Commonly Used Special Tests in Sports Medicine

Northwest Texas Sports Medicine Clinic: General Medical: Commonly Used Special Tests in Sports Medicine
By
Tommie DeBerry, PT, LAT on Monday, March 25, 2002 - 11:50 pm:

COMMONLY USED SPECIAL TESTS FOR EVALUATING INJURIES


CERVICAL TESTS:


Foraminal Compression (Spurling) Test
Pt bends or side flexes head to one side. Examiner carefully presses straight down on the head.

-- Test is positive if pain radiates into the arm toward which the head is flexed during compression.

** This indicates pressure on the nerve root.


Distraction Test
Place one hand under the pt's chin and the other hand around the occiput. The examiner slowly lifts the pt's head.

-- Test is positive if the pain is relieved or decreases when the head is lifted or distracted.
** This indicates pressure on the nerve roots.

** Test may also be used to check the shoulder. Pt moves the arms while traction is applied and the symptoms are often relieved or lessened in the shoulder.
** This indicates pressure on the cervical nerve root.


Brachial Plexus Tension (Upper Limb Tension) Test
Patient lies supine and the examiner passively abducts the patient's arm just behind the coronal plane to the point just short of pain. The examiner then passively externally rotates the glenohumeral joint to a position just short of pain while the elbow is flexed. This shoulder position is held and the forearm supinated. While these positions are held, the elbow is passively extended.

** Reproduction of symptoms implies problems of cervical origin (C5 - C7 ), primarily C5 nerve root.

** Also, if the cervical spine is then flexed, symptoms that then include aching in the cubital fossa extending to the forearm (anterior and radial aspects) and onto the radial side of the hand and tingling in the thumb and lateral three fingers will increase. Side flexion of the head to the test side will decrease the symptoms 70% of the time, whereas side flexion to the opposite side will increase the symptoms.


Shoulder Depression Test
Examiner side bends the pt's head while applying a downward pressure on the opposite shoulder.

-- Test is positive, if pain increases.

** This indicates irritation or compression of the nerve roots, foraminal encroachments such as osteophytes in the area, or adhesions around the dural sleeves of the nerve and adjacent joint capsule on the side being stretched.


Jackson's Compression Test
Pt rotates the head to one side. Examiner then carefully presses straight down on the head. Repeat to other side.

-- Test is positive if on testing, pain radiates into the arm.

** This is indicative of nerve root pressure with pain indicating nerve root affected


Valsalva Test
Examiner asks the pt to take a deep breath and hold it while bearing down, as if moving the bowels.

-- Test is positive, if pain increases.

** This may be indicative of increased intrathecal pressure and is usually due to a space-occupying lesion, such as a HNP, a tumor, or osteophyte formation.
** Perform with care and caution. Pt may become dizzy and pass out while performing the test as the procedure can block the blood supply to the brain.


Vertebral Artery (Cervical Quadrant) Test
Pt supine, Examiner passively takes the pt's head and neck into extension and side flexion. When this movement is achieved, the examiner rotates the pt's head to the same side and holds it for approximately 30 seconds.

-- Test is positive, if referring symptoms are noted to the side to which the head is taken.

** This is indicative of nerve root compression in the lower cervical spine. To test the upper cervical spine, the examiner pokes the pt's chin and follow with extension, side flexion, and rotation. If dizziness or nystagmus occurs, this indicates that the vertebral arteries are being compressed.

** Indicates whether or not there is pathology of C7 (facial) nerve


Dizziness Test
Examiner actively rotates the pt's head as far as possible to the right then to the left. Pt's shoulders are then actively rotated as far as possible to the right, then to the left while keeping the eyes looking straight ahead.

-- If pt experiences dizziness in both cases then the problem lies in the vertebral arteries. If dizziness persists only when the head is rotated.

** This test is indicative of a problem that lies in the semicircular canals.


SHOULDER TESTS:


TESTS FOR ANTERIOR SHOULDER INSTABILITY:


Anterior Drawer Test
Pt is lying supine and the examiner places the hand of the affected shoulder in the examiner's axilla, holding the pt's hand with the arm so that the pt remains relaxed. The shoulder being tested is abducted between 80-120 degrees ; forward flexed 0-20 degrees; and laterally rotated 0-30 degrees. The examiner then stabilizes the pt 's scapula with the opposite hand pushing the spine of the scapula forward with the index and middle finger. The examiner's thumb exerts counter pressure on the pt's coracoid process. Using the arm that holds the pt's hand, the examiner places the hand around the pt's relaxed upper arm and draws the humerus forward.

