Evaluation of Elbow Pain in Adults

SHAWN F. KANE, MD; JAMES H. LYNCH, MD, MS; and JONATHAN C. TAYLOR, MD
Womack Army Medical Center, Fort Bragg, North Carolina

The elbow is a complex joint designed to withstand a wide range of dynamic exertional forces. The location and quality
of elbow pain can generally localize the injury to one of the four anatomic regions: anterior, medial, lateral, or poste-
rior. The history should include questions about the onset of pain, what the patient was doing when the pain started,
and the type and frequency of athletic and occupational activities. Lateral and medial epicondylitis are two of the more
common diagnoses and often occur as a result of occupational activities. Patients have pain and tenderness over the
affected tendinous insertion that are accentuated with specific movements. If lateral and medial epicondylitis treat-
ments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered. Ulnar collateral ligament
injuries occur in athletes participating in sports that involve overhead throwing. Biceps tendinopathy is a relatively
common source of pain in the anterior elbow; history often includes repeated elbow flexion with forearm supination
and pronation. Olecranon bursitis is a common cause of posterior elbow pain and swelling. It can be septic or aseptic,
and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. Plain radiography is
the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and
joint effusions. Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. Musculoskeletal
ultrasonography allows for an inexpensive dynamic evaluation of commonly injured structures. (Am Fam Physician.
2014;89(8):649-657. Copyright © 2014 American Academy of Family Physicians.)

D
CME This clinical content etermining the underlying etiol- occupation and recreational activities can be
conforms to AAFP criteria ogy of elbow pain can be difficult important clues to diagnosis. Table 1 pro-
for continuing medical
education (CME). See because of the complex anatomy vides the differential diagnosis of elbow pain
CME Quiz Questions on of this joint and the broad differ- by anatomic location.
page 623. ential diagnosis. As with other musculoskel-
Author disclosure: No rel- etal problems, the keys to diagnosing elbow Anatomy
evant financial affiliations. pain are a history to include mechanism of The elbow is primarily a hinged joint, but
injury or exacerbating movements, and a possesses the unique ability to rotate the
focused physical examination. The patient’s distal arm in pronation and supination
(Figure 11). These unique motions, along
with a wide range of dynamic exertional
Table 1. Differential Diagnosis of Elbow Pain Based forces, predispose the elbow and its struc-
on Anatomic Location tures to significant injuries, particularly
with repetitive motions. Understanding the
Anterior Medial
anatomy and the physical forces of move-
Anterior capsule strain Cubital tunnel syndrome
ment will aid in diagnosis.2
Biceps tendinopathy Medial epicondylitis
Gout Ulnar collateral ligament injury
Anterior Elbow Pain
Intra-articular loose body Valgus extension overload
BICEPS TENDINOPATHY
Osteoarthritis syndrome
Pronator syndrome Posterior The biceps tendon is a relatively com-
Rheumatoid arthritis Olecranon bursitis mon source of pain in the anterior elbow.
Lateral Olecranon stress fracture Although distal biceps tendon ruptures are
Lateral epicondylitis Osteoarthritis rare, comprising 3% of all tendon ruptures,
Osteochondral defect Posterior impingement distal biceps tendinopathy is more common.3
Plica Triceps tendinopathy This condition presents with an insidious
Posterolateral rotatory instability course of anterior elbow pain, especially with
Radial tunnel syndrome/posterior resisted flexion and resisted supination of
interosseous nerve syndrome the forearm. Patients with biceps tendinopa-
thy may present with vague anterior elbow

