Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Webcombination of forearm supination, axial loading, valgus (posterolateral) stress, and elbow extension causes progressive failure of the lateral collateral ligament complex and anterior capsule, resulting posterolateral subluxation of the radial head and external rotation of the semilunar notch away from trochlea [35], An ACL avulsion occurs when the ACL is torn away from either the femur or the tibia. WebVestibular problems can have a range of different causes, some of which respond extremely well to physiotherapy intervention. A tunnel view may also be helpful. Medial Collateral Ligament Injuries and Subsequent Load on the Anterior Cruciate Ligament: A Biomechnical Evaluation in a Cadaveric Model. if difficult to determine on exam, can get dynamic CT scan in neutral, pronation and supination for stress-test. This CPG identifies three high risk populations and outlines different program most suited for each: The most supported programs involved multiple components such as: Flexibility - Quadriceps, hamstrings, hip adductors, hip flexors, & calf muscles. When refering to evidence in academic writing, you should always try to reference the primary (original) source. MCL injuries are common in the athletic population and can occur as either isolated injuries, When refering to evidence in academic writing, you should always try to reference the primary (original) source. 4. The above video of on-field sport training program have been curated and published by JOSPT and provide a holistic program consistent with the recommendations of this clinical Practice guidelines forExercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. In children, the cyst can be isolated and the knee joint normal. Study Design Cohort study (diagnosis); Level of evidence, 2. Injuries to this region, that result in posterolateral rotatory instability, are usually associated with concurrent ligamentous injuries elsewhere in the knee. Clinical examination of the knee: know your tools for diagnosis of knee injuries. Assess for anterior displacement and whether there is an endpoint. BMC Sports Science, Medicine and Rehabilitation [online]. Identification of athletes with high knee abduction moments is possible with less expensive equipment and time. The bone bruise is most likely caused by impaction between the posterior aspect of the lateral tibial plateau and the lateral femoral condyle during displacement of the joint at the time of the injury. Copyright 2022 Lineage Medical, Inc. All rights reserved. WebIf you can work out the force of the injury this gives you clues on likely stretched/ damaged structures (Valgus force may indicate an MCL sprain, varus force may indicate an LCL sprain, foot planted and twisted may indicate an ACL sprain/rupture). anteroinferior aspect of medial epicondyle. inserts on anterolateral aspect of fibular head. The instructions below are for examining the right knee, use the opposite hands if assessing the left knee. translation in sagittal plane > 50% compare to contralateral side is abnormal. Ultrasound can be used to objectively measure the degree of laxity when combined with functional testing (Lachman and anterior drawer tests)[65]. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Kiani A, Hellquist E, Ahlqvist K, Gedeborg R, Byberg L. Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R. Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo. It is recognised that either partial or complete ruptures in the ligament significantly increases the load on the ACL. Bony abnormality may suggest an associated fracture of the tibial plateau. Surgical management may be indicated for high grade injuries in the setting of persistent valgus instability. Necessary cookies are absolutely essential for the website to function properly. Valgus Stress Test - Elbow (CR). MCL injuries often occur in sports, being the most common ligamentous injury of the knee, and 60% of skiing knee injuries involve the MCL)[1]. This includes physical activity, strengthening, stretching, neuromuscular, proprioceptive, agility, or plyometric exercises and other training modalities. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. A valgus force is then applied, a positive result of the knee in this position would be an increase in joint space medially. Tenderness at the medial side of the joint which may indicate cartilage injury. Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lzaro-Haro C, Cugat R. Thompson JA, Tran AA, Gatewood CT, Shultz R, Silder A, Delp SL, Dragoo JL. With low load, the ligament is relatively compliant; with increasing load, the ligament responds with increasing stiffness until it is nearly linear. Medically. An ACL tear will have a more distinctive and loud popping sound than an MCL tear. Although predictors of ACL injury that are potentially modifiable like measures of high knee abduction moment during landing tasks, these measurements utilized expensive measurement tools (e.g., motion analysis systems, force plates) and laborintensive data collection and reduction techniques to identify important biomechanical risk factors. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). nterior cruciate ligament injury: towards a gendered environmental approach. WebResources on Valgus stress test of the knee and related topics in OrthopaedicsOne spaces. In the interval from 50 to 70 of elbow flexion, there is a maximum valgus opening when the anterior band, articular capsule and posterior band of the MLC are sectioned[2]. Weak hamstrings and hip abductors may lead to an increased valgus load on the knee. The radiohumeral joint is the hinge joint (between the capitulum of the humerus and the head of the radius) and is known to be one of the most congruent (maximum contact between bony surfaces) of the human body. A qualified Sports Injury Therapist with a degree in Physical Education, Sports Science and Physics, and a Postgraduate Certificate in Education. The MCL is commonly injured in overhead throwing athletes, such as pitchers, javelin throwers, quarterbacks, tennis, volleyball, and water polo players, when a valgus moment is placed on the elbow during the late cocking and early acceleration phases of the movement. Laboratory tests are shown in Figure A. The Physician and Sportsmedicine [online]. Sansone V, De Ponti A, Paluello GM, Del Maschio A. Stein D, Cantlon M, MacKay B, Hoelscher C. De Maeseneer M, Debaere C, Desprechins B, Osteaux M. Turner da,Podromos CC, Petsnick JP, Clark JW: Johnson DL, Urban WP, Caborn DN, Vanarthos WJ, Carlson CS. [38] The focal signal abnormalities in subchondral bone marrow seen on MRI (undetectable on radiographs) arethought to represent micro trabecular fractures, haemorrhage and edema without disruption of adjacent cortices or articular cartilage. The therapist takes hold of the leg, ensuring the knee is slightly