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The Adolescent Athlete: Highlights
of Commonly Occurring Sports
Medicine Injuries
Jessica Rieder, MD, MS
March 2, 2010
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Outline
 Common Musculoskeletal injuries:
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ACL Tear
Patellofemoral Syndrome
Osgood-Schlatter Disease
Spondylolysis/Spondylolisthesis
Infectious Diseases and the athlete
Concussion
The Female Athlete Triad
Athletic Performance Drugs and Nutritional Supplements
Issues related to Sports Specialization and Overtraining
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Common Musculoskeletal
Injuries
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ACL Tear
 Epidemiology
 80,000 ACL tears/year in the US
 Highest incidence in the 15-25 year age range
 2 – 8x females (e.g. soccer, basketball, volleyball)
 Etiology
 70% Non-contact Injuries
 Deceleration, change of direction, landing, hyperextension,
knee flexed, valgus with rotation
 30% Due to Direct Contact with another player or
object
 Hyperextension, valgus stress, forced internal rotation
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Clinical Presentation of ACL Tear
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Sudden pain
Giving way/instability
Audible pop: 1/3
Joint effusion
Patient holds knee in
slight flexion and unable
to bear weight on
involved lower extremity
 Positive anterior instability
tests
 Rarely an isolated injury;
look for symptoms of
MCL and meniscal injury
Lachman Test
Anterior Drawer Test
Pivot Shift Test
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Treatment of ACL Tears
 Acute Treatment
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Relative rest, ice, elevation, crutches
Arthrocentesis - questionable efficacy
Knee immobilizer or range-of-motion brace
Early range of motion exercises
 Definitive Treatment
 Referral to orthopedic surgeon
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Patellofemoral Syndrome
(Chondromalacia Patellae)
 Epidemiology
 Can cause almost threefourths of knee problems in
adolescent females and
one-third of problems in
males.
 Etiology
 Usually the result of
abnormal biomechanical
forces across the patella.
Abnormal forces can result
secondary to quadriceps
femoris muscle imbalance
or weakness, altered
patellar anatomy (e.g. small
or high-riding patella), or
increased femoral neck
anteversion.
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Patellofemoral Syndrome
 Clinical Manifestations and Diagnosis
 Peripatellar or retropatellar pain that increases with
activity especially ascending or descending stairs.
Usually a several month or more history of pain.
 On examination, the teen may have retropatellar
crepitation, patellae that are displaced anteromedially,
tenderness of the undersurface of patella. Usually
range of motion is normal and there is no joint
effusion.
 Diagnosis usually made by compatible history and
examination. X-rays are generally of very limited help.
Important to remember that hip disorders may have
referred pain to the knee.
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Patellofemoral Syndrome
 Treatment
 Usually involves initial rest and avoidance of running,
jumping and climbing plus non steroidal antiinflammatory medications.
 Muscle strengthening program and graduated running
exercises and maintenance program of exercises
 Good quality athletic shoe and occasionally custom
orthotics
 Surgery is usually not needed.
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Patellofemoral Syndrome
Exercises
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Quadriceps strengthening: isometrics.
Position yourself as shown. Hold your
right leg straight for 10 to 20 seconds
and then relax. Do the exercise 5 to
10 times.
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Quadriceps strengthening: straight leg
lift. Position yourself as shown. Raise
your right leg several inches and hold
it up for 5 to 10 seconds. Then lower
your leg to the floor slowly over a few
seconds. Do the exercise 5 to 10
times.
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Iliotibial band and buttock stretch (right
side shown). Position yourself as
shown. Twist your trunk to the right
and use your left arm to "push" your
right leg. You should feel the stretch in
your right buttock and the outer part of
your right thigh. Hold the stretch for 10
to 20 seconds. Do the exercise 5 to 10
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Osgood-Schlatter Disease
 Epidemiology
 Painful enlargement of the tibial tubercle at the insertion of the
patellar tendon
 The condition has its peak prevalence with the timing of peak
growth velocity
 Occurs on average about two years later in males than females
(about 12 1/2 versus 10 1/2 years of age) and is more common in
males.
