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Patient education: Anterior cruciate ligament injury (Beyond the Basics)

Patient education: Anterior cruciate ligament injury (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Oct 04, 2022.

ANTERIOR CRUCIATE LIGAMENT INJURY OVERVIEW — The anterior cruciate ligament (ACL) is an important stabilizing ligament in the knee. It is frequently injured by athletes and trauma victims; in the United States alone, there are between 100,000 and 200,000 ACL tears per year.

This topic review will discuss the causes, signs and symptoms, diagnostic tests, and treatment options (including surgery) for ACL injuries.

WHAT IS THE ANTERIOR CRUCIATE LIGAMENT? — The knee joint is held tightly together by four ligaments: the inner and outer fan-shaped hinge ligaments (medial and lateral collateral ligaments) and the crossing (cruciate) ligaments, which sit in the middle of the joint (the anterior and posterior cruciate ligaments) (figure 1).

The collateral ligaments are firmly attached to the far end of the femur (thigh bone) and the near end of the tibia and fibula (lower leg bones). The ligaments hold the two bones together and prevent side to side motion. The anterior cruciate ligament (ACL) prevents forward and backward motion. You can partially or completely tear the ligament(s).

Other structures can be damaged during an acute ACL injury, including:

The meniscus

The joint capsule (the tissue that surrounds the joint)

Articular cartilage (cartilage that covers the ends of bones where they meet in a joint)

The ends of the femur or tibia

Other ligaments (medial collateral ligament [MCL], lateral collateral ligament [LCL], posterior cruciate ligament [PCL]) (figure 2)

One common injury is called the "athlete's triad," in which the ACL, MCL, and medial meniscus are all torn.

CAUSES OF ANTERIOR CRUCIATE LIGAMENT INJURY — Non-contact anterior cruciate ligament (ACL) injuries typically occur when a person is running or jumping and then suddenly slows and changes direction (eg, cutting) or pivots in a way that involves rotating or bending the knee sideways. Women appear to be at a higher risk of non-contact ACL injuries than men, although the exact reason for this is not clear.

Contact-related ACL injuries usually occur from a direct blow causing hyperextension or when the knee is forced inwards towards the other leg. This is often seen in American football when a player's foot is planted and an opponent strikes him on the outside or front of that thigh.

ACL injuries most commonly occur during the following activities:

Noncontact sports, such as downhill skiing, gymnastics, and tennis

Certain contact sports, including rugby, American football, soccer, and basketball

Motor vehicle collisions

ANTERIOR CRUCIATE LIGAMENT INJURY SYMPTOMS — People who have an anterior cruciate ligament (ACL) injury often complain of feeling a "pop" in their knee at the time of injury and have a feeling the knee is unstable or "giving out." Within a few hours of the ACL injury, nearly everyone develops swelling in the knee, caused by bleeding from injured blood vessels; this is called an effusion.

After the initial swelling has improved, most people are able to bear weight but feel unsteady on the affected knee. Movements such as squatting, pivoting, and stepping sideways, and activities such as walking down stairs, in which the entire body weight is placed on the affected leg, can cause the feeling of unsteadiness.

ANTERIOR CRUCIATE LIGAMENT INJURY TESTS — If you have a knee injury followed by pain, swelling, and/or an unsteady feeling while standing, see a healthcare provider for evaluation. He or she will do a physical examination and may recommend imaging tests to look at your bones and ligaments.

ANTERIOR CRUCIATE LIGAMENT INJURY TREATMENT — Anterior cruciate ligament (ACL) injuries are treated with surgery and post-surgical rehabilitation or a non-surgical rehabilitation program. The decision to have surgery is based upon several factors, including your age, how active you are, and whether you have other knee injuries. When deciding whether to have surgery, it's also important to think about how the recovery process will impact your life. (See 'What to expect after surgery' below.)

