title: Rotator cuff tear

text: Intrinsic factors refer to injury mechanisms that occur within the rotator cuff itself. The principal is a degenerative-microtrauma model, which supposes that age-related tendon damage compounded by chronic microtrauma results in partial tendon tears that then develop into full rotator cuff tears. As a result of repetitive microtrauma in the setting of a degenerative rotator cuff tendon, inflammatory mediators alter the local environment, and oxidative stress induces tenocyte apoptosis causing further rotator cuff tendon degeneration. A neural theory also exists that suggests neural overstimulation leads to the recruitment of inflammatory cells and may also contribute to tendon degeneration.


title: Rotator cuff tear

text: Depending upon the diagnosis, several treatment alternatives are available. They include revision repair, non-anatomic repair, tendon transfer and arthroplasty. When possible, surgeons make tension-free repairs in which they use grafted tissues rather than stitching to reconnect tendon segments. This can result in a complete repair. Other options are a partial repair, and reconstruction involving a bridge of biologic or synthetic substances. Partial repairs typically are performed on retracted cuff tears.


title: Rotator cuff tear

text: Tendon transfers are prescribed for young, active cuff-tear individual who experience weakness and decreased range of motion, but little pain. The technique is not considered appropriate for older people, or those with pre-operative stiffness or nerve injuries. People diagnosed with glenohumeral arthritis and rotator cuff anthropathy have the alternative of total shoulder arthroplasty, if the cuff is largely intact or repairable. If the cuff is incompetent then a reverse shoulder arthroplasty is available and, although not as robust a prosthesis, does not require an intact cuff to maintain a stable joint.


title: Rotator cuff tear

text: Diagnosis is based upon physical assessment and history, including description of previous activities and acute or chronic symptoms. A systematic, physical examination of the shoulder comprises inspection, palpation, range of motion, provocative tests to reproduce the symptoms, neurological examination, and strength testing. The shoulder should also be examined for tenderness and deformity. Since pain arising from the neck is frequently 'referred' to the shoulder, the examination should include an assessment of the cervical spine looking for evidence suggestive of a pinched nerve, osteoarthritis, or rheumatoid arthritis.


title: Rotator cuff tear

text: Neer promoted the concept of three stages of rotator cuff disease. Stage I, according to Neer, occurred in those younger than 25 years and involved edema and hemorrhage of the tendon and bursa. Stage II involved tendinitis and fibrosis of the rotator cuff in 25- to 40-year-olds. Stage III involved tearing of the rotator cuff (partial or full thickness) and occurred in those older than 40 years. For surgical purposes, tears are also described by location, size or area, and depth. Further subclasses include the acromiohumeral distance, acromial shape, fatty infiltration or degeneration of muscles, muscle atrophy, tendon retraction, vascular proliferation, chondroid metaplasia, and calcification. Again, in surgical planning, age-related degeneration of thinning and disorientation of the collagen fibers, myxoid degeneration, and hyaline degeneration are considered.


title: Rotator cuff tear

text: Diagnostic modalities, dependent on circumstances, include X-ray, MRI, MR arthrography, double-contrast arthrography, and ultrasound. Although MR arthrography is currently considered the gold standard, ultrasound may be most cost-effective. Usually, a tear will be undetected by X-ray, although bone spurs, which can impinge upon the rotator cuff tendons, may be visible. Such spurs suggest chronic severe rotator cuff disease. Double-contrast arthrography involves injecting contrast dye into the shoulder joint to detect leakage out of the injured rotator cuff and its value is influenced by the experience of the operator. The most common diagnostic tool is magnetic resonance imaging (MRI), which can sometimes indicate the size of the tear, as well as its location within the tendon. Furthermore, MRI enables the detection or exclusion of complete rotator cuff tears with reasonable accuracy and is also suitable to diagnose other pathologies of the shoulder joint.


title: Rotator cuff tear

text: Clinical judgement, rather than over reliance on MRI or any other modality, is strongly advised in determining the cause of shoulder pain, or planning its treatment, since rotator cuff tears are also found in some without pain or symptoms. The role of X-ray, MRI, and ultrasound, is adjunctive to clinical assessment and serves to confirm a diagnosis provisionally made by a thorough history and physical examination. Over-reliance on imaging may lead to overtreatment or distract from the true dysfunction causing symptoms.


title: Rotator cuff tear

text: Acute injury is less frequent than chronic disease, but may follow bouts of forcefully raising the arm against resistance, as occurs in weightlifting, for example. In addition, falling forcefully on the shoulder can cause acute symptoms. These traumatic tears predominantly affect the supraspinatus tendon or the rotator interval and symptoms include severe pain that radiates through the arm, and limited range of motion, specifically during abduction of the shoulder.


title: Rotator cuff tear

text: Chronic tears occur among individuals who constantly participate in overhead activities, such as pitching or swimming, but can also develop from shoulder tendinitis or rotator cuff disease. Symptoms arising from chronic tears include sporadic worsening of pain, debilitation, and atrophy of the muscles, noticeable pain during rest, crackling sensations (crepitus) when moving the shoulder, and inability to move or lift the arm sufficiently, especially during abduction and flexion motions.


title: Rotator cuff tear

text: Pain in the anterolateral aspect of the shoulder is not specific to the shoulder, and may arise from, and be referred from, the neck, heart or gut.


title: Rotator cuff tear

text: Symptoms will often include pain or ache over the front and outer aspect of the shoulder, pain aggravated by leaning on the elbow and pushing upwards on the shoulder (such as leaning on the armrest of a reclining chair), intolerance of overhead activity, pain at night when lying directly on the affected shoulder, pain when reaching forward (e.g. unable to lift a gallon of milk from the refrigerator). Weakness may be reported, but is often masked by pain and is usually found only through examination. With longer-standing pain, the shoulder is favored and gradually loss of motion and weakness may develop, which, due to pain and guarding, are often unrecognized and only brought to attention during the physical exam.


title: Rotator cuff tear

text: Primary shoulder problems may cause pain over the deltoid muscle intensified by abduction against resistance – the impingement sign. This signifies pain arising from the rotator cuff, but cannot distinguish between inflammation, strain, or tear. Individuals may report that they are unable to reach upwards to brush their hair or to lift a food can from an overhead shelf.


title: Rotator cuff tear

text: No single physical examination test distinguishes reliably between bursitis, partial-thickness, and full-thickness tears. The most useful single test for infraspinatous tendon tears is the drop sign (the examiner lifts the arm straight out from the body with the palm up, the person then needs to hold it there for 10 seconds) and the external rotation lag sign (with the arm by the side and the elbow bent to 90 degrees the person tries to rotate outwards against resistance).


