subscapularis tendon: A cadaver study. A bursa is a synovial lined potential space which reduces friction at tendon-tendon and tendon-bone interfaces. However, if subcoracoid im-pingement was the referring di agnosis, prospective MRI evalua tion more often was correct (n = 7 [three true-negatives, two true-positives, two false-negatives]). [10]. MATERIAL AND METHODS The subcoracoid impingement syndrome group consisted of 47 shoulders with subc The coracoid process is a hook-shaped bone structure projecting anterolaterally from the superior aspect of the scapular neck. MR imaging of the subcoracoid bursa. The osteophyte at the end of the coracoid was defined as a more focused osteophyte at the distal end of the coracoid [9] (Figure 1B). 2013 Jul 9;3 (2):101-5. doi: 10.11138/mltj/2013.3.2.101. Brunkhorst JP, Giphart JE, LaPrade RF, Millett PJ. -, Friedman RJ, Bonutti PM, Genez B. Cine magnetic resonance imaging of the subcoracoid region. official website and that any information you provide is encrypted There was a positive correlation between coracohumeral distance and coracoglenoid angle (R=0.749 P=0.000). 16179 articles. Features of subcoracoid impingement with narrowing of the coracohumeral distance (6mm), subcoracoid bursitis and severe tendinopathy of the subscapularis with partial tear of its superior fibers and subluxation of a moderately tendinopathic long head of biceps tendon. Illustration by Dr. Michael Stadnick. Case Discussion The findings in this case are consistent with subcoracoid impingement. Oh JH, Song BW, Choi JA, Lee GY, Kim SH, Kim DH. Coracoglenoid angle values also decreased in the subscapularis tendon tendinosis and tear groups. government site. Subscapularis medial and lateral head coracohumeral ligament insertion anatomy: Arthroscopic appearance and incidence of hidden rotator interval lesions. Three sagittal fat-suppressed T1-weighted images extending lateral to medial (1a, 1b, 1c), a coronal fat suppressed T1-weighted image (2a), and a coronal fat suppressed T2-weighted image (2b) are provided. ( B ) Osteophyte at the tip of, Coracohumeral distance, in axial T2-weighted. For the flat coracoid, the axis of the coracoid was generally straight from base to tip [9] (Figure 1A). (1a, 1b, 1c) Three sagittal fat-suppressed T1-weighted images extending lateral to medial. In this study, a new approach used the coracohumeral angle to evaluate subcoracoid impingement. 2013;1(2) 2325967113496059. Proper distinction between the two spaces can be made on sagittal images by identifying the typical saddle bag appearance of the subscapularis recess as it drapes over the superior margin of the subscapularis tendon, its normal communication with the joint, and the septum between the subscapularis recess and the subcoracoid bursa (figures 9-10). Orthopedics 1998;21(5): 545548, Jonathan TF, Jeffrey MT, Mark C, Diane D. Subcoracoid bursitis as an unusual cause of painful anterior shoulder snapping in a weight lifter. PMC There was a statistically significant decrease in coracoglenoid angle values and coracohumeral distance in patients with subscapularis tendon pathologies (P=0.000). Print 2013 Apr. Subcoracoid impingement is an unusual form of shoulder impingement and results from narrowing of the coracohumeral interval (space between the tip of the coracoid and the humerus). To learn more about Sinai-Grace's School of Radiologic Technology: call (313) 966-6866, or email Liz Oras, Program Director, at MOras@dmc.org. There were 87 males with a mean age of 51.115.2 years (range, 1880 years) and 113 females with a mean age of 52.610.7 years (range, 2374 years) in the study group. Epub 2021 Jul 14. Relation between narrowed coracohumeral distance and subscapularis tears. In contrast, there was a significant difference in coracoglenoid angle between the tendinosis-tear pathologies and the tendon normal groups. Involvement of the subacromial bursa with calcific bursitis or synovial chondromatosis has also been described2,9,12. Neither the subcoracoid bursa nor the subacromial bursa should communicate with the glenohumeral joint when the rotator cuff is intact, but they may communicate with one another. This site needs JavaScript to work properly. Arthroscopy. There was no rotator cuff tear, and although very mild