-- Test is considered positive, if movement is accompanied by a click and/or patient apprehension. The amount of movement available is compared with that of the normal shoulder.

** This test is indicative of anterior shoulder instability


Protzman Test
Pt is sitting and the examiner abducts the pt's arm to 90 degrees and supports the arm against the examiner's hip so that the pt's shoulder muscles are relaxed. The examiner palpates the anterior aspect of the head of the humerus with the fingers of one hand deep in the pt's axilla while the fingers of the other hand are placed over the posterior aspect of the humeral head. The examiner then pushes the humeral head anteriorly and inferiorly.

-- This test is positive, if this movement causes pain and palpation indicates abnormal anteroinferior movement.

** This test is indicative of anterior instability


Anterior Instability Test
The examiner stands behind the shoulder being examined while the pt sits. The examiner places the examiner's "inside" hand over the shoulder so that the index finger is over the head of the humerus anteriorly and the middle finger over the coracoid process. The thumb is placed over the posterior humeral head. The examiner's other hand grasps the pt's wrist and carefully abducts and laterally rotates the arm.

-- Test is positive if, on movement of the arm, the finger palpating the anterior humeral head moves forward. When the arm is returned to the starting position, the index finger will return to the starting position as the humeral head glides backward.

** This test is indicative of anterior shoulder instability


Rockwood Test
Examiner stands behind the seated patient. With the arm by their side, the examiner laterally rotates the shoulder. The arm is abducted to 45 degrees, and passive lateral rotation is repeated. The same procedure is repeated at 90 degrees and 120 degrees.

-- Test is positive, if the patient shows marked apprehension with posterior pain when the arm is tested at 90 degrees. At 45 degrees and 120 degrees, the patient will show some uneasiness and some pain. At 0 degrees, there is rarely apprehension.

** This test is indicative of anterior shoulder instability


Rowe Test
Patient lies supine and places the hand behind the head. The examiner places one hand (clenched fist) against the posterior humeral head and pushes up while extending the arm slightly.

-- Test is positive, if a look of pain or apprehension is noted.

** This test is indicative of anterior shoulder instability


Fulcrum Test
Patient lies supine with the arm abducted to 90 degrees. Examiner places one hand under the glenohumeral joint to act as a fulcrum. The examiner then extends and laterally rotates the arm gently over the fulcrum.

-- Test is positive if apprehension is noted.

** This test is indicative of anterior shoulder instability


Apprehension (Crank) Test For Anterior Dislocation
Examiner abducts and laterally rotates the patient's shoulder slowly.

-- Test is positive, if a look or feeling of apprehension or alarm is present on the patient's face and they resist further motion. The patient may also state that the feeling experienced is what it felt like when the shoulder dislocated previously.

** Imperative that this test is performed slowly or the humerus may dislocate

** This test is indicative of anterior shoulder dislocation


TESTS FOR POSTERIOR SHOULDER INSTABILITY:


Posterior Drawer Test
Patient lies supine. Examiner stands at the level of the shoulder and grasps the patient's proximal forearm with one hand, flexing the patient's elbow to 120 degrees and the shoulder to 80 to 120 degrees of abduction and 20 to 30 degrees of forward flexion. With the other hand, the examiner stabilizes the scapula by placing the index and middle fingers on the spine of the scapula and the thumb on the coracoid process. The examiner then rotates the forearm medially and forward flexes the shoulder to 60 to 80 degrees while at the same time taking the thumb of the other hand off the coracoid process and pushing the head of the humerus posteriorly. The head of the humerus can be felt by the index finger of the same hand.

-- Test is positive, if patient exhibits apprehension. Test is usually pain free.

** This test is indicative of posterior instability


Jerk Test
Patient sits with the arm medially rotated and forward flexed to 90 degrees. The examiner grasps the patient's elbow and axially loads the humerus in a proximal direction. While maintaining axial loading, the arm is moved horizontally in adduction.

