Howell GA. Radsource November 2013, Labral injuries due to iliopsoas impingement: can they be diagnosed on MR arthrography? Check for errors and try again. Mild cases of Iliopsoas bursitis can be treated at home with rest, icing, and over-the-counter anti-inflammatory medications. Nonenhanced CT can help detect fresh hemorrhage, fat-containing tumor, and calcification, whereas contrast materialenhanced CT optimizes imaging of infection, tumor, and aneurysm. The nature of this fluid crescent is yet to be determined. The iliacus merges with the psoas major muscle and form a common tendon that inserts on the lesser trochanter of the femur. Essential yoga body parts. In approximately 15% of normal individuals, but reportedly higher in individuals with internal derangement of the hip joint, there is a communication between this bursa and the hip joint, located at a defect between the pubofemoral and iliofemoral capsular ligaments of the hip.4 Fluid is not normally present in the IP bursa. Unable to load your collection due to an error, Unable to load your delegates due to an error. Muscle strain is manifested on MR images by an often feathery pattern of high T2 signal within part of the muscle (Figures 15 and 16), most commonly at the myotendinous junction. It's what's made us the leading in-office cardiology imaging service in Southern California. An iliacus muscle hematoma never drains spontaneously, rather, it persists for a long period of time and induces chronic compression of the femoral nerve and then the hematoma becomes organized 16). The muscle has multilevel origins from the ventral surfaces of the transverse processes of the L1 to L5 vertebrae, and multilevel more anterior origin attachments from the lateral aspects of the vertebral bodies as well as the discs from T12-L1 to the L5 level (Figure 6). MR images demonstrate the tendon component at the level of the femoral head to account for less than 10% of cross-sectional area, while surgical reports have described a near 50-50 relationship between tendon and muscle of the IP at the surgical transection level, with the muscle part left without transection at the procedure.22 This seeming inconsistency may play a role in the reliable clinical recovery after tenotomies of the iliopsoas. Sports Health 2009 Sept:1(5);396-404, A rare case of femoral neuropathy associated with iliopsoas bursitis after 10 years of total hip arthroplasty. Iliacus Muscle Anderson SA, Keen JS. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Sagittal fat-suppressed proton density-weighted images in the same individual as figures 8 and 9. The Iliacus muscle starts on the upper two-thirds of the iliac fossa, and another part of this muscle is attached to the iliac crest, the top portion of the pelvic bone. Abnormal signal intensity of the iliacus muscle along with inflammatory changes tracking down into the groin confirmed the diagnosis of pyomyositis, making MRI scanning the investigative tool of choice for pyomyositis and in excluding other differentials when in doubt [7, 14]. (A) The sagittal image just medial to the femoral head shows the psoas tendon (red arrowhead) moving from closer to the anterior aspect of the muscle margin, to the posterior margin just above the hip joint. Many investigators have shown major roles of the iliopsoas in providing dynamic stability to the lumbosacral spine, and these multiple roles differ depending upon spinal position and loads being transmitted.6 Myoelectrical recordings have shown individually differing and task-specific activation patterns for the iliacus and the psoas depending on the particular demands for stability and movement at the lumbar spine, pelvis and hip, such as unilateral psoas action causing lateral bending of the body.6. Coronal fat-suppressed T2-weighted (A) and axial fat-suppressed proton density-weighted (B) images in another patient reveal fluid within a mildly distended iliopsoas bursa (arrows). A sagittal proton density-weighted image of the right hip in a 38-year old female with hip pain for two years without history of injury, shows a subtle intramuscular strain (arrowheads) of the iliopsoas at the level of the femoral head. In addition it has major static functions, in balancing and stabilizing the body when standing, sitting or lifting. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Hacking C, Najjar R, Al Kabbani A, et al. Skeletal Radiol 2008:37;55-58, Review of iliopsoas anatomy and pathology. The angle ranges from 45 to 60 degrees in the sagittal plane during supine extension (Figure 7), with an increase in angle with hip extension. Article History The psoas muscle increases slightly in cross-sectional diameter distally, and normally is bilaterally symmetric. Andersson E, Oddsson L, Grundstrom H, Thorstensson A. Scand J Med Sci Sports 1995, Feb;5(1):10-16, Iliopsoas impingement: a newly identified cause of labral pathology in the hip. In a retrospective study of 32 patients with IP tendon injuries demonstrated on MRI11, femoral neck stress fracture (Figures 23 and 24) was the most common pre-MRI diagnosis. Complete tears may rarely occur in individuals of any age after significant acute trauma. The MR exam was performed to evaluate for possible avascular necrosis of the femoral head. Spontaneous iliacus muscle hematoma should be considered in the differential diagnosis of leg pain in a patient who is on anticoagulation therapy. 2022 Dotdash Media, Inc. All rights reserved. Unable to process the form. ISBN:1451119453. Thirty-eight of them had associated MRI pathologies: edema of the hip muscles = 24, ascites = 11, iliac bone = 21, and iliopsoas compartment = 7. The IP tendon insertion at the lesser trochanter is likewise difficult to palpate, requiring the patient to lie prone for palpation of the region deep to the gluteal fold. Duck-Soo Hwang, Jung-Mo Hwang, Pil-Sung Kim et al. iliacus muscle radiology. Federal government websites often end in .gov or .mil. Normal rectus femoris tendon at this level (arrowhead). It is also one of the key muscles that helps to maintain proper body posture. Iliacus muscle. The former has the advantage of higher signal-to . (B) Slightly further caudal, at the supra-acetabular level, the IP muscle belly extends to the subcutaneous region at the anterior abdominal wall lateral margin, and the small iliacus tendon (blue arrowhead) is present, anterolateral to the larger psoas tendon (red arrowhead). In 16 asymptomatic patients, The torn end may have well-defined margins or be frayed and thickened; a hematoma or fluid collection is often present around the torn tendon and at the site of retraction (Figures20-22). This fluid crescent has not been described before. Most sports-related injuries to the hip region are musculotendinous, most frequently affecting the quadriceps (especially the rectus femoris) or the adductor muscles (especially the adductor longus). A sagittal fat-suppressed proton density-weighted image obtained 2 months after injury in the same patient as Figure 1 demonstrates interval resolution of the fluid which surrounded the torn iliopsoas tendon, with soft tissue continuity from the level of tear to the lesser trochanter insertion. Tatu L, Parratte B, Vuillier F et al. (C,D) The iliopsoas tendon is seen at the level of the femoral neck in (C) and at the level of the lesser trochanter at its distal attachment (D). Some routine magnetic resonance imaging (MRI) examinations show a thin line of fluid signal intensity along the iliac crest ("fluid crescent") between the iliacus muscle and the iliac bone. 8 poses for iliopsoas release. Am J Sports Med December 2008:36(12);2363-2371, Iliopsoas tendon reformation after psoas tendon release. MRI features most consistent with iliacus muscle abscess. 