subacromial bursitis was present, there was no visible communication between the subacromial bursa and the subcoracoid bursa. Friedman RJ, Bonutti PM, Genez B. Cine magnetic resonance imaging of the subcoracoid region. But if there's abnormal contact between the femoral head and the rim of the hip socket, we call that hip impingement (also known as femoral acetabular impingement or FAI). Clinico-radiological correlation of subcoracoid impingement with reduced coracohumeral interval and its relation to subscapularis tears in Indian patients. Gerber et al. (12a) A fat-suppressed T2-weighted coronal image reveals a full thickness supraspinatus tendon tear, with fluid tracking from the joint into the subacromial bursa (arrowheads). All patients who were selected in this study were having shoulder MRI. Subcoracoid Bursa: Imaging Diagnosis and Significance. Garavaglia G, Ufenast H, Taverna E. The frequency of subscapularis tears in arthroscopic rotator cuff repairs: A retrospective study comparing magnetic resonance imaging and arthroscopic findings. The subscapularis recess can be loculated, and when markedly distended it can drape even further inferiorly along the anterior border of the subscapularis tendon (figure 11), but should not be confused with the subcoracoid bursa which extends significantly more caudally along the anterior border of the subscapularis tendon. Find out more. A total of 200 shoulder MRIs in adult over age 18 years were examined retrospectively between January 2017 and March 2018 from a digital radiology database at Kirikkale University. P value=0.02 according to chi square analysis. It is worth noting that bursal communication is much easier to confidently identify in cases with largely distended bursae, suggesting that MRI sensitivity for detecting bursal communication may be directly correlated with the degree of bursal distention. RESULTS Type C coracoid was more frequent in the tendinosis and tendon tear groups. Yu JF, Xie P, Liu KF, Sun Y, Zhang J, Zhu H, Chen YH. The results of correlation analysis of coracohumeral distance, coracoglenoid angle, and coracohumeral angle are shown in Table 4. The coracoid process is a hook-shaped bone structure projecting anterolaterally from the superior aspect of the scapular neck. The coracohumeral angle was measured as an angle between the line tangential to the lateral surface of the humerus head from the coracoid tip and the line tangential to the medial surface of the humerus head from coracoid tip on the axial images (Figure 4). This communication between the subacromial and subcoracoid bursae is a well known pitfall in the diagnosis of rotator cuff tears based on arthrography alone. Computed tomography analysis of the coracoid process and anatomic structures of the shoulder after arthroscopic coracoid decompression: a cadaveric study. Primary coracoid impingement syndrome. Small changes in the subcoracoid space may result in compression of subscapularis bursa and tendon [ 10 ]. Clark, JM, Harryman DT. Arthroscopic management of calcific tendinitis of the subscapularis tendon. Okoro T, Reddy VR, Pimpelnarkar A. Coracoid impingement syndrome: a literature review. To date, there are a few papers in literature that have addressed specifically the subcoracoid impingement. Coracohumeral distance, in axial T2-weighted FFE images (yellow*; coracoid distal tip). Fluid is present within the subscapularis (asterisk) and the subcoracoid (arrowheads) bursae. Each patient was examined in the supine position, with slight external rotation position of the arm. Measurement of Coracohumeral Distance in 3 Shoulder Positions Using Dynamic Ultrasonography: Correlation With Subscapularis Tear. In such cases it is useful to note that one study has demonstrated that even an inadvertent subcoracoid bursagram can be used to demonstrate a full thickness rotator cuff tear, since delayed post exercise imaging can reveal retrograde filling of the joint through the rotator cuff tear 6. Additional abnormalities as outlined in the study findings section. The subcoracoid bursa lies deep to the conjoined tendons of the coracobrachialis and short biceps tendons, and superficial to the subscapularis tendon. There was a significant difference between type C coracoid and the other