-- Test is positive, if a sudden jerk is produced as the humeral head slides off the back of the glenoid. As the arm is returned to 90 degrees a second jerk may be felt as the humeral reduces.

** This test is indicative of recurrent posterior instability


Posterior Apprehension Test
Patient lies supine and the examiner forward flexes and medially rotates the patient's shoulder. Examiner then applies posterior pressure on the patient's elbow. Test should also be performed at 90o of abduction, while the examiner palpates the humeral head with one hand and the other pushes the head posteriorly.

-- Test is positive, if a look of apprehension or alarm is noted on the patient's face and further motion is resisted and if the humeral head moves more than 50% of its size. Clunk may be present.

** Test is indicative of posterior instability


TEST FOR INFERIOR AND MULTIDIRECTIONAL INSTABILITY:


Inferior Shoulder Instability Test (Sulcus Sign)
Patient is sitting with the arm at the side relaxed. The examiner grasps the patient's forearm below the elbow and pushes the arm distally.

-- Test is positive, if the presence of a sulcus sign occurs.

** This test is indicative of inferior instability


Feagin Test
The patient stands with his arm abducted to 90 degrees and the elbow is extended resting on the top of the examiner's shoulder. Examiner's hands are clasped together over the pt's humerus between the upper and middle third. The examiner pushes the humerus down and forward.

-- Test is positive, if a look of apprehension is seen on the pt's face.

** This test is indicative of anteroinferior instability


Rowe Test For Multidirectional Instability
The patient stands forward flexed 45 degrees at the waist with the arms relaxed, pointing to the floor. Examiner places one hand over the pt's shoulder so the index and middle fingers sit over the anterior aspect of the humeral head and the thumb sits over its posterior aspect. The examiner then pulls the arm down slightly. To test for anterior instability, the humeral head is pushed anteriorly with the thumb while the arm is extended 20-30 degrees from the vertical position. To test for posterior instability, the humeral head is pushed posteriorly with the index and middle fingers while the arm is flexed 20-30 degrees from the vertical position. To test for inferior instability, more traction is applied to the arm and the sulcus sign is evident.


TESTS FOR OTHER SHOULDER JOINTS:


Acromioclavicular Shear Test
The patient is in a sitting position and the examiner cups his hands over the deltoid muscle with one hand on the clavicle and the other hand on the spine of the scapula. The examiner then squeezes the heels of the hands together.

-- Test is positive, if pain or abnormal motion at the acromioclavicular joint is present.

** Test is indicative of acromioclavicular joint pathology


TEST FOR MUSCLE/TENDON PATHOLOGY:


Yergason's Test
With the pt's elbow flexed to 90 degrees and stabilized against the thorax with the forearm pronated, the examiner resists supination while the patient also laterally rotates the arm against resistance.

-- Positive result elicits tenderness in the bicipital groove or the tendon may pop out of the groove.

** Indicative of bicipital tendinitis


Speed's Test (Biceps or Straight Arm Test)
Examiner resists shoulder forward flexion by the pt while the pt's forearm is supinated and the elbow is completely extended.

-- Positive test elicits increased pain tenderness in the bicipital groove.

** Indicative of bicipital tendinitis


Transverse Humeral Ligament Test
Examiner abducts and externally rotates the patient's shoulder as the examiner fingers are placed in the bicipital groove while the shoulder is externally rotated

-- Positive test, if the examiner feels the tendon snap in/out of the groove as they externally rotate.

** Indicates tearing or rupture of the transverse ligament




TESTS FOR ROTATOR CUFF TEARS AND IMPINGEMENT:


Clunk Test
Patient lies supine. Examiner places one hand on the posterior aspect of the shoulder over the humeral head. The examiner's other hand holds the humerus at the elbow. Examiner fully abducts the arm over the patient's head. The examiner then pushes anteriorly with the hand over the humeral head while the other hand rotates the humerus into lateral rotation.

-- Test is positive, if a "clunk" or grinding occurs.

** This test is indicative of a tear of the labrum or instability
-- If the above maneuver is followed with horizontal adduction that will relocate the humerus, a clunk or click may also be heard


Drop Arm Test
Examiner abducts the patient’s shoulder to 90 degrees and then asks them to slowly lower it to their side in the same arc of movement.

-- Positive test is indicated if the patient is unable to return the arm to the side slowly or has severe pain when attempting to do so.