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 Elbow Pain

pain. History often includes repeated elbow flexion with

forearm supination or pronation, such as in dumbbell
curls. On physical examination, with the elbow flexed
to 90 degrees, passive supination and pronation of the
forearm should reveal a normal piston-like movement of
the biceps muscle belly. Absence of this motion indicates
a complete tear. Resisted supination typically recreates
pain deep in the antecubital fossa. The hook test, which
involves the examiner hooking the biceps tendon with
his or her fingertip, will confirm an intact tendon and
may assist in localizing the pain generator (Figure 2).
Magnetic resonance imaging (MRI) or musculoskeletal
ultrasonography can be used to demonstrate continuity Figure 2. The hook test is used to assess the continuity
of the biceps tendon. The examiner’s finger is used to
and changes in caliber of the tendon.4
hook under the distal biceps tendon. The distal biceps
tendon is ruptured if the examiner’s finger does not meet
OTHER CAUSES
resistance.
Uncommon etiologies of anterior elbow pain include
intra-articular processes such as osteoarthritis, rheuma- stress and flexion at the elbow, as well as repetitive wrist
toid arthritis, and gout. flexion and pronation. It is a tendinopathy of the com-
mon flexor tendon, usually the flexor carpi radialis and
Medial Elbow Pain the pronator teres.1,5
MEDIAL EPICONDYLITIS (GOLFER’S ELBOW) Patients typically report the insidious onset of pain at
Medial epicondylitis is much less common than lateral the medial elbow with or without accompanying grip-
epicondylitis and typically occurs in athletes or workers strength weakness. The point of maximal tenderness
who participate in activities that involve repetitive valgus is usually at the insertion of the flexor-pronator mass,
5 to 10 mm distal and anterior to the medial
A B epicondyle. Pain during resisted pronation
is the most sensitive physical examination
Humerus finding. The pain can also usually be recre-
ated with resisted wrist flexion.6
Olecranon
Lateral fossa
ULNAR COLLATERAL LIGAMENT INJURY
epicondyle
Medial The anterior bundle of the ulnar collateral
Capitellum epicondyle ligament (UCL) is the primary restraint
to valgus stress during overhead throwing
Head
Head Ulna (Figure 3). UCL injuries commonly occur in
Radius athletes participating in sports that involve
Radius overhead throwing, such as baseball, javelin,
C and volleyball.7-9 Injury to the UCL results in
significant valgus elbow instability and may
Humerus Capitellum predispose an athlete to secondary injuries.8,10
ILLUSTRATION BY MYRIAM KIRKMAN-OH

Head Radius The history should include questions

Ulna about the onset of pain, what the patient was
doing when the pain started, sports played,
and the frequency of participation. Patients
with an acute UCL injury usually report the
sensation of a pop followed by the immedi-
Figure 1. Bones of the elbow: (A) anterior view, (B) posterior view, and ate onset of pain and bruising around the
(C) lateral view. medial elbow. Tenderness over the UCL has
Reprinted with permission from Chumbley EM, O’Connor FG, Nirschl RP. Evaluation of over- a sensitivity of 81% to 94%, but a specificity
use elbow injuries. Am Fam Physician. 2000;61(3):692. of only 22% for UCL tears.11

650  American Family Physician www.aafp.org/afp Volume 89, Number 8 ◆ April 15, 2014
 Elbow Pain

The most important examination for a

possible UCL injury is assessment of the
medial joint space laxity or instability Ulnar
against valgus forces. The medial joint space nerve
of the symptomatic elbow should be com-
pared with the asymptomatic side for the Medial
epicondyle
amount of opening, the subjective quality of of
the end point while a valgus force is applied humerus
across the joint, and pain. A normal joint