title: Rotator cuff tear

text: A combination of tests seems to provide the most accurate diagnosis. For impingement, these tests include the Hawkins-Kennedy impingement sign in which an examiner medially rotates the injured individual's flexed arm, forcing the supraspinatus tendon against the coracoacromial ligament and so producing pain if the test is positive a positive painful arc sign, and weakness in external rotation with the arm at the side.


title: Rotator cuff tear

text: For the diagnosis of full-thickness rotator cuff tear, the best combination appears to include once more the painful arc and weakness in external rotation, and in addition, the drop arm sign. This test is also known as Codman's test. The arm is raised to the side to 90° by the examiner. The injured individual then attempts to look to lower the arm back to neutral, palm down. If the arm drops suddenly or pain is experienced, the test is considered positive.


title: Rotator cuff tear

text: Magnetic resonance imaging (MRI) and ultrasound are comparable in efficacy and helpful in diagnosis although both have a false positive rate of 15–20%. MRI can reliably detect most full-thickness tears although very small pinpoint tears may be missed. In such situations, an MRI combined with an injection of contrast material, an MR-arthrogram, may help to confirm the diagnosis. It should be realized that a normal MRI cannot fully rule out a small tear (a false negative) while partial-thickness tears are not as reliably detected. While MRI is sensitive in identifying tendon degeneration (tendinopathy), it may not reliably distinguish between a degenerative tendon and a partially torn tendon. Again, magnetic resonance arthrography can improve the differentiation. An overall sensitivity of 91% (9% false negative rate) has been reported indicating that magnetic resonance arthrography is reliable in the detection of partial-thickness rotator cuff tears. However, its routine use is not advised, since it involves entering the joint with a needle with potential risk of infection. Consequently, the test is reserved for cases in which the diagnosis remains unclear.


title: Rotator cuff tear

text: Musculoskeletal ultrasound has been advocated by experienced practitioners, avoiding the radiation of X-ray and the expense of MRI while demonstrating comparable accuracy to MRI for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears. This modality can also reveal the presence of other conditions that may mimic rotator cuff tear at clinical examination, including tendinosis, calcific tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture, and adhesive capsulitis. However, MRI provides more information about adjacent structures in the shoulder such as the capsule, glenoid labrum muscles and bone and these factors should be considered in each case when selecting the appropriate study.


title: Rotator cuff tear

text: X-ray projectional radiography cannot directly reveal tears of the rotator cuff, a 'soft tissue', and consequently, normal X-rays cannot exclude a damaged cuff. However, indirect evidence of pathology may be seen in instances where one or more of the tendons have undergone degenerative calcification (calcific tendinitis). The humeral head may migrate upwards (high-riding humeral head) secondary to tears of the infraspinatus, or combined tears of the supraspinatus and infraspinatus. The migration can be measured by the distance between:


title: Rotator cuff tear

text: Normally, the former is positioned inferiorly to the latter, and a reversal is therefore indicating a rotator cuff tear. Prolonged contact between a high-riding humeral head and the acromion above it, may lead to X-rays findings of wear on the humeral head and acromion and secondary degenerative arthritis of the glenohumeral joint (the ball and socket joint of the shoulder), called cuff arthropathy, may follow. Incidental X-ray findings of bone spurs at the adjacent acromioclavicular joint may show a bone spur growing from the outer edge of the clavicle downwards towards the rotator cuff. Spurs may also be seen on the underside of the acromion, once thought to cause direct fraying of the rotator cuff from contact friction, a concept currently regarded as controversial.


title: Rotator cuff tear

text: As part of clinical decision-making, a simple, minimally invasive, in-office procedure may be performed, the rotator cuff impingement test. A small amount of a local anesthetic and an injectable corticosteroid are injected into the subacromial space to block pain and to provide anti-inflammatory relief. If pain disappears and shoulder function remains good, no further testing is pursued. The test helps to confirm that the pain arises from the shoulder primarily rather than referred from the neck, heart, or gut.


title: Rotator cuff tear

text: If pain is relieved, the test is considered positive for rotator-cuff impingement, of which tendinitis and bursitis are major causes. However, partial rotator-cuff tears may also demonstrate good pain relief, so a positive response cannot rule out a partial rotator-cuff tear. However, with demonstration of good, pain-free function, treatment will not change, so the test is useful in helping to avoid overtesting or unnecessary surgery.


title: Rotator cuff tear

text: Tears of the rotator cuff tendon are described as partial or full thickness, and full thickness with complete detachment of the tendons from bone.


title: Rotator cuff tear

text: Long-term overuse/abuse of the shoulder joint is generally thought to limit range of motion and productivity due to daily wear and tear of the muscles, and many public web sites offer preventive advice. (See external links)


title: Rotator cuff tear

text: According to a study which measured tendon length against the size of the injured rotator cuff, researchers learned that as rotator cuff tendons decrease in length, the average rotator cuff tear severity is proportionally decreased, as well. This shows that larger individuals are more likely to develop a severe rotator cuff tear if they do not "tighten the shoulder muscles around the joint".


title: Rotator cuff tear

text: Another study observed 12 different positions of movements and their relative correlation with injuries occurred during those movements. The evidence shows that putting the arm in a neutral position relieves tension on all ligaments and tendons.


title: Rotator cuff tear

text: One article observed the influence of stretching techniques on preventive methods of shoulder injuries. Increased velocity of exercise increases injury, but beginning a fast-movement exercise with a slow stretch may cause muscle/tendon attachment to become more resistant to tearing.


title: Rotator cuff tear

text: When exercising, exercising the shoulder as a whole and not one or two muscle groups is also found to be imperative. When the shoulder muscle is exercised in all directions, such as external rotation, flexion, and extension, or vertical abduction, it is less likely to develop a tear of the tendon.


title: Rotator cuff tear

text: A rotator cuff tear can be treated operatively or non-operatively. No benefit is seen from early rather than delayed surgery, and many with partial tears and some with complete tears will respond to nonoperative management. Consequently, an individual may begin with nonsurgical management. However, early surgical treatment may be considered in significant (>1 cm – 1.5 cm) acute tears, or in young individuals with full-thickness tears who have a significant risk for the development of irreparable rotator cuff damage.


title: Rotator cuff tear

text: Rotator-cuff surgery appears to result in similar benefits as nonoperative management. As a conservative approach has less complications and is less expensive it is recommended as initial treatment.


