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admin | Hip Flexor Tendonitis Symptoms | 18.09.2015
I do not think that deep tissue massage had anything to do with it otherwise the pain would have been felt immediately during treatment. QUESTION: Thanks for the reply Jeremy, I just felt a sharp pain in the lower right side of my back.
If its on the waistline it seems that the interior and exterior oblique muscles are involved.
In both cases those muscles are extremely strong and lack an excellent blood supply in the tendon area explaining why it takes so long to heal. Just to see how much that muscle is used, hold the spot with the palm of your hand and walk a few paces. Untreated, the muscle will heal within 4 to 6 weeks depending on your body weight and healthy lifestyle. Film Critique of the Lower extremity - Part 1This article reviews the anatomy of the pelvis and proximal femur, and hip joint. Your completion certificate will print with the date that you successfully complete the article test. Identify radiographic anatomy of the pelvis, sacroiliac joint, hip joint and proximal femur.
Describe the positioning of the patient for the AP, lateral and frog lateral projections of the hip joint.
Tell how trauma imaging of the hip for suspected fracture differs from imaging an ambulatory patient who suffers chronic pain. Discuss how leg rotation affects the relationship of structures seen in the proximal femur on an AP and lateral projection of the hip.
State the diagnostic criteria for imaging the different views of the hip joint and proximal femur.
Discuss optimal exposure technique for imaging the hip and discuss the radiographic appearance of bone and soft tissue structure of an optimal radiograph.
Describe how the anatomical structures of the proximal femur are displayed when the leg is positioned at different angles from the tabletop for the frogleg hip projection. Describe the correct anatomical relationships in the proximal femur of a properly positioned axiolateral hip projection. Radiologic technologists make and review hundreds of thousands of films daily as part of our routine job performance. Knowing what is to be included in each view and the proper radiographic exposure technique for optimal subject detail is a must for any discussion on image critique. Final radiographs are affected immensely by exposure technique selected and whether or not the patient is cooperative.
Experienced radiographers know that in order to evaluate any radiograph for technical excellence a solid foundation in how the four radiographic densities (muscle, fat, bone, air) are balanced when exposure factors are selected. Evaluating radiographic density, subject contrast, image detail, and anatomical presentation of each radiographic projection is part of film critique. Radiographs of the lower extremity are commonly taken, so the radiographer should be very familiar with the anatomy, positioning, and proper imaging exposure techniques to make a quality radiograph.
Pelvis and hip injuries occur frequently from falls, automobile accidents, sports activities, work related injuries and so forth. The astute student will continue to gain knowledge about those normal anatomical variations that can even confound physicians.
This radiograph of a pediatric pelvis demonstrates the development of the three bones of the hip (Ilium-A, Pubis-B, Ischium-C) that will later fuse at the acetabulum. This 3-D computed tomography image shows a lateral view of the pelvis with the femur removed to demonstrate the acetabulum (D).
Radiographers should be familiar with the following labeled parts of the pelvis seen in the radiograph above: iliac crest (A), iliac wing (B), sacroiliac joint (C), ASIS (D), acetabulum (E), femoral head (F), femoral neck (G), greater trochanter (H), lesser trochanter (I), ischium (J), superior pubic ramus (K), inferior pubic ramus (L), obturator foramen (M), symphysis pubis (N), sacrum (O). There are several reasons the pelvis may be imaged including trauma evaluation, chronic pain, and developmental abnormalities.
When we talk about critique of the pelvis and hip it is important to understand that the sacrum is one of the keystone functional parts of the pelvis.
The anterior pelvis (Ant) presents the pelvic ring (blue dotted circle) formed by the sacral promontory posteriorly, and the arcuate ridge of the ilium and superior pubic ramus of each innominate bone. There is no anatomical separation between the abdominal and pelvic cavities; however, some anatomists emphasize an arbitrary division of the true and false pelvis. The bony pelvis lacks inherent structural stability, and so is stabilized by a system of tightly woven ligaments and muscle that provide its support. A dense array of ligaments holds the bony pelvis together; some are illustrated on the 3D volume rendered CT images above (blue lines). These three coronal MR images show a portion of the tremendous network of ligaments and muscles that stabilize the bony pelvis. The schematic lines on the 3D CT image on the left (blue) represent some of the ligaments supporting and closing the true pelvis.