bent (approx 30 degrees). The risk of ACL injury increase if there are more than one of these movements happened; knee joint twisted, bent backward, or side to side stress. However, as the knee is flexed, the femoral attachment of the ACL assumes a more horizontal orientation, causing the AMB to tighten and the PLB to loosen and thus leave the AMB as the restraint to anterior tibial load[6]. LCL tear classification (based on lateral joint opening compared to contralateral side) varus stress test. Available from: 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. Mike is creator & CEO of Sportsinjuryclinic.net. [viewed 12 September 2016]. [78] published Clinical Practice Guidelines (CPG)reviewing the latest injury prevention programs for ACL and knee ligament injuries. [40], Occult bony lesions have been reported in 84-98% of the patients with ACL rupture. If seen in combination with a medial meniscus tear and an MCL Injury, it is termed ODonohues Triad which has 3 components:[1]. The presence of bone bruise indicates impaction trauma to the articular cartilage. 2% (19/1231) 3. The sMCL, specifically the proximal division, resists valgus forces through all degrees of knee flexion. Available from: 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. Available from: Cavignac, E. et al., 2015. Cavalheiro CS, Razuk Filho M, Rozas J, Wey J, de Andrade AM, Caetano EB. 2% (19/1231) 3. 1(2), pp. Associated injuries of the menisci and the MCL tend to increase the progression of bone contusion. WebThe most common types of physical examination tests for assessing these injuries are the valgus and varus stress tests. They stabilize the thigh whilst applying outward pressure on the lower leg (tibia) and this stretches the medial ligament. Currently, there is not a gold standard assessment to diagnose PFPS. Examination under anesthesia and arthroscopy. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Top Contributors - George Prudden, Kim Jackson, WikiSysop, Vidya Acharya, Rucha Gadgil, Saimat Lachinova and Lucinda hampton. Positive Posterior drawer test . Vol 2; 2nd edition, https://www.youtube.com/watch?v=NrwWBRGL-1w, Diagnosis of acute knee injuries with hemarthrosis, Arthroscopy in acute traumatic hemarthrosis of the knee. Very little is known about the effect of type of competition on the risk of an athlete suffering ACL injury. Wetters N, Weber AE, Wuerz TH, Schub DL, Mandelbaum BR. With the patient Standing, sitting, or supine. Common Types of Sports Injuries. Lohmande. MCL Injuries of the Knee: Current Concepts Review. [19], Common assessment tools such as the star excursion balance test, functional hop tests, strength measures, balance and stability measures and dynamometry, in addition to development of new techniques to help identify lower extremity asymmetry and high risk landing and cutting. WebThe valgus stress test, also known as the medial stress test, is used to assess the integrity of the medial collateral ligament (MCL) of the knee. When the valgus stress test is performed, your knee feels stable with a hard end feel and no joint laxity. Differentiation can mostly be made based on a thorough examination with particular attention for the mechanism at the time of injury. City Clinic on YouTube. A professional therapist may use tinels test to diagnose tarsal tunnel syndrome: A calcaneal stress fracture is a hairline fracture of the calcaneus or heel bone. Episodes of giving way especially on pivoting or twisting motions. 2% The reason for this is that the nerves supplying pain signals have also ruptured. (physiological), Lachman, FRD, Losee, ALRI, Pivot 'slide' but not 'jerk'. The most common cause of failure following UKA for this condition is from tibial stress fractures. LCL tear classification (based on lateral joint opening compared to contralateral side) varus stress test. Dynamic US examinations for measuring laxity three static indirect signs of ACL rupture have been described: The validity of the US femoral notch sign shows sensitivity and specificity ranging from 88% to 96.2% and 65% to 100%, respectively. Isolated determinants from history-taking and physical examination showed some diagnostic value; the likelihood ratio positive was 2.0 for "trauma by external force to leg" and 2.3 for "pain valgus stress 30 degrees ." Palpation follows inspection and should begin with the uninvolved extremity. However, very little is known about the effect of these variables on an athletes risk of suffering an ACL injury. The therapist places the patients elbow in approximately 20 degrees of flexion while palpating the medial joint line and stabilizing the distal humerus with one hand and applying a valgus stress to the elbow with the other hand. Weakened quadriceps may decrease knee flexion control. When the MCL is stretched beyond its ability or exposed to an excessive load, it evokes neurological feedback signals that then generate a muscle contraction. Several factors have been identified to explain this sex disparity. Women have more quadriceps dominant neuromuscular patterns than men. Stallenberg B, Gevenois PA, Sintzoff Jr SA, Matos C, Andrianne Y, Struyven J. Harner CD, Vogrin TM, Hoher J, Ma CB, Woo SL. [viewed 13 September 2016]. Patella baja. The medial meniscus is often also injured due to its relationship with the dMCL. The bony bruising itself is unlikely to cause pain or reduced function. Include plyometric exercises in to the training program. The therapist then applies a valgus (inward) stress to the knee whilst the other hand rotates the leg externally (outwards) and extends the knee. anatomy. WebCreate Personal Test; Create Group Test; Enter Test Code; Active Test; Search Groups ; Study Plans; SAE Exams; Events; secondary stabilizer to valgus stress. Posterolateral corner injuries to the knee. [2], The VST assesses laxity of the MCL compared to the contralateral knee as a control. B., Fujikawa, K. (2001). 3% (111/3814) L 3 C Select Answer to see Preferred Response. The assessment includes palpation and a special test, the valgus stress test VST, The anterior aspect of the ligament can be palpated moving vertically, roughly midway along the medial joint line. When there is an ACL rupture or tear the ATT increase up to 10-15 mm when the knee is 30 flexion and under anterior tibial load, and the tibial will located more anterior even under non-weight bearing. Assessment tests, such as the valgus stress test will show significant movement in the joint (laxity.) WebElbow Stress Tests (Valgus and Varus pressures, at different angles to test all bands of the MCL) Verify with static positions and repetitive movements cause pain or physical limitations; Functional assessment: weight bearing positions, lifting activities, provocative testing (what activities are causing pain) Periarticular tenderness should also be examined. The medial collateral ligament is innervated by branches of the radial, ulnar and medial nerves in the elbow joint. Part 1: Mechanisms of injury and underlying risk factors. Medial collateral ligament assessment (valgus stress test) The medial collateral ligament (MCL) assessment involves the application of a valgus force to assess the integrity of the MCL of the knee joint. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett Jr W. 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. The purpose of the dynamic warm-up phase is to allow the athlete to prepare for activity and it greatly reduces the risk of injury. (SBQ07SM.17) It involves placing the leg into extension, with one hand placed as a pivot on the knee. ACL vs. MCL tears: Although symptoms of ACL and MCL tears are similar, a few key differences will help identify whether the injury affected the ACL or MCL. Strength is full compared to the other side. A valgus stress test, during which a physician tests your elbow for instability, is the best way to assess the condition of the MCL. There is also rotational instability as indicated by a positive. Hewett TE, Myer GD, Ford KR, Paterno MV, Quatman CE. Apleys test. Articular cartilage changes seen with magnetic resonance imaging-detected bone bruises associated with acute anterior cruciate ligament rupture, Orthopaedic sports Medicine,Principles and Practice, Quantitative analysis of the measuring capabilities of the KT1000 knee ligament arthrometer, Efficiency of knee ultrasound for diagnosing anterior cruciate ligament and posterior cruciate ligament injuries, Anterior Cruciate Ligament and Meniscal Tears, http://www.youtube.com/watch?v=cOWszWYN_a8, Orthopaedic sports Medicine,Principles and Practice. 2000-2010. Direct US visualization of the ACL is challenging,but US is increasingly being used as an extension of the physical examination on the sidelines, in training rooms, and in clinics. The arthrometer provides an objective measurement of the anterior translation of the tibia that supplements the Lachman test in ACL injury. Tony Lowe. http://www.youtube.com/watch?v=Cd25qGCo-kQ, https://www.physio-pedia.com/index.php?title=Elbow_Valgus_Stress&oldid=266023. The Merchant's radiograph viewnot only shows the joint space between the femur and patella but also helps to determine whether the patient has patellofemoral malalignment. Patella alta. WebMedial collateral ligament Injury of the knee (MCL Tear) are the most common ligament injuries of the knee and are frequently associated with ACL tears. The therapist takes hold of the leg, ensuring the knee is slightly bent (approx 30 degrees). Take your program with you to the gym or training field. Current Reviews in Musculoskeletal Medicine [online]. The most common cause of failure following UKA for this condition is from tibial stress fractures. Webperform an arthroscopic valgus stress test to identify medial gapping which may be indicative of an incompetent MCL. Webtensile strength: 750 N (valgus) Classification. The valgus stress test will usually reproduce symptoms and you may have some degree of laxity (excess movement) in your knee. Flex the knee to 30 degrees. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Apleys test is also used in cases of suspected meniscus tears. Webattaches to medial epicondyle (anterior aspect), anterior bundle of MCL. Strength Muscle weakness is another modifiable risk factor, specifically weak gluteus medius, gluteus minimus, quadriceps, hamstrings and hip abductor muscles. Valgus Extension Overload (Pitcher's Elbow). An MCL sprain is a tear to the ligament on the inside of the knee joint. [33], Potential neuromuscular imbalances may be related to components of the injury mechanism. These exercises are explosive and help to construct power, strength and speed. These test would include; Eye tests; Balance tests; Positional tests; Gait analysis There may be a little swelling or a lot of swelling. Valgus stress test for MCL: Push on lateral aspect of knee while pulling ankle away from midline. 5% (220/4758) 4. and Hackett, T.R., 2019. In the normal knee, intra-articular volume and pressure are minimized by the osmotic suction exerted by the synovial matrix. Treatment is generally nonoperative with bracing. Physiotutors. 3(25), pp. Also it was seen that the inner angle of lateral femoral condyle is a better predictive factor for ACL tears in young female handball players compared to intercondylar notch width. Available from: Luke, A., no date. The ACL arises from the posteromedial corner of the medial aspect of the lateral femoral condyle in the intercondylar notch and inserted anterior to the In some cases, residual instability may occur, leading to a functional impairment. Between the superficial MCL and medial head of the gastrocnemius . When the knee is extended the PLB is tight and the AMB is moderately lax. Biomechanical risk factors of non-contact ACL injuries: A stochastic biomechanical modeling study, http://www.youtube.com/watch?v=lpIOMuqXWrE, Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball and basketball, Non-contact ACL injuries in female athletes, Rehabilitation techniques for sports medicine and athletic training, Intercondylar notch size and anterior cruciate ligament injuries in athletes: a prospective study, Anterior Cruciate Ligament Rupture with Medial Collateral Ligament Tear with Lateral Meniscus Posterior Root Tear with Posterolateral Tibia Osteochondral Fracture: A New Injury Tetrad of the Knee, Bone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture, Bone bruising and bone marrow edema syndromes: incidental radiological findings or harbingers of future joint degeneration, Clinical Outcome of Isolated Subcortical Trabecular Fractures (Bone Bruise) Detected on Magnetic Resonance Imaging in Knees, Occult osseous lesions documented by magnetic resonance imaging associated with anterior cruciate ligament ruptures. Views. ACL vs. MCL tears: Although symptoms of ACL and MCL tears are similar, a few key differences will help identify whether the injury affected the ACL or MCL. A normal ACL is seen as a well-defined band of low signal intensity on sagittal image through the intercondylar notch. 1% (18/1231) 4. These clinical prediction tools show moderate to high interrater reliability (intraclass correlation coefficiencies 0.600.97) and have continued to simplify and optimize the screening tools to include a calibrated physician's scale, a standard measuring tape, standard camcorder, Image software, and an isokinetic dynamometer. 5th Ed. Vrije Universiteit Brussel Evidence-Based Practice Project, Anterior Cruciate Ligament (ACL) Reconstruction, Anterior Cruciate Ligament (ACL) Rehabilitation, Clinical Practice Guidelines: Knee Ligament Sprain Revision 2017, Biomechanical characteristics of the knee joint in female athletes during tasks associated with anterior cruciate ligament injury, Anterior cruciate ligament injury patterns among collegiate men and women, Anterior cruciate ligament injuries in men and women: how common are they? Suspicion of additional injury may require imaging.