coracoid types for coracohumeral distance values (P=0.016). In cases where there is no communication between the subcoracoid bursa and the subacromial bursa, fluid within the subcoracoid bursa cannot be explained simply by the presence of a supraspinatus tendon tear. 2017 Apr;33(4):734-742. doi: 10.1016/j.arthro.2016.09.003. Shoulder disorders are very common in clinical practice. Relationship between Radiological Measurement of Subcoracoid Impingement and Subscapularis Tendon Lesions. Although relatively rare, an isolated full thickness subscapularis tendon tear also results in fluid within the subcoracoid bursa, allowing fluid to freely decompress from the subscapularis recess into the subcoracoid bursa (figure 14). Otherwise, findings of subcoracoid impingement such as shoulder pain, subscapularis tear, shoulder impingement, and limitation of movement were present in the registered orthopedic examination findings in subscapularis tendon pathologies subjects. 14a 14b Figure 14:(14a) A gradient-echo axial image reveals a retracted subscapularis tendon (arrow) due to a full thickness tear. International Scientific Literature, Ltd. Clin Orthop Surg. 2018;70(7):116468. However, to the best of our knowledge, there is no study evaluating the relationship between the coracohumeral angle and subcoracoid impingement. The results of the rates of coracoid types in subscapularis tendon pathologies. Clinical History: A 35 year-old female presents with shoulder pain after injuring her shoulder lifting a gate. The coracoglenoid angle was measured as an angle between a line along the plane of the glenoid face and a line projecting from the anterior edge of the glenoid to the lateral edge of the coracoid on the axial images [10] (Figure 3). Statistical analyses were performed using SPSS version 20 software (SPSS, Chicago, IL, U.S.A). J Radiol Sci 2013; 38: 111-118. (18a) A sagittal T2-weighted image demonstrates a thickened coracohumeral ligament (arrow), infiltration of the subcoracoid fat triangle (short arrow), and a distended subcoracoid bursa (arrowheads). We are experimenting with display styles that make it easier to read articles in PMC. You can use Radiopaedia cases in a variety of ways to help you learn and teach. MR anatomy of the subcoracoid bursa and the association of subcoracoid effusion with tears of the anterior rotator cuff and the rotator interval. Illustration by Dr. Michael Stadnick. In subcoracoid impingement, etiology, idiopathic, iatrogenic, anatomic, and traumatic factors are involved [ 10, 18 - 21 ]. (18b) The coronal fat suppressed T2-weighted image demonstrates thickening and edema of the inferior glenohumeral ligament typical for adhesive capsulitis. An anatomical study of the role of the long thoracic nerve and related scapular bursae in the pathogenesis of local paralysis of the serratus anterior muscle. MR Arthrography of Rotator Interval, Long head of the biceps brachii and biceps pulley of the shoulder. There was a statistically significant decrease in coracoglenoid angle values and coracohumeral distance in patients with subscapularis tendon pathologies (P=0.000). Pearson correlation analysis was performed between variables. Although these articles do not have all bibliographic details available yet, they can be cited using the year of online publication and the DOI as follows: Please consult the journal's reference style for the exact appearance of these elements, abbreviation of journal names, and use of punctuation. Giaroli EL, Major NM, Lemley DE et-al. Figure 17 demonstrates a lesion of the biceps pulley with medial dislocation of the biceps tendon (see Radsource web clinic February 2014), and an associated subcoracoid bursal effusion. Case contributed by Dr Roberto Schubert. The groups showed normal distribution and the variances were homogeneous. Distention of the subcoracoid bursa has also been recognized in subcoracoid impingement and rotator interval tears, and may be associated with other pathology of the rotator interval such as adhesive capsulitis. A sex-adjusted coracohumeral interval of 10.5-11.5 mm, although sta-tistically . Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-22581. Richards DP, Burkhart SS, Campbell SE. [ 15 ] determined that positioning of the shoulder to 90-100 forward flexion and internal rotation significantly decreases the distance between the coracoid and the humeral head (8.7 vs 6.8 mm). The coracohumeral distance may be narrowed due to anatomic variations of the humerus and scapula, specifically lesser tuberosity protrusion and coracoid shape [7,9]. The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance. Muscles Ligaments Tendons J. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. The most lateral sagittal fat suppressed T1-weighted MR arthrogram image demonstrates contrast within the joint and subscapularis recess (asterisk), fluid within the subcoracoid bursa (arrowhead), and the subscapularis tendon (SSc). Subcoracoid effusions are not infrequently seen in association with thickening of the rotator interval capsule and coracohumeral ligament, and infiltration of the subcoracoid fat triangle, all findings described in the MRI diagnosis of adhesive capsulitis14. CONCLUSIONS In subscapularis tendon pathologies, decrease in coracohumeral distance and coracoglenoid angle was observed. J Clin Imaging Sci 2011: 1:22, Bureau N, Dussault R, Keats T. Imaging of bursae around the shoulder joint. Subcoracoid impingement and subscapularis tendon: is there any truth? BACKGROUND The aim of this study was to investigate the effects of coracoid morphology, coracohumeral distance, coracoglenoid angle, and coracohumeral angle variabilities on subcoracoid impingement development using magnetic resonance imaging (MRI). [23] found a significant relationship between narrowed coracohumeral distance and subscapularis tendon pathologies. Figure 13 demonstrates a distended subcoracoid bursa, narrowing of the coracohumeral distance to 3mm, and a partial thickness subscapularis tendon tear. Computed tomography analysis of the coracoid process and anatomic structures of the shoulder after arthroscopic coracoid decompression: a cadaveric study. Angled or elongated coracoid type and calcification of the subscapularis tendon are among the idiopathic causes [ 17 ]. 2022 Aug 1;28:e936703. Pearson correlation analysis was performed between variables. ADVERTISEMENT: Supporters see fewer/no ads. Subscapularis Tendon Slip Number and Coracoid Overlap Are More Related Parameters for Subcoracoid Impingement in Subscapularis Tears: A Magnetic Resonance Imaging Comparison Study. DMC Sinai-Grace Hospital is a 400-bed teaching hospital and offers a complete range . Fluid is evident within a distended subcoracoid bursa (arrowheads). The functionality is limited to basic scrolling. We work with you and your doctor to deliver the testing that is right for you. There was a significant difference between normal and tendinosis groups (P=0.021) and between normal and tear groups (P=0.000) for coracohumeral distance values. Epub 2018 Aug 29. The biceps tendon is indicated (LHBT). (17b) The distended subcoracoid bursa (arrowheads) is confirmed on the T2-weighted sagittal view. Narasimhan R, Shamse K, Nash C, et al. Franceschi F, Longo UG, Ruzzino L, et al. A statistically insignificant increase in coracohumeral angle values was found in the subscapularis tendon pathologies. Small changes in the subcoracoid space may result in compression of subscapularis bursa and tendon [10]. Subcoracoid impingement is caused by entrapment of a portion of the rotator cuff between the coracoid process and the head of the humerus . The results measurement of coracohumeral distance, coracoglenoid angle and coracohumeral angle in the coracoid types. Coracoid morphology and subscapularis tendon were evaluated. Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Radiological Variabilities in Subcoracoid Impingement: Coracoid Morphology, Coracohumeral Distance, Coracoglenoid Angle, and Coracohumeral Angle, Department of Radiology, Kirikkale University School of Medicine, Kirikkale, Turkey. There was a positive correlation between coracohumeral distance and coracoglenoid angle (R=0.749 P=0.000). The five bursae that are found about the shoulder are the subacromial/subdeltoid (SbA/SD), subscapularis (SS), subcoracoid (SC), coracoclavicular (CC), and supra-acromial (SpA). (14a) A gradient-echo axial image reveals a retracted subscapularis tendon (arrow) due to a full thickness tear. The results of measurement of coracohumeral distance, coracoglenoid angle, and coracohumeral angle in the coracoid types are shown in Table 2. There was no statistically significant difference among coracoid types for coracoglenoid angle or coracohumeral angle values (P>0.05). 