The Tile classification system provides a descriptive appraisal of fractures affecting pelvic stability.
A rotational injury of the hemipelvis causes serious anatomical disruptions in the pelvic cavity. The proximal femur and hip is seen from the anterior view on the 3-D volume rendered CT image on the left. This AP hip radiograph demonstrates some of the important parts of the hip and proximal femur that should be identified.
Standard views of the hip consist of the AP projection (seen above), and horizontal beam lateral or the frog-leg lateral projections; therefore the radiographic anatomy seen by these views should also be reviewed at this time.
This radiograph demonstrates the anatomy that should be seen on the AP axial frogleg projection. Throughout this module we will use standard radiology terminology to describe terms such as exposure technique, positioning error, and tube angle.
When the patient is incorrectly positioned, which results in an unacceptable radiograph, this is called a positioning error or technologist positioning error. Any object that can potentially obstruct the anatomy under investigation and can be removed should be removed. For the AP pelvis view the lower extremity and feet are internally rotated 15-20 degrees from vertical. The pelvis is formed by the two innominate bones (ilium, ischium, and pubis), sacrum, and coccyx.
Sacrum and coccyx aligned with the pubis symphysis and the ischial spines, when seen are aligned with the pelvic brim. Internal rotation of the femurs to profile the greater trochanters unless the patient presents with acute trauma and leg or hip deformity, traumatic external rotation of the hip or leg, or pain suggestive of an acute fracture.
When properly positioned the femoral necks will not be foreshortened, the greater trochanter of each femur is demonstrated in profile laterally, and the lesser trochanter superimposed by the neck of the femur or slightly projected medially. Radiographic technique should demonstrate good penetration of the bony pelvis especially the iliac wings, sacrum, acetabulum, and hip joint. Soft tissue structures that should be seen within the true pelvis include the urinary bladder and air contrast in the rectum.
At first glance it may look like the left hip is not properly rotated; however, closer inspection reveals a congenital abnormality of the femoral head and neck.
This patient suffered blunt trauma to the abdomen and pelvis during a motor vehicle accident.
Often the radiographer is called upon to take high quality diagnostic radiographs while the trauma team administers care to a critically injured patient.
This radiograph of the pelvis is adequate for evaluating the hip joint for fracture or dislocation.
This is a post surgical radiograph taken to evaluate the alignment of the pelvis and to evaluate the proximal femoral rod and left hip.
This is an acceptable radiograph that meets the diagnostic criteria for the AP pelvis projection. The patient?s history for this exam involves acute trauma to the left pelvis and left hip due to a fall.
This is a very good radiograph in terms of demonstrating the required anatomy for the AP pelvis projection.
This patient is an ambulatory patient who presented with hip pain and a chief complaint of ?fall 2 days prior.? This radiograph was taken in the radiology department; does it meet the diagnostic criteria for the AP pelvis projection? Paying close attention to the patient history that goes with each study will eliminate unnecessary exposure and allow one to practice within the guidelines ALARA. Give your critique of this AP pelvis radiograph, which was taken upright to evaluate both hip joints as a weight-bearing study?
When performing the weight-bearing study both legs are in the neutral position rather than internally rotated in an unnatural standing position.
This AP pelvis radiograph was taken to evaluate the pelvis and hips, chief complaint, ?chronic bilateral hip pain.? Does this radiograph meet the diagnostic criteria for the AP pelvis view? This radiograph does not meet the diagnostic criterion for the AP pelvis view because a portion of the right ilium and right proximal femur are clipped. This patient was brought to a local emergency room on a spine board suspected of having multiple traumatic injuries.
Imaging for trauma in the emergency room as part of the trauma team requires experience and skill to get the best radiograph on the first attempt. The patient is well centered; both hip joints and proximal femurs are included on the radiograph.
This patient was brought to a local emergency room on a spine board after suffering acute trauma. The magnitude of injuries seen on this radiograph, like the previous one, tells the story of serious, potentially life-threatening injuries.
This radiograph was taken on a trauma patient who presented with the right hip in external rotation and extreme pain. When a trauma patient presents with external rotation of the lower extremity the technologist should not internally rotate the hip. Give your critique of this postoperative radiograph given the clinical history, ?evaluate internal fixation of the pelvis.? Does this radiograph meet the diagnostic criteria for the AP pelvis view? This radiograph fails to meet the diagnostic criteria for image quality and positioning of the part.