title: Rotator cuff tear

text: Those with pain but reasonably maintained function are suitable for nonoperative management. This includes medications that provide pain relief such as anti-inflammatory agents, topical pain relievers such as cold packs, and if warranted, subacromial corticosteroid or local anesthetic injection. Topical glyceryl trinitrate appears effective at relieving acute symptoms however, headaches were reported as a side effect. A sling may be offered for short-term comfort, with the understanding that undesirable shoulder stiffness can develop with prolonged immobilization. Early physical therapy may afford pain relief with modalities (e.g. iontophoresis) and help to maintain motion. Ultrasound treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected.


title: Rotator cuff tear

text: Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including rotator cuff disease, but evidence of its efficacy remains dubious. In a review of 2020, the benefits and harms of shock wave therapy for rotator cuff disease, with or without calcificationcurrently, were investigated. They found low to moderate certainty evidence, that there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety.


title: Rotator cuff tear

text: A conservative physical therapy program begins with preliminary rest and restriction from engaging in activities which gave rise to symptoms. Normally, inflammation can usually be controlled within one to two weeks, using a nonsteroidal anti-inflammatory drug and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period, rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented.


title: Rotator cuff tear

text: A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period. Stiffness negatively affects the tendon-bone healing process, a critical part of recovery. Stiffness during rehabilitation is related to worse clinical outcomes, so it is important for the patient to understand the importance of a proactive regimen. Strain induced tendon remodeling, which is part of an accelerated rehabilitation protocol, has been shown to speed up the time to return to daily activities. Exercises, for the anterior, inferior, and posterior shoulder, should be part of this program. Codman exercises (giant, pudding-stirring), to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required" are widely used. The use of NSAIDs, hot and cold packs, and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective. Corticosteroid injections are recommended two to three months apart with a maximum of three injections. Multiple injections (four or more) have been shown to compromise the results of rotator cuff surgery which result in weakening of the tendon. Kinesio taping was compared to sham taping and other conservative treatment for the approach of the rotator cuff disease and has uncertain effects in terms of self‐reported pain, function, pain on motion and active range of motion.


title: Rotator cuff tear

text: Rockwood coined the term orthotherapy to describe the program which is aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. This program involves a home therapy kit which includes elastic bands of six different colors and strengths, a pulley set, and a three-piece, one-meter-long stick. The program is individually customized. Participants are asked to use their exercise program whether at home, work, or traveling.


title: Rotator cuff tear

text: Benefits of surgery are unclear as of 2019. Several instances when surgery may be recommended include:


title: Rotator cuff tear

text: These individuals more often benefit from operative treatment because they are willing to tolerate the risks of surgery to return to their preoperative level of function, and have higher likelihood of a successful outcome. Those who do not respond to, or are unsatisfied with, conservative treatment can seek a surgical opinion.


title: Rotator cuff tear

text: In the past, small tears were treated arthroscopically, while larger tears would usually require an open procedure. Advances in arthroscopy now allow arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many retracted tears. The results match open surgical techniques, while permitting a more thorough evaluation of the shoulder at time of surgery, increasing the diagnostic value of the procedure, as other conditions may simultaneously cause shoulder pain. Arthroscopic surgery also allows for shorter recovery time although differences in postoperative pain or pain medication use are not seen between arthroscopic- and open-surgery. A 2019 review found that the evidence does not support decompression surgery in those with more than 3 months of shoulder pain without a history of trauma.


title: Rotator cuff tear

text: Even for full-thickness rotator cuff tears, conservative care (i.e., nonsurgical treatment) outcomes are usually reasonably good.


title: Rotator cuff tear

text: If a significant bone spur is present, any of the approaches may include an acromioplasty, a subacromial decompression, as part of the procedure. Subacromial decompression, removal of a small portion of the acromion that overlies the rotator cuff, aims to relieve pressure on the rotator cuff in certain conditions and promote healing and recovery. Although subacromial decompression may be beneficial in the management of partial and full-thickness tear repair, it does not repair the tear itself and arthroscopic decompression has more recently been combined with "mini-open" repair of the rotator cuff, allowing for the repair of the cuff without disruption of the deltoid origin. The results of decompression alone tend to degrade with time, but the combination of repair and decompression appears to be more enduring. Subacromial decompression may not improve pain, function, or quality of life.


title: Rotator cuff tear

text: Repair of a complete, full-thickness tear involves tissue suture. The method currently in favor is to place an anchor in the bone at the natural attachment site, with resuture of torn tendon to the anchor. If tissue quality is poor, mesh (collagen, Artelon, or other degradable material) may be used to reinforce the repair. Repair can be performed through an open incision, again requiring detachment of a portion of the deltoid, while a mini-open technique approaches the tear through a deltoid-splitting approach. The latter may cause less injury to muscle and produce better results. Contemporary techniques now use an all arthroscopic approach.


title: Rotator cuff tear

text: Recovery can take as long as three–six months, with a sling being worn for the first one–six weeks. In the case of partial thickness tears, if surgery is undertaken, tear completion (converting the partial tear to a full tear) and then repair, is associated with better early outcomes than transtendinous repairs (where the intact fibres are preserved) and no difference in failure rates.


title: Rotator cuff tear

text: Biceps tenotomy and tenodesis are often performed concomitantly with rotator cuff repair or as separate procedures, and can also cause shoulder pain. Tenodesis, which may be performed as an arthroscopic or open procedure, generally restores pain free motion it the biceps tendon, or attached portion of the labrum, but can cause pain. Tenotomy is a shorter surgery requiring less rehabilitation, that is more often performed in older patients, though after surgery there can be a cosmetic 'popeye sign' visible in thin arms.


title: Rotator cuff tear

text: In a small minority of cases where extensive arthritis has developed, an option is shoulder joint replacement (arthroplasty). Specifically, this is a reverse shoulder replacement, a more constrained form of shoulder arthroplasty that allows the shoulder to function well even in the presence of large full thickness rotator cuff tears.


title: Rotator cuff tear

text: The latest systematic reviews suggests (with low quality evidence) that total shoulder arthroplasty does not provide important benefits over hemiarthroplasty for glenohumeral osteoarthritis and rotator cuff tears. It highlighted the current lack of high-quality evidence and need for randomized controlled trials.


title: Rotator cuff tear

text: The main goal in biological augmentation is to enhance healing. There are a number of potential options. These include injecting an individual's own stem cells, growth factors or platelet rich plasma (PRP) into the repair site, and installing scaffolds as biological or synthetic supports to maintain tissue contour. A 2014 Cochrane review evaluated PRP and found insufficient evidence to make recommendations. Mesenchymal stem cells have no convincing evidence for their use overall, with quality human trials lacking. The greater tuberosity can also be microfractured to create a small blood clot just lateral to the repair site.