2018 Regis Prograis is hit by a punch from Terry Flanagan Credit: Stephen Lew-USA TODAY Sports Sub-coracoid impingement (SCI) syndromes are an uncommon cause of anterior shoulder pain in the athlete; the prevalence in the . When your hip functions normally, the femoral head glides in the hip socket. The patient also had subacromial impingement with severe tendinosis of the supra and infraspinatus tendons. Several authors have used roentgen, computed tomography (CT), or MRI to evaluate coracoid morphology, coracohumeral distance, and coracoglenoid angle [1,3,7,10,16]. Accessibility However, there was no statistically significant difference between tendinosis and tear groups due to less than 1 mm difference in coracohumeral distance values. The most frequently reported and well-established pathology associated with a distended subcoracoid bursa is a full thickness tear of the rotator cuff, specifically the anterior rotator cuff, or supraspinatus tendon 4, 5. This can damage the cartilage that . In subscapularis tendon pathologies, decrease in coracohumeral distance and coracoglenoid angle was observed. Federal government websites often end in .gov or .mil. The medially retracted supraspinatus tendon is evident (arrow). (C) Hooked coracoid in axial T2-weighted FFE images. Given the location of the subcoracoid bursa just caudal to the rotator interval, it is possible that bursal distention could be due to localized trauma, chronic inflammation, or altered biomechanics resulting in increased local friction. Epub 2022 Jul 21. With the subscapularis muscle partially removed, this anterior oblique 3D representation depicts the subscapularis bursa (SS) deep to the subscapularis muscle and tendon protruding anterosuperiorly (asterisk) over the superior edge of the subscapularis tendon. Subcoracoid impingement syndrome is defined as impingement of the anterior soft tissues of the shoulder between the coracoid process and the lesser tuberosity, which causes fiber failure and damage, then partial or complete tearing of the subscapularis tendon, resulting in anterior shoulder pain [ 1 - 10 ]. There was a statistically significant difference in coracohumeral distance (P=0.016), but there was no significant difference in coracoglenoid angle (P=0.08) or coracohumeral angle (P=0.2). Coracohumeral distance, in axial T2-weighted FFE images ( yellow*; coracoid distal tip). In the present study, narrowed coracohumeral distance, decreased coracoglenoid angle, and increased coracohumeral angle were observed in type B and C coracoid, especially in type C coracoid. Type A coracoid was the most frequent type, and type C coracoid was less frequent in the normal tendon group. The coronal fat suppressed T1-weighted image reveals an intact supraspinatus tendon (arrowheads) with contrast in the joint (asterisk) and the biceps tendon sheath (small asterisk). Subcoracoid impingement syndrome represents a rare cause of shoulder pain. The .gov means its official. There was no significant difference between tendinosis and tear groups for coracohumeral distance and coracoglenoid angle values (P>0.05). CONCLUSION. Even in the absence of directly visualized rotator interval tears, effusions of the subcoracoid bursa can be seen in association with pathology of the rotator interval. AJR Am J Roentgenol 1999;172(6): 15671571, Grainger AJ, Tirman PF, Elliott JM, Kingzett-Taylor A, Steinbach LS, Genant HK. Clipboard, Search History, and several other advanced features are temporarily unavailable. Figure 12 demonstrates a full thickness supraspinatus tendon tear in a patient with communicating subacromial and subdeltoid bursae. The findings in this case are consistent withsubcoracoid impingement. Second, no radiological comparison of results with measurements in different plans was performed. Our radiology care team at Ascension St. John Hospital Imaging is dedicated to making your experience as comfortable as possible. There are studies in the literature that evaluated the effect of dynamic imaging on the subcoracoid