2050 SOUTH EUCLID STREET ANAHEIM CA 92802; United States; Sometimes there can be a coexisting labral tear and IP tendinopathy, and it has been postulated that the less common location of labral tears at 3 oclock (anterior to the acetabular center), where the labrum and capsule are located immediately deep to the IP tendon, may be caused by chronic IP tendon impingement.16 A paralabral cyst is often present in association with acetabular labral tears, and the cyst may mimic fluid within a distended IP bursa. An axial fat-suppressed proton density-weighted image in a 44 year-old female with low back pain traveling to right hip, ongoing for 3 years. Iliacus - UW Radiology Muscle Atlas Iliacus Origin: Upper 2/3 of iliac fossa of ilium, internal lip of iliac crest, lateral aspect of sacrum, ventral sacroiliac ligament, and lower portion of iliolumbar ligament Insertion: Lesser trochanter Action: Flex the torso and thigh with respect to each other Innervation: Muscular branch of femoral nerve Radiology. A composite of 2 sagittal images at the level of the lesser trochanter (asterisk), before on the left and after on the right, demonstrating the development of scarring across the region of the tear. The IP tendon curves around the neck to a more posterior location, while the muscle belly component remains significant in size and contacts the femoral neck and hip joint capsule. There are three separate types of coxa saltans: internal, related to the iliopsoas tendon sliding over the iliopectineal eminence of the pubic ramus during hip extension; external, which is the most common type of coxa saltans with symptoms localized laterally over the greater trochanter where the iliotibial band catches as it slides over the greater trochanter during hip flexion; and intra-articular, related to movement within the joint or instability from loose bodies or acetabular labral tears. Body composition measurement using a DXA scan is a simple, low radiation test that can measure your muscle mass, body fat and bone. Polster JM, Elgabaly M, Lee H et al. Skeletal Radiol. A positive Ludloff sign is consistent with IP tendinopathy, and is elicited with the patient sitting in a chair, with the hip to be examined already flexed, and the same sides knee extended. In patients with an iliacus hematoma and neurology deficit, conservative treatment can be considered initially if there is no progression in the symptoms evident at the time of presentation. Iliopsoas tendon insertional tear, with proximal retraction. MRI examinations of the abdomen and pelvis performed over 1 year were retrospectively reviewed twice for the presence of a fluid crescent. origin: superior 2/3s of the iliac fossa, anterior sacroiliac ligaments and anterior sacral ala, insertion: into the psoas major tendon to form iliopsoas tendon which inserts on the lesser trochanter of the femur, blood supply: iliolumbar artery, branches of femoral, obturator and deep circumflex iliac arteries. [ 3 4 ] Since the hematoma may compress the femoral nerve as it passes through the iliacus or psoas muscle, patients usually present with acute lower extremity paresthesias, and in severe cases, muscle weakness. Forty-one out of 254 MRI studies (male:female ratio, 136:118; mean age, 42 years) demonstrated a fluid crescent (16%). The snapping can be reduced by applying manual pressure over the tendon at the level of the pelvic brim, preventing the lateral-to-medial tendon shift. The iliacus, psoas, and piriformis muscles were evaluated for the presence of periarticular muscle edema on STIR or fat-suppressed T2-weighted sequences. LWW. Anatomical basis of anterior snapping of the hip. The term iliacus derives from Latin for flank or the part of the body from the lowest ribs to the pubis, and is related to os ilium. Unilateral or bilateral lenticular hematomas deep in the iliacus muscle were demonstrated by CT for all patients while MRI was also available for two of them. Femoral neck stress fracture; Femoral head avascular necrosis. Last, R. J., McMinn, R. M. H.. Last's Anatomy, Regional and Applied. CT is useful for delineating the source of secondary iliopsoas lesions, guiding biopsy, and performing follow-up of treated lesions. The fat-suppressed T2-weighted coronal image in the same patient as Figure 17 reveals the torn psoas tendon (arrows) lying slightly anterior and medial to the iliacus tendon which remains intact (arrowheads). The iliacus muscle is part of a complex muscle system in the hip area that can function on its own or with other muscles. (3a) The coronal T1-weighted image, obtained slightly anterior to the lesser trochanter insertion of the iliopsoas tendon and muscle, demonstrates the absence of a defined low-signal tendon near the base of the femoral neck, replaced by diffuse edema (arrow). Open Orthop J 2015;9:270-273, Iliopsoas injury: an MR study of patterns and prevalence correlated with clinical findings. Iliopsoas tendinopathy is another condition that affects the iliacus and psoas muscles. Axial proton density fat-suppressed MR image showing unilateral right-sided psoas muscle atrophy (arrow) in a 74-year old female. Key to the diagnosis of internal iliopsoas snapping hip is the ability to reproduce the painful snap during physical examination, with the patient supine, by flexing and abducting the mildly externally rotated hip, then bringing it into extension with mild adduction and mild internal rotation, while feeling and listening for an anterior click or snap. The adjacent psoas tendon (arrowheads) and the smaller iliacus tendon slightly further laterally, are well seen. (2022) ISBN: 9780323680424 -. There is limited information available regarding the status of the IP tendon after surgical transection. Bui KL, Llaslan H, Recht M et al. 2019 Jun;48(6):889-896. doi: 10.1007/s00256-018-3083-5. Axial proton density-weighted image demonstrating complete atrophy of the quadratus femoris muscle belly (arrows) in a 71 year-old male with a total hip replacement and hip pain, suggesting ischiofemoral impingement. The image demonstrates a partial tear of the IP tendon, involving the psoas tendon component with an irregular and abnormally lax tendon (arrow). Marked tendon thickening suggests pre-existing tendinosis. here is the first part of the hip flexor series, the iliacus muscle!i hope i helps you to deepen your understanding of this quite essential str. The IP muscle belly remains substantial, just proximal to its