ILLUSTRATION BY MYRIAM KIRKMAN-OH

space will open less than 3 mm, with a firm
end point.7,8,12 Ulnar collateral
ligament
The moving valgus stress test (Figure 4) has
Posterior bundle
a 100% sensitivity and a 75% specificity for
Intermediate bundle
diagnosing UCL injuries (Table 2 3,7,8,11,13-17). Anterior bundle
This test is performed with the shoulder in
90 degrees of abduction and external rota- Figure 3. Course of the ulnar nerve at the medial elbow and the three
tion. While maintaining constant valgus distinct bands of the ulnar collateral ligament.
torque on the elbow, the elbow is quickly
flexed and extended. A positive result is
defined as pain between 70 and 120 degrees
of flexion.11 A video of the moving valgus
stress test is available at http://www.youtube.
com/watch?v=plk7G2s8V30.
The milking maneuver (Figure 5) can pro-
vide additional information on the possible
presence of a UCL injury. This maneuver
is performed with the forearm supinated,
shoulder abducted, and elbow flexed beyond
90 degrees. The examiner then pulls the
patient’s thumb posteriorly, creating a val-
gus force (Table 2 3,7,8,11,13-17). Patients with a A B
UCL injury will have pain, instability, and
Figure 4. The moving valgus stress test is performed with (A) the shoul-
apprehension.11 der in 90 degrees of abduction and external rotation. (B) While con-
stant valgus torque on the elbow is maintained, the elbow is quickly
CUBITAL TUNNEL SYNDROME
flexed and extended. A positive result is defined as pain between
Cubital tunnel syndrome is a compressive 70 and 120 degrees of flexion.
or traction neuropathy of the ulnar nerve
as it passes through the cubital tunnel of the medial and cervical spine is essential to rule out other compres-
elbow (Figure 3). After carpal tunnel syndrome, it is sive neuropathies.14,20,21
the second most common compressive neuropathy of A positive Tinel sign at the cubital tunnel has a speci-
the upper extremities.18 Approximately 60% of patients ficity of 48% to 100% and a sensitivity of 44% to 75%
with medial epicondylitis have a concomitant compres- for a compressive neuropathy  12,21
(Table 2 
3,7,8,11,13-17
).
sive ulnar neuropathy.19 Physical examination should focus on muscles inner-
Patients will have medial elbow pain with repetitive vated by the ulnar nerve distal to the cubital tunnel: the
activity. The pain is usually associated with numbness flexor carpi ulnaris, the flexor digitorum palmaris, the
and tingling in the ulnar border of the forearm and hand, hypothenar eminence, and the intrinsic muscles of the
and in the ring and little fingers. If the condition exists hand. Wartenberg sign (the inability to adduct the little
for an extended period of time, weakness of the intrin- finger), a clawhand deformity, and flexion of the proxi-
sic muscles of the hand may develop.19 Patients may also mal interphalangeal joint and the distal interphalangeal
have nighttime pain from sleeping with the elbow fully joint of the ring and small fingers may also be present
flexed. A physical examination of the upper extremities (Table 2 3,7,8,11,13-17). The ulnar nerve should be palpated in

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Elbow Pain
Table 2. Selected Diagnostic Tests for Elbow Pain

Test How performed Positive findings Suggested diagnosis

Elbow abduction Valgus stress applied against an elbow held Absence of a firm end point and Ulnar collateral ligament
stress test in 20 to 30 degrees of flexion movement of the articular surfaces injury
of the medial epicondyle and ulna
Hook test Shoulder abducted to 90 degrees with the Finger does not hook onto the Distal biceps tendon
elbow in 90 degrees of flexion biceps tendon rupture
Examiner’s finger attempts to hook behind
the distal biceps tendon
Middle finger test With an outstretched arm, the patient Weakness or inability to resist force Posterior interosseous nerve
attempts to extend the middle finger compression syndrome
against resistance Pain isolated at the lateral epicondyle Lateral epicondylitis
Milking maneuver Forearm supinated, shoulder abducted, and Apprehension, instability, and medial Ulnar collateral ligament
elbow flexed beyond 90 degrees joint pain injury
Valgus stress is placed on the elbow by
pulling on the thumb
Modified milking Shoulder adducted and externally rotated Apprehension, instability, and medial Ulnar collateral ligament
maneuver joint pain injury
Moving valgus Shoulder abducted and externally rotated Pain between 70 and 120 degrees Ulnar collateral ligament
stress test While maintaining a constant valgus force, injury
the elbow is quickly flexed and extended
through a complete range of motion
Tinel test Gentle tapping over the course of a Tingling, paresthesias over the distal Cubital tunnel syndrome,
superficial nerve course of the nerve radial tunnel syndrome

Information from references 3, 7, 8, 11, and 13 through 17.