You may choose to have surgery if you:

Participate in high-level sports or have a job that requires a strong and stable knee (eg, requires twisting and pivoting)

Are unsteady when standing on the injured knee

Have multiple injuries (eg, meniscal tear and ACL tear)

Have completed rehabilitation and still have instability in the knee

Are willing to complete the rigorous post-surgical rehabilitation program. Most programs require daily strengthening and stretching exercises and one or more weekly visits with a physical therapist for the first three to six months after surgery (see 'Post-surgical rehabilitation' below). Failure to follow this program could increase the risk of re-injury, allow scar tissue to develop, and lead to limited movement of the knee.

You may decide not to have surgery if you:

Have a small partial tear in the ACL that may heal with rest and rehabilitation

Do not participate in sports that require pivoting or stopping quickly, especially if you are older than 55 years

Are willing to complete a non-surgical rehabilitation program to strengthen and stabilize the knee (see 'Non-surgical rehabilitation' below)

If you do not have surgery to reconstruct your ACL, you may be at an increased risk of future knee problems, including chronic pain, a decreased level of activity, and injury to other parts of the knee (the meniscus). However, surgery is also not a "quick fix," as it involves a challenging recovery period and requires committing to a rigorous rehabilitation program.

Presurgical rehabilitation — Surgery is not usually performed immediately after an ACL injury because this could cause excessive scar tissue (arthrofibrosis) to develop, which would limit knee motion. In most cases, surgery is delayed until the swelling has resolved and the person is able to bend and straighten the knee without difficulty. Using ice packs and elevating the knee above the chest can help to reduce swelling.

The time between an ACL injury and surgical reconstruction depends upon how quickly the person recovers, but it is often at least two to four weeks from the date of injury. In some cases, patients are uncertain about surgery or do not want surgical repair initially but subsequently change their mind, causing the procedure to be delayed for weeks or months. Provided no further injury occurs, such delays do not appear to alter the effectiveness of surgical repair.

During the time between the injury and the surgery, many surgeons recommend a "pre-habilitation" exercise program to help reduce pain and swelling, improve range of motion (the ability to flex and extend the knee), and increase strength in the muscles of the thigh, knee, and hip. Walking, bike riding, and swimming (with light kicks and no breast stroke) can be continued, although other sports should be avoided.

An example of a presurgical rehabilitation exercise program is detailed below. (See 'Non-surgical rehabilitation' below.)

Surgery — After the ACL is torn, it is not possible to repair the ligament. This is due to several factors, including a damaged blood supply to the ligament (blood vessels damaged during injury) and cells inside the synovial fluid (normal fluid in the knee), that prevent healing. Research is underway to determine how to repair the native tendon, but the only way to repair the ACL currently is to reconstruct it.

Surgical reconstruction of the ACL is usually done in a hospital or surgical center. Most people are given general anesthesia to induce sleep and prevent pain. The surgery itself usually takes less than two hours.

To reconstruct the torn ligament, a piece of healthy tendon, called an autograft, is removed or "harvested" from another area in the leg. There are several common autograft sites, including the patellar tendon, hamstring tendon, or rarely the quadriceps tendon (figure 3). Another option is to use a tendon from a deceased donor, called an allograft. No one type of graft has been proven to be better than another. Thus, the type of graft that is used depends upon the surgeon's preference and experience.

Patellar autograft – When harvesting a patellar autograft, an extra incision is made in the skin to remove a strip of tendon with a piece of bone at each end. The graft site usually heals quickly and regains normal strength. Some people have soreness in this area for several months after surgery, especially if pressure is applied to the area (eg, while kneeling).

Hamstring autograft – If using a hamstring autograft, there are no extra incisions needed and the pain at the harvest site is usually less than that seen with a patellar autograft. Hamstring strength usually returns to normal within three to six months.

Allograft – Allografts do not require any extra incisions, and there is no risk of pain or weakness at the site of graft harvest.