[9]. Views. Innervation is greatest in the epiligament and near the insertions. Webattaches to medial epicondyle (anterior aspect), anterior bundle of MCL. As with the varus stress test , this test can be repeated in varying degrees of elbow extension to test different portions of the MCL. 198-204. Beyond this, the MCL will continue to absorb energy until failure. (OBQ12.90) A biomechanical video analysis of ACL injury in football observed that: The typical ACL injury occurs with the knee externally rotated and in 10-30 of flexion (shallow knee flexion) when the knee is placed in a valgus position as the athlete takes off from the planted foot and internally rotates with the aim of suddenly changing direction[30]. 1-10. [89] Injury treatment and the return to activities for an individual is entirely dependent upon the ACL injury grade and any associated injuries. A positive result for a valgus stress test. It typically presents with paresthesias of the small and ring finger, and can be treated with both nonoperative modalities such as elbow splinting. Valgus instability. How do you perform the Elbow Valgus Stress Test? 39-54. However, the vascular supply of the MCL is unknown. The most important component when considering performance technique is the landing. Available from: Chen, L. et al., 2008. All of the following are true regarding grade III medial collateral ligament (MCL) tears of the knee EXCEPT: Proximal ruptures have decreased residual valgus laxity following nonoperative treatment than distal ruptures, They result in greater than 10 mm of valgus opening, They require operative repair when there is a concomitant anterior cruciate ligament tear, Proximal ruptures have better healing potential with nonoperative treatment than distal ruptures, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Evolving Technique: A Repaired MCL, Dominant Arm In A 19-Year-Old Baseball Pitcher, Decided To Throw At 4 Months & Has A New Partial Tear Of His MCL (Mid-Substance) - The Role Of A Brace, PRP & Biologics? primary restraint to valgus stress in maximal elbow flexion. These cookies do not store any personal information. Roos, E.M. Roos, M.-P. Hellio Le Graverand, R. Buck, J. Tamez-Pena, S. Totterman, T. Boegard, L.S. fibers run parallel to MCL. WebLachmans test for ACL: Patient must be relaxed. Impingement of lateral tibial plateau in subluxation position, which requires examiner to back off during pivot shift test to effect reduction. MCL / LCL injuries. Stability of both elbows is assessed using the moving valgus test 19 and the valgus stress test. Cross friction massage is used to treat MCL sprains (medial collateral knee ligament sprains). WebElbow Stress Tests (Valgus and Varus pressures, at different angles to test all bands of the MCL) Verify with static positions and repetitive movements cause pain or physical limitations; Functional assessment: weight bearing positions, lifting activities, provocative testing (what activities are causing pain) Olsen OE, Myklebust G, Engebretsen L, Bahr R. Kocher MS, Sterett WI, Briggs KK, Zurakowski D, Steadman JR. McDevitt ER, Taylor DC, Miller MD, Gerber JP, Ziemke G, Hinkin D, Uhorchak JM, Arciero RA, Pierre PS. over-resection of the posteromedial osteophyte past its native margin or >3mm may lead to increased stress on the MCL and valgus instability. China: Elsevier. (2008). This difference in vascular supply may be a factor in the differential healing capacities of the MCL based on the location of injury[3]. This relationship did not exist for male athletes. Warm ups and cool downs are a critical part of a training program. Valgus stress test for MCL: Push on lateral aspect of knee while pulling ankle away from midline. The distal division of the sMCL helps stabilize external rotation of the knee at 30-degree flexion. Smaller size and different shape of the intercondylar notch: A narrow intercondylar notch and a plateau environment are risk factors of predisposing female non-athletes with knee OA to ACL injury aged 41-65 years. Olsen et al[21] reported that the risk of suffering an ACL injury is greater in female team handball athletes who compete on artificial floors that have a higher torsional resistance at the foot-floor interface than in those who compete on wood floors. Development of clinical assessment tools to identify athletes at risk for ACL injury would aid clinicians to target the populations that will benefit most from intervention. found that 44 of 47 popliteal cysts studied were associated with intra-articular lesions. Apleys test. Orthopaedic: Examination, evaluation, and intervention (2nd ed.). The test will probably not have a definite endpoint when the medial ligament is stressed as there is no ligament stopping the movement. These may include throwing athletes, wrestlers and some individuals involved in highly active physical activity which demands stability of the elbow. Positive Posterior drawer test . Here elite level Sports Physiotherapist Neal Reynolds demonstrates how it is, MCL Sprain taping is a knee strapping technique that provides a high level of support and protection following a medial knee ligament sprain. A close relationship was observed in a study between their capsular and motor branches[4]. WebFunctionally, the medial collateral ligament complex (MCL) acts as the primary restraint to valgus rotation of the tibia, providing as much as 80% of the restraining force to valgus loads. 3101-3107. They stabilize the thigh whilst applying outward pressure on the lower leg (tibia) and this stretches the medial ligament. The valgus stress test or medial stress test is a test for damage to the medial collateral ligament of the knee. Start these exercise using a flat cone (2 inches) or with a visual line on the field. Treatment is often non-operative because the MCL has strong vascular support for healing[9]. Anatomy, Bony Pelvis and Lower Limb, Knee Medial Collateral Ligament. 4th ed. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Symptoms | Valgus stress test | MCL sprain rehabilitation program. Rapid swelling. [45] Rehabilitation and the long-term prognosis may be affected in those patients with extensive bony and associated articular cartilage injuries. When there is a varus torque the interaction of the contact points between medial femoral condyle and the medial tibial plateau generates anterior tibial load because of the posterior tibial slope resulting an anterior tibial translation in antero-proximal direction. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. It is usually caused by overuse and is more common in Read More Bunion. The superficial and deep ligaments each have a unique function, making the MCL the primary responder to valgus stress and a secondary restraint to rotational forces. LCL. It travels from the medial meniscus to the distal edge of the articular cartilage of the medial tibial plateau. The shear range refers to the range of motion that causes pain while the elbow is being extended with valgus stress. WebFull member Area of expertise Affiliation; Stefan Barth: Medical Biotechnology & Immunotherapy Research Unit: Chemical & Systems Biology, Department of Integrative Biomedical Sciences Plyometrics - Single leg hopping anterior & posterior, ice skaters, jump to header or catching a ball overhead. With an acute injury to the ACL, the continuity of the ligament fibers appears disrupted and the ligament substance is ill defined, with a mixed signal intensity representing local edema and haemorrhage.[61]. [37]It was estimated to be found in every fifth case with the ACL was rupture. Cubital Tunnel Syndrome is a compressive neuropathy of the ulnar nerve at the elbow, and is the 2nd most common compression neuropathy of the upper extremity. Posterior stress radiographs. [viewed 12 September 2016]. - Daniel Cooper, MD, Honored Professor Lecture: My 30-Year Expeience With MCL Injuries - Peter Indelicato, MD. Valgus stress test opening at 0 and 30 degrees of flexion. A normal foot will leave a print of the heel, connected to the forefoot by a strip approximately half the width of the foot on the outside of the sole. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Most common are the non-contact injuries are more likely to occur with lower BMI[11], it caused by forces generated within the athletes body. Our step-by-step MCL Sprain Rehab app tells you what treatment and exercises to do each day and tracks your progress. Three major types of ACL injuries are described: Anterior cruciate ligament (ACL) injuries are common in young individuals who participate in sports activities associated with pivoting, decelerating and jumping. Active Range of Motion (Extension / Flexion / Supination / Pronation), Extension: 0 or up to -10 (hyper extension - especially with women). Convert to a constrained TKA design. Implementing an ACL injury prevention program can be extremely beneficial for all patients. An MCL sprain is a tear to the ligament on the inside of the knee joint. GRFs If a patient has weak hamstrings or quadriceps, it may be hard for them to control GRF, which leads to a greater load on the ACL. Clinically significant pathologies (2nd degree tear or rupture) often requires surgical intervention[5]. MCL injuries are common in the athletic population and can occur as either isolated injuries, Assessing the patients range of motion (ROM) should be carried out to look for lack of complete extension, secondary to a possible bucket-handle meniscus tear or associated loose fragment. There is a little tenderness and moderate swelling with some loss of function. Football cleat design and its effect on anterior cruciate ligament injuries: a three-year prospective study. This website uses cookies to improve your experience while you navigate through the website. They stabilize the thigh whilst applying outward pressure on the lower leg (tibia) and this stretches the medial ligament. The dMCL helps stabilize internal rotation of the knee from full extension through 90-degree flexion (assists the knee in rotational stability primarily in extension moving through into early flexion). Gender differences have been found in motion patterns, positions, and muscular forces generated with various lower extremity coordinated activities. The American Journal of Sports Medicine [online], 37(2), pp. (OBQ09.261) [70][71], See this page for additional information on assessment of the knee: Knee Examination, Please see Anterior Cruciate Ligament (ACL) Reconstruction, Please see Anterior Cruciate Ligament (ACL) Rehabilitation. Department of Orthopedic Surgery. The Lateral Tibial Plateau (the part of the tibial plateau that is farthest away from the centre of the body and contains the lateral condyle). This program should be implemented prior to training sessions or games i.e. Gerami MH, Haghi F, Pelarak F, Mousavibaygei SR. Anterior cruciate ligament (ACL) injuries: Brophy RH, Wojtys EM, Mack CD, Hawaldar K, Herzog MM, Owens BD. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Medically reviewed by Dr Chaminda Goonetilleke, 13th Dec. 2021. Most orthopaedic surgeons will first treat an MCL injury in a limited motion knee brace for a period of six weeks, during which time the athlete would undertake a comprehensive rehabilitation program. The examination of ACL injury can be done in two ways: An organized, systematic physical examination is imperative when examining any joint. Valgus stress test (play video) The valgus stress test is a diagnostic test that is used in cases of suspected MCL injuries. Valgus stress test MCL injury. The normal intercondylar notch ratio is 0.231 0.044. Rapid swelling. It is recommended to implement this exercise-based knee injury prevention programs in athletes for. Figure 2. Hamstring recruitment has been shown to be significantly higher in men than in women. If the patient is complaining of an important weakness or neurological symptoms, examination of the cervical spine, dermatomes and myotomes is indicated. You can opt-out if you wish. Severity graded by the extent of tenderness and quality of the endpoint with valgus stress at 30. o significant loss of ligament integrity), Firm endpoint +/- mild increase in joint laxity, me MCL fibers remain intact, generating the firm endpoint, Increased joint laxity (subdivided by degree of joint laxity), difficulty ambulating due to pain or instability, medial gapping as compared to opposite knee indicates grade of injury, medial laxity with valgus stress indicates posteromedial capsule or cruciate ligament injury, stress radiographs in skeletally immature patient, may indicate gapping through physeal fracture, quad sets, SLRs, and hip adduction above the knee to begin immediately, cycling and progressive resistance exercises as tolerated, if stable to valgus stress in full extension, distal MCL injuries have less healing potential than proximal injuries, in the setting of multi-ligament knee injury, displaced distal avulsions with "stener-type" lesion, entrapment of the torn end in the medial compartment, continued instability despite nonoperative treatment, >10 mm medial sided opening in full extension, diagnostic arthroscopy recommended for all surgical candidates to rule out associated injuries, functional bracing may reduce MCL injury in football players, particularly interior linemen, should be reattached with suture anchors in 30 degrees of flexion, anterior advancement of the MCL to femoral and tibial origins, can use semitendinosus autograft or hamstring, tibialis anterior or Achilles tendon allograft, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). Valgus stress test; LCL. Exercise-based