title: Rotator cuff tear

text: Rehabilitation after surgery consists of three stages. First, the arm is immobilized so that the muscle can heal. Second, when appropriate, a therapist assists with passive exercises to regain range of motion. Third, the arm is gradually exercised actively, with a goal of regaining and enhancing strength. The empty can and full can exercises are amongst the most effective at isolating and strengthening the supraspinatus.


title: Rotator cuff tear

text: Following arthroscopic rotator-cuff repair surgery, individuals need rehabilitation and physical therapy. Exercise decreases shoulder pain, strengthens the joint, and improves range of motion. Therapists, in conjunction with the surgeon, design exercise regimens specific to the individual and their injury.


title: Rotator cuff tear

text: Traditionally, after injury the shoulder is immobilized for six weeks before rehabilitation. However, the appropriate timing and intensity of therapy are subject to debate. Most surgeons advocate using the sling for at least six weeks, though others advocate early, aggressive rehabilitation. The latter group favors the use of passive motion, which allows an individual to move the shoulder without physical effort. Alternatively, some authorities argue that therapy should be started later and carried out more cautiously. Theoretically, that gives tissues time to heal; though there is conflicting data regarding the benefits of early immobilization. A study of rats suggested that it improved the strength of surgical repairs, while research on rabbits produced contrary evidence. Individuals with a history of rotator cuff injury, particularly those recovering from tears, are prone to reinjury. Rehabbing too soon or too strenuously might increase the risk of retear or failure to heal. However, no research has proven a link between early therapy and the incidence of re-tears. In some studies, those who received earlier and more aggressive therapy reported reduced shoulder pain, less stiffness and better range of motion. Other research has shown that accelerated rehab results in better shoulder function.


title: Rotator cuff tear

text: There is consensus amongst orthopaedic surgeons and physical therapists regarding rotator cuff repair rehabilitation protocols. The timing and duration of treatments and exercises are based on biologic and biomedical factors involving the rotator cuff. For approximately two to three weeks following surgery, an individual experiences shoulder pain and swelling; no major therapeutic measures are instituted in this window other than oral pain medicine and ice. Those at risk of failure should usually be more conservative with rehabilitations.


title: Rotator cuff tear

text: That is followed by the "proliferative" and "maturation and remodeling" phases of healing, which ensues for the following six to ten weeks. The effect of active or passive motion during any of the phases is unclear, due to conflicting information and a shortage of clinical evidence. Gentle physical therapy guided motion is instituted at this phase, only to prevent stiffness of the shoulder; the rotator cuff remains fragile. At three months after surgery, physical therapy intervention changes substantially to focus on scapular mobilization and stretching of the glenohumeral joint. Once full passive motion is regained (at usually about four to four and a half months after surgery) strengthening exercises are the focus. The strengthening focuses on the rotator cuff and the upper back/scapular stabilizers. Typically at about six months after surgery, most have made a majority of their expected gains.


title: Rotator cuff tear

text: The objective in repairing a rotator cuff is to enable an individual to regain full function. Surgeons and therapists analyze outcomes in several ways. Based on examinations, they compile scores on tests; some examples are those created by the University of California at Los Angeles and the American Shoulder and Elbow Surgeons. Other outcome measures include the Constant score; the Simple Shoulder Test; and the Disabilities of the Arm, Shoulder and Hand score. The tests assess range of motion and the degree of shoulder function.


title: Rotator cuff tear

text: Due to the conflicting information about the relative benefits of rehab conducted early or later, an individualized approach is necessary. The timing and nature of therapeutic activities are adjusted according to age and tissue integrity of the repair. Management is more complex in those who have had multiple tears.


title: Rotator cuff tear

text: While people with rotator cuff tears may not have any noticeable symptoms, studies have shown that, those with age related tears, over time 40% will have enlargement of the tear over a five-year period. Of those whose tears enlarge, 20% have no symptoms while 80% eventually develop symptoms.


title: Rotator cuff tear

text: Most usually regain function and experience less pain following surgery. For some, however, the joint continues to hurt. Weakness and a limited range of motion also may persist. Those who report such symptoms frequently are diagnosed with failed rotator cuff syndrome. There is no irrefutable evidence that rotator cuff surgery benefits more than non-surgical management and a percentage of individuals never regain full range of motion after surgery.


title: Rotator cuff tear

text: Arthroscopic procedures produce "satisfactory results" more than 90 percent of the time. However, 6-8 percent of patients have "incompetent" rotator cuffs because their repaired tendons either fail to heal or develop additional tears. In some cases, persistent rotator cuff type pain after surgery can be due to disease elsewhere. For example, cervical spine disease and can involve neck pain radiating into the shoulder. Suprascapular neuropathy, shoulder impingement, superior labral anterior-posterior (SLAP) tears and arthritis can all mimic rotator cuff disease and cause persistent pain that does not respond to rotator cuff surgery.


title: Rotator cuff tear

text: A rotator cuff tear can be caused by the weakening of the rotator cuff tendons. This weakening can be caused by age or how often the rotator cuff is used. Adults over the age of 60 are more susceptible to a rotator cuff tear, with the overall frequency of tears increasing with age. By the age of 50 10% of people with normal shoulders have a rotator cuff tear.


title: Rotator cuff tear

text: In an autopsy study of rotator cuff tears, the incidence of partial tears was 28%, and of complete rupture 30%. Frequently, tears occurred on both sides and occurred more often with females and with increasing age. Other cadaver studies have noted intratendinous tears to be more frequent (7.2%) than bursal-sided (2.4%) or articular-sided tears (3.6%). However, clinically, articular-sided tears are found to be 2 to 3 times more common than bursal-sided tears and among a population of young athletes, articular-sided tears constituted 91% of all partial-thickness tears. Rotator cuff tears may be more common in men between the ages of 50–60, though between 70 and 80 there is minimal difference across genders.


title: Rotator cuff tear

text: In terms of the size of tears, a study compared the ages of patient to the size of tears. It was emphasized the older you are, the more massive of a tear you will have. It was found that mean age increased with larger tear sizes (small tears 59 years, medium tears 62 years, large tears 64 years, and massive tears 66 years).


title: Dir En Grey

text: Dir En Grey (stylized as DIR EN GREY and previously as Dir en grey) is a Japanese heavy metal band formed in February 1997 and currently signed to Firewall Div., a sub-division of Free-Will. With a consistent lineup of guitarists Kaoru and Die, vocalist Kyo, drummer Shinya and bassist Toshiya, they have released eleven full-length records. Numerous stylistic changes have made the genre of their music difficult to determine, though it is generally considered to be a form of metal. Originally a visual kei band, the members later opted for more subtle attire, but have continued to maintain a dramatic image on stage.