The torn ACL is removed and replaced with the graft using a narrow telescope-like device, called an arthroscope. The scope contains a camera and light source, and can be inserted into the knee joint through a small skin incision. Instruments are inserted into other small incisions, allowing the physician to place the graft with precision. After the graft is secured, the knee is wrapped with sterile dressings and an immobilizer is placed around the knee to allow the person to walk more easily with crutches.

Most people are able to go home after spending several hours in the recovery room; it is not usually necessary to spend the night in the hospital. Many surgeons recommend using a machine that moves the knee through a range of motion, called a continuous passive motion (CPM) machine. CPM can help prevent the formation of scar tissue. If your surgeon recommends this machine, you will get specific instructions about how often to use it at home. You will also get a prescription for pain medications and a cooling device to help decrease inflammation and pain after surgery. The device is a wrap that goes around your knee and connects to a cooler filled with ice water. Another option that may be available is a machine that compresses the knee in addition to cooling (see 'What to expect after surgery' below). Most people visit their surgeon for follow-up one to two weeks after surgery.

The recovery period can be difficult, but it can help to know what to expect. There may be things you can do ahead of time to help make things a bit easier for yourself. (See 'What to expect after surgery' below.)

Potential complications — Most people do well after ACL reconstruction and have no major complications. However, complications occasionally occur during surgery or during the rehabilitation period. The most common complications include:

Bleeding into the joint (effusion)

Joint infection

Blood clot in the deep veins of the leg (deep vein thrombosis)

Arthrofibrosis (scar tissue)

Loosening of the graft

What to expect after surgery — ACL reconstruction is major surgery and recovery can be very challenging, both physically and emotionally. Having realistic expectations can be helpful in both making the decision to have surgery and preparing for the recovery period.

During the first few days, the goal is to control swelling and pain. Elevating your knee above your chest and applying ice are the best ways to do this (see 'First phase' below). Most people use crutches to assist with walking for the first week or so after surgery, although you will likely be encouraged to begin bearing weight on the affected leg as soon as possible. (If your surgery was more extensive, your surgeon may recommend delaying weight bearing for a longer period.)

You will probably need to wear a brace that keeps your leg straight for at least two weeks after surgery. This brace protects your knee, but many surgeons recommend removing it to do gentle range-of-motion exercises (with a CPM machine) beginning about three to five days after surgery. Stretching and strengthening exercises can usually begin within the first few days after surgery. (See 'Post-surgical rehabilitation' below.)

Some other issues to think about and plan for include:

Getting around your house – It might help to practice using crutches before your surgery. Ask your surgeon how long you will need to use them. You may also need to rearrange your living space; for example, if your bedroom is on the second floor, you may have to set up a sleeping area on the main level. Take note of where your home has steps, which will be challenging especially while you are in the brace, or other obstacles that may make it more difficult to get around.

Sleeping – It can be hard to find a comfortable position for sleeping, especially during the first phase of recovery when you can't bend your leg. It might help to get extra pillows for support and comfort.

Entertainment – Since you will have to spend a lot of time resting during the first few weeks, it might help to have something relaxing you enjoy doing.

Driving - While you are in the knee brace, you will not be able to drive; it may be even longer if the surgery was on your right knee. It's a good idea to plan ahead for help getting to your doctor's appointments as well as for other transportation help (eg, driving your children to school or activities).

Showering – Showering is also difficult while you are wearing the brace and unable to bend your leg. A shower chair can be helpful; you may also need someone to help you get into and out of the shower. Some doctors recommend buying a shower chair prior to your surgery.

Cold compression machine – Your doctor might recommend a cold compression device to help with pain relief. This is a machine that you plug in and connect to a plastic sleeve that goes on your knee; the machine inflates the sleeve to provide compression and circulates cold water to the area. The combination of cold and compression can help to reduce swelling and pain, often more than ice alone. In the United States, the cost of these machines may not be covered by insurance, so it is helpful to talk with your surgeon ahead of time about whether this is an option for you. If your surgeon recommends it, his or her office may be able to coordinate getting the machine to you before your surgery, so you can start using it right away when you get home. Some doctors feel that cold compression devices are helpful for relieving pain and decreasing the need for strong pain medication. However, they are cumbersome to move around and can also be cost prohibitive. If you do not have one of these machines, it can still help to use the cooling wrap given to you after surgery.