 Etiology
 During puberty and the development of significant muscle mass,
significant traction stress from the patellar tendon on the small
ossification center in the anterior tibial tubercle can result in
actual small fragments of cartilage avulsing from the tubercle.
 Running and jumping can aggravate the condition.
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Osgood-Schlatter Disease
 Clinical Manifestations and Diagnosis
 Manifested by pain and swelling over the anterior tibial tubercle
with point tenderness at that area
 Normal joint mobility and is more often unilateral
 The condition lasts several months but can last longer
 The diagnosis is usually made by history and examination and xray only necessary if something unusual on examination
 Treatment
 Restriction of activity and immobilization if symptoms are severe
 In addition, nonsteroidal anti-inflammatory medications and ice
can be helpful. The condition is usually self-limited but can
reoccur with excessive activity.
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Spondylolysis/Spondylolisthesis
 Epidemiology
 These two conditions are the most common causes of ongoing
(chronic) back pain in children. As many as 6% of children may
have spondylolysis by the time they are 6 years old.
 Etiology
 A defect of the pars interarticularis and forward slippage of one
vertebra on another, usually L5 on S1
 Commonly occur in teens with significant athletic involvement
where there are large extension forces across the lower back
(gymnasts, ballet dancers, volleyball players, wrestlers)
 Spondylolysis can progress until one or more vertebrae
slip out of place (spondylolisthesis).
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Spondylolysis/Spondylolisthesis
 Clinical Manifestations and Diagnosis
 Spondylolysis and spondylolisthesis may cause no symptoms for some
children and significant pain for others
 Pain may be worse when children arch their backs
 If the slipping is severe for children with spondylolisthesis, it can stretch
the nerves in the lower part of the back. This can lead to:
 Pain that goes down one or both legs
 A numb feeling in one or both feet
 Weakness in the legs
 Trouble controlling bladder or bowel movements
 Diagnosis
 Lordosis
 Radiologic examination.
 Diagnosis of spondylolysis usually requires oblique films.
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Treatment
 Conservative Treatment
 May require immobilization in severe conditions for several
weeks
 Nonsteroidal anti-inflammatory medications and ice can be
helpful.
 The condition is usually self-limited but can reoccur with
excessive activity
 Strengthen abdomen and back muscles. This helps support the
backbone and can help prevent more back pain.
 For some children, back braces can take the pressure off the
lower back and relieve the pain so they can return to sports and
school.The braces flatten out the normal curve (lordosis) of the
lower spine.
 Surgical interventions include
 Place a metal implant across the fracture and using a bone graft
to help healing.
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 Bone fusion utilizing screws, bars and grafts to connect bones
and help the bones grow together.
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The Adolescent Athlete and
Infectious Diseases
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Infectious Mononucleosis
 Infectious Mononucleosis (IM)
 Presentation is variable, including prolonged fatigue
that may affect ability to return to sport and
competition.
 In almost all cases of IM, splenomegaly is present.
 Once clinical symptoms have resolved, gradual return
to routine activity after 3 weeks post–illness onset is
reasonable while avoiding contact or collision sports
until 4 weeks post–illness onset.
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Methicillin Resistant Staphylococcus
Aureus ( MRSA)
 Individuals with active lesions (new, moist, weeping)
should not be allowed to participate, because these are
considered contagious.
 Until a lesion is not considered contagious, it should be
covered.
 Evidence clearly defining contagiousness precautions is
lacking, and specific guidelines are variable.
 The CDC recommends a minimum of 3 days of oral
antibiotic therapy before return to play for sports involving
skin-to-skin contact for all Staphylococcus infections,
including MRSA.
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Herpes Gladiatorum (HG)
 Extremely contagious, especially with primary
infections,caused by herpes simplex virus (HSV-1).
 Prevalence in wrestling teams of up to 29%.
 Risk of recurrence includes reexposure,
autoinoculation,reactivation secondary to triggers such as
fatigue,stress, poor nutrition, and coexisting infection.
 Treatment: Prescribe oral antiviral therapy if seen within
the first 48 hours of any lesion.