the cubital tunnel during flexion and extension to detect 30s and 40s and develop lateral epicondylitis as a result
any subluxation or dislocation of the nerve.19 of occupational rather than recreational activities.14 The
lateral elbow is affected four to 10 times more often than
Lateral Elbow Pain the medial side.22
LATERAL EPICONDYLITIS (TENNIS ELBOW) The lateral epicondyle of humerus serves as the com-
This overuse tendinopathy occurs in approximately 1% mon extensor origin for the active supinators of the
to 3% of the population annually, and although it is forearm, including the extensor carpi radialis brevis
commonly called tennis elbow, only 5% to 10% of tennis (Figure 6). Physical examination reveals maximal ten-
players develop the condition. Most patients are in their derness approximately 1 cm distal to the epicondyle
at the origin of the extensor carpi radialis
brevis. Pain and decreased strength with
resisted gripping and with wrist supination
and extension are often present.22

RADIAL TUNNEL SYNDROME AND POSTERIOR

INTEROSSEOUS NERVE SYNDROME

There is some controversy about whether

radial tunnel syndrome and posterior inter-
osseous nerve syndrome are two separate
entities or a continuum of the same condi-
tion. A small percentage of patients who
present with lateral elbow pain and are
thought to have lateral epicondylitis on ini-
A B tial presentation actually have an entrap-
ment neuropathy of the radial nerve.15,23
Figure 5. In the milking maneuver, (A) the elbow is flexed to
90 degrees while a valgus force is applied to the elbow by (B) gently For both syndromes, patients typically
pulling the patient’s thumb in the posterior direction. A positive find- present with a history of repetitive forearm
ing is pain, instability, and apprehension. supination and pronation (e.g., carpenters,

652  American Family Physician www.aafp.org/afp Volume 89, Number 8 ◆ April 15, 2014
 Elbow Pain

Extensor carpi history of minor trauma to the elbow and a

radialis longus boggy, nontender mass over the olecranon
Extensor carpi
radialis brevis without redness, warmth, limited range of
motion, or other signs of infection.26 Because
aspiration of bursae can be associated with
complications such as introducing infection,
this should be performed only when the
diagnosis is uncertain or to relieve symp-
ILLUSTRATION BY MYRIAM KIRKMAN-OH

toms in refractory cases.24

Olecranon TRICEPS TENDINOPATHY

Lateral Tendinopathy at the triceps insertion occa-
epicondyle Extensor carpi Extensor digitorum
sionally occurs in weight lifters or industrial
ulnaris communis
workers in whom repetitive elbow exten-
Figure 6. Lateral epicondyle and the origin of the common extensor sion against resistance is required. Diagnosis
tendon. is fairly straightforward in the setting of a
suggestive history. On physical examina-
mechanics) and have insidious, poorly localized pain tion, the patient reports pain at the posterior elbow
in the forearm. Physical examination typically reveals with resisted extension, and tenderness at the triceps
a positive Tinel sign at the radial tunnel. The point of insertion.27
maximal tenderness usually resides over the anterior
radial head. The presence of weakness with resisted supi- POSTERIOR IMPINGEMENT
nation of the forearm and extension of the middle finger Valgus extension overload syndrome is a condition that
(middle finger test; Figure 7) is common with posterior presents in younger athletes who are subjected to repeti-
interosseous nerve syndrome 20 (Table 2 3,7,8,11,13-17). In con- tive valgus stresses while in hyperextension (i.e., jav-
trast, radial tunnel syndrome typically presents as a pure elin throwers). This stress causes impingement of the
pain syndrome without any objective clinical muscular olecranon tip in the olecranon fossa, which may cause
weakness.15,19,23 osteophyte formation and a fixed flexion deformity over
time. A similar condition exists in older persons with
OSTEOCHONDRAL DEFECT (OSTEOCHONDRITIS osteoarthritis. On physical examination, the patient will
DISSECANS)
have posterior elbow pain when forced into full elbow
The articular surface most commonly injured within the extension.27
elbow is the radial aspect of the joint, which can pres- Table 3 summarizes key aspects of the diagnosis and
ent as lateral elbow pain. Athletes in overhead throwing treatment of selected causes of elbow pain.4,14,15,17,24-36
sports or sports that require repetitive valgus stress or
compressive forces on the elbow (e.g., gymnastics) are
prone to these types of injuries. Occasionally, separation
of the osteochondral fragment may occur, resulting in a
loose body. Symptoms may include locking, catching, or
inability to fully extend the elbow.16