Support at home – Particularly during the first several weeks after surgery, regular daily activities (such as cooking, cleaning, and caring for children and pets) can be difficult. It can be very helpful to organize assistance in these areas ahead of time.

Work – Discuss with your surgeon how much time off from work you will need for recovery. The time will vary depending on the physical demands of your job. If your job allows for any flexibility or the ability to work from home, you may want to discuss this ahead of time so you have options for when you are ready to return to work.

Post-operative depression – In addition to the physical challenges around recovery, it can be very hard to feel immobile and dependent on other people, especially if you are a very independent and active person. In some cases, this can lead to post-operative depression. This usually gets better within a few weeks as you become more active, start physical therapy, and have fewer restrictions. However, if you are feeling sad or down, talk to your doctor about it. It may be helpful to talk to a counselor or other mental health professional.

It's important to keep in mind that everyone heals differently. While your surgeon can give you a general idea of how long your recovery will take and how you will feel at each stage, this can vary. It can be frustrating to have to rebuild your strength and range of motion. It may help to keep in mind that even though the recovery can be very challenging, especially in the early weeks, you will likely be back to most of your normal activities after about six months. Depending on your sport(s), it may take a bit longer to return to full participation. (See 'Return to sports' below.)

ANTERIOR CRUCIATE LIGAMENT INJURY REHABILITATION — Rehabilitation is a several month long program that is designed to stretch and strengthen the knee after anterior cruciate ligament (ACL) injury or reconstruction. No one program is best for everyone, although the following exercises are one example of a program that may be recommended.

Non-surgical rehabilitation — If you do not plan to have surgery, rehabilitation can help to reduce your risk of further injury. Rehabilitation should begin as soon as swelling and pain begin to improve. Use the stretching and strengthening exercises listed below at least once per day for four to six weeks. These exercises are also recommended as a pre-surgical rehabilitation program. (See 'Presurgical rehabilitation' above.)

These exercises may cause some discomfort but should not cause significant pain, especially after the exercise session is over. If your pain is severe or continues after resting and icing the knee, talk to your health care provider.

Assisted knee flexion – Sit on the floor with your legs extended in front of your body. Place your hands behind the thigh of your injured leg, bend your knee and pull it towards your chest, keeping your back straight (picture 1). Hold for five seconds then straighten leg. Repeat 10 to 15 times (one set). Perform a total of three sets.

Quad sets – Sit on the floor with your legs extended in front of your body. Place the hands behind your injured knee. Keep your leg straight and contract your quadriceps muscle (just above the knee), which should cause your knee cap to move towards the body (picture 2). Hold for a count of 10 seconds. Release and rest as needed. Repeat 10 to 15 times (one set). Perform a total of three sets.

Straight leg raises – Lie on a bed or the floor. Bend your non-injured knee and keep your foot on the floor. Keep your injured leg straight. On the injured side, tighten your quadriceps (as above), keep the leg straight, and lift your leg about 18 inches off the floor (picture 3). Slowly lower the leg back to the bed or floor. Rest as needed. Repeat 10 to 15 times (one set). Perform a total of three sets.

Calf raises – Stand behind a chair, holding onto the chair. Slowly rise up and stand on the balls of your feet and toes (picture 4). Hold for five seconds then slowly roll down onto your entire foot. Rest as needed. Repeat 10 to 15 times (one set). Increase the difficulty of this exercise by rising higher, holding longer, or moving up and down more quickly. Perform a total of three sets.