title: Dir En Grey

text: Dir En Grey was preceded by the independent rock band La:Sadie's, which included four of Dir En Grey's members before disbanding. They disbanded due to leader and bassist Kisaki not wanting to debut as he felt that it was too soon, but guitarist Kaoru believed that they were ready for it. After parting ways with Kisaki, members Kaoru, Kyo, Die and Shinya recruited bassist Toshiya and regrouped as a new band. After playing one show as a Kuroyume cover-band called "DEATHMASK" at the live house Nagano J on January 24, they officially formed "Dir en grey" on February 2, 1997.


title: Dir En Grey

text: The band name is a combination of German "dir", French "en" and English "grey" and was thought to mean ; the Japanese translation was used as the name of their fanclub's magazine. They wanted to convey a musical image that was neither black nor white, so they picked grey. In an early interview, vocalist Kyo explained that he knew the name before the band was formed. During the WOWOW Special in 2020, Kaoru elaborates that they took the name from another band that was famous around that time. This band was Lareine, who had released a song called "Dir en gray" in 1995. The song starts with the line "", with the Latin part being a correct translation of the Japanese part. Both mean "to you in grey". In a later interview, Kaoru explained that "at the time we chose the band name, it had some meaning but right now it doesn't express the band anymore, so it has come to not mean anything specific. We chose the band name because it sounded right, and it also reflects an image that probably doesn't exist elsewhere."


title: Dir En Grey

text: They released their first EP, "Missa", a few months later and attracted mainstream attention in 1998, by entering the top ten on the Oricon music charts with the still independently produced songs "Jealous" and "-I'll-". Five subsequent singles, arranged and produced by X Japan co-founder Yoshiki Hayashi, were published during the first half of 1999. The band's first full-length record, "Gauze", followed. One of the shows in support for the album (filmed at the Osaka-jo Hall) would later become the first of several live concerts to be released on VHS and DVD.


title: Dir En Grey

text: In 2000, vocalist Kyo was hospitalized with hearing trouble and several dates of the tour in support of Dir En Grey's then-upcoming album, "Macabre", had to be postponed. Tour 00 » 01 Macabre eventually took off later the same year and was concluded at Nippon Budokan shortly after the release of the single "Ain't Afraid to Die" in April 2001.


title: Dir En Grey

text: In the following year, along with the release of a third full-length album, "Kisō", Dir En Grey gave their first performances abroad, touring China, Taiwan, and South Korea. Back in Japan, the last dates of the lengthy Rettou Gekishin Angya tour were already in support for the band's second EP, "Six Ugly". In the same year, they released the single "Child Prey", which was featured as the second opening theme of the "Baki the Grappler" anime series, and also the beginning of their fourth album called "Vulgar". In summer 2003, Dir En Grey performed at Akasaka Blitz for five evenings in a single week, with each show (except the first) themed after a certain album, the last featuring songs from the then yet to be released "Vulgar". A DVD set, titled "Blitz 5 Days", was later released exclusively for members of the band's official fan club, titled "A Knot". "Vulgar" was released in September 2003 and tours in support for the record would last well into 2004.


title: Dir En Grey

text: In 2005, Dir En Grey performed in Europe for the first time. Their concerts in Berlin and Paris (as part of the It Withers and Withers tour) sold out without promotion save for newsletters by import record stores and internet-based word of mouth.


title: Dir En Grey

text: The band also performed at two major festivals, Rock am Ring and Rock im Park. Becoming more involved with the international music scene, French band Eths opened for them at the Paris concert and Dir en Grey invited American musician Wednesday 13 and his band to play at a show in Japan. Dir En Grey also appeared at the Japanese leg of that year's Taste of Chaos tour.


title: Dir En Grey

text: 2005 saw the group's first official European releases as well, beginning with "Withering to Death". The band's music had previously been available through means of import and Internet file-sharing only for European fans. The album achieved Dir En Grey's first non-Asian chart position, reaching No. 31 in the Finnish album charts. The subsequent single, "Clever Sleazoid", later climbed to No. 15 on the singles charts in the same country. Several Dir En Grey songs were also featured in the soundtrack of the 2005 film "Death Trance".


title: Dir En Grey

text: In early 2006 touring expanded to the United States. The band performed in Austin, Texas at the South by Southwest festival, New York City at the Avalon Club and Los Angeles, California at the Wiltern Theatre, followed by the North American release of "Withering to Death." Again, all shows sold out within days. After more concerts and festival appearances in Germany during the summer, singer Kyo was again hospitalized due to inflamed vocal cords. While two concert dates in Japan had to be postponed, Dir En Grey was still able to join Korn's Family Values Tour 2006. In October, the band was back in Japan to perform at the Loudpark Festival, along with bands such as Megadeth, Slayer and Children of Bodom. Their 22nd single "Agitated Screams of Maggots" was released on 15 November during the Japanese leg of the Inward Scream tour. On 30 December, the music video for -Saku- was voted the No. 1 video of the year on the MTV2 show "Headbangers Ball".


title: Dir En Grey

text: In February, Dir En Grey went on its first North American headlining tour, visiting sixteen cities as its sixth full-length album "The Marrow of a Bone" was released on February 7 in Japan and in the United States and Europe in the following months. From May to July, the group opened for the Deftones on their United States tour and afterwards did another European tour, which included their debut shows in Denmark, Finland, Poland, Sweden, and the United Kingdom, as well as several festival performances across the continent, including Ankkarock, M'era Luna Festival and Wacken Open Air.


title: Dir En Grey

text: The group went on another international tour in September named after their most recent single "Dozing Green", beginning in Japan and continuing in Europe, including their first performance in the Netherlands and Switzerland. In late November, Dir En Grey opened two shows for Linkin Park at Saitama Super Arena and in December performed another Japan tour with 10 Years as a supporting act. Commemorating Dir En Grey's tenth anniversary as a band, two greatest hits compilations, titled "Decade 1998–2002" and "Decade 2003–2007" respectively, were released on December 19.


title: Dir En Grey

text: At the beginning of 2008, Dir En Grey announced plans to begin recording a new studio album. Their first touring of the year in May was another Japan tour with a conclusion of three shows at Shinkiba Studio Coast, titled Death over Blindness. Between touring, Dir En Grey performed at one night of the two-night hide memorial summit on May 4, alongside X Japan, Luna Sea, and others. A second Japanese tour, titled Tour 08 The Rose Trims Again began on September 10, the same day as the release of their single "Glass Skin".