Posterior Elbow Pain

OLECRANON BURSITIS
Olecranon bursitis is the most common superficial bur-
sitis and is a common cause of posterior elbow pain and
swelling.24 Olecranon bursitis can be septic or aseptic.
Patients with septic olecranon bursitis present with
pain, swelling, warmth, and erythema over the olec-
ranon; roughly one-half will have a fever. Diagnosis is Figure 7. With the middle finger test, the patient attempts
confirmed by bursal fluid analysis.25 By contrast, patients to resist a downward applied force to the fully extended
with aseptic olecranon bursitis may present with a middle finger.

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Elbow Pain

Table 3. Diagnosis and Treatment of Selected Causes of Elbow Pain

Diagnosis Clinical presentation Diagnostic approach Treatment

Anterior
Biceps Vague anterior elbow pain; Resisted supination Relative rest, ice, short course of NSAIDs,
tendinopathy 4,28 history of repeated elbow recreates pain deep in the physical therapy
flexion with forearm antecubital fossa
supination and pronation
Lateral
Lateral epicondylitis Much more common than Pain and decreased strength Relative rest and watchful waiting, ice,
(tennis elbow)14,29-32 medial epicondylitis; with resisted gripping and bracing, short course of NSAIDs
insidious onset of pain with wrist supination and Stretching and strengthening with or without
because of increase in extension; pain at the formal physical therapy
occupational or recreational lateral elbow with isolated
Bracing (consider wrist extension brace
activities; tenderness to resisted extension of the
instead of commonly used counterforce
palpation over the common middle finger
traction brace)
extensor tendon
Injections of corticosteroids, autologous
blood, or platelet-rich plasma; prolotherapy;
dry needling
Topical nitroglycerin
Surgery for recalcitrant cases
Posterior interosseous Painless loss of the ability to Positive result on the middle Cessation of inciting activity
nerve syndrome15 extend the middle finger finger test (the inability to Splinting to maintain forearm supination and
against resistance actively extend the middle wrist extension
finger against resistance)
Physical therapy focusing on ergonomics,
stretching, and then strengthening
Surgery may be considered for refractory cases
Radial tunnel Pain in the lateral aspect of Pain only, with no motor Same treatment as for posterior interosseous
syndrome15 the forearm in the absence findings nerve syndrome
of any motor symptoms
Medial
Cubital tunnel Insidious onset of pain Positive Tinel sign at the Conservative treatment: cessation of
syndrome33 and paresthesias down cubital tunnel; may feel the inciting activity, night splint to keep arm
the medial aspect of the ulnar nerve subluxate over in extension, physical therapy with nerve
forearm into the ring and the medial epicondyle with gliding exercises
little fingers flexion and extension Surgery for recalcitrant cases that fail to
respond to four to six months of treatment
Medial epicondylitis Insidious onset of pain Pain with resisted wrist Relative rest, ice, bracing, short course of
(golfer’s elbow)17,29 because of increase flexion and pronation NSAIDs (topical or oral)
in occupational or Stretching and strengthening with or without
recreational activities; formal physical therapy
tenderness to palpation of
Injections with corticosteroids (may be more
flexor-pronator mass
effective than NSAIDs in the short term),
autologous blood, or platelet-rich plasma;
dry needling
Topical nitroglycerin
Surgery for recalcitrant cases
Ulnar collateral Sensation of a pop over the Positive result on moving Rest, ice, sling, short course of NSAIDs
ligament injury17 medial elbow valgus stress test or milking Grade 1 and 2 partial tears should be treated
maneuver; lack of end with relative rest and prolonged guided
point with valgus stress rehabilitation
Surgery should be considered early on for elite
level/professional athletes

continued

654  American Family Physician www.aafp.org/afp Volume 89, Number 8 ◆ April 15, 2014
 Elbow Pain

Table 3. Diagnosis and Treatment of Selected Causes of Elbow Pain (continued)