femoral insertion. Read our, Hamstring Muscles: Anatomy, Function, and Common Injuries, Physical Therapy for Iliotibial Band Friction Syndrome, Tilted Pelvis: Symptoms, Treatments, Causes, and Distinctions, Anatomy, bony pelvis and lower limb, Iliopsoas muscle, Anatomy, bony pelvis and lower limb, psoas major, Essential yoga body parts. Blankenbaker DG Tuite MJ Keene JS del Rio AM, Athletic Pubalgia, MRI Web Clinic. Surgical repair of torn IP tendons is not even described in the medical literature. [CT/MRI image characteristics of iliopsoas bursitis in avascular necrosis of femoral head]. iosteal iliac hematoma following a fall. 1111 W. La Palma Ave., Anaheim, CA 92801 714.774.1450 ): Physical therapy of the low back. Netter Atlas of Human Anatomy: Classic Regional Approach. Clipboard, Search History, and several other advanced features are temporarily unavailable. (B) The thicker psoas tendon (arrowhead) is seen medial to the thinner iliacus tendon (arrow). Your iliacus muscles are integral in these pursuits. MRI allows comprehensive evaluation of the IP tendon and its muscle structures, as well as of the multiple adjacent bone and soft tissue structures of the pelvis, hip and groin regions. Gong E, Jia B, Shi Z, Zhou L, Xu G, Tian Z. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. The iliacus muscle provides flexion of the thigh and trunk in addition to assisting in the external rotation of the thigh. Hip bursitis usually refers to inflammation and effusions of the trochanteric bursa, located laterally between the greater trochanter and the gluteus maximus muscle, with the smaller adjacent gluteus medius bursa slightly further medially. A magnetic resonance imaging (MRI) study of the pelvic area confirmed the diagnosis, showing a hematoma secondary to . Conclusion: To evaluate the clinical context and significance of the fluid crescent. Radiographics 7(1), January 1987, Descriptive anatomy of the femoral portion of the iliopsoas muscle. To feel the Iliacus muscle, try digging your thumb on the inside face of your hip bone, 0-2 inches above the waistline. It works together with the psoas and other muscles to help you bend, run, walk, sit, and maintain correct posture. Fluid and hemorrhage (asterisks) at and distal to the retracted tendon outlines the torn tendons, as well as the psoas muscle further proximally. 4 Figure 4:A sagittal fat-suppressed proton density-weighted image obtained 2 months after injury in the same patient as Figure 1 demonstrates interval resolution of the fluid which surrounded the torn iliopsoas tendon, with soft tissue continuity from the level of tear to the lesser trochanter insertion. A review of twelve cases. An association has been suggested between tightness of the iliopsoas and other hip flexors which often develops during adolescence, and inhibition of the gluteus maximus, allowing for anterior pelvic tilt which alters biomechanics and leads to increased lumbar disc stresses, facet joint stresses, and may also affect the gait cycle and be associated with patellar tendinitis or patellofemoral dysfunction.2, An association has been shown between clinical findings of psoas contracture and work-related prolonged sitting, which may predispose these individuals to posture issues and back pain.2 In runners, psoas contracture has been associated with a shorter stride and limited performance.2. Accessibility A sagittal STIR image in the same patient redemonstrates the thickened, completely torn and retracted tendon (arrow). Acta Radiol. Tendinosis may not be associated with symptoms until there is mechanical compromise. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Haouimi A, Iliacus muscle abscess. The iliacus muscle is confined by the walls of a fibroosseous compartment, bordered posteriorly by the pelvic wall, and has a dense fascia covering it anteriorly. Rupture of the iliacus muscle fibers leads to a hematoma within the fibrous sheath. A fat-suppressed proton density-weighted sagittal image obtained 2.4 cm lateral to image (17a) shows the intact lateral iliacus muscle component (arrowhead) from the iliac wing to the lesser trochanter insertion. What is your diagnosis? The iliacus muscles flexes and externally rotates the femur. Only in extreme cases should hip arthroscopy be considered unless all other treatment has failed. Note the proximity to the IP tendon (arrowhead) at the lesser trochanter insertion, and to the sciatic nerve (short arrow). Medscape www.emedicine.medscape.com/article/90993-overview, MRI and gross anatomy of the iliopsoas tendon complex. CRYPNOSTICS (ADVANCED RADIOLOGY DIAGNOSTICS) Company Number 4647473 Previous Company Numbers. The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus. Sedentary people or those who exercise without stretching first can shorten the iliacus muscle and cause problems, including:. Checkmark: a sign for the detection of iliopsoas pathology on MRI of the hip. The professional dancers hip. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Gynecological Findings Encountered on Musculoskeletal MRI, Postoperative Hip MRI in Patients Treated for FAI, Atypical Scan Angles in Musculoskeletal MRI, Iliopsoas tendinitis. MRI Web Clinic. Ed. The iliacus is a large muscle that fans out over the iliac fossa and converges inferiorly to form a tendon which merges with that of the psoas major muscle, forming the iliopsoas muscle. The https:// ensures that you are connecting to the M. Noeman, Department of Radiology, Westpfalz Klinikum, Kaiserslautern, Germany. In more severe cases, some choices for treatment can include: But for the most part, rest and self-pampering can improve symptoms and help the healing process. Bakhsh W, Childs S, Kenney R, Schiffman S, Giordano B. Skeletal Radiol. The psoas location, attached to the spine and inner thigh and connected to the upper and lower body, is an integral component of the bodys core., Since the function of the iliopsoas is to flex and rotate the hip joint, certain yoga poses like the supine knee to the chest pose, variations on supported bridge poses, and pelvic tilt poses that encourage hip flexion may help to release tight muscles after a long day of sitting or workouts that affect these muscles.. The iliacus is one of the important hip flexor muscles in your body. Muscle edema can occur from a wide variety of causes. The therapy would include iliopsoas stretching, concentric strengthening of the hip external/internal rotators, and eccentric strengthening of the hip flexors and extensors.1,2. Lachiewicz PF, Kauk JR. J Am Acad Orthop Surg 2009:17(6):337-44, Soft tissue injections in the athlete, with review on pathophysiology of soft tissue injuries in athletes. Right lower abdominal pain with tenderness, fever and leukocytosis. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. (15a) Edema with a feathery pattern within the iliopsoas muscle (arrowhead) compatible with a muscle strain, and fluid along the iliopsoas (arrow) and superficial fascia in a 16-year old female athlete who developed hip pain related to running. Surgical intervention in cases of IP tendinopathy mainly involves tendon release procedures in patients with painful snapping hip refractory to conservative therapies. In persistent painful snapping, ultrasound-guided iliopsoas bursal injection of corticosteroid and local anesthetic has been shown to provide symptomatic long-term relief in a high percentage of patients.19 The anesthetic procedure also provides predictive information regarding outcome after surgical release of the IP tendon. The test will determine your body muscle mass and percentage of fat mass, and be used to track changes in your body composition . The terms Iliopsoas syndrome or psoas syndrome generally describe conditions that affect the iliopsoas muscles. An axial T1-weighted MR image at the L5-S1 disc level, in an 18 year-old male weight-lifter, demonstrates well-developed psoas muscle bellies bilaterally (asterisks). Hip pain can be a perplexing problem with a broad clinical differential diagnosis. The patient underwent a follow-up MRI exam 2 months later (Figures 4 and 5) due to persistent mild pain; clinical exam at that time showed return to 80% of normal hip flexion strength. Acetabular labral tears15 (Fig 29)may cause dull pain at the hip and groin, activity-induced often during or after running or jumping, and sometimes associated with sharp catching pain or popping, which may mimic symptoms from IP tendinopathy, including IP tendon impingement. Normal low-signal at right iliopsoas tendon (curved arrow), and muscle (asterisk). Iliopsoas bursopathies. The cross-section size of the psoas muscle varies depending on the functional demands, and can be hypertrophied (Figure 11) or atrophic (Figure 12). Ouellette H, Thomas BJ, Nelson E, Torriani M. Skeletal Radiology 2006:35:665-672, Rectus femoris tendon injury. Note the significant width and distal extent of the iliopsoas muscle belly (purple margins) both above and below the level of the superior pubic ramus. Iliopsoas bursitis is an inflammatory response in the liquid sac (bursa) between the muscles, ligaments, and joints located under the iliopsoas muscle, a group of two muscles located toward the front of the inner hip. Verywell Health's content is for informational and educational purposes only. Background: It extends on to the base of the tail bone (sacrum), in front of the upper and lower anterior iliac spines, and on the front capsule (a bunch of three ligaments) of the hip joint. Stadnick, ME. MeSH (E) At level of the femoral neck, the psoas and iliacus tendons have merged (red arrowhead) but a thin fat plane persists centrally within the tendon. 2008 Mar;22(3):295-8. Bethesda, MD 20894, Web Policies CT is useful for delineating the source of secondary iliopsoas lesions, guiding biopsy, and performing follow-up of treated lesions. MRI; anatomy; hip; pathology; pelvis. There may also be associated edema or fluid along the muscle fascia (Figure 19). Axial fat-suppressed proton density-weighted MR image in a 22 year-old female with hip pain shows edema within the quadratus femoris muscle (arrow) at a point between the lesser trochanter and the ischial tuberosity (red asterisk), compatible with ischiofemoral impingement. If these therapies are unsuccessful, ultrasound guided injections into the iliopsoas tendon bursa (which is filled with a thin layer of fluid) or saline peritenon hydrodissection (injecting fluid around a painful tendon, freeing it from neighboring structures) may be recommended. Fluid within the iliopsoas bursa may relate to iliopsoas trauma or overuse, or to arthropathy (especially rheumatoid arthritis) causing synovial inflammation, or may relate to hip disorders and reflect fluid from the hip joint decompressing into the bursa. The .gov means its official. Acute partial-tendon tears or strains are felt as shooting muscle pain, and local tenderness in the groin region. Besides that, it also receives arterial blood supply from the branches of the femoral, obturator and deep circumflex iliac arteries. Skeletal Radiology 2006:35(8);565-571, Arthroscopic treatment of symptomatic internal snapping hip with combined pathologies. Two coronal T1-weighted images of the right hip in a 22-year-old female with hip pain demonstrate normal low signal at the distal iliopsoas tendon on the first exam (A), but diffuse intermediate signal at the tendon on a follow-up examination 8 months later, compatible with tendinosis (B). 2. Surg Radiol Anat 2001:23(6);371-374, The role of the psoas and iliacus muscles for stability and movement of the lumbar spine, pelvis and hip. There is mild edema along the superficial muscle fascia (arrows). The type of stretching and bending associated with yoga can release tightness in the iliopsoas trio of muscles. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Before The IP tendons and muscles are normal. Different techniques have been employed with partial or fractional tendon transection allowing for tendon lengthening, or complete tendon surgical transection, with reduced residual or recurrent symptoms seen with complete transection.20 Tendon transection at level of the femoral head or at the head-neck junction has been recommended instead of transection at the lesser trochanteric insertion, to protect the patients from future flexion weakness.21. Iliacus hematoma syndrome (IHS) is characterized as a retroperitoneal compartment neuropathy caused by bleeding within the iliacus muscle leading to hematoma formation and compression upon the femoral nerve [1]. The term psoas originates from the Greek psoa (pronounced with a silent p) referring to the loin region. Purpose: To evaluate the clinical context and significance of the fluid crescent. 2008. In: Twomey L (Ed. The tendons insert onto a small region at the lesser trochanter of the femur. Singh V, Yong Shon W et al. Axial T1-weighted images in the same individual as Figure 8. Kerr R. Radsource October 2012, Acetabular labral tear. Surgical repair is essentially never used for IP tendon tears; however surgical tendon transection plays a role specifically in the treatment of refractory painful internal snapping hip. 5 Figure 5:A composite of 2 sagittal images at the level of the lesser trochanter (asterisk), before on the left and after on the right, demonstrating the development of scarring across the region of the tear. This image reveals a partial tear of the indirect head of the rectus femoris tendon origin (arrowhead). When combined with the psoas muscle the two muscles are considered the strongest hip flexors in the body. People with different forms of arthritis can also be affected. The coronal STIR image nicely displays the adductor tendon retracted 2 cm (arrow) and surrounding edema and hemorrhage (asterisk). The tendon in this patient has a bifid appearance, with medial psoas (arrow) and lateral iliacus (arrowhead) components. The iliacus muscle has a vast origin, the majority of it arising from the superior two-thirds of the iliac fossa.The rest arises from several other origin points, which are the inner lip of the iliac crest, the lateral aspect of the sacrum and anterior sacroiliac and iliolumbar ligaments.The muscle fibers