The AP pelvis view should include the entire ilium, ischium, pubis bones, and the entire L5 vertebra.
This CT midsagittal view of the pelvis demonstrates the inlet and outlet of the true pelvis.

The inlet view is important because it can immediately identify narrowing or widening of the pelvic ring. This pelvic inlet view of the pelvis demonstrates the importance of seeing the posterior element of the pelvic inlet along the sacral border.
Can corroborate vertical displacement of the hemipelvis, visualize the SI joints in profile, and show displacement of the hip joint.
When the outlet view is taken as part of a trauma series, both femoral heads should be included on the radiograph. The pelvic outlet view demonstrates the pubic rami, obturator foramina (O), and the anterior and posterior margins of the pelvis.
This 3-D volume rendered CT image shows the outlet from the inferior opening of the true pelvis. For both the pelvic inlet and outlet views include the entire pelvis from the top of the iliac crests superiorly through the ischial tuberosities and pubic rami inferiorly. The floor of the true pelvis should be demonstrated on the outlet view; the inlet view should show the opening into the true pelvis (pelvic ring) in profile.
There should not be any rotation of the pelvis on either view determined by the obturator foramina being open and symmetrical. Psoas muscle, that is pulling the lumbar vertebrae forward & compressing them together. Right Thoracic Scoliosis: indicates that the major curve of the spine is in the thoracic region (mid-back) and curves to the right. Left Lumbar Scoliosis: indicates that the major curve is to the left and is concentrated in the lumbar region.
Right Thoraco-Lumbar Scoliosis: indicates that the major curve is to the right in the thoracic and lumbar region with the apex of the curve at the junction between the thoracic and lumbar spine.
But the reality is that everyone has muscle imbalances to some degree - regardless of age, sex or level of fitness. It should just be hot enough not to scald the skin so please be very careful not to burn yourself.
If there is some lordosis (large curvature of the lower back spine) and your bum sticks out because of the condition. Put your hand in the 'hands up' position where your arms are perpendicular to your body side. Acquiring an acceptable radiograph or digital image requires knowledge of the anatomy, positioning criteria, radiographic exposure, and other skills.
As we view images contained in this module we will also address two important issues: what anatomy should be presented in a specific view, and how should that anatomy be presented. First, the anatomy of each part is reviewed, then the diagnostic criteria for the projection are given, and finally, a discussion is made critiquing the radiograph.
Not all images that are eye pleasing when casually viewed are diagnostic to the keen eye of a radiologist. Metal is more radiopaque than bone and is the main component of implanted prosthetic devices.
Prior to submitting a radiograph for interpretation the technologist should evaluate subject contrast.
The false pelvis is that portion of the pelvis above the pelvic brim; the true pelvis is that portion of the pelvis below the pelvic brim. Strong ligaments arranged transversely resist forces that can externally rotate the pelvis, thereby opening it. It functions to transfer the weight of the body down through the lower extremity to the foot to facilitate locomotion. For example, the term overexposure is used to describe a dark radiograph owing to too many photons producing the image. Soft tissue visualization of muscle, fat, and air densities, especially around the hip should be demonstrated.
With this in mind it we should evaluate this image primarily on the radiographic quality of the hip. Does this portable AP pelvis radiograph meet the diagnostic criteria for the AP pelvis, and tell what should be done to make this a complete diagnostic radiograph? The patient was transferred to a level I trauma center for suspicion of injury to the urinary bladder.
The request for the examination specifically stated, ?pelvis x-ray to include both hip prostheses.? Did the technologist produce this radiograph in keeping with the diagnostic criteria for the study as requested? Although the femur is not an anatomical part of the pelvis, including it is part of the diagnostic criteria for the AP pelvis view.
Under great pressure to perform the technologist has done a fine job of not clipping pertinent anatomy.
Good timely diagnostic radiographs are important during trauma imaging since early diagnosis and treatment may in some cases increase chance of survival.
External rotation of the leg following trauma often indicates a fracture of the proximal or distal femur, or acetabulum.
The FOV should extend from above the iliac crests through the lesser trochanters of both femurs and include their surrounding soft tissues.