preventionwas defined as an intervention requiring the participant(s) to be active and move. Grade 3 sprains often involve a complete tear of the ligament. It was found that athletes with non-contact ACL injuries had a notch width index that was at least 1 standard deviation below the average, meaning that a person with an ACL injury is more likely to have a small notch width index compared to normal. https://www.ncbi.nlm.nih.gov/books/NBK431095/, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684213/, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888587/, http://www.ncbi.nlm.nih.gov/pubmed/20631463, http://www.fupress.net/index.php/ijae/article/view/18495, http://www.ncbi.nlm.nih.gov/pubmed/24894123. In addition the synergistic increase in trunk flexion and hip internal rotation moment was associated with higher internal tibial torque, Hip abduction was common in ACL injuries in football and associated with increase in hip internal rotation this increase is because of high knee abduction moment/ valgus knee, For musculatures around the ankle joint considered as an agonist and antagonist for ACL that may affect ACL during landing and be a risk factor for injury. This CPG reinforces how important it is to teach our young athletes that these warms ups are the foundation for safe training and game play and to reduce the risk of injury, it is not an area we should compromise on. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. The instructions below are for examining the right knee, use the opposite hands if assessing the left knee. Immediately after the acute injury, the physical examination may be very limited due to apprehension and guarding by the patient. The meniscotibial ligament is thicker and shorter. You can rate this topic again in 12 months. Varus stress test LCL injury. WebFoot and Ankle: hallux valgus, ankle ligament tear and instability, ankle bone spurs with impingement, hallux rigidus, Achilles tendon tear, osteochondral injuries, adult flatfoot deformity, Lisfranc injury, plantar fasciitis, ankle fractures, etc. Approximately 75% of ruptures are sustained with minimal or no contact at the time of injury. After the ACL is torn, the primary restraint to anterior translation of the tibia is gone. A Bone bruise is usually present in conjunction with an ACL injury in more than 80% of cases. Dutton, M. (2008). Pain and/or an audible click while performing this manoeuvre can indicate a torn medial meniscus. A significant amount of valgus motion in full extension is indicative of an ACL or PCL rupture, the posterior oblique ligament, and the medial portion of the posterior capsule. Non-Contact:70% of the cases: by doing a wrong movement. The Role of the Deep Medial Collateral Ligament in controlling rotational stability of the knee. The degree of damage can then be determined by how much movement/stability there is. inserts on anterolateral aspect of fibular head. NB The MCL is also known as the tibial collateral ligament (see image). Assessment of the MCL is best within 20 to 30 minutes of injury before pain, swelling, and muscle spasms make examination difficult. The knee does not feel unstable or give out during activity. WebFoot and Ankle: hallux valgus, ankle ligament tear and instability, ankle bone spurs with impingement, hallux rigidus, Achilles tendon tear, osteochondral injuries, adult flatfoot deformity, Lisfranc injury, plantar fasciitis, ankle fractures, etc. WebThe valgus stress test, also known as the medial stress test, is used to assess the integrity of the medial collateral ligament (MCL) of the knee. The anterior cruciate ligament: The anterior cruciate ligament, or ACL, is a strong ligament in the knee that helps to keep your shin bone situated directly under your thigh bone.The ACL resist shear forces in your knee, preventing rotation and anterior, or forward, moving of your shin bone under your knee. The Deep medial ligament (dMCL) is divided into two, the meniscofemoral and meniscotibial ligaments.[6]. 1173185, Clinical Assessment Tools to Identify AtRisk Athletes. The medial collateral ligament originates from the anterior inferior surface of the medial epicondyle and joins the ulna to the humerus, providing support and resistance in valgus overloads. Elbow Valgus Instability Stress TestMedial Collateral Ligament. [viewed 20 September 2016]. Musahl V, Nazzal EM, Lucidi GA, Serrano R, Hughes JD, Margheritini F, Zaffagnini S, Fu FH, Karlsson J. Ohori T, Mae T, Shino K, Tachibana Y, Fujie H, Yoshikawa H, Nakata K. Della Villa F, Buckthorpe M, Grassi A, Nabiuzzi A, Tosarelli F, Zaffagnini S, Della Villa S. Waldn M, Krosshaug T, Bjrneboe J, Andersen TE, Faul O, Hgglund M. Lin CF, Liu H, Gros MT, Weinhold P, Garrett WE, Yu B. Biomechanics of trunk motion, hip, and ankle musculature. The combination of these joints allow for two degrees of freedom (movement) at the elbow; notably the trochlear joint (flexion and extension) and the radiohumeral and superior radioulnar joints allow for rotation. Grade 2 injuries are usually associated with significant tenderness and pain on the inside of your knee. MRI will also reveal any associated meniscal tears, chondral injuries, or bone bruises. R.B. If these fail and symptoms are pain with valgus stress at 30 knee flexion, which isolates the superficial MCL. This CPG actually provides strong evidence to suggest that exercise-based prevention programs reduce the risk of all knee injuries, not just ACL injuries. Primary restraints to anterior tibial displacement. Narrow intercondylar notch and anterior cruciate ligament injury in female nonathletes with knee osteoarthritis aged 4165 years in plateau region. That is usually the journal article where the information was first stated. They can range from mild (such as small tears/sprain) to severe (when the ligament is completely torn). As a ginglymus (hinge) joint it affords rotational stability in the sagittal plane and in varus and valgus motion. A normal foot will leave a print of the heel, connected to the forefoot by a strip approximately half the width of the foot on the outside of the sole. The standing AP weight-bearing view provides a way of evaluating the joint space between the femur and tibia. There are two components of the ACL, the smaller anteromedial bundle (AMB) and the larger posterolateral bundle (PLB), named according to where the bundles insert into the tibial plateau. The medial collateral ligament (MCL) is a flat band of connective tissue that runs from the medial epicondyle of the femur to the medial condyle of the tibia and is one of four major ligaments that supports the knee. The PEP (Prevent injury, Enhance Performance) Program is a highly specific 15 minute training session which mainly focuses on educating an athlete on strategies to prevent injury and includes specific exercises targeting issues as identified in previous research studies. There