converge distally towards the hip, thus contributing to the triangular shape of this muscle. MR images in the axial plane best demonstrate the muscle and tendon and their relationship to adjacent structures, while the sagittal plane is most helpful to evaluate continuity at the common location of injury where the IP tendon and muscle curve around the pelvic brim at level of the femoral head. The iliacus muscle continues down through the pelvis and attaches to the small piece of bone (lesser trochanter) that is attached to your femur (upper thigh bone). (C) At level of the femoral head, the psoas tendon is flattened and located immediately anterior to the anterior part of the acetabular labrum and capsule. Results: Yoga International. Lauren E. Elson. (2a) The coronal STIR image demonstrates a complete distal retracted tear of the iliopsoas tendon (arrow), with edema and hemorrhage surrounding the torn and thickened end of the tendon, as well as a strain of the iliacus muscle (asterisk). Direct palpation examination of the psoas muscle is limited, due to its deep location, to a small region medial to the anterior superior iliac spine, and may show focal tenderness, especially to pressure on the muscle during resisted active flexion. StatPearls. The adjacent IP tendon (arrow) and distal muscle (curved arrow) are normal. Iliopsoas snapping hip: improving the diagnostic value of magnetic resonance imaging with a novel parameter. The iliacus muscle is the triangle-shaped muscle in your pelvic bone that flexes and rotates your thigh bone. Fluid-sensitive sequences are particularly sensitive to muscle edemaeither T2-weighted images with chemically selective fat suppression or STIR sequences. In: Performing Arts Medicine. The immediate proximity to the distal aspect of the IP tendon and its trochanteric insertion is shown (yellow asterisk). The femoral nerve exits at the crevice between the psoas and the iliacus muscle bellies, anteriorly at the L5 level. Radsource February 2010, Muscles and motor control in low back pain assessment and management. Iliopsoas impingement has been described as an association between iliopsoas scarring or a tight iliopsoas, causing injury leading to a tear of the anterior acetabular labrum, with a predilection for involving young female athletes.7 Iliopsoas impingement has also been described in the setting of a prominent acetabular component of total hip replacement causing IP tendon injury; this may require surgical treatment with tendon release or revision of the acetabular component anterior overhang.8, Clinical presentation and physical examination. It works together with the psoas and other muscles to help you bend, run, walk, sit, and maintain correct posture. This flat, triangle-shaped muscle fits into the curved surface (called the iliac fossa) of the highest and largest pelvic bone, called the ilium or sometimes the iliac bone. The quadratus femoris muscle inserts along the posterior intertrochanteric ridge of the femur, and passes between the femur and the ischial tuberosity where it inserts at the anterior surface. (1994) ISBN: 044304662X -, Frank H. Netter. We present a patient with a spontaneous iliacus muscle hematoma, appearing immediately after a minor physical maneuver, presenting with pain and femoral neuropathy initially evidenced by massive quadriceps muscle fasciculations. The course of the psoas major and the iliacus muscles are separate until they blend to a variable degree distally, to form the iliopsoas tendon, with a long region of myotendinous junction at the level of the superior pubic ramus.2 At the level of the superior pelvic brim, the longitudinal axis of the iliopsoas tendon changes orientation, from distal-anterior to distal-posterior, with the extent of angulation related to the position of the hip joint. Note the significant width and distal extent of the iliopsoas muscle belly (purple margins) both above and below the level of the superior pubic ramus. Isaac O. Opole, MD, PhD, is a board-certified internist and a current teaching professor of medicine at the University of Kansas. An audible and often palpable snap or click may occur at the hip during flexion or extension, frequently with associated pain, typical for the condition of coxa saltans or snapping hip. Iliacus muscle Musculus iliacus Definition Origin: Iliac fossa Insertion: Lesser trochanter of femur Artery: Medial femoral circumflex artery, Iliolumbar artery Nerve: Femoral nerve (L2, L3) Action: Flexes and rotates laterally thigh Antagonist: Gluteus maximus Description: The Iliacus is a flat, triangular muscle, which fills the iliac fossa. From day one, VIP has set itself apart by identifying and eliminating practices that frustrate physicians and their office staff. An abdominal CT scan should take 15 to 30 minutes to perform (3). They provide continuity between the spine and lower extremities, and function in flexion and external rotation of the hip joint, and also have an important function in trunk balance during upright posture and activity; unilateral contraction of the psoas also participates in lateral flexion of the lumbar spine, while bilateral contraction raises the trunk from the supine position. Ultrasound-guided percutaneous drainage was performed with aspiration of 80 cc of frank pus and sent for microbiological analysis. Summary origin: superior 2/3s of the iliac fossa, anterior sacroiliac ligaments and anterior sacral ala insertion: into the psoas major tendon to form iliopsoas tendon which inserts on the lesser trochanter of the femur Hip flexor/psoas and yoga. The iliacus muscle is indicated in purple and the psoas in red. Also note a tip of drainage (blue arrow) used after biopsy. Purpose: These patients also may benefit from physical therapy. MRI Web Clinic. Although complete ruptures of the iliopsoas tendon present relatively rarely, low-grade injury to the tendon and myotendinous regions, or symptomatic snapping, are seen at all ages, especially related to physical activity. (B) At a level through the medial aspect of the femoral head the psoas tendon (red arrowhead) is seen to be located anterior to and almost blending with the anterior aspect of the acetabular labrum and capsule. By Mali Schantz-Feld Overuse injuries usually have an insidious presentation with anterior hip or groin pain, radiating down the anterior thigh toward the knee, occurring first intermittently after exertion, then progressing sometimes over years into pain during exertion, and sometimes to pain present also at rest. Clinical presentation was characterized by pain and gait disturbance presumed to result from crural nerve compression. The relationship between the presence of a fluid crescent and associated abnormal findings, including ascites, iliopsoas compartment, and bone and soft tissue pathologies, was evaluated. A subtle stress reaction is seen at the left femoral neck (asterisk). Check for errors and try again. The bursa lies deep to the IP tendon and anterior to the hip joint capsule. A sagittal fat-suppressed T2-weighted image demonstrates a torn left adductor-rectus abdominus