title: Dir En Grey

text: On August 1, Dir En Grey announced the release of their seventh studio album, "Uroboros", which was released on November 11, 2008, in the United States. The band also toured the United States and Canada in support of the album, with dates scheduled for November and December (overlapping the release of "Uroboros") with opening act The Human Abstract. Touring that fall included a series of four shows titled Bajra, two being fan-club exclusive, and a single show on December 29 under the moniker Uroboros -Breathing- at the famous Osaka-jo Hall where Dir En Grey had not performed since December 18, 1999 (as seen on "1999.12.18 Osakajo Hall").


title: Dir En Grey

text: Beginning in 2009, Dir En Grey made their first thorough tour of the United Kingdom and Ireland with "Kerrang!"'s "Relentless Tour '09" alongside Mindless Self Indulgence, Bring Me the Horizon, Black Tide and In Case of Fire. In February, the band announced the public release of the live DVD, "Tour 08 The Rose Trims Again", as well as switching European record labels to the newly founded Okami Records, a sister label of their former European representation, Gan-Shin.


title: Dir En Grey

text: During spring of 2009, the band began to fully promote "Uroboros" with a series of nationwide tours under the title Tour 09 Feast of V Senses. The tour was interrupted briefly while in Sapporo and Sendai, with an announcement on the band's official website, explaining that Kyo had been diagnosed with edema of the larynx, and would require the postponement of three shows, which were rescheduled for early May.


title: Dir En Grey

text: Dir En Grey continued their Feast of V Senses tour in Europe, with a mixture of festival performances, headlining shows, and one co-headlining show with Killswitch Engage. The festival performances included their third appearances at Rock am Ring and Rock im Park, as well as their initial concerts at Download Festival, Nova Rock, and Metaltown. Among the headlining shows, Dir En Grey were also making debut concerts in Italy and the Czech Republic.


title: Dir En Grey

text: After several shows of their late-summer tour, All Visible Things, Dir En Grey announced their next single for December, "Hageshisa to, Kono Mune no Naka de Karamitsuita Shakunetsu no Yami", as well as a North American and South American tour also under the title All Visible Things. Their new single was released on December 2, 2009, and reached number 2 on the Oricon Weekly Chart: the highest position to date for the band. Their 2009 tour season ended with a three-live tour titled Dorje. They finally ended their long "Uroboros" centered tour by doing two back to back performances at the Nippon Budokan, titled Uroboros: with the proof in the name of living..., where tickets sold out in 15 minutes.


title: Dir En Grey

text: It was announced on April 7, 2010, that the band would be returning to the United Kingdom in August on the lineup for the Sonisphere Festival in Knebworth, playing on a bill headlined by Iron Maiden and Rammstein. According to the festival website, this was to be their only UK festival performance during the year. Regarding the announcement, Kaoru (on the Sonisphere UK website) is quoted as saying:


title: Dir En Grey

text: """I'd never have thought that we would play a festival of this caliber! It is like a dream come true to be playing with such great bands at Sonisphere. Although we're not back in the UK for a tour, we wanted to play this festival to give something back to the fans who were disappointed last year from our cancelled finale in London."


title: Dir En Grey

text: It was announced on April 28, 2010, that Dir En Grey would be playing an exclusive club date at London's Koko venue on August 3 as part of The Unwavering Fact of Tomorrow Tour 2010. Dir En Grey announced later on that they also would do their debut performances in Russia by adding one show in Moscow at Tochka Club on August 5 and one show in St Petersburg at Glav Club on August 6. Dir En Grey also toured North America on a co-headlining tour with the Finnish band Apocalyptica with a special guest of Kyo interpreting the song "Bring Them to Light", one of the tracks of the cello-metalers latest record.


title: Dir En Grey

text: In September 2010 the band confirmed in an interview with "Kerrang!" magazine that they were in the process of writing new material for the follow-up to "Uroboros". In addition to "Hageshisa to, Kono Mune no Naka de Karamitsuita Shakunetsu no Yami" appearing on the soundtrack of the American movie "Saw 3D", they also participated on December 1, 2010's "Romantist - The Stalin, Michiro Endo Tribute Album" by covering "Warushawa no Gensō" in celebration of the 60th birthday of The Stalin's frontman Michiro Endo. The album also featured bands such as Buck-Tick, Group Tamashii, Merry, Jun Togawa, and Wagdug Futuristic Unity.


title: Dir En Grey

text: The single "Lotus" was released on January 26, 2011, along with a new fan-club only tour named The Decomposition of the Moon, scheduled to run from May 14 to 26. The band released "Different Sense" on June 22. On August 1, 2011, Dir en Grey released an open letter on their official Facebook that accused the Japanese government of lying to its people and hiding the true danger of the radiation levels after the nuclear accidents caused by the 2011 Tōhoku earthquake and tsunami. In October, the band launched a campaign called Scream for the Truth, complete with a website and a billboard hanging in Times Square in New York City, in hopes of stopping the alleged misinformation and getting correct numbers. Their eighth studio album, "Dum Spiro Spero", was released on August 3. Material from this album was showcased on the band's South and North American tour Age Quod Agis in November and December 2011.


title: Dir En Grey

text: In February 2012, following a doctor's visit, vocalist Kyo was diagnosed with vocal nodule dysphonia, leading to Dir En Grey pulling out of the North American The Still Reckless Tour consisting of Asking Alexandria, Trivium, Motionless in White, and I See Stars. Although Kyo had been hospitalized before in 2006 and 2009 for vocal inflammation, he had not required surgery until this time. Kyo later stated that his condition was treated with medication.


title: Dir En Grey

text: On August 11, 2012, Dir En Grey won the Extreme Metal Olympics organized by "Loudwire", beating Death in the final. The band released the single "Rinkaku" on December 19 after their one-year and a half hiatus since their previous single release. Also, a tour titled In Situ began on December 25 in Tokyo.


title: Dir En Grey

text: On April 3, 2013, they released their third EP, titled "The Unraveling", with one new song and six re-recordings. Just a couple of days later on April 5, the band started their supporting tour Tabula Rasa for the new EP. In June 2013, the band participated in a short European tour.


title: Dir En Grey

text: In September 2013, the band started their Ghoul tour, which ran from September 18 until October 23 in Japan and continued on November 3 in North America. The band also announced two back-to-back shows at the Nippon Budokan for March 2014 titled "Dum Spiro Spero" along with a new single, "Sustain the Untruth", which was released in January 2014.