** Positive results are indicative of a tear in the rotator cuff complex


Supraspinatus Test
Patient's shoulder is abducted to 90 degrees in a neutral position and the examiner gives resistance to abduction. The shoulder is then internally rotated and angled forward 30 degrees, so that the thumb points to the floor. Resistance to abduction is given again with the examiner looking for pain and weakness.

-- Positive sign is indicated, if pain/weakness wit resisted abduction with internal rotation.

** Indicates a tear of the supraspinatus tendon/ muscle


Impingement Sign/Test
Examiner forcibly abducts the patient's arm through forward flexion causing a jamming of the greater tuberosity against the anterior lateral acromial surface.

-- Positive test, if patient's face shows pain upon motion.

** Indicates an overuse injury to the supraspinatus and sometimes the biceps tendon


Hawkins-Kennedy Impingement Test
Examiner forward flexes the arm to 90 degrees and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament.

-- Positive, if pain is felt on forward flexion of the arm.

** Indicate a test for supraspinatus tendinitis


THORACIC OUTLET SYNDROME TESTS:


Allen Test
Patient sitting, examiner flexes the patient's elbow to 90 degrees and shoulder abducted 90 degrees with external rotation. Patient rotates his head away from test side while the examiner palpates the radial pulse.

-- Positive, if pulse disappears.

** Indicates Thoracic Outlet Syndrome


Adson Maneuver - Thoracic Outlet Syndrome
Patient sitting, the examiner locates the radial pulse. Patient rotates the head toward the test shoulder. Patient extends his head, while the examiner extends and externally rotates the shoulder.
Patient takes a deep breath and holds it.

-- Positive, if pulse disappears.

** Indicates Thoracic Outlet Syndrome


Halstead Maneuver
Examiner finds the radial pulse, and applies a downward traction on the arm, while his neck is hyperextended and head rotated to the opposite side.

-- Positive, if absence or disappearance of pulse.

** Indicates Thoracic Outlet Syndrome


ELBOW TESTS:


Ligamentous instability - Collateral ligaments
Patient's arm is stabilized at the elbow and wrist with a varus then valgus force at the elbow.

-- Positive, if signs of laxity or increased mobility or pain.

** Indicates injury to the collateral ligaments


Lateral Epicondylitis
The examiner stabilizes patient’s elbow and thumb rests on the lateral epicondyle.
Patient makes a fist, pronates, radial deviates, and extends the wrist.

-- Positive, if sudden severe pain is found at the lateral epicondyle.

** Indicates tennis elbow


Lateral Epicondylitis - Method Two
Patient sitting, examiner palpates the lateral epicondyle while the patient pronates the forearm (by the examiner), full wrist flexion, and extends the elbow.

-- Positive, if pain over the lateral epicondyle.

** Indicates tennis elbow


Medial Epicondylitis - Golfer’s Elbow
Examiner palpates the patient's medial epicondyle. Patient's forearm supinated with elbow and wrist extended.

-- Positive, if pain over medial epicondyle.

** Indicates injury to the medial epicondyle


Tinel's Sign - Ulnar nerve injury
Examiner stabilizes hand/wrist and elbow, while palpating ulnar nerve at medial epicondyle and olecranon.

-- Positive, if tingling sensation in ulnar distribution occurs.

** Indicates injury to the ulnar nerve


HAND TESTS:


Finkelstein Test - Tenosynovitis of the abductor and extensor pollicis longus and brevis
Patient makes a fist with the thumb inside the finger. Examiner stabilizes the forearm and ulnar deviates.

-- Positive, if pain occurs.

** Used to determine DeQuervain's disease


Tinel Sign - Carpal Tunnel Syndrome
Examiner taps over the carpal tunnel at the anterior wrist (Over retinaculum).

-- Positive, if paresthesia, tingling into the thumb, 1st, 2nd, middle, and lateral 1/2 of ring finger occurs.

** Indicates carpal tunnel syndrome


Phalens - Carpal Tunnel Syndrome (Median Nerve)
Patient places the posterior aspects of the hands together. Examiner flexes the wrist maximally and holds 1 min.

-- Positive, if tingling occurs as above.

** Indicates carpal tunnel syndrome


HIP TESTS:


Trendelenburg Test
Patient stands on 1 foot and tries to maintain his position.