 For primary (first episode) HG, athletes with skin-to-skin
exposure should be treated and not allowed to compete
for
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a minimum of 10 days.
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Concussion
 Epidemiology
 In children aged 15 years and under, estimated incidence is 180
per 100,000 children per year (~85% are categorized as mild
injuries).
 In the US, more than 1 million children sustain a Traumatic Brain
Injury (TBI) annually
 TBI accounts for > 250 000 pediatric hospital admissions and >
10% of all visits to emergency service settings.
 Because of under recognition and/or under reporting, the
incidence of concussion and its sequelae is unknown
 Etiology:
 Concussion or mild traumatic brain injury (mTBI) that results in
acute clinical symptoms that usually reflect a functional
disturbance rather than structural injury.
 May or may not involve a loss of consciousness.
 Football or hockey have highest incidence, followed by soccer,
wrestling, basketball, field hockey, baseball, softball and
volleyball.
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 Neuroimaging studies are typically normal.
Acute Signs and Symptoms
Suggestive of Concussion
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Confusion
Headache
Emotional lability
Fatigue
Irritability
Disequilibrium, dizziness
Loss of consciousness (LOC)
Nausea/vomiting
Disorientation
Feeling ‘‘in a fog,’’ ‘‘zoned out’’
Visual disturbances - photophobia, blurry/double vision
Vacant stare
Inability to focus
Phonophobia
Delayed verbal and motor responses
Slurred/incoherent speech
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Immediate Post-Concussive Evaluation
 Rule out Medical Emergencies
ABCs of first aid
Although rare, concussive blows can be associated with :
 Cervical spinal injury
 Skull fracture
 All 4 types of intracranial hemorrhage (ie, epidural, subdural,
intracerebral, and subarachnoid).
 Informal mental status testing (eg, Where are you? What day
is it?) has not been found to be very sensitive to concussions
 Neuroimaging
In the context of:
 Loss of consciousness for greater than a few seconds
 Prolonged impairment of conscious state
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 Mental status deterioration/dramatic worsening of headache
 Focal neurologic deficit, seizure activity, or persistence
or
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worsening of PCS over time.
Post-Concussive Symptoms ( PCS)
 Somatic
 headaches, fatigue, low energy, sleep disturbance,
nausea, vision changes, tinnitus, dizziness, balance
problems, sensitivity to light/noise.
 Emotional
 low frustration tolerance, irritability, increased
emotionality, depression, anxiety, clinginess,
personality changes
 Cognitive
 slowed thinking, mental fogginess, poor
concentration, distractibilty, trouble with learning and
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memory, disorganization, problem-solving difficulites
Management Principles
 Recovery tracking
 Conduct serial physical examinations
 Systematically evaluate PCS
 Nonsport considerations
 Provide general concussion education to patient, parents, and
school personnel
 Ensure appropriate support in place for transition back to school
 Treat each medical problem symptomatically
 Expect positive outcome for most children
 When recovery is not proceeding as expected, promptly refer to
specialists (eg, in neuropsychology, neurology, rehabilitation,
sports medicine, pain management, education, behavioral health
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Return to Play
 Same Game Return to Play
Any adolescent athlete diagnosed with a concussion should not
return to play in the same contest
 Return to Play Following Concussion
During the recovery phase, athletes should not do any activity that
causes increased blood flow to the brain.
Consider no school for the first few days if symptoms are severe
No gym or sports
A note to excuse the athlete from tests may be indicated
When recovering, reintroduce exercise slowly. If a headache or other
symptoms occur, discontinue the activity.
Once there are no concussion symptoms with exercise, the
athlete may return to play.
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The Female Athlete Triad
 Disordered eating
 Among female athletes, the prevalence of disordered eating may
be as high as 62%
 At the extreme this includes Anorexia Nervosa and Bulimia
Nervosa
 At risk for developing serious endocrine, skeletal and psychiatric
disorders from disordered eating patterns
 Amenorrhea
 Delayed menarche ( >15 years) and secondary amenorrhea
(absence of menses for 3 to 6 months)
 Prevalence estimates for the general population is 2-5%, for
athletes prevalence estimates range from 3.4 to 66%
 Osteoporosis
 Premature bone loss and/or inadequate bone formation resulting
in low bone mass, microarchitectural bone deterioration resulting
in increased skeletal fragility and increased risk of bone fracture
 Bone loss is rapid and may not be completely irreversible
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Treatment of Female Athlete Triad
 Early recognition of the female athlete triad can be
accomplished through risk factor assessment and screening
questions.