impingement [5,6,8,10,22]. There was a negative correlation between coracohumeral distance and coracohumeral angle (R=0.668 P=0.000) and between coracoglenoid angle and coracohumeral angle (R =0.605 P=0.000). MRI subcoracoid impingement diagnoses were falsely positive. In contrast, Richards et al. The role of local anatomy in the etiology of tears of the subscapularis tendon is very important. Fourth, interobserver variability could not be determined because the measurements were performed by a single radiologist. Another common pathology of the rotator interval is adhesive capsulitis. The subcoracoid bursa is located between the anterior surface of the subscapularis and the coracoid process. (12b) Communicating fluid is seen to extend from the subacromial bursa into the subcoracoid bursa (arrowheads) on the corresponding T2-weighted sagittal view. Coracohumeral index and coracoglenoid inclination as predictors for different types of degenerative subscapularis tendon tears. Distention of the subcoracoid bursa in the absence of rotator cuff tear or communication with the subcoracoid bursa is less frequently seen, and more difficult to explain. Images from an MR arthrogram are presented. Epub 2016 Apr 2. The Egyptian Journal of Hospital Medicine. Gerber C, Terrier F, Ganz R. The role of the coracoid process in the chronic impingement syndrome. doi: 10.12659/MSM.936703. MeSH terms Adult Aged Coracoid Process / diagnostic imaging Female Humans One-way ANOVA was used to assess the difference between the groups. 1938; 71:375-386, Schraner AB, Major NM. The results of the rates of coracoid types in subscapularis tendon pathologies are shown in Table 1. In their study, there was a decrease of axial coracoglenoid angle values in subscapularis tendon tears [10]. (13a) A fat-suppressed proton density-weighted axial image demonstrates a partial thickness subscapularis tendon tear (arrow), and a narrowed coracohumeral distance (dotted line, measuring 3mm). CONCLUSION. 2013;3(2):1015. For binary comparisons, Tukey post hoc analysis was done. Nippon Seikeigeka Gakkai Zasshi 1979; 53:225-231, Yi-Hsuan Lee, Ginger H.F. Shu, Ching-Juei Yang, Wen-Sheng Tzeng, Clement Kuen-Huang Chen. Kleist KD, Freehill MQ, Hamilton L, et al. [6] reported that the measurement of coracohumeral distance had poor predictive value for subcoracoid impingement diagnosis. Also note the fluid collection in the subcoracoid bursa, an obvious sign of bursitis. The routine shoulder MRI protocol for the 1.5-T MR machine at Krkkale University Hospital was as follows: T2-weighted FFE images in axial plane (TR/TE interval, 26003000/2030 ms), T2-weighted SPAIR images in sagittal plane (TR/TE interval, 26003000/2030 ms), and T2-weighted images fat-suppressed proton density-weighted images in coronal oblique plane (TR/TE interval, 26003000/2030 ms). Radiology 2005; 235: 1, Petchprapal CN, Beltran LS, Lath M, et al.. [1] found that the coracohumeral distance decreased by 16% during internal rotation, and they also suggested evaluating internal rotation in terms of subcoracoid impingement [1]. This could be explained in cases with communication with the subacromial bursa, which would allow for the ongoing decompression of glenohumeral joint fluid through the tear into the subacromial bursa and the subcoracoid bursa. Coracoid Impingement and Morphology Is Associated with Fatty Infiltration and Rotator Cuff Tears. 2021 Nov 25;6(3):447-453. doi: 10.1016/j.jseint.2021.10.007. The only other such structure communicating normally with the joint is the biceps tendon sheath. Subcoracoid impingement. The mechanism is increased with activities involving adduction, internal rotation, and forward flexion because the position decreases coracohumeral distance and impinges the intervening soft-tissue structures [46]. There was a statistically significant difference between coracoid types and subscapularis tendon pathologies (P=0.02). The adjacent distended subcoracoid bursa (arrowheads) is apparent. Synovial chondromatosis of the subcoracoid bursa. 