-- The unsupported pelvis should rise for negative.
-- If pelvis stays level or descends for positive.

** Indicates gluteus medius weakness


Leg Length - True
Measure the distance from the ASIS to the medial malleolus of the ankle. To determine if the tibia or the femur is longer, have the patient lie supine and bend their knees to 90 degrees.

-- If knee appears higher - tibia is longer
-- If knee projects further anteriorly - femur is longer

*** Perform true first


Leg Length - Apparent
Patient lies supine and measure from umbilicus to the medial malleolus of the ankle.


Ober - ITB contraction
Patient sidelying, lift their leg into abduction with the knee flexed to 90 degrees.

-- Release the leg and if normal the leg will drop - negative
-- If leg stays abducted - positive

** Indicates ITB tightness


Thomas Test - Hip flexor tightness
Hip flexor I - Patient lies supine and pulls their knee to their chest.

-- Positive, if thigh flexes.

** Indicates tightness of the iliopsoas


Hip flexor II
- Patient lies supine with their hips at the edge of the table. Patient pulls 1 knee to their shoulder.

-- Positive, if straight knee stays extended.

** Indicates tightness of the rectus femoris and ilioposas


KNEE TESTS:


Valgus Stress - Medial collateral ligament
Patient is supine with examiner with one hand about the ankle and the other hand over the head of the fibula. A medial stress is applied at the knee.
Test is performed with:
** Knee in full extension / O degrees
** Knee flexed to 15 degrees

-- Positive, if laxity or pain is noted along medial joint line and MCL

** Indicates medial collateral ligament sprain or tear.


Varus Stress - Lateral collateral ligament
Patient is supine with examiner having one hand at the ankle (laterally) and the other hand at the medial joint line of the knee. A lateral stress is applied at the knee.
** Knee at full extension / 0 degrees
** Knee flexed 30 degrees

-- Positive, if laxity or pain is noted along lateral joint line and LCL.

** Indicates lateral collateral sprain or tear.


Anterior Drawer - Anterior cruciate ligament
Patient is supine with their knee flexed to 90 degrees and foot flat in a neutral position. Examiner sits on the table, on their foot to stabilize, with their hands grasped about the knee wit fingers over the hamstrings and thumbs on the medial and lateral joint line The examiner pulls the tibia forward.

-- If movement occurs the test is considered positive
-- If the anterior draw is positive, then test should be repeated with the tibia:
Internal rotation - 20 degrees
External rotation - 15 degrees
** Sliding forward of the tibia with external rotation indicates that the post/med joint capsule, ACL, and possible MCL are torn with anterior medial rotatory instability
** Sliding forward of the tibia with internal rotation indicates that the post/lat capsule and ACL may be torn with anterior lateral rotatory instability.

** Indicates sprain or tear of the anterior cruciate ligament.


Posterior Draw - Posterior cruciate ligament
Same position as that of the anterior draw test except with a posterior force on the tibia.

-- Positive, if tibia displaces posterior on the femur.
** Sliding of the tibia backward with internal rotation indicates that the LCL, lateral capsule, arcuate, and PCL with posterior lateral rotatory instability
** Sliding backward of the tibia with external rotation indicates that the MCL, medial capsule, and PCL are torn with posterior medial instability.

** Indicates sprain or tear of the posterior cruciate ligament.


Lachman Drawer - Anterior cruciate ligament
Preferred because it does not force the acute knee into 90 degrees of flexion. Knee is positioned at 15 degrees of knee flexion with the leg externally rotated. One of the examiners hands grabs the distal end of the patient's thigh, while the other hand grabs the proximal tibia with an anterior force applied.

-- Positive, if laxity or instability is noted, usually accompanied by pain.

** Indicates sprain or tear of the anterior cruciate ligament.


Degrees
1st - 1.3 cm (1/2”)
2nd - 1.3 - 1.9 cm ( 1/2 - 3/4)
3rd - 1.9 cm or more ( 3/4 or more)


Pivot Shift - Anterolateral rotatory instability
Patient is supine with one hand head of fibula and the other hand at the patient's ankle. The lower leg is internally rotated and knee extended. The thigh is then flexed 30 degrees at the hip and the knee flexed with a valgus force applied to the knee.