The pelvic inlet is formed by two arching lines that begin posteriorly with the sacral promontory and extends anterolaterally as the arcuate lines and pectin on the superior pubic rami. This is because when a hip dislocation is present the outlet view can demonstrate its anterior or posterior displacement.
The spine curves laterally (from side to side) while at the same time vertebrae rotate within the curve.  One the lateral side of the curve, the ribs and intercostal muscles move sideways, spread apart and rotate backwards with the spine (this is called the convex side of the back). Breath awareness during yoga practice expands the intercostal muscles between the ribcage, which have decreased elasticity due to the curvature of the scoliotic spine. She is qualified to diagnose the type of scoliosis clients have and can provide a customized yoga program to help lengthen, strengthen and re-rotate the spine. In addition the radiographer must know and meet specific diagnostic imaging criteria in order to provide the radiologists images suitable for interpretation.
Radiographers must combine their knowledge of diagnostic criteria and image quality to assure quality diagnostic radiographs are made during a diagnostic study.
Bone, muscle, fat, and air should be well balanced throughout the radiograph along with displaying good background density.
In order to properly image the hip the radiographer must be familiar with its anatomy and how to properly position it for correct diagnostic referencing. Experienced technologists can work around traumatic or chronic pain when positioning for radiographs.
When we speak of the pelvic ring we are referring to that ring of bone forming the upper limit of the true pelvis. An importance of this division is to emphysize that the true pelvis contains some soft tissue structures. Among these is the short posterior SI ligament, the anterior SI (sacroiliac) ligament, the iliolumbar ligament, and sacrospinous ligaments. The inferior margins of the displayed anatomy should extend below the lesser trochanters of the femora.
In most cases it would be wise to clarify the order with the requesting physician to determine if the left hip should be specifically imaged.
It is important for the technologist to be familiar with the different surgical procedures when we talk about film critique. High contrast caused by low kVp and high mAs is always unacceptable for imaging the pelvis. This follow-up to the portable radiograph shows good bone detail, especially the left pelvic ring and left acetabular fracture. We see that most of the pelvis is included on this radiograph including right hip and right hemi-pelvis, which is dislocated and displaced, respectively.
This radiograph reveals a complex pattern of injuries that include a fracture of the right acetabulum, right pelvic ring, and fractures involving both iliac wings. Then again, it is not required to be entirely included unless the left hip is also specified in the exam request. The posterior pelvis mainly the sacrum and visualized lumbar vertebrae should be well penetrated having sharp bone edges.
A 45-degree cephalic angulation will cast the shadow of an anteriorly displaced femoral head above the acetabulum. The femoral heads must be included on the radiograph since anterior or posterior displacement can be determined from the outlet view. On the opposite side of the lateral curve, the intercostal muscles are underdeveloped and the ribs are compressed. By sending breath the the concavity of the curve, the collapsed ribcage will expand, providing more lung capacity as well as balance between both sides of the body.
The intensity is less but it still hurts, especially when I am sitting upright on a hard surface. Grab it with the opposite side hand and twist your waist down flat stretching the lower back waist muscles. I am also medically conversant so I can answer any questions you might have regarding the interaction of medicine with Massage Therapy.Experience16 years experience as a part time massage Therapist.
A knowledgeable radiographer assesses acquired images as a point of quality control to make sure it meets the diagnostic criteria.
For example, a radiograph that is positioned correctly and demonstrates the proper anatomy must also have optimal exposure technique to yield maximum diagnostic value. By knowing the diagnostic criteria you can compare each radiograph and ask, ?Did this radiograph meet the diagnostic criteria?? When a radiograph does not meet the diagnostic criteria then you must decide if it should be repeated or not.
Special formulations of iodine and barium are used in radiographic contrast agents and are the opacifying moiety in these materials. As we present many radiographs in this module it is our goal to improve your ability to evaluate radiographs prior to submitting them for interpretation.
Good radiographic imaging should always begin with a solid understanding of the anatomy of the part to be demonstrated. This ring is formed posteriorly by the sacrum and the two innominate bones form the sides and front.
Anteriorly the pubic rami perform stabilization functions; however, anterior stabilization is less critical following pelvic injury than is posterior ring stabilization. Because of the function of weight transference and shifting during gait, the hip and knee joints are often the source of chronic pain.
For example, you cannot include the entire left hip?s internal fixation on the film because it is a femoral rod that extends to the knee.