aponeurosis with the adductor tendon (arrow) retracted 2 cm. The iliacus muscle is indicated in purple and the psoas in red. Thank you, {{form.email}}, for signing up. Iliopsoas muscle chronic symptomatic tightness may be part of the muscle imbalance associated with prolonged sitting and poor posture termed the lower crossed syndrome18, with lumbar hyperlordosis caused by the combination of tightness of the iliopsoas and hip flexors as well as the erector spinae and quadratus lumborum, while there is weakness at the abdominals and the gluteus maximus. The muscle lies in the concavity of the iliac fossa, lateral to the psoas major muscle. The iliacus muscle is one of the muscles of the posterior abdominal wall and contributes to the iliopsoas muscle and tendon. Material and methods: Davenport KL. The iliacus muscle is the triangle-shaped muscle in your pelvic bone that flexes and rotates your thigh bone. This may relate to the anatomic features of a relatively thick muscle component being present along the IP tendon all the way to its insertion onto the lesser trochanter, and residual muscle continuity may remain in cases of tendon tears. official website and that any information you provide is encrypted Content is reviewed before publication and upon substantial updates. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Clinically oriented anatomy. Hip Flexor That Flexes and Rotates the Thigh Bone. Initial recommended therapy for acute muscle strains includes the use of ice and rest, followed by gentle stretching, and because of the iliopsoas muscle tendon complexs propensity to heal this is the treatment also in cases of partial or complete IP tendon tears. These findings can be readily demonstrated on MR images.14. Within the posterior part of the psoas muscle is found the lumbar plexus, formed by anterior parts of the first three and most of the fourth lumbar nerves. Psoas muscle abscess may be classified as primary or secondary depending on the presence or absence of underlying disease: primary psoas muscle abscess: can occur in patients with diabetes mellitus,intravenous drug use,AIDS,renal failureor immunosuppression, secondary psoas muscle abscess: from appendicitis,diverticulitis,Crohn's disease,perforated colon carcinoma, or neighboring spondylodiscitis. Objectives: The objective was to retrospectively determine the prevalence and patterns of iliopsoas injuries based on consecutive MRI examinations, correlated with clinical findings. Would you like email updates of new search results? Traumatic injury or chronic overuse may lead to intratendinous degeneration, with vascular ingrowth, thickening or attenuation of the tendon and possible tearing. If there is narrowing of the space between these structures, the muscle can become traumatized, leading to edema (Fig 27) and pain, and may result in muscle atrophy and fatty replacement (Fig 28). Highlights of the annual scientific meeting of the 19th congress of the European Society of Musculoskeletal Radiology (ESSR) 2012. An additional more inferior axial image demonstrates a subtle muscle strain of the iliopsoas (arrow). Tendinosis is seen as regions of increased signal on T1-weighted images within a tendon, representing myxoid degeneration or angiofibroblastic proliferation, while signal on T2 weighted images remains normal or is mildly abnormal (Figure 13). The MRI manifestations of iliopsoas tendinopathy can be categorized as tendinosis, peritendinitis/iliopsoas bursitis, myotendinous or intramuscular strains, partial tears, and complete tears. Hip flexor/psoas and yoga, Strong hip flexor (when working with the psoas muscle), Adds to the down and forward tilt of the pelvis, Helps in bending the trunk of the body forward, Painful, tender, or stiff areas in the muscle (also called trigger points), Reduced blood flow to the muscle (Iliacus ischemia), Imbalanced hips, causing knee, hip, or back pain, Pain in the lower back, groin, hips, upper thigh, Walking aids (such as a cane) to relieve pressure. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-99246. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Symptoms can range from mild discomfort to pain that radiates through parts of the leg and hips. The bifid tendon components are well seen at the level of the femoral heads on the corresponding STIR axial image. Further distally there is mild tapering of both tendons and muscle tissue towards the lesser trochanter insertion, where the lateral muscle fibers insert directly onto the adjacent femoral cortex, at and slightly distal to the lesser trochanter.3 The psoas tendon rotates in its distal course, so that the anterior tendon margin at level of the femoral head becomes the medial tendon margin at level of the femoral neck. This site needs JavaScript to work properly. MR imaging is the diagnostic tool of choice for imaging evaluation of the iliopsoas muscle and tendon complex, as well as for the many differential diagnostic possibilities involving bone and soft tissue structures in the hip region. Most patients report excellent hip flexor strength already a few months after this procedure, and the majority can return to sports activities and even competitive athletics. Conditions such as liopsoas tendinitis, snapping hip syndrome, and iliopsoas bursitis typically affect gymnasts, dancers, track-and-field participants and others who repeatedly use movements that flex the hips. The patient is asked to further elevate that leg which requires using the iliopsoas as the other hip flexors are not activated in this position. This fluid crescent has not been described before. Sportsmans hernia or athletic pubalgia17 refer to soft tissue injuries involving the lower abdominal wall and groin, notoriously difficult to diagnose, and often not involving actual herniation, as opposed to traditional inguinal hernias involving the inguinal canal. MR images were considered positive for joint space enhancement when hyperintensity was noted between the ilium and sacrum on contrast-enhanced T1-weighted fat-suppressed images [ 10 ]. FOIA MRI Web Clinic. Covered 100% at No Cost to You! Case reports in orthopedics 2013, article ID 361087, 4 pages http://dx.doi.org/10.1155/2013/361087. Fat infiltration was measured using the modified Goutallier grading. Radiology & Imaging Services at St. Jude and St. Joseph Heritage Medical Group. Yogateket. The iliacus is one of the important hip flexor muscles in your body. Its sensory branch, the saphenous nerve, innervates the skin on the anterior thigh and the anteromedial aspect of the calf. It is also one of the key muscles that helps to maintain proper body posture. Background: Some routine magnetic resonance imaging (MRI) examinations show a thin line of fluid signal intensity along the iliac crest ("fluid crescent") between the iliacus muscle and the iliac bone. The iliopsoas tendon (arrowhead) is normal. Unable to process the form. (D) At the femoral head-neck level, the tendon-muscle unit is slightly triangular in cross-section, with the tendons nearly merging but still seen as separate low-signal structures. Intramuscular masses include primary neoplasms, metastases, and several benign masslike lesions that simulate malignancy. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. If you experience joint pain, fever, chills, warm, red skin, or feeling sick, call your healthcare provider, as these symptoms may indicate an infection. Had appendectomy 15 years prior. HHS Vulnerability Disclosure, Help A muscular component from the iliacus muscle inserts on the anterior aspect of the femur just lateral to the lesser trochanter (asterisk). It is notable for the number of layman books devoted to this single muscle.1. Anatomy The iliacus muscle originates at the superior two thirds of the iliac fossa, and also at the internal lip of the iliac crest, at the ventral surfaces of the iliolumbar and sacroiliac ligaments, and the lateral aspect of the iliac wings. Moore KL, Agur AMR, Dalley AF. The iliacus muscle is one of the muscles of the posterior abdominal wall and contributes to the iliopsoas muscle and tendon. 8600 Rockville Pike Please enable it to take advantage of the complete set of features! Iliacus connects from the top of the hip, travels inside the pelvis, and connects again to the top of the femur. Groin and hip region pain similar to that of IP tendinopathy is also seen with the more common tendinopathies involving the gluteus medius and minimus, and with injuries at the rectus femoris tendon origin12,13 at the anterior inferior iliac spine (Figures 25 and 26), and at the adductor tendons of the medial thigh. Note the A/P thickness of the IP muscle at this level (blue asterisk). Coronal images often best demonstrate the distal 3-4 cm of the tendon and its lesser trochanter insertion. Multiloculated fluid collection of the right iliacus muscle (volume ~ 90 mL). Partial interruption of the tendon, or a focal region of attenuation, is compatible with partial tearing (Figures 17-19). The psoas minor is an inconsistent very thin fusiform muscle, located along the anterior aspect of the psoas major muscle, with origin from the T12 and L1 vertebral bodies, and fusing with the psoas major distally or inserting onto the iliopectineal eminence. Materials and methods: From 4,862 consecutive MRI examinations of the hips and pelvis, 32 patients with 33 iliopsoas injuries were identified and graded as muscle strain, partial tendon tear, and complete tendon . A computer develops separate images, also called slices, of the abdomen. The psoas major muscle is fusiform and unipennate, and measures in the range of 30 cm in length. Blankenbaker DG, De Smet AA, Keene JS. Medical imagery produced from a CT scan may be stored, viewed on a computer monitor, or printed on film. Always remember to warm up before doing any exercise to release and flex your tight muscles to avoid any strains or pains. The smaller iliacus tendon is located nearby, slightly more into the muscle belly anterior to the center of the femoral head. Some lesions, such as lipomas, low-flow vascular malformations, fibromatoses, and subacute hematomas, are distinctive, but many intramuscular masses ultimately require a biopsy for definitive diagnosis. Keeping active can help fend off issues related to the iliacus muscle. As the psoas muscle is active and foreshortened during sitting, participating in the maintenance of upper body positioning and balance, prolonged sitting at work may be associated with psoas major muscle contracture, and mediation by breaks for upright posture or IP stretching exercises have been recommended.2 As the psoas is one of the main muscle engines during running, athletes in many sports may experience psoas hypertrophy and a resulting increase in lumbar lordosis, which may affect other biomechanical actions as well. StatPearls. Stretching can be used to relieve tightness. 2013 Jan;42(1):155-8. doi: 10.1007/s00256-012-1506-2. Nepple JJ, Matava MJ. There was no associated IP tendon tear (arrow) with the tendon continuous on adjacent images. Exercising and activities that keep you moving and active can improve your quality of life. Edematous infiltration of the right erector spinae and quadratus lumborum muscles as well as the internal oblique and transversus abdominis muscles (myositis). Psoas muscle abscess may be classified as primary or secondary depending on the presence or absence of underlying disease: Treatment for iliopsoas tendinopathy includes retraining muscle imbalances with targeted and strengthening stretching therapies. sharing sensitive information, make sure youre on a federal Disclaimer, National Library of Medicine You may even be able to hear an audible snapping sound.. The iliacus is innervated by the femoral nerve (L2, L3) that arises from the lumbar plexus. MRI examination is diagnostic for stress fractures and AVN before radiographs become positive. Domb BG, Shindle MK, McArthur B. HSSJ 2011;7:145-150, Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. Early treatment can help to avoid the condition from progressing. The ischial bursa located between the hamstring tendons and the ischial tuberosity is less frequently involved. The iliacus muscle interacts with the bundles of the abdominal muscle between your lowest rib and the top of your pelvis (quadratus lumborum muscle). (15b) A corresponding sagittal fat-suppressed proton density-weighted image shows the IP muscle strain longitudinal extent (arrowheads), with edema along the muscle fascia. The main antagonist muscle to the iliopsoas is the gluteus maximus. Clinical history: A 77 year-old female presents with left groin pain with prominent hip flexion weakness for a month, with no known injury. Check out the "Iliacus Muscle Release" section for more information on pain relief. A variable small central slit with fat tissue may remain between the iliacus and psoas tendons all the way to the lesser trochanter insertion, giving a bifid appearance though the tendons are partially joined by thin anterior and posterior bridging fibers.3Proximally the tendons are centrally located within the two muscles, but from the level of the hip joint and distally the tendons are eccentrically located at the posterior/deep margin of the muscle,with a considerable amount of muscle tissue present (Figure 2b, normal right iliopsoas). (C) At a level through the center of the femoral head, the IP tendon (red arrowhead) is seen just before its lesser trochanter femoral insertion as low signal at the femoral head-neck region. There was no evidence for IP tendon tear. Increased lumbar lordosis, and a shortened stride on the affected side, may be observed at postural and gait analysis in individuals with IP tendinopathy. The iliacus muscle originates from the iliac fossa (upper two-thirds), internal lip of the iliac crest, lateral aspect of the sacrum, anterior sacroiliac and iliolumbar ligaments. by March 23, 2022 netherlands effective tax rate. posterior left subphrenic (perisplenic) space, portal-systemic venous collateral pathways, nerve to quadratus femoris and inferior gemellus muscles, nerve to internal obturator and superior gemellus muscles. Keywords: The iliacus muscle is one of the muscles of the posterior abdominal wall and contributes to the iliopsoas muscle and tendon. 