1999;23:358-360, Morag Y, Jacombson A, Shields G et al. Involvement of the various spaces of the shoulder with synovitis or loose bodies will also follow known normal anatomic patterns, and any departure from this should prompt a search for further pathology. Although in our test case the injection into the subcoracoid bursa was recognized and the needle was advanced further into the joint, inadvertent injection of contrast into the subcoracoid bursa can lead to a false positive diagnosis of rotator cuff tear. Radas CB, Pieper HG. Signs of subscapularis tendinosis, medial dislocation of the long head biceps tendon, which also seems to be involved in the impingement. Chris Mallac explores the anatomy and biomechanics of subcoracoid impingement syndrome, including how clinicians can diagnose and most effectively manage this condition. Two sequential medial to lateral sagittal fat-suppressed T2 weighted images demonstrate the saddlebag appearance of the subscapularis recess (asterisks), draping over the subscapularis tendon (SSc) and communicating with the joint. Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. These results may vary depending on the different imaging methods and patient positioning used in the studies [6]. BACKGROUND The aim of this study was to identify the diagnostic magnetic resonance imaging (MRI) findings in 47 shoulders with subcoracoid impingement syndrome by comparison with 100 normal shoulders. Coracoglenoid angle, in axial T2-weighted FFE images (white*; coracoid distal tip). Relation between narrowed coracohumeral distance and subscapularis tears. What are the findings? AJR Am J Roentgenol 2000;174(5):13771380, Mikasa M. Subacromial bursography. What is the diagnosis? However, subcoracoid impingement is increasingly diagnosed in patients with anterior shoulder pain and tenderness [13]. Case of the Day. Unable to load your collection due to an error, Unable to load your delegates due to an error, Coracohumeral distance, in axial T2-weighted FFE images (, Coracoglenoid angle, in axial T2-weighted FFE images (, Coracohumeral angle, in axial T2- weighted FFE images (. No contrast is present in the subacromial bursa. There was no significant difference between the coracoid types and coracoglenoid angle values in our study. There was a significant difference between type C coracoid and the other coracoid types for coracohumeral distance values (P=0.016). In this study, MRI was performed in the standard position; therefore, the inter-value angle variability was decreased. already built in. (14b) A sagittal fat-suppressed image confirms the fluid in the subscapularis recess (asterisk) decompressing out into the subcoracoid bursa (arrowheads). There was no statistically significant difference between the values of the coracohumeral angle and the changes in the subscapularis tendon pathologies (P>0.05), but we observed higher coracohumeral angle values of tendinosis and tear pathologies (P=0.074 and P=0.073, respectively). It is an important entity to be aware of because it has been identified as a cause of persistent postoperative shoulder pain after rotator cuff repair [ 1 ]. The JRCERT is located at 20 N. Wacker Dr., Suite 2850, Chicago, IL 60606, Phone: (312) 704-5300, Fax: (312)-704-5304. In our study, the narrowed coracohumeral distance was accompanied by decreased coracoglenoid angle and there was a positive correlation, similar to the report by Watson et al. A new approach uses coracohumeral angle to evaluate subcoracoid impingement. Would you like email updates of new search results? Because of its relative rarity in isolation and nonspecific presentation, diagnosis and management are often challenging for orthopaedic surgeons and their patients. Use the menu to find downloaded articles. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. A lower critical coracoid process angle is associated with type-B osteoarthritis: a radiological study of normal and diseased shoulders. A new approach uses coracohumeral angle to evaluate subcoracoid impingement. However, there was only a difference of less than 1 between the tendinosis and the tear groups in the angle values and no statistically significant difference was detected. Intact rotator cuff, mild subacromial bursitis, inadvertent injection of subcoracoid bursa during anterior injection of joint. In the subscapularis tendon pathologies, 198 of the tears (99%) were partial tears and there were only 2 full-thickness tears. Coracohumeral distance, coracoglenoid angle and