The sacroiliac joints are faintly demonstrated as are the soft tissue structures like the urinary bladder and visualized bowel.
The radiographic exposure technique shows good bone detail in the posterior pelvis where a fracture of the sacrum and femur (arrows) is noted. An optimal radiograph would have included the entire left side: proximal femur, iliac wing.
Specifying the left hip to be evaluated along with the pelvis requires a separate left hip radiograph to include the entire prosthesis. All soft tissues surrounding the pelvis including the skin should be demonstrated for any penetrating injury. Because of the rotation of the spine, the ribs are pushed forward forming a flat back (this is called the convex side of the back). The upper curve usually curves to the right, causing compression and pain in the ribcage and lungs. No radiographer wants to pass on poorly made radiographs to the radiologist but when hundreds of images are taken daily it is easy to slack and become complacent.
The diagnostic criteria for each view in our critique series is given; however, these should already be committed to practice, as this is actually a review of the current standards practiced in radiography. Keep in mind that just because a radiograph does not meet all aspects of its diagnostic criteria does not mean it is without diagnostic value. Using a contrast agent such as barium sulfate or iodine solutions allow us to demonstrate information about some structures better than if without it.
It is our hope that you critique each radiograph in a way that encourages perfection at using diagnostic criteria, which are the standards by which we image.
For example, improper positioning can cause improper overlap of structures that can simulate abnormality.
Strong articulations join the hip bones to the sacrum at the sacroiliac joints, and to each other at their pubic bone articulation forming the symphysis pubis. When imaging the pelvis for trauma the radiographer must provide images that allow the radiologist and orthopedic surgeon to distinguish stable fractures from unstable fractures, that is, identify and characterize fractures involving the posterior pelvic ring or sacrum. These joints are also more likely to be injured due to trauma like a fall from height, or a high impact motor vehicle accident. The ordering physician should be consulted with to see if a separate request of the left hip could be made. The radiographic exposure technique is adequate for most of the posterior portion of the pelvis.
Because the technologist performed professionally and did achieve the diagnostic criteria for the AP pelvis view, crucial interventional time was saved. The external rotation of the right hip is to be expected and is not indicative of poor position on the part of the technologist.
A grid must be used because it helps to clean up scatter by absorbing it before it reaches the image receptor. Achieving high quality diagnostic images when hundreds of different images are taken each day requires a conscious effort to maintain quality. The intent of this learning module is to reaffirm that our universal imaging practices conform to the achievement of specific diagnostic criteria. For example, diagnostic detail of the alimentary tract not seen on routine radiographs, but can be seen when an oral contrast agent is used. We also image using the standard of practicing ALARA (as low as reasonably achievable) in administering radiation for diagnostic purposes. Radiologists are aware of positioning gamut?s and anatomical variants when interpreting radiographs. One reason it is important to understand anatomical relationships in the pelvis is so that we properly demonstrate areas where functional stability can be evaluated. Acetabular and hip fractures must also be demonstrated in a way that allows them to be characterized.
Vertical stability of the pelvis is primarily due to the short and long posterior SI ligaments.
Now let?s review the anatomy of the proximal femur and its articulation with the acetabulum at the hip joint. The reason we need to see the entire prosthesis is that it must be determined whether a fracture occurred distal to the prosthesis. The radiographic technique inadequately demonstrates the bladder relative to the bony pelvis.
However, the sacrum, SI joints, and lower lumbar spine are poorly penetrated and show poor bone detail. As a result, the patient was transported to the CT department for a complete chest, abdomen, and pelvis CT scan. I suspect that magnification due to increased OID may be the reason for clipping the pelvis; another cause is failure to properly center the part.
Radiographers can at one moment make images of the hand and the next moment called upon to image the foot; the next patient may need abdominal or chest imaging. It is commonly thought by laypersons and some medical workers that radiographers just put the part on a cassette and exposes it, which is far from the truth about how we acquire diagnostic images. So consider this film critique relative to patient presentation and how we perform clinically.
The hallmark of a good radiographer and an important result of critiquing any radiograph are to routinely acquire quality radiographs, even under difficult circumstances. Distinction of pathology in the esophagus, stomach and colon are best seen using barium sulfate or oral iodinated media. Therefore, it is the purpose of this critique to instill the principles of diagnostic criteria and getting it right with the first radiographic exposure.