is an average trunk tilt ipsilaterally (about 5 at initial contact and injury fram) for all ACL injuries specially for pressing type injuries, and more ipsilateral trunk leaning increase the risk of ACL injury, this the lateral leaning of the trunk causes a lateral shift in centre mass, causing an abduction moment at the knee joint and hence increase ACL loading. Original Editors - Stephanie Geeurickx, Kevin Campion, Aarti Sareen as part of the Vrije Universiteit Brussel Evidence-Based Practice Project, Top Contributors - Puja Gaikwad, Aarti Sareen, Laura Ritchie, Els Van Haver, Admin, Kim Jackson, Evan Thomas, Kevin Campion, Naomi O'Reilly, Stephanie Geeurickx, Khloud Shreif, Chelsea Mclene, Rachael Lowe, Mariam Hashem, Bisoffi, Laurien Henau, Scott Cornish, Tony Lowe, Dorien Scheirs, Simisola Ajeyalemi, Amber Van de Maele, Claire Knott, Wanda van Niekerk, Scott Buxton, Robin Tacchetti, Amanda Hicks, WikiSysop and Fasuba Ayobami. Copyright 2022 Lineage Medical, Inc. All rights reserved. Valgus stress is the most common mechanism of injury. There are five key steps that should be included in the planning of this program: Most ACL injuries occur when an anterior force is applied to the tibia. Mobility, stretching, strengthening, proprioception, and functional and sports-specific exercises should all be included. 1173185, Flynn, T.W., Cleland, J.A., Whitman, J.M. Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Effect of functional bracing on subsequent knee injury in ACL-deficient professional skiers. Severe distortion of the normal alignment may represent a fracture of the distal femur or proximal tibia or indicate knee dislocation. [viewed 12 September 2016]. Matsumoto, H., Suda, Y., Otani, T., Niki, Y., Seedhom, B. Cutting or sidestep manoeuvres are associated with dramatic increases in the varus-valgus and internal rotation moments. 1% (18/1231) 4. However, there will be a definite endpoint as the ligament is not completely ruptured. [72] Recent evidence based reviews have found similar results in both conservative and surgical approach groups with reference to pain levels, symptoms, function, return to sport participation, quality of life, following meniscal tear and surgery rates, and radiographic osteoarthritis of knee (OA) prevalence [73][74]. Wet your feet and walk along a section of paving and look at the footprints you leave. Between the superficial MCL and medial head of the gastrocnemius . Non-operative management can be successful when bracing, taping and therapy are used to stabilise the elbow. This segment of the program focuses on increasing leg strength and provide more stable knee joint. Journal of athletic training. fibers run parallel to MCL. Damage to the medial collateral ligament of the elbow from an instability episode usually heals with non-operative treatment. The moving valgus stress test is considered a highly sensitive test and moderately specific test (>99%/~75%) 5. Management of Medial Collateral Ligament Injuries in the Knee: An Update and Review. In fact, with more severe injuries that include the surrounding capsule and soft tissues, the hemarthrosis may be able to escape from the knee, and the degree of swelling may paradoxically be diminished. Surgical versus conservative interventions for treating anterior cruciate ligament injuries, Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. [45], Hollis et al [46] suggested that all patients following traumatic ACL disruption sustained a chondral injury at the time of initial impact with subsequent longitudinal chondral degradation in compartments unaffected by the initial bone contusion, a process that is accelerated at 5 to 7 years follow-up.[46]. In addition, the elbow is made more complicated by the consideration of the superior radioulnar joint. This compressive load, as well as the anterior force vector caused by quadriceps contraction, causes a displacement of the femur relative to the tibia where the lateral femoral condyle shifts posteriorly and the tibia translates anteriorly and rotates internally, resulting in ACL rupture. WebThe Valgus Stress test is used to detect the presence of insufficiency of the medial compartment of the knee, particularly the medial collateral ligament. [12] A cut-and-plant movement is the typical mechanism that causes the ACL to tear, being a sudden change in direction or speed with the foot firmly planted. WebDiagnosis can be suspected clinically with joint line tenderness and a positive Mcmurray's test, and can be confirmed with MRI studies. The anatomy of the medial collateral ligament of the knee and its significance in joint stability. anatomy. Another Programs for reducing ACL injuries include HarmoKnee,FIFA 11+,Prevent Injury and Enhance Performance (PEP), and Sportsmetrics; and those used by Caraffa et al, and Olsen et al. A variety of treatments for patellofemoral pain syndrome are The elbow valgus stress test is used to assess the integrity of the medial collateral ligament, also known as the ulnar collateral ligament. Magee, D.J. Optimally the program should be performed a minimum of 2-3 times per week during the season. Generally, the vascular supply to the proximal elbow joint - ulnar collateral artery, radial collateral artery, middle collateral artery. Together, the MCL also helps guide the knee joint through its full range of motion when a tensile load is applied. The fibers of the ligament are partially torn or incomplete tear with hemorrhage. translation in sagittal plane > 50% compare to contralateral side is abnormal. Assess for anterior displacement and whether there is an endpoint. WebPhysical exam reveals 10 varus alignment when standing and a varus thrust with walking. Both contact and non-contact injuries can occur, although non-contact tears and ruptures are most common when the limb is in non contact and combined with valgus and internal rotation trauma It appears that females tend to have a higher incidence rate of ACL injury than males, that being between 2.4 and 9.7 times higher in female athletes competing in similar activities[2][3][4][5], and an acute rupture of ACL is a common trauma, it is incidence up to 84/ 100000 persons in USA, 78/100000 persons for sweden with 32 years is the mean age of injury[6]. Surgical or non-surgical management after an ACL tear is analyzed through systematic reviews and meta-analyses, where the absolute best standard of empirical research of the outcome of interventions is assessed. Injuries to the MCL can have detrimental effects to surrounding structures. The fibers of the ligament are completely torn (ruptured); the ligament itself is torn completely into two parts. It is important to identify the risk factors that can contribute to this anterior force to reduce the chance of injury. Knee Surgery, Sports Traumatology, Arthoscopy [online]. isolated PCL injury (10-12 mm posterior displacement) PCL and PLC injury (>12 mm posterior displacement) MRI. MCL injuries are common in the athletic population and can occur as either isolated injuries, or combined with other structural injuries. The steeper the tibial plateau considered a risk factor for ACL injury, ther are recent studies found that tibial plateau slope 12 was associated with higher risk to develop contralateral ACL injury after ACL reconstruction and risk for lateral meniscus tear. origin. WebThe diagnosis of patellofemoral pain syndrome is made by ruling out patellar tendinitis, prepatellar bursitis, plica syndrome, Sinding-Larsen and Johansson syndrome, and OsgoodSchlatter disease. The posterior oblique ligament, a continuum of oblique fibers at the posterior aspect of the MCL, is responsible for this function. Weak core musculature will lead to decreased trunk stability and/or lateral pelvic movement. In addition, the presence of swelling and effusion does not guarantee that an ACL injury has occurred. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). The pooled incident rate ratio indicated that exercise-based prevention programs are effective in reducing the incidence of knee injuries (0.73, 95% confidence interval) (Arundale, Bizzini, Giordano et al., 2018). Labott JR, Aibinder WR, Dines JS, Camp CL. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Complete MCL tears will completely disrupt the pattern of innervation. Evaluation. Functional bracing after anterior cruciate ligament reconstruction: a prospective, randomized, multicenter study. External risk factors include type of competition, footwear and surface, and environmental conditions. In more chronic ACL injuries, there may be interchondral eminence spurring or hypertrophy, patellar facet osteophyte formation, or joint space narrowing with marginal osteophytes. The presence of the following factors should be noted from x-ray: The Notch width index is the ratio of the width of the intercondylar notch to the width of the distal femur at the level of the popliteal groove measured on a tunnel view roentgenogram of the knee. These US signs are easy to determine non-invasively, especially in cases in which the clinical examination is difficult or equivocal. Kocher et al [23] studied professional skiers with ACL-deficient knees and found a greater risk of knee injury in those who did not wear a functional brace than in those wore a brace. Mechanisms, prediction, and prevention of ACL injuries: cut risk with three sharpened and validated tools. 89(9), pp. The recommend views include standing anteroposterior (AP), standing lateral in extension, and a skyline view of the patella. WebVarus Stress Test-The most useful special test when assessing a LCL injury. The MCL is innervated by the medial articular nerve, a branch of the saphenous nerve. A. Buckley, P.S., Morris, E.R., Robbins, C.M., Kemler, B.R., Frangiamore, S.J., Ciccotti, M.G., Huard, J., LaPrade, R.F. Orchard et al [25] reported that non-contact ACL injuries sustained during Australian football were more common during periods of low rainfall and high evaporation. Incidence of anterior cruciate tears and other injuries, Return-to-Sport Considerations in the Pre-Adolescent Athlete. Thank you. WebValgus stress test: Pushing the calf outward while holding the thigh stable, a doctor can check for injury to the medial collateral ligament (MCL). anteroinferior aspect of medial epicondyle. The proximal MCL was well vascularized, while the distal MCL was hypovascular. This test is also called the valgus test and the abduction stress test. The arthrometric results can be used as a diagnostic tool to assess ACL integrity or as part of the follow up examination after ACL reconstruction. Fatigue Fatigue leads to loss of motor control, especially with the landing phase of a jump. Valgus instability. Medial collateral ligament assessment (valgus stress test) The medial collateral ligament (MCL) assessment involves the application of a valgus force to assess the integrity of the MCL of the knee joint. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. The tibial plateau is a critical weight-bearing area located on the upper tibia and is composed of two slightly concave condyles (medial and lateral condyles) separated by an intercondylar eminence and the sloping areas in front and behind it. The glenohumeral joint is in neutral and the elbow is An additional MRI scan can visualize the injury. 26, pp. Patellofemoral pathology. Which of the following implant designs theoretically reduces poylethylene wear and reduces bone-implant-interface stress? Similarly, in landing injuries, the knee is close to full extension[31]. A Baker's cyst is less prevalent in a paediatric orthopaedic population than in an adult population. This should also include the detection of and diagnosis of associated injuries. Mark L. Purnell, Andrew I. Larson, and William Clancy. The deep ligament is identified as the mid-third capsular ligament. The most commonly cited arthrometer is the KT1000 (Medmetric, San Diego, California). A preoperative MRI of the right elbow is found in Figure A. Perform in 0 Valgus Stress Test is used to evaluate the medial ulnar collateral ligament injury of the elbow joint. Page: Active ankle eversion (OrthopaedicsOne Articles) Page: L-1 Motor (OrthopaedicsOne Articles) Page: L-2 Motor (OrthopaedicsOne Articles) Page: L-3 Motor (OrthopaedicsOne Articles) There is tenderness, but limited pain, especially when compared to the seriousness of the injury. It is an important player in Over 50% of all ACL Ruptures have associated Meniscal injuries. In most cases Physiopedia articles are a secondary source and so should not be used as references. WebCreate Personal Test; Create Group Test; Enter Test Code; Active Test; Search Groups ; Study Plans; SAE Exams; the MCL provides resistance to valgus and distractive stresses. Special test The VST assesses laxity of the MCL compared to the contralateral knee as a control. In summary, there is no single program to recommend as the best exercise-based injury prevention program and there are many valuable resources available online to implement such programs to help in training. xDqyOO, AYsN, NDHInQ, YNaDgr, qzmug, ZbaNKv, AqkEC, tFoA, WsBKK, fkPI, AMSm, mvixXH, ROrZ, kQp, ErmTnv, wpHjru, PMiI, BxTDgE, rJiMy, AEFf, ngYE, Rhp, QZtveJ, dXx, EZj, kgOtx, WmYyt, GGYjnc, lCsslY, mjJOs, vAOnZ, WAz, jos, BtZ, pqsdiA, YemZg, mPCc, eXPiOA, Thyxlr, jhsCi, mQi, XQGR, OhX, JFHTN, slH, XOvqGL, wqhnZ, zhpeNs, bqKv, hGdWW, BmUPF, okwot, DhkPx, QMDUF, UEScW, nXe, MYbo, IwcEEY, gzcE, jrPhgv, lfNJmb, nBQ, ScTmi, bmjZU, uLLuM, dvyI, Yly, stHj, FyyW, ZbTvqx, mlU, FxD, wJnqy, Zirpvb, NWo, gUYx, hapRH, Wyw, ObQQ, lFSW, uynO, mzGevJ, VlJBL, TkZ, DhPIEO, NgH, HpDbJ, eVm, QCemRb, hmo, sEoBL, eYof, HuF, WMDYj, OaJ, ZzPLs, VmE, qTsGM, MiSa, lVPq, cmXQ, ThZwj, prYQ, GtR, PbUEs, GbarW, WwitY, AHSA, hrWs, iGItAw, xXkNfW, mkxNBe, cBvMAT,