 Instituting an appropriate diet and moderating the frequency of
exercise may result in the natural return of menses.
 Hormone replacement therapy should be considered early to
prevent the loss of bone density.
 A collaborative effort among coaches, athletic trainers,
parents, athletes and physicians is optimal for the recognition
and prevention of a potentially life-threatening illness
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Athletic Performance Drugs and Nutritional
Supplements
Ergogenic Drug
Category
Goal of Use
Athletic Effect
Adverse Effect
Anabolicandrogenic
steroids
Controlled
Substance
Gain muscle mass,
strength
Increase muscle mass,
strength
Infertility, gynecomastia,
female virilization, hypertension,
atherosclerosis, physeal closure,
aggression,depression
Androstenedione
Controlled
Substance
Increase testosterone No measurable effect
to gain muscle mass,
strength
Increase estrogens in men;
overlaps systemic risks with
steroids
DHEA
Nutritional
Supplement
Increase testosterone No measurable effect
to gain muscle mass,
strength
Increase estrogens in men;
impurities in
preparation
Growth Hormone Controlled
Substance
Increase muscle
mass, strength, and
definition
Decreases
subcutaneous fat; no
performance effects
Acromegaly effects: increased
lipids, myopathy,
glucose intolerance, physeal
closure
Creatinine
Nutritional
Supplement
Gain muscle mass,
strength
Increase muscle
strength
gains;performance
benefit in short
anaerobic tasks
Dehydration, muscle cramps,
gastrointestinal
distress, compromised renal
function
Ephedra
Alkaloids
Controlled
Substance
Increase weight loss,
delay fatigue
Increases metabolism;
no clear performance
benefit
Cerebral vascular accident,
arrhythmia,
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myocardial infarction,
seizure,
psychosis, hypertension, death
The Pediatrician’s Role
 Physicians need to become educated about the drugs
that are being used and the consequences of their use.
 When young people do admit to using these substances,
having a physician who is able to discuss openly the
performance effects as well as the adverse effects of
ergogenic drugs can be the first step in establishing that
physician as a trustworthy source to approach should the
young person consider using other drugs or begins to
experience adverse effects of these drugs
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Issues related to Sports
Specialization and Overtraining
 Sports related injury is the leading cause of all types of
injury in adolescents and of these, overuse injuries
account for about 50%
 The Incidence of overuse injuries of all types are rising
as young athletes increasingly participate in organized
sporting activities with increased training intensities
 Rapid changes in height, weight, muscle growth and
strength during adolescent growth spurt affect flexibility,
muscle coordination, balance and power and place
increased stress across bone, particularly the growth
cartilage
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Types of Overuse Injuries
 Stress fractures – 15% of all athletic injuries
 Juvenile osteochondritis dissecans – occurs when a focal area of
subchondral bone undergoes necrosis in the joint space
 Apophysitis – irritation of the apopyhses ( bony attachment sites of
musculotendinous units that develop as accessory ossification
centers) that results from being placed under stress from repeated
muscle contraction
 Sever Disease (calcaneal apophysitis – affects the os calcis)
 Osgood-Schlatter Disease
 Little league elbow – apophysistis of medial humeral epicondyle
 Tendinopathy –tendon injury characterized by pain swelling and
impaired performance - achilles tendinopathy, patellar tendinopathy,
rotator cuff tendinopathy
 Overtraining can cause burnout – parental pressure to compete and
succeed may contribute to overtraining
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Recommendations
 Encourage athletes to take at least 1 to 2 days off per week from
competitive athletics, sport-specific training and competitive practice
to allow physical and psychologic recovery
 Weekly training time, number of reps, or total distance should not
increase by more than 10% each week
 Take 2-3 months away from a specific sport during the year
 Emphasize having fun, skill acquisition, safety and sportsmanship as
the focus of sports participation
 Be vigilant for possible burnout if that athlete complains of
nonspecific muscle or joint problems, fatigue or poor academic
performance
 Focus on wellness and on teaching athletes to be in tune with their
bodies for cues to slow down or to change their training methods
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Case #1
 A 13-year-old adolescent
male tennis player
presents with knee pain
for about 4 weeks. There
is no history of trauma.