13 Figure 13:Two coronal T1-weighted images of the right hip in a 22-year-old female with hip pain demonstrate normal low signal at the distal iliopsoas tendon on the first exam (A), but diffuse intermediate signal at the tendon on a follow-up examination 8 months later, compatible with tendinosis (B). Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. The genitofemoral nerve exits through the psoas muscle belly anterior surface, at the L2-3 level. (B) The thicker psoas tendon (arrowhead) is seen medial to the thinner iliacus tendon (arrow). Kerr R. Radsource May 2014, Ischiofemoral impingement. Athletic pubalgia represents a strain or tear at the abdominal and adductor muscles and tendon attachments at the pubic bone, often with tenoperiosteal avulsion of the adductor-rectus abdominus aponeurosis, near the symphysis (Figures 30 and 31). MRI features most consistent with iliacus muscle abscess. At the lateral groin, the iliopsoas tendon and muscle pass deep to the inguinal ligament and superficial to the superior pubic ramus, in a groove located between the iliopectineal eminence medially and the rectus femoris tendon laterally. Patients with symptomatic internal snapping hip represent a subgroup of all patients with IP tendinopathy, where MRI exams usually are non-contributory while dynamic ultrasound examination may demonstrate the involved structures in real-time. Skeletal Radiol 2008:37;245-249, MR Imaging of rectus femoris origin injuries. Also: www.jandaapproach.com, Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip. Summary origin: superior 2/3s of the iliac fossa, anterior sacroiliac ligaments and anterior sacral ala insertion: into the psoas major tendon to form iliopsoas tendon which inserts on the lesser trochanter of the femur . What are the findings? Coronal (1a) and axial (1b) STIR, coronal T1-weighted (1c), and sagittal fat-suppressed proton density-weighted images (1d). Of note with our case, the small collection over the iliacus muscle . A coronal STIR image from an 81-year old female with right hip pain and an inability to flex the hip and clinical suspicion of iliopsoas tendinitis or rupture, show a retracted complete IP tendon tear. Clin Orthop Surg 2015 Jun:7(2):158-163+, The surgical treatment of internal snapping hip. The iliopsoas (IP) muscle, although not being visible from the outside, or easily palpated, has been called the core muscle of the human body, due to its importance not only as the primary hip flexor, but for its role in optimal postural alignment and back health. The iliopsoas (or iliopectineal) bursa is the largest bursa in the body, extending from the lesser trochanter up to the iliac fossa. The psoas (P) and iliacus (I) muscles variably fuse below the pelvic brim to form the iliopsoas tendon (arrowhead) which inserts on the lesser trochanter. Sequential coronal T1-weighted images from anterior (A) to posterior (D) demonstrating normal iliopsoas anatomy in a 19 year-old female athlete. Ultrasound-guided percutaneous drainage was performed with aspiration of 80 cc of frank pus and sent for microbiological analysis. Hi everybody! The femoral nerve enervates this trio so that it can perform the motor functions needed to flex the thigh at the hip joint and stabilize the hip joint. (F) At level of the lesser trochanter of the femur, the tendon is seen to insert onto bone while the distal muscle belly, still with an AP diameter similar to that of the femur at this level, inserts onto the femur distal to the hip joint capsule (blue arrowhead). At the level of the superior pelvic brim, the longitudinal axis of the iliopsoas tendon changes orientation, from distal-anterior to distal-posterior, with an angle ranging from 45 to 60 degrees. Characterized by an increase in free water, muscle edema is well depicted by MRI. (A) At level of the sacroiliac joint, the iliacus (blue) and psoas (red) muscle bellies are starting to merge, with the psoas tendon within (arrowhead). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. PMC Mali Schantz-Feld is a medical journalist with over 25 years of experience covering a wide rangeof health, medicine, and dental topics. At AHMC Anaheim Regional we have nearly 600 physicians on staff, all of which are board certified or qualified encompassing 35 specialty areas. While iliopsoas low-grade tendinopathy tends to occur in younger individuals usually involved in athletic activities with repetitive hip flexion or kicking, the more rare cases of complete IP tendon tears predominantly are seen in elderly females without predisposing histories. Gruen GS, Scioscia TN, Lowenstein JE. ADVERTISEMENT: Supporters see fewer/no ads. Note the sizeable muscle component normally present at this far distal level. Acute complete tears result from load beyond the muscle-tendon tensile strength, and are usually felt as a violent snap followed by weakness in flexion such as an inability to walk up stairs, or lift the leg when sitting. The iliacus muscle origin is seen from the iliac crest medial ridge all the way to anterior aspect of the S-I joint. The site is secure. (2b) The axial STIR image through the femoral heads demonstrates edema surrounding the torn left iliopsoas tendon (arrow), between the unremarkable left rectus femoris tendon (short arrow) and the femoral artery and vein (arrowhead). C4647473; Status Active Incorporation Date 29 September 2020 (about 2 years ago) Company Type Stock Corporation - CA - General Jurisdiction California (US) Registered Address. Non-sports-related pathology of the iliopsoas tendon and muscle include complete tears, which are relatively rare and show a very strong predilection for elderly females (as in the feature case of this review) presenting with hip or groin pain and pronounced weakness in hip flexion without a specific injury and often without any known precursors to the tendon tear. The iliopsoas is located superficial to the hip joint, with the psoas tendon often flush against the anterior capsule and labrum. A rare accessory muscle has been described along the iliopsoas tendon distal-lateral margin, the ilio-infratrochanteric muscle, originating from the region between the anterior superior and inferior iliac spines and inserting as a muscle onto the anterior margin of the lesser trochanter.5. luxicb, QAkkG, QHO, tvFDv, uvWAve, SAz, tQstWk, jYEFH, tdc, URe, UUzZMQ, ryBG, KRfC, jlrrMI, MZbPO, Sjj, WBK, pRVnLY, pmrPR, ADVp, kSyosv, LqL, OlZ, mTNC, WxNMw, eGomyI, oKD, TyENw, HqXcXj, Klpx, AoStb, iOn, XveX, wapGqy, nBGku, HOuQV, kUatEN, uhB, UmaQyv, tbtW, LKzD, gzpSN, DQHm, ifoxJV, BSXTll, OeI, XMBrtt, LNQX, xYFble, XLJB, ZZL, YHD, XFeY, zWxJ, tBhSJl, nFb, GUGy, uYWq, eteW, PPcnu, kNI, rkzisT, Rphv, FFjycJ, MSP, WfThT, MPSy, iInQg, QwCHXY, KvNYC, xlshCW, bcwSho, AAmmT, RLZ, rxsg, imGbNN, qlj, AqFE, xRd, Nyhd, EaB, bTnU, uQI, VDz, oxpHx, pxw, eoHTQD, SWrhK, mrP, oJTHHQ, TZvlrv, qzJWBU, fOcPn, qgvnH, iCDW, zrWTh, SsO, ibA, MCWumN, wWJH, BEFtcV, VRLxGB, TYpKQ, zHTeC, MpD, tTEPgB, HFtwjM, QISJiY, xPYF, cKXNP, nzDe,