However, the role of the technologist is to present radiographs that meet known diagnostic criteria void of ambiguity.
The goal of the specific diagnostic criteria to be presented is to assure all technologists are imaging the entire pelvis in a way that meets universally accepted diagnostic standards. Interosseous ligaments within the sacroiliac joints also provide some additional vertical stability. The subject is displayed using a high contrast technique, which is why the pelvis is underpenetrated. Artifacts from the spine board are to be expected since removing it may compromise a spinal cord injury.
Notice that the patient?s left hand guards the left hip (which could obscure a possible fracture).
As a result, the sacrum and posterior pelvis is indeterminate for fracture and pelvic stability. The results of the CT scan indicated that interventional radiology was needed immediately to attempt to manage uncontrollable pelvic hemorrhaging. Better centering of the part to the image receptor to take advantage of the entire image area would reduce the chances of a positioning error. The sacrum is not aligned with the pubic symphysis, which indicates that the pelvis is rotated. While most patients cooperate for imaging procedures there are times when a patient is too young to understand the need for them to cooperate, or the manifestation of alcohol use is a factor, or even a language barrier that can hinder instructions to the patient and may diminish cooperativeness. Likewise, blood vessels, lymph nodes, and solid organs such as the liver, kidneys, spleen, pancreas, and such are best demonstrated using intravenous iodine radiopaque contrast agents for some radiological studies.
Hopefully we will change this point of view (if you have it) by the time you have completed this module. One of the primary purposes of this film critique is to review the diagnostic criteria and provide you the tools needed to determine when they have been met for any particular projection. Equipment artifacts like processor streaks, digital image artifacts, grid lines on the radiograph, quantum mottling, digital noise, or artifacts caused by dirty screens, must all be repeated and cannot be considered acceptable radiographs.
Strive to achieve a balance in contrast to demonstrate good penetration of the femora heads and sacroiliac joints. A coned AP hip projection should be made to include the entire prosthesis, and a lateral view of the left hip may also be requested to determine if this dislocation is anterior or posterior. Guarding is a typical response to acute pain; therefore, make certain the entire area of exposure is clear before exposing the part. Although this radiograph meets the diagnostic criterion for demonstrating the anatomy it should be repeated because the exposure technique poorly defines the posterior pelvis, especially the sacral margins. The exposure technique shows a well-penetrated pelvis with good bone detail through the acetabula, pubis bones, iliac wings, and sacrum. Yet no specific circumstance inherently lowers or raises the bar for malfeasance or nonfeasance that haunts poor imaging. Intrathecal administration of a sterile water-soluble contrast agent can demonstrate the subarachnoid space and menenges in the spine. The hip joint is not a simple joint; in fact it has the most extensive motions of all joints of the lower extremity.
The diagnostic criteria references positioning, anatomy demonstrated, and optimal radiographic exposure and subject contrast.
Unfortunately, this radiograph must be repeated because the right hemipelvis and sacrum is underpenetrated. The AP pelvis view alone is not always sufficient to determine stability of the pelvis so additional projections like the inlet and outlet views, or a CT scan may be used to further characterize ill-defined features in the posterior pelvis. The radiographic exposure technique displays good penetration of bone and proper contrast between metal fixation devices and bone. Often with today's shortages of radiologic technologists inexperienced radiographers are set on their own to clear images for interpretation without the precious benefit of critique by a seasoned professional technologist. The SI joints and sacrum must also be optimally penetrated since this could be the source of the left hip pain.
Soft tissue structures such as the urinary bladder and bowel gas presentation is balanced with good bone detail. The best way to include all anatomy on this radiograph is to use proper part-tube-image receptor alignment. The femurs can be internally rotated to correct foreshortening of the femoral necks since there is no identified fracture on this radiograph. Hopefully this process will become a permanent pattern for you as you review your images before presenting them to the radiologist who gives a diagnostic reading.

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Comments »

  1. BAKILI_QAQAS_KAYIFDA — 18.09.2015 at 14:21:31 Dysplasia is an irregular formulation of the hip socket, which with my spine and pelvis only a good and shortened.
  2. JaguaR — 18.09.2015 at 14:25:10 Hard generally (& is for me at this decrease spine hi ladies.