-- If positive for ACL, a palpable shift is felt or a pop in the early stages of knee flexion.

** Indicates sprain or tear of the anterior cruciate ligament.


McMurray - Meniscal tear
Patient is supine with the knee fully flexed, the examiner places one hand on the foot and the other hand on top of the knee with fingers touching the medial and the thumb lateral joint line. The ankle hand scribes small circles with the leg pulled into extension.

-- If positive, the hand may feel a clicking response in the joint line and/or accompanied by pain.
** External rotation - Medial meniscus
** Internal rotation - Lateral meniscus

** Indicates a tear of the medial or lateral meniscus


Apley's Compression - Meniscal tear
Patient lies prone with their knee flexed to 90 degrees. While stabilizing the thigh, a hard downward pressure is applied to the leg. The leg is rotated in and out at the tibia.

-- If pain results, positive for meniscal tear
** External rotation - medial meniscus
** Internal rotation - lateral meniscus

** Indicates a tear of the medial or lateral meniscus.


Apley's Distraction - Collateral ligament tear
Patient lies prone with the knee flexed to 90 degrees. The examiner places their knee across the patient's thigh to stabilize and applies a traction force, while moving it in and out.

-- Positive, if pain occurs for capsular and ligamentous pathology.
-- If meniscus is torn, no pain will occur.

** Indicates sprain or tear of the collateral ligaments.


Godfrey - Posterior cruciate ligament
Patient is supine with hips and knees flexed to 90 degrees. The foot is supported at the lower calf or ankle.

-- If positive, a posterior sag of the tibia occurs and there is posterior instability. If pressure is applied, displacement may increase.

** Indicates a sprain or tear of the posterior cruciate ligament.


Bounce Home - Meniscal tear
Patient lies supine with the heel of the patient's foot cupped in the examiners hand. Patient's knee is completely flexed and then passively allowed to extend.

-- If extension is incomplete or with a rubbery end-feel, then something is blocking full extension.

** Indicates a tear of the medial or lateral meniscus.


Clarke's Sign - Patellar chondromalacia
Patient is supine with the knee extended and the examiner has his hand pressing down on the upward proximal pole or the base of the patella. Patient is asked to do a quad set and hold.

-- If there is pain, and cannot hold a contraction then the test is positive.

** Indicates chondromalacia or patellofemoral syndrome.


Patellar compression - Chondromalacia of the patella
Patient is supine with their knee slightly flexed. The patella is pressed in the femoral groove and moved forward/backward.

-- If positive, pain or crepitus will be noted.

** Indicates patellar chondromalacia.


Apprehension - Patellar dislocation
Patient is supine with the knee/patella relaxed. The examiner pushes the patella laterally.

-- Positive if, apprehension is noted at the point of dislocation.

** Indicates patellar dislocation.


ANKLE TESTS:


Fractures - Tibial or fibular
Patient is positioned supine or prone with the heel struck with a reflex hammer.

-- Positive, if pain is felt or radiates through the leg


Anterior Drawer - Anterior talofibular ligament
Patient lies supine with their foot relaxed and the examiner stabilizes the tibia/fibula with the foot in 20 degrees of plantarflexion. The examiner grabs the ankle and draws the talus forward in the mortise.
Inversion gives an anterolateral stress with increased stress on the ATF.
Straight anterior translation will indicate both medial and lateral deficits.

-- If positive, laxity and pain will be noted along the ATF.

** Indicates sprain or tear of the ATF.


Posterior Drawer – Posterior talofibular ligament
Patient lies supine with their foot relaxed and the examiner stabilizes the tibia/fibula with the foot in 20 degrees of plantarflexion. The examiner grabs the ankle and draws the talus backwards in the mortise.

-- Positive if, laxity and/or along the PTF

** Indicates sprain or tear of the PTF.


Talar Tilt - Calcaneofibular ligament
Patient is supine or sidelying with the foot relaxed and knee flexed to 90o to relaxed the gastrocnemius. Examiner applies adduction stress to the talus.

-- Positive, if lateral gapping is present.

** Indicates sprain or tear of the CFL.


Thompson Test - Achilles tendon
Patient lies prone with foot over the edge of table. Examiner squeezes the calf muscle.

-- Positive, if plantarflexion is absent.

** Indicates strain, tear, or rupture of the Achilles tendon.


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