Ahmed A, Ibrar M, Arsh A, Wali S, Hayat S, Abass S. Comparing the effectiveness of Mulligan mobilization versus Cyriax approach in the management of patients with subacute lateral epicondylitis. Differentiating tendonitis vs tendinopathy defines whether your management should focus on suppressing inflammation for acute elbow tendonitis presentations or, instead, generating a controlled inflammatory reaction for chronic elbow tendinopathy. Bmj. The American journal of sports medicine. Persons of middle age, 35 to 60, are afflicted with this condition most often. Link, 32. A New Test for the Advanced Diagnosis of Lateral Elbow Tendinopathy with Concomitant Intrasubstance Tear: Failure to Resist Extension Effort (the Free Test). Archives of physical medicine and rehabilitation. Can You Heal A Tendon Tear Without Surgery With Tennis Elbow Or Golfers Elbow? Complications. Abstract Lateral elbow pain is a common issue amongst adult populations today, and the most common factors that causes the pain is lateral epicondylitis. 2011 Nov;39(11):2429-35. Link, 107. The American Journal of Sports Medicine. Sudden, sharp tearing sensation in the elbow. Link, 90. Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis. An ulnar collateral ligament (UCL) tear is an injury to one of the ligaments on the inner side of your elbow. It should be addressed immediately to prevent further injury. How Important Is Rest In Treating Tennis Elbow? An intrasubstance tear is a partial tear of a tendon or cartilage. some loss of motion in your shoulder. After time, you can reasonably expect to return to heavy activities and jobs involving manual labor. The treatment options for a UCL injury depend on your goals. Link, 99. Bernard BP, Putz-Anderson V. Musculoskeletal disorders and workplace factors; a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Oct 1994;18(5):263-267. 4,6,10,13,20 With complete rupture of the tendon, . Although the anterior and posterior bands are referred to as two separate and distinguishable structures, the fibers are fan-shaped and continuous making distinction between the two difficult. At the end of the 3 weeks of physical therapy I went back to the orthopedic surgeon. A study of 775 rotator cuff tears diagnosed over 5 years by our ultrasonography utilising the described ultrasound technology compared against arthroscopy found a sensitivity of 92-99% (Kurz, Kelly, Hackett, Murrel, 2016). Link, 21. Cook JL, Rio E, Purdam CR, Docking SI. 51. 2009 Jun;39(6):484-9. Sports Med. To this end, the oblique coronal imaging plane provides optimal visualization of both the common flexor and common extensor tendons, underscoring the importance of obtaining high signal-to-noise ratio fluid-sensitive images in the coronal plane. However, these tests are rarely used as the sole basis for a diagnosis. Treatment of lateral epicondylitis with acupuncture and glucocorticoid: A retrospective cohort study. Elbow, forearm and wrist injuries in the athlete. He also gave me a prescription for Ativan to help with the agitated feeling and the skin crawling sensation. Link, 129. American Journal of Roentgenology. 2023 ICD-10-CM Diagnosis Code S56.511A - ICD10Data.com It attaches at the elbow to a small bump on the radius bone called the radial tuberosity. He gave me blood pressure medicine to take when my blood pressure got up over 160/95. 2008 Jan 1;16(1):19-29. TFCC Tear - Symptoms, Causes, Treatment & Surgery Explained 2019 Dec 1;9(1):12. Scandinavian journal of medicine & science in sports. Journal of Hand Therapy. Greene C, Droppelmann G, Garca N, Jorquera C, Verdugo A. Rupture of the distal biceps tendon occurs almost exclusively in males and generally in the age range of 40 to 60 years. MRI showed a high-grade tear in the common extensor tendon. Associated tenderness over the common extensor tendon origin. He said the only thing that could be done was to let the cortisone run its course and get out of my system. Link, 68. Soft tissue dissection of the ulnar soft tissues shows the ulnar collateral ligament (, Figure 10.4Ulnar collateral ligament distal attachment. Since the advent of the MRI (magnetic resonance imaging), it is more likely that an intrasubstance tear will be diagnosed. pain that increases with shoulder use. After age 30, these are very common findings of a meniscal tear on MRI, which is of little consequence. 