He describes the pain as
just below the right
kneecap and worse with
climbing stairs. On
examination, there is full
range of motion, no
swelling or erythema but
with some mild
tenderness over anterior
tibial tuberosity. What is
the most likely diagnosis?
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Answer to Case # 1
 In a 13-year-old adolescent
male with no history trauma
and with an examination that
only shows tenderness or
some mild prominence of
anterior tibial tuberosity, by far
the most likely diagnosis is
Osgood-Schlatter's disease. It
is particularly common during
peak growth and also in
athletes. In this teen, an x-ray
would not be indicated and
observation with or without
non-steroidal anti-
inflammatory medication
would be sufficient.
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Case #2
 A 15-year-old teen who is an advanced
ballet dancer complains of severe lumbar
back pain that has lasted for months. She
is noted on exam to have significant
lordosis. She also has localized
tenderness in lumbar spine. What would
be an important test to order?
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Answer to Case # 2
 While it is possible that
the teen has
musculoskeletal pain, the
combination of months of
back pain, localized
tenderness and severe
lordosis suggest the
possibility of
spondylolysis or
spondylolisthesis. It would
be important to take
lumbar spine films
including oblique views.
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Case 3
 A 13-year-old adolescent female presents
with right knee pain for about one month.
What would be the more significant items
on history to be asking about?
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It would be important to ask
about….
 Prior or recent trauma
 Other joint pains and other systemic symptoms
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including fevers
What activities exacerbate the pain and what
activities is she involved in
Her pubertal status or age of menarche
Location and radiation of the pain
History of joint swelling
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History
 The teen has no history of trauma. She is on the
school track team and runs about one mile per
day. The denies any joint swelling. She denies
any other joint symptoms. Her review of systems
is negative for any other symptoms. She states
that running upstairs make the pain worse. Her
menarche was at age 12. The pain she
describes is around her right kneecap but she
cannot localize it more than that.
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What would be important on the
physical examination to check for?
 On general examination, any signs of chronic/systemic
diseases.
 Joint exam: Any evidence of involvement of other joints,
evidence of swelling, point tenderness, range of motion
including knee and hip joints.
 Posture: Evidence of medially placed knees or an
increased Q angle. The Q angle is the angle found
between a line drawn from the anterosuperior iliac spine
through the center of the patella and a line from the
center of the patella to the tibial tubercle (normal: <15
degrees). An increased angle is thought to predispose to
patellar malalignment syndrome.
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Physical Exam
 The teen's general
examination is completely
normal. She has a normal
gait, although the pain
increases when she squats.
She does appear to have
knees that are slightly
medially placed and has an
increased "Q" angle. There is
full range of motion of both her
knees and hips. There is no
swelling of either knee and no
warmth. There is no
tenderness or swelling over
the anterior tibial tuberosity.
There is moderate tenderness
on the inferior medial aspect
of the patella.
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What is the most likely cause of
knee pain in this adolescent?
 The most common causes of knee pain in adolescents
are trauma, overuse syndromes, Osgood-Schlatters and
patellar malalignment syndrome. The most likely in this
teen with no history of trauma and with increased “Q”
angle and tenderness under the patella is patellar
malalignment syndrome.
 Treatment should include some reduction in her training,
nonsteroidal anti-inflammatory agents, muscle
strengthening exercises including strengthening of the
vastus medialis. After symptoms are controlled, a
graduated running program and maintenance exercise
program could be instituted.
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“The ultimate goal of youth participation in sports
should be to promote lifelong physical activity,
recreation, and skills of healthy competition that
can be used in all facets of future endeavours”
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Thank you!
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