title: Dir En Grey

text: During the month of August in 2014, the band celebrated the 15th anniversary of their debut album, "Gauze". During this time, they embarked on a Japanese tour titled "Tour14 Psychonnect: Mode of "Gauze"?", similarly named after the tour they held back in 1999 in support of the album.


title: Dir En Grey

text: On August 5, 2014, it was announced that Dir En Grey's ninth album, "Arche," would be released on December 10, 2014. After its release, the album was accompanied by the 2014–2015 tour "By the Grace of God". The tour was followed by another one called "The Unstoppable Life", in April and May 2015. On 27 June 2015, Dir En Grey performed at Luna Sea's Lunatic Fest at Makuhari Messe. On 5–6 February 2016, Dir en Grey performed their album "Arche" at Nippon Budokan with a June 2016 release date of Blu-ray & DVD.


title: Dir En Grey

text: The band released a single, "Utafumi", in July 2016. They also embarked on various tours based around previous albums called "Tour16-17 From Depression To ________ [mode of Vulgar]", "Tour16-17 From Depression To ________ [mode of Dum Spiro Spero]", and "Tour16-17 From Depression to ________ [mode of 鬼葬]" from June to November 2016.


title: Dir En Grey

text: In 2017, the band did further tours themed around previous albums They also covered "Easy Make, Easy Mark" by D'erlanger for the "D'erlanger Tribute Album ~Stairway to Heaven~".


title: Dir En Grey

text: Their compilation album, "Vestige of Scratches", was released on January 2, 2018. Dir en Grey's twenty-ninth single "Ningen wo Kaburu" was released on April 25, 2018. One of its B-sides is a remake of "Ash", a song with origins as far back as 1997.


title: Dir En Grey

text: On June 29, 2018, Dir en Grey announced that their tenth studio album "The Insulated World" was to be released on September 26, 2018. The band also announced a European tour to start in October 2018, under the title "Wearing Human Skin". They followed this tour with a North American tour in December 2019 and another European tour in January and February 2020.


title: Dir En Grey

text: Their 30th single, "The World of Mercy", released on September 18, 2019. They provided a cover of "National Media Boys" for the January 29, 2020 Buck-Tick tribute album "Parade III ~Respective Tracks of Buck-Tick~"


title: Dir En Grey

text: Dir En Grey has been categorized in many genres such as extreme metal, alternative, experimental, avant-garde and various others. Dir En Grey's format has been subject to change throughout their career, initially being a rather experimental form of alternative rock. Some tracks of their debut album "Gauze" also demonstrated a distinct pop appeal, which was largely dropped in favor of a more progressive sound on the following albums, "Macabre" and "Kisou". While up to that point some songs had already been more fast-paced, raw and aggressive than others, the band's music took a decisive turn with the release of the EP Six Ugly, from then on sporting more metal influences in general. Dir En Grey's style gravitated towards riffs and song structures more along the lines of contemporary North American fusion genres, such as nu metal and metalcore, until 2007's "The Marrow of a Bone". In a review of their sixth full-length album, "The Marrow of a Bone", AllMusic's Thom Jurek comments on their evolution and diversity, saying:


title: Dir En Grey

text: Since the release of their album "Uroboros" in 2008, Dir En Grey have been repeatedly described as progressive metal. Uroboros and their 2011 album "Dum Spiro Spero" represent a particular musical departure from previous albums, with critics noting that their sound on these albums bears almost nothing in common to their earliest work. With Uroboros, and particularly on "Dum Spiro Spero", the band have moved away from their alternative rock roots towards a heavier metal sound. These albums feature complex song structures and guitarwork, longer track lengths, and a broader variety of particularly western influences, such as death metal, deathcore and groove metal.


title: Dir En Grey

text: Kyo's singing is considered a pivotal aspect of the band, and he has gained recognition for his distinctive vocal work and for his large range and versatility, being able to "howl, croon, emote cleanly, scream, shriek, growl, bellow, and make nearly inhuman sounds." Jurek has compared him favorably to experimental and avant-garde vocalists Mike Patton and Diamanda Galas. "Loudwire" wrote "Sporting incredibly low death metal gutturals, Kyo can also turn a complete 180 as one of metal's highest shriekers." Dane Prokofiev of "PopMatters" said that his "natural ease at and inclination towards striking such a stark contrast between the two opposite ends of the human vocal spectrum can be obtained as only a kind of pre-birth winning lottery ticket—you know, that much coveted prize we call "talent"."


title: Dir En Grey

text: Commentators have noted how Dir en Grey have gained a significant international fanbase with vocals in Japanese. Kaoru said "when I was growing up, I listened to American bands. They were all singing in English and I had no idea what they were saying. But I still remember the excitement that I experienced. I know as a listener that our fans can connect to our music in the same way — even with the language barrier." When asked why they almost always use Japanese instead of English, which would give them more broad international appeal, he said that "We consider our music [to be] a piece of art. [...] The language is part of that artwork." The guitarist explained that Kyo, who writes all of the lyrics, prefers "the sensitivities that Japanese language offers. There are expressions and nuances that can only be conveyed in Japanese; he values that." However, he noted that likewise there are some expressions that are only able to be shown in English, so they also plan to use English when they feel the need. The lyrics deal with subjects such as society and mass media, as well as sexual obsessions and love, usually with negative implications. The vocabulary varies from subtle to explicit (though the use of profanity has greatly decreased as the band matured, last featuring on "Uroboros"), and several songs rely heavily on double entendres and other wordplay, often involving the multiple meanings of a kanji character.


title: Dir En Grey

text: Although they got their start as a visual kei band, the members of Dir en Grey seem to be irked being associated with the term in some later interviews. Speaking of the change in their appearance, Kaoru said "Eventually, we felt that dressing like we used to onstage put up a wall between us and the audience, so we stopped wearing the kind of makeup we did before." However, he said they still occasionally wear makeup, just not as much. Toshiya explained "To be honest, when we first started and we were wearing a lot of makeup on stage and stuff, there were a lot of bands doing that at the time in Japan, and people thought it was cool. But not anymore, ha ha." Die said "They saw us as idols but we aren't idols. We are a band, we play music and want to be known for it. So we decided to change our style slowly." Kyo stated that for Dir en Grey it was always about the music and when wearing lots of makeup became popular, "we didn't want to be associated with a lot of the poor quality bands in that scene."