Hip extension – You will need 18 to 24 inches of rubber tubing or an elastic band (eg, Theraband) for these exercises. Secure the tubing around the leg of a heavy piece of furniture or close it in a door. Stand facing the furniture/door and place your injured leg in the loop of the tubing. You should not have any slack in the tubing. Hold the door/furniture and extend your injured leg backwards, stretching the tubing as far as possible (picture 5). Hold for five seconds. Slowly return your leg to the floor. Rest as needed. Repeat 10 to 15 times (one set). Perform a total of three sets.

Hip abduction – As above, you will need a piece of rubber tubing or elastic band. Stand with the legs shoulder width apart, with your non-injured leg closest to the furniture or door. The tubing should loop around the outside of your injured leg. Lift the injured leg to the side, 18 to 24 inches away from your body, stretching the tubing (picture 6). Hold for five seconds, then slowly release. Rest as needed. Repeat 10 to 15 times (one set). Perform a total of three sets.

Stretching and strengthening should then continue as discussed below. (See 'Second phase' below.)

Post-surgical rehabilitation — Most people who have ACL reconstruction will be under the care of a surgeon and physical therapist who will work together to design a rehabilitation program. The rehabilitation process is difficult, and it can be frustrating to have to rebuild your muscles and learn to walk again after your injury. Your knee will likely feel stiff for some time as you work to regain normal range of motion.

The following rehabilitation schedule is an example of one that your team may recommend:

First phase — During the first two weeks after surgery, the goal is to increase your range of motion (flexing and extending the knee), maintain strength, minimize the development of scar tissue, and eliminate swelling. Most people begin to walk without crutches by the end of the first week. You should apply ice and elevate your knee daily to minimize swelling.

Exercises during this phase should include those discussed above. Surgeons differ in their approach to rehabilitation during the first several weeks after surgery (when the graft is at greatest risk of damage). It is important to listen carefully to instructions about which exercises to do and which to avoid. Especially early in the rehabilitation process, more exercise is not always better.

Second phase — Between the third and twelfth weeks after surgery, the goal is to improve range of motion, strength, walking, and balance. Most people are allowed to walk or use an exercise bike for 15 to 20 minutes per day. When possible, walking or running in a pool with a floating belt can be helpful.

You will likely do many of the exercises discussed above (see 'Non-surgical rehabilitation' above) The following exercises may also be recommended.

Quarter squats – Stand 18 to 24 inches from a wall. Lean back against the wall. Bend both knees slightly (the buttocks should not be lower than the knees), keeping your back straight (picture 7). Hold for five seconds then slowly stand up straight. Rest as needed. Repeat 10 to 15 times (one set). Perform a total of three sets. To increase the difficulty, bend your knees more deeply, hold for a longer time, and increase the speed.

Alternately, use an exercise ball to perform squats. Stand up straight, holding the ball between your back and the wall. Slowly bend the knees and lower your back (roll the ball down the wall). Hold for a count of five. Stand up. Repeat 10 to 15 times.

Bridges – Lie on your back on the floor. Keep the feet on the floor and bend both knees. Place the hands about 12 inches to the side of the body (on the floor). Lift the buttocks six to eight inches off the floor (picture 8). Hold for five seconds, then slowly release. Rest as needed. Repeat 10 to 15 times (one set). Perform a total of three sets.

To increase the difficulty, keep your right foot on the floor and lift your left foot off the floor, keeping the left leg straight. Raise the buttocks using the right foot to support your lower body. Switch sides. Repeat 10 to 15 times (one set). Perform a total of three sets.

Single-leg calf raises – Stand behind a chair, holding onto the chair. Lift the foot on your non-injured side off the floor so that you are standing on your injured leg. Slowly rise up and stand on the ball of your foot and toes (picture 9). Hold for five seconds then slowly roll down onto your entire foot. Rest as needed. Repeat 10 to 15 times (one set). Increase the difficulty of this exercise by rising higher, holding longer, or moving up and down more quickly. Perform a total of three sets.

Step ups – Use a stair climber or steps, step up first with your injured leg. Continue for 10 to 15 minutes per day.

Balance – Use a wobble board or balance disk to improve your knee strength and balance ability.