2015;2015:1-11. Urology 36 years experience. Figure 11.4Components of the common extensor tendon. It can identify peritendinous fluid, thickening of the common extensor origin, intrasubstance tears, and focal hypoechoic areas. Smoking. The area of maximal tenderness lies 2 to 5 mm distal and anterior to the midpoint of the lateral epicondyle (, As previously noted, current theories indicate that lateral epicondylitis appears to begin as a microtear, usually in the origin of the extensor carpi radialis brevis, with formation of subsequent fibrosis and granulation tissue as a consequence of chronic repetitive microtrauma (, Further exploration into the specific components of overuse that result in the clinical expression of lateral epicondylitis suggest that increased age of the patient as well as increased time performing the offending activity play a role in the development of symptoms (, As previously noted, the MRI diagnosis of pathology in the common extensor tendon focuses primarily on signal intensity and morphology changes to distinguish between tendinosis and tear. Your biceps tendons attach the biceps muscle to bones in the shoulder and elbow. Introduction. Intrasubstance Tear of the Short Head of Biceps With Musculo - LWW Navarro-Santana MJ, Sanchez-Infante J, Gmez-Chiguano GF, Cummings M, Fernndez-de-Las-Peas C, Plaza-Manzano G. Effects of manual acupuncture and electroacupuncture for lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. US of the Elbow: Indications, Technique, Normal Anatomy - RadioGraphics Light activities can begin soon after surgery. 2008;2(1):16-25. The muscles in the lateral group include the supinator, brachioradialis, and extensor muscles of the hand and wrist, the latter arising primarily from the common extensor tendon. 2020 Aug;15(4):526. So now that we can identify when someone is in the latter stages of tendinopathy, what can we do about it? 20 Exclusion criteria were any previous treatment such as platelet-rich plasma (PRP), corticoid injection, or surgical intervention. Link, 41. The timing of the injury can be ascertained from the patients presenting history and can be corroborated by MRI findings. Walrod BJ. Tear of Distal Bicep tendon. 2006 Nov 2;333(7575):939. Lucado AM, Dale RB, Vincent J, Day JM. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? These tears are produces by mechanical overload during activities that stress tendon fibers. Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy. This is an injury to the growth plates on the ends of the bones forming the elbow joint. Treatment For Intasubstance Tear Of The Extensor - 78 Steps Health 2022 Mar 17;11(6):1666. 2020 Dec;21(1):1-1. Journal of manipulative and physiological therapeutics. Often, MRI studies show tears in people with no pain or problems using the wrist. Editors note- Intrasubstance tendon tears were confirmed by diagnostic ultrasound; however, sensitivity and specificity statistics were based on a small study size of 41 patients. Another method is to attach the tendon to the bone using small metal implants (called suture anchors or buttons). College athlete Michael Perry was a young and healthy offensive lineman until he was knocked over on his elbow after practice. Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. This may require additional surgery. MRI showed a high-grade tear in the common extensor tendon. Annals of medicine. Link, 126. Journal of Hand Surgery. Dynamic Chiropractic. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. PM&R. I tried playing squash again, but the elbow just felt funny and I didnt want to reinjure it, however, I didnt want surgery either. Pathology. Clinical Rehabilitation. Erak S, Day R, Wang A. Hammer WI. A surgeon therefore needs to consider and carefully evaluate the tear . As you struggle, the stress on your biceps increases and the tendon tears away from the bone. Link. Link, 110. Link, 43. 45. 2. What is a UCL injury of the elbow? PM&R Knowledge Now. Medicine. UYGUR E, AKTA B, YILMAZOGLU EG. Figure 11.15Full-thickness tendon tears. Verified. Tendon injury related to a single isolated event is uncommon, although exceptions to this rule do occur. 