Diagnosis Clinical presentation Diagnostic approach Treatment

Posterior
Olecranon bursitis
Aseptic24,26,34-36 History of minor trauma Bursal fluid analysis; absence Ice, compressive dressings, avoidance of
to the elbow; boggy, of redness, warmth, aggravating activity
nontender mass over the limited range of motion, or For failed conservative treatment, aspiration
olecranon other signs of infection of the bursa followed by two weeks of
compressive dressing
Surgical bursectomy may be required for
refractory cases persisting longer than three
months
Intrabursal corticosteroid injection may be
considered but can be complicated by
infection and skin atrophy
Septic25 Pain, swelling, warmth, Bursal fluid analysis Aspiration, mechanical rest, systemic oral or
and erythema over the intravenous antibiotics directed by bursal
olecranon; approximately fluid culture
50% of patients have fever
Posterior Pain at the posterior elbow, Posterior elbow pain when Avoidance of offending movements
impingement 27 especially at full extension forced into full elbow If conservative treatment fails, arthroscopic
extension; radiography to osteotomy of osteophytes on the posterior
evaluate for osteophyte elbow is effective
formation
Triceps Pain at the posterior elbow, Pain at the posterior elbow Relative rest, ice, short course of NSAIDs, refer
tendinopathy 27,28 especially with extensor use with resisted extension; for physical therapy
(pushing motions) tenderness at the triceps Surgery is rarely indicated
insertion

NSAIDs = nonsteroidal anti-inflammatory drugs.

Information from references 4, 14, 15, 17, and 24 through 36.

Imaging
Plain radiography is the initial choice for the evalu-
ation of acute injuries and is best for showing bony
injuries, soft tissue swelling, and joint effusions. Plain
radiography also has a role in the evaluation of chronic
conditions such as enthesopathy, bone spurs, and osteo-
chondral diseases.18 At a minimum, anteroposterior and
lateral plain radiography should be performed at the
initial visit.37
Most conditions that cause chronic elbow pathology
are clinical diagnoses; imaging may be used to confirm
the diagnosis before further intervention or referral.
MRI is the preferred imaging modality for chronic elbow
pain.37,38 MRI can identify pathologic conditions such as
bone marrow edema, tendinopathy, nerve entrapments, Figure 8. T1-weighted image of the lateral epicondyle
demonstrating a partial tear/tendinopathy (arrowhead)
and joint effusions. Magnetic resonance arthrography of the common extensor tendon (arrow).
may be performed in patients without an effusion to
Reprinted with permission from Stadnick ME. Lateral epicondylitis. MRI web
identify ligament tears, osteochondral defects, or loose clinic–November 2003. http://www.radsource.us/clinic/0311. Accessed
bodies18,37 (Figure 839). March 12, 2014.

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Elbow Pain

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

If an ulnar collateral ligament injury is suspected, the medial joint space of the symptomatic elbow C 7, 8, 12
should be compared with the asymptomatic side for the amount of opening, the subjective
quality of the end point while a valgus force is applied across the joint, and pain.
In patients with signs of compressive ulnar neuropathy at the cubital tunnel, a physical examination C 14, 20, 21
of the upper extremities and cervical spine is essential to rule out other compressive neuropathies.
To avoid introducing infection, aspiration of olecranon bursitis should be performed only when the C 24
diagnosis is uncertain or to relieve symptoms in refractory cases.
Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. C 37, 38

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Compared with MRI, computed tomography has a JAMES H. LYNCH, MD, MS, is a staff family physician/primary care sports
medicine physician at Womack Army Medical Center.
limited role in the evaluation of chronic elbow pain. It
may be superior to MRI in detecting soft tissue calcifica- JONATHAN C. TAYLOR, MD, is a staff family physician at Womack Army
tion, such as myositis ossificans or intra-articular bodies. Medical Center.
Musculoskeletal ultrasonography is more operator- Address correspondence to Shawn F. Kane, MD, USASOC(A), Attn:
dependent than MRI but allows for an inexpensive AOMD, 2929 Desert Storm Dr. (Stop A), Fort Bragg, NC 28310 (e-mail:
shawn.f.kane.mil@mail.mil). Reprints are not available from the
dynamic evaluation of commonly injured structures. authors.
Ultrasonography is less expensive than MRI and, in
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