If a wobble board or balance disk is not available, try balancing on your affected leg while lifting the unaffected leg off the ground; do not hold onto any support (picture 10). Hold this position for a count of five to 10. Rest and repeat 10 to 15 times. To increase the difficulty, raise your unaffected leg into the air.

Third phase — Four or more months after surgery, the difficulty and intensity of the exercises described above should be continued. In addition, you will likely be able to resume exercises that include jumping and landing.

Lunge – Stand with your feet together. Step the right foot approximately 36 inches in front of the body. The right knee should be over the right ankle and the left calf should be parallel to the floor (picture 11). Hold for five seconds. Step the right foot back so that the feet are together. Rest as needed. Repeat with the left leg. Repeat 10 to 15 times (one set). Perform a total of three sets.

You will likely be able to resume some low-risk activities at this point, including jogging in a straight line, swimming (kick lightly), and biking on the road. As your strength and ability improve, running and other activities can be restarted as well.

Return to sports — Most people who have surgical reconstruction of the ACL have a good outcome.

In general, athletes can return to sports once the reconstructed knee has had sufficient time to heal and demonstrates strength, balance, and function roughly equal to the uninjured knee (assuming the uninjured knee is healthy). This generally occurs by about 8 to 12 months after surgery but can vary depending upon the sport and the person's compliance with the rehabilitation program. Waiting at least 10 months before returning to sports may reduce the risk of re-injuring the knee; in some cases, it is necessary to wait even longer to allow for full healing.

There is no specific set of criteria that guarantees that a person is completely ready to return to sports after an ACL repair. Effective criteria should include some functional assessment that reflects the demands of the sport to which you are returning. It's essential to follow all of your doctor's and physical therapist's instructions and not try to do too much too soon. Even if you feel like you are ready to return to sports, your body might not be. Sticking with your rehabilitation program will maximize your chances of a complete recovery and reduce your risk of reinjury.

ANTERIOR CRUCIATE LIGAMENT INJURY PREVENTION — Several expert organizations, including the American Academy of Orthopaedic Surgeons and the American College of Sports Medicine, agree that programs to prevent anterior cruciate ligament (ACL) injury are beneficial, particularly for female athletes. Many experts also believe that any athlete who is at high-risk for an ACL injury (eg, American football players, skiers) should participate in a prevention program.

An analysis of ACL injury prevention programs noted the following:

Programs that incorporated high-intensity jumping exercises reduced injury rates.

Programs that analyzed athletes’ movements and provided direct feedback about proper positioning and movement reduced injury rates.

Programs that incorporated strength training reduced injury rates, although strength training alone did not.

Balance training alone is unlikely to reduce injury rates, although it may enhance other prevention techniques.

Athletes must participate in prevention training at least two times per week for a minimum of six consecutive weeks to accrue benefit.

Prevention programs are usually tailored to a particular sport and should initially be taught and supervised by a knowledgeable athletic trainer, physical therapist, or comparable professional (ACL injury prevention sports tips). Use of external braces or other devices has not been shown to reduce the risk of ACL tears and is not recommended for prevention.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Anterior cruciate ligament tear (The Basics)
Patient education: Knee pain (The Basics)
Patient education: How to use crutches (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Knee pain (Beyond the Basics)
Patient education: Total knee replacement (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Anterior cruciate ligament injury
Approach to the adult with unspecified knee pain
Knee bursitis
Medial (tibial) collateral ligament injury of the knee
Meniscal injury of the knee
Running injuries of the lower extremities: Risk factors and prevention
Patella fractures
Patellofemoral pain
Proximal tibial fractures in adults
Proximal tibial fractures in children

The following organizations also provide reliable health information.

National Library of Medicine

(https://medlineplus.gov/ency/article/007208.htm, available in Spanish)

American Academy of Orthopaedic Surgeons

(orthoinfo.aaos.org/topic.cfm?topic=A00549)

American Physical Therapy Association

(http://www.apta.org/)

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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