title: Dir En Grey

text: Dir en Grey have created some controversy in Japan as some of their music videos have been banned from television for "abrasive visuals including baby-eating, murder, [and] gore." Similarly, stations refused to play the video for 2008's "Vinushka" which included stock footage of World War II and newspaper headlines following the atomic bombings of Hiroshima and Nagasaki.


title: Dir En Grey

text: Kyo cited Bauhaus's "Press the Eject and Give Me the Tape" and David Sylvian's "Secrets of the Beehive" as his favorite albums. Kaoru listed X's "Blue Blood", Pantera's "Vulgar Display of Power", Nine Inch Nails' "The Downward Spiral", The Beatles' "1962–1966" and "1967–1970" in his favorite albums list. Die's inspirations included D'erlanger's "La Vie En Rose" and Ziggy's "Kool Kizz". Toshiya hailed Alice in Chains' "Dirt" and Radiohead's "OK Computer". Shinya cited Aion's "Absolute" and Gargoyle's "Furebumi" as his influences.


title: Dir En Grey

text: Die (born December 20, 1974, in Mie); rhythm guitar, backing vocals. Has been with the group since its inception in 1997. In the mid-1990s, he was a member of the bands Ka･za･ri and La:Sadie's. In 2015, Die began a side project, Decays, for which he is the vocalist and guitarist. Die composed several songs for Dir En Grey, such as "304 Goushitsu, Hakushi no Sakura", "Wake", and "Mr.Newsman". Die became interested in rock music after hearing Buck-Tick's album "Aku no Hana" in junior high school. He developed his love of guitar from D'erlanger's debut album "La Vie En Rose" and called their guitarist Cipher his "guitar hero."


title: Dir En Grey

text: Shinya (born February 24, 1978, in Hirakata, Osaka); drums. In 1995 he helped form La:Sadie's, which disbanded in 1997, after which Dir En Grey was formed. Shinya has composed a handful of songs for Dir En Grey, his compositions alternating between melodic ("Hotarubi", "Fukai") and upbeat tunes ("Raison Detre", "Umbrella").


title: Dir En Grey

text: Toshiya (born March 31, 1977, in Nagano); bass, backing vocals. He has been with the band since its inception, although he was not in La:Sadie's. Toshiya composed "Erode" and "Bottom of the Death Valley". His compositions tend to have a distinct, bass-driven sound.


title: Peter of Castile

text: Peter (; 30 August 133423 March 1369), called the Cruel () or the Just (), was King of Castile and León from 1350 to 1369. Peter was the last ruler of the main branch of the House of Ivrea. He was excommunicated by Pope Urban V for his persecutions and cruelties committed against the clergy.


title: Peter of Castile

text: Peter was born in the defensive tower of the Monasterio de Santa María la Real de Las Huelgas in Burgos, Spain. His parents were Alfonso XI of Castile and Maria of Portugal.


title: Peter of Castile

text: According to chancellor and chronicler Pero López de Ayala, he had a pale complexion, blue eyes and very light blonde hair; he was tall and muscular. He was accustomed to long, strenuous hours of work, lisped a little and "loved women greatly". He was well read and a patron of the arts, and in his formative years he enjoyed entertainment, music and poetry.


title: Peter of Castile

text: He was to be married to his contemporary Joan, the second and favourite daughter of King Edward III of England; however, on their way to Castile she and her retinue travelled through cities infested with the Black Death, ignoring townspeople who had warned them not to enter their settlements. Since the plague had not yet entered England, it is likely that they underestimated the danger. Joan soon contracted the disease and died in 1348, aged 14.


title: Peter of Castile

text: About two years later Peter began his reign when almost sixteen years old and subject to the control of his mother and her favourites. Though at first controlled by his mother, Maria of Portugal, Peter ascended the throne with the encouragement of his mother's second cousin, the Portuguese minister Count Alburquerque. Becoming attached to María de Padilla, he married her in secret in 1353. María turned him against Alburquerque, who fled to Portugal.


title: Peter of Castile

text: In the summer of 1353, the young king was practically coerced by his mother and the nobles into marrying Blanche of Bourbon; he deserted her at once upon hearing rumors that she had slept with his half-brother Fadrique, who was supposed to be guarding her virtue and made her instead "an unwilling Isolde to his Tristan," according to one historian. This marriage necessitated Peter's denying that he had married María, but his relationship with her continued and she bore him four children. He also apparently went through the form of marriage with Juana de Castro, widow of Don Diego de Haro, convincing her that his previous marriage to Queen Blanche was a nullity. The bishops of Avila and Salamanca were asked to concur, and were afraid to say otherwise. Peter and Juana were married in Cuellar, and Juana was proclaimed Queen of Castile. After two nights, he then deserted her. She bore him a son who died young, after Peter's death. A period of turmoil followed in which the king was for a time overpowered and, in effect, imprisoned. The dissension within the party striving to coerce him enabled him to escape from Toro, where he was under observation, to Segovia.


title: Peter of Castile

text: In 1361, Queen Blanche died at Medina Sidonia. French historians claim that Peter ordered two Jews to murder her; another version of the story says she was poisoned; a third one that she was shot with a crossbow, although it may have been the plague. Also that year, Maria de Padilla died in Seville.


title: Peter of Castile

text: From 1356 to 1366, Peter engaged in constant wars with Aragon in the "War of the Two Peters", in which he showed neither ability nor skill in his support of his English ally or Castilian interests in the Mediterranean against the French and Aragonese. The king of Aragon then supported Peter's bastard brothers against him. It was during this period that Peter perpetrated the series of murders which made him notorious.


title: Peter of Castile

text: In 1366 began the calamitous Castilian Civil War, which would see him dethroned. He was assailed by his bastard brother Henry of Trastámara at the head of a host of soldiers of fortune, including Bertrand du Guesclin and Hugh Calveley, and abandoned the kingdom without daring to give battle, after retreating several times (first from Burgos, then from Toledo, and lastly from Seville) in the face of the oncoming armies. Peter fled with his treasury to Portugal, where he was coldly received by his uncle, King Peter I of Portugal, and thence to Galicia, in the northern Iberian Peninsula, where he ordered the murder of Suero, the archbishop of Santiago, and the dean, Peralvarez.


title: Peter of Castile

text: Peter's rival Henry of Trastámara continuously depicted Peter as "King of the Jews", and had some success in taking advantage of popular Castilian antisemitism. Henry instigated pogroms beginning a period of anti-Jewish riots and forced conversions in Castile that lasted approximately from 1370 to 1390. Peter took forceful measures against this, including the execution of at least five anti-Jewish leaders of a riot.


title: Peter of Castile

text: The prominence of Samuel ha-Levi, King Peter's treasurer, has often been