2021 Apr 4:02692155211006860. Bigorre N, Raimbeau G, Fouque PA, Saint Cast Y, Rabarin F, Cesari B. Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: Is outcome influenced by the occupational disease compensation aspect?. Ultrasonography (US) has become an important imaging modality for evaluating pathologic conditions of the elbow. 3 Tips For Sleeping With Golfers & Tennis Elbow Pain: Best / Worst Arm Positions, Remedies, Etc. BMC Musculoskeletal Disorders. This is called an avulsion fracture, and its rare. A systematic literature review. Cleland JA, Flynn TW, Palmer JA. Yan C, Xiong Y, Chen L, Endo Y, Hu L, Liu M, Liu J, Xue H, Abududilibaier A, Mi B, Liu G. A comparative study of the efficacy of ultrasonics and extracorporeal shock wave in the treatment of tennis elbow: a meta-analysis of randomized controlled trials. Link, 98. Short-Term Effects of Steroid Injection, Kinesio Taping, or Both on Pain, Grip Strength, and Functionality of Patients With Lateral Epicondylitis: A Single-Blinded Randomized Controlled Trial. Pain around the crease of the elbow. 2019 Jan 4. Figure 10.3Ulnar collateral ligament dissection. 50. Cleland JA, Whitman JM, Fritz JM. Clinical rheumatology. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. Link, 115. Zwerus EL, Somford MP, Maissan F, Heisen J, Eygendaal D, Van Den Bekerom MP. But, for moderate tears, the difficulty of healing gets very high. Dr. Riddle and his crew are masters in teaching the most potent multimodal tools for musculoskeletal pain and injury management. When Should You Get An MRI For Tennis Elbow Or Golfers Elbow? However, they cannot fulfill all the functions of the elbow, especially the motion of rotating the forearm from palm down to palm up. Bmj. Review 2: L125- "tear size was measured" - what is the experimental deviation of the measurement. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Link, 133. 2020 Aug;39(8):2255-65. Br J Sports Med. In the long term it's all bad news, unfortunately. Axial and sagittal images are useful to confirm suspected pathology. Lateral epicondylitis | Radiology Reference Article | Radiopaedia.org This ligament connects the inside of your upper arm (humerus) to the inside of your forearm (ulna) and helps support and stabilize your arm. This is especially common in athletes who play sports that require overhead arm use or throwing. 2008 Feb;36(2):254-60. Lucado AM, Dale RB, Kolber MJ, Day JM. Pain. Today they are much more common in people over the age of 60 and quite rare in people under the age of 40. It is easy playing football to twist a knee from direct contact or from hitting the ground. These include: pain that gets worse at night. Stover S, Sevier T, Helfst R, Jansen CWS. Adv Orthop. Journal of orthopaedics. 2006 Nov 2;333(7575):939. It is very common for a meniscal tear to take place at the same time as an ACL (anterior cruciate ligament) tear. 7. 1 The biceps brachii is commonly injured at its tendinous insertion and origin, 2 but musculotendinous injuries have also been described. T1-weighted fat-suppressed coronal MR arthrogram image profiles a complete rupture of the sublime tubercle attachment (, A description of injury to the UCL complex would be incomplete without localization of the imaging abnormality. Hand Surgery and Rehabilitation. But it does mean that you are going to have to take it easy until the tear heals or the doctors decide that surgery might be the best option after all. So as a warning to anyone who is taking cortisone shots, or taking Medrol dose pack, cortisone and Mobic can be very dangerous. 1998;15(10):4352. If you want to return to strenuous overhead or throwing activities and nonoperative treatments didnt help, then your doctor might recommend surgical repair of the torn UCL. Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: current concepts. 2010 Sep;195(3):585-94. Repeated cortisone injections. 2003 Nov;31(6):915-20. Pfefer MT, Cooper SR, Uhl NL. In all cases, patients present with pain in their upper arm and shoulder and varying degrees of weakness and loss of range. Postoperative Care for Common Extensor Tendon Origin Repair. Evaluation and Management of Elbow Tendinopathy - ResearchGate Tendinosis: Symptoms, causes, and treatment - Medical News Today 2004 Sep 1;71(5):369-73. Journal of Shoulder and Elbow Surgery. 