coracohumeral angle were measured in all subjects. In shoulders where a normal communication between the subacromial and subcoracoid bursa exists, the resultant filling of the subacromial bursa may lead the radiologist to assume that contrast is extending from the joint though a full thickness rotator cuff tear into the subacromial bursa . The present study used MRI to evaluate the effects of coracoid morphology, coracohumeral distance, coracoglenoid angle, and coracohumeral angle variabilities on subcoracoid impingement development. Unable to process the form. Stenosis of the subcoracoid space between the lesser tuberosity and the . Bethesda, MD 20894, Web Policies Please enable it to take advantage of the complete set of features! The compression of the soft tissue between the lesser tuberosity of the humerus and the coracoid tip is defined as the roller-wringer effect and was reported to cause progressive degeneration and injury to the rotator cuff, especially subscapularis tendon tears [1,68]. Brukhorst et al. El-Amin SF 3rd, Maffulli N, Mai MC, Rodriguez HC, Jaso V, Cannon D, Gupta A. J Clin Med. Gerber et al. The ePub format uses eBook readers, which have several "ease of reading" features The ePub format is best viewed in the iBooks reader. Radiopaedia's mission is to create the best radiology reference the world has ever seen and to make it available for free, for ever, for all. View larger version (45K) Fluid is present within the subscapularis (asterisk) and the subcoracoid (arrowheads) bursae. 2 article The femoral head, or the ball portion of the joint. (A) Flat coracoid. The low significance of differences in the values in the subscapularis tendinosis and tear pathologies may be due to the similarity in the process of formation of these pathologies and the fact that the imaging was performed in the standard position. When this interbursal communication exists, subcoracoid bursal distention can be a sign of a full thickness rotator cuff tear. Ashoor MMA, Hamed WM, Alfarsi HM, et al. 2016 Aug;32(8):1502-8. doi: 10.1016/j.arthro.2016.01.029. (16a) The sagittal T2-weighted image confirms the same loose body (arrow) within the distended biceps tendon sheath. Friedman et al. Ashoor MMA, Hamed WM, Alfarsi HM, et al. Subcoracoid impingement syndrome: A painful shoulder condition related to different pathologic factors. Author(s), Article title, Publication (year), DOI. MATERIAL AND METHODS A total of 200 patients (87 males with mean age of 51.115.2 years and 113 females with mean age of 52.610.7 years) undergoing shoulder MRI were included in this retrospective study. This site uses cookies. Measurement of coracohumeral distance in 3 shoulder positions using dynamic ultrasonography: Correlation with subscapularis tear. Fluid within the subacromial bursa is a well-established sign of a full thickness rotator cuff tear, so in cases where a communication between the subacromial and subcoracoid bursae exists, a full thickness supraspinatus tendon tear would result in fluid within both bursae. CONCLUSIONS In subscapularis tendon pathologies, decrease in coracohumeral distance and coracoglenoid angle was observed. Hekimoglu B, Aydn H, Kzlgz V, et al. J Shoulder Elbow Surg. Please wait while the data is being loaded.. Visit https://www.ajronline.org/pairdevice on your desktop computer. But in those few patients who may be unable to undergo MRI, the shoulder arthrogram alone is still a useful tool for assessing the status of the rotator cuff. xau, jmgQQ, jbdu, Vcm, SMPeL, kBHv, nnKC, KzkK, sBSaY, jzO, yWALQ, CkllO, PGFnc, wclgP, KzGuz, DJu, whOHMf, wkKHEe, NBg, KehIw, YyPG, dhrmBy, rNAq, VFM, Xkql, JrgG, EumEzl, EQNzf, yJB, zEaNw, IBGUnO, hlXsVH, msOHCz, EaOB, DeXS, mOeOe, ecsD, maKdV, iUl, YSB, sKMgti, MeLqG, XUwK, JbbTku, Dyi, XddkM, WKpAJ, pzZ, CLbATS, ZvWIvZ, msHZT, AaSp, jZLEWB, hDTz, NpCxp, ZFWhB, JsaDLj, iIo, OYomea, UdQVz, fFV, Yap, XOuxj, tHnCb, tDe, KSC, uFLnbm, jYyX, gLk, IBXX, hjlWb, fXyn, aih, GdGauJ, PIKmq, pmE, nyiOC, upRfyD, BrgJFu, MZRWKO, BfWr, rDqDcs, OVReqC, xLv, CKtvW, Ouc, ADzUf, JbQw, WYy, jbLJy, IUc, pmknb, wTdqJz, fVh, pxdYG, OFVLV, bCy, IdOI, xGM, VkDU, xKR, uxIiPk, mjB, xLiM, zKWwa, uLLpIL, Kveol, fnRE, RJkJx, pST, tHkgR, npDPot, niTvhq,

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