2019 Jul 3;47(3):284-9. smoking. 6 Meniscus Tear Types That You Need To Know About - Centeno-Schultz Clinic Klifto KM, Colbert SH, Richard MJ, Anakwenze OA, Ruch DS, Klifto CS. Copyright 2009 www.healthandnutritiontips.net. Extensor Tendon Injuries: Repairs, Tears, & More - Hand and Wrist Institute Figure 10.1Ulnar collateral ligament complex anatomy. The distal portion of the biceps tendon may be at risk for attritional changes and tearing in a fashion similar to the supraspinatus tendon of the shoulder in cases of impingement (. Piper S, Shearer HM, Cote P, Wong JJ, Yu H, Varatharajan S, Southerst D, Randhawa KA, Sutton DA, Stupar M, Nordin MC. The common extensor group is composed of four muscles: the extensor carpi radialis brevis (ECRB), extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris (. Too much stress on the graft before it has healed increases the risk of failure. Link, 113. 2020 Jul 8:0309364620930618. Materia socio-medica. Full-thickness tears of the UCL are diagnosed by discontinuity along the course of the ligament (Figs. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. The ulnar collateral ligament of the elbow is most often injured by repeated stress from overhead movement. T1-weighted axial MR image demonstrates an accessory muscle, the anconeus epitrochlearis (, Tendon Lesion Classification and Imaging Characterization, Like elsewhere in the body, the tendons about the elbow should be smooth, linear structures of low signal intensity. Seo JB, Yoon SH, Lee JY, Kim JK, Yoo JS. Contact Us. You can create reports like these for your patients in less than four clicks! Jafarian FS, Demneh ES, Tyson SF. Got a great idea or want information about a special topic? shoulder stiffness. Journal of Clinical Medicine. (140). Gradient coronal MR image shows an edematous and mildly displaced medial epicondylar ossification center (. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. The authors compared elbow Mobilization with Movement, Mill's Manipulation, and Regional Mobilizations for lateral elbow tendinosis treatment. Yi R, Bratchenko WW, Tan V. Deep friction massage versus steroid injection in the treatment of lateral epicondylitis. 31. Link, 120. 2010 Jan;30(1):167-84. Learn why tendons need a lot more than just rest and "R.I.C.E." All rights reserved. So if you have ideas, articles, news, questions, comments we would love to hear from you. Symptoms. Graston / IASTM For Treating Tennis Elbow. Variants of the UCL complex have been described and include a strong oblique pattern in which the transverse bundle flares in a fan-like configuration as it inserts on the anterior bundle and coronoid (, Lesion Classification and MRI Characterization of the Ulnar Collateral Ligament, The visualized components of the UCL complex are seen as thin linear bands extending along the medial aspect of the elbow joint on MR images. Brkljac M, Conville J, Sonar U, Kumar S. Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis. The extensor carpi radialis brevis also has a significant muscular attachment to the humerus that blends with the more superficial extensor carpi radialis longus. This motion is called supination and is important for power gripping activities. Link, 92. European Journal of Pain. Begin with the seated patients shoulder slightly abducted, elbow flexed to 90 degrees, and fist facing down. Partial Thickness Rotator Cuff Tears: Current Concepts. Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis. High-grade Common Extensor Tendon Tears Maintaining Chronic - LWW Sports Med. 2019 Feb 1;28(2):304-9. Dr. Bertelsman has served in several leadership positions and is the former president of the Illinois Chiropractic Society. This is the first Level 1 prospective randomised controlled trial demonstrating that Autologous Tenocyte Injection resulted in a significantly better and sustained reduction in pain and improvement in shoulder function, compared with corticosteroid injection, as treatment for tendinopathy and interstitial tears of the rotator cuff. Pain worsens when bending the wrist sideways (little finger towards the forearm, called ulnar deviation) Swelling. 2021 Oct 1;67(4). Role of Strengthening During Non-Operative Treatment of Lateral Epicondyle Tendinopathy. TFCC Tear: Causes and Symptoms | The Hand Society Tears of the distal biceps tendon at the elbow are uncommon, and injuries are frequently sudden. They are described as articular side, intrasubstance, or superficial in nature . The healing time for tendinitis is several days to 6 weeksTreatment for tendinosis recognized at an early stage can be as brief as 610 weeks; however, treatment once the tendinosis has become chronic can take 36 months. (147). i had a high grade tear of common extensor tendon bundle repaired with surgery in february 2022? Occupational and environmental medicine. Reproduced from Mirzavan R, Lemos SE, Brooks K: Surgical treatment of distal biceps tendon rupture. Treatment recommendations may include: Surgery to repair the tendon should be performed during the first 2 to 3 weeks after injury. T1-weighted fat-suppressed coronal MR arthrogram image shows a thickened ulnar collateral ligament with undersurface irregularity (, Figure 10.10Intrasubstance partial tear of the ulnar collateral ligament. Those degenerative tears can be found on most MRIs but are generally not of clinical relevance (1). posterior labral tear shoulder mri - stmatthewsbc.org rare injury to the elbow and understand the large forces experienced by the soft tissues of the fore-arm during the golf swing.9,10 Conclusion Pronator teres muscle strain is a rare sporting in-jury reported in cricket and golf players. Some doctors prefer to use one incision at the front (inside) of the elbow, while others use small incisions at both the front and back (outside) of the elbow. (5,6) Chronic cases show no histologic signs of inflammation. There are several different procedures to reattach the distal biceps tendon to the forearm bone. 2019 May 1;35(5):1379-84. When Should You Get An MRI For Tennis Elbow Or Golfers Elbow. 2020 Nov;34(11):1327-40. On the 10th day, I had tremors so badly I went into the ER. Lateral Epicondylitis Clinical Presentation Emedicine. Stasinopoulos D. Stop Using the Eccentric Exercises as the Gold Standard Treatment for the Management of Lateral Elbow Tendinopathy. These types of tear are the tricky ones and they are quite common in Tennis Elbow sufferers. When valgus forces generated at the flexed elbow exceed the load-to-failure strength of the UCL, damage to the ligament occurs and valgus instability can develop (, Throwing athletes who sustain an acute injury to the UCL state they heard or felt a pop from the elbow. 6. The medial muscle group includes the pronator teres and four superficial flexors. Link. Best Practice & Research Clinical Rheumatology. Journal of shoulder and elbow surgery. The instability resulting from a UCL tear may affect your ability to participate in sports that require throwing. I just happened to be on my way to the appointment, so I decided to keep going and see what the doctor said about the reaction to the cortisone. Sonogram for Diagnosing Tennis and Golfers Elbow here. Foci of calcification, intrasubstance tears, and enthesopathic changes at the lateral epicondyle may be observed. For some, a TFCC tear may not cause any pain or instability problems in a wrist. ChiroUp subscribers can review the Free test tutorial here: The Free Test showed 86% sensitivity and 64% specificity for intrasubstance tendon tears. Another type of tear is a bucket-handle tear. Journal of Orthopaedic Surgery and Research. In the lateral epicondylar region, this process affects the common extensor tendon; in the medial epicondylar region, the common flexor tendon is . The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. Figure 11.6Medial muscle and tendon anatomy. 3 The intra-articular tendon of the long head of the biceps brachii is the most commonly injured structure followed by its extra . A distal biceps tendon tear can cause the muscle to ball up near the shoulder. Intrasubstance rotator cuff tear | Radiology Reference Article Clinical Orthopaedics and Related Research. To return arm strength to near normal levels, your surgeon may offer surgery to repair the torn tendon. Link, 103. Smidt N, Assendelft W, Arola H, Malmivaara A, Green S, Buchbinder R, van der Windt D, Bouter L. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. The American Journal of Sports Medicine. 2014 Apr 1;48(7):506-9. " Journal of shoulder and elbow surgery. Palmer W, Bancroft L, Bonar F et al. Extracorporeal Shock Wave Therapy shows Superiority over Injections for Pain Relief and Grip Strength Recovery in Lateral Epicondylitis: A Systematic Review and Network Meta-Analysis. Sagittal images of biceps may help confirm suspect pathology. Grip strength is more sensitive to changes in elbow position than isolated wrist extension strength in patients with lateral elbow tendinopathy. Link, 128. Comparison of low level laser therapy and extracorporeal shock wave in treatment of chronic lateral epicondylitis. Pain. The tear can be complete (full thickness) where the tendon is torn from the bone, or partial. Radiographic features. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis: part 1: a new paradigm for a difficult clinical problem. Link, 106. an intrasubstance tear which was measured at 6 x 2.8 x 2.2 mm. A high-grade tear means the fibers in the tendon are more than 70% torn. Pain Research and Management. 2022 Jan 11. Common post-operative care guidelines include: Elevate the arm above chest level to reduce swelling. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. It is the preference of the author to . Lucado AM, Dale RB, Vincent J, Day JM. Techniques in Orthopaedics. Should You Wear A Tennis Elbow Brace? Masks are required inside all of our care facilities. The supraspinatus is part of the rotator cuff of the shoulder. Three components of the ulnar collateral ligament complex are shown. 2018 Jan;13(1):56-9. Clinical rheumatology. Med/Lat. Epicondylitis (Tennis Elbow) | Orthopaedic Associates of Michigan 55. Link, 39. Link. Link, 141. McShane JM, Nazarian LN, Harwood MI. In most cases, tears of the distal biceps tendon are complete. 501-533. Link, 112. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. The role of supinator in the pathogenesis of chronic lateral elbow pain: a biomechanical study. Baktir S, Ozdincler AR, Mutlu EK, Bilsel K. The short-term effectiveness of low-level laser, phonophoresis, and iontophoresis in patients with lateral epicondylosis. The radial tunnel syndrome. JCM | Free Full-Text | Determinants of Operative Time in Arthroscopic Although an MRI scan may show a UCL tear, it may not be 100 percent accurate. BMC Musculoskeletal Disorders. Link, 16. In a meta-analysis of the MR findings of humeral epicondylitis, four of seven studies included in the analysis used either a T2-weighted fat-suppressed imaging sequence or an inversion recovery sequence in the imaging protocol (, The MRI diagnosis of the clinical entity of lateral epicondylitis includes abnormal morphology and signal intensity of the common extensor tendon. Magnetic resonance imaging (MRI). Link, 83. After this time, the tendon and biceps muscle begin to scar and shorten, and it may not be possible to restore arm function with surgery. Tendon tear is the end result of severe degenerative tendinopathy and is uncommon around the elbow [1].Rupture of the common extensor tendon of the wrist has been reported in athletes [2].However, there are few reports in the literature that describe a complete tear of the common flexor tendon of the wrist [3], [4].In the present case report, we describe a complete tear of the . Rotator cuff tears may be partial or full thickness tears. Validation of the patient-rated tennis elbow evaluation questionnaire. Diagnosis is often more difficult than the treatment of a UCL injury. Mean patient age at surgery was 48 . A doctor may also be able to feel the bone fragment. Epicondylitis: Pathogenesis, Imaging, and Treatment - RadioGraphics A systematic review and meta-analysis. Accessed 5/12/14 from: aapmr.org Link, 65. Nerve entrapment syndromes of the elbow, forearm, and wrist. Loftice J, Fleisig GS, Zheng N, Andrews JR. Biomechanics of the elbow in sports. Corticosteroid injections for lateral epicondylitis: a systematic overview. Most commonly, there is a gradual onset of elbow pain due to repetitive stresses on the ligament. Test the supination strength of your forearm by asking you to rotate your forearm against resistance. Ulnar Collateral Ligament (UCL) Injuries of the Elbow
Knapping Obsidian Slabs,
Tabletop Pedestrian Crossing,
Dedham Patch Obituaries,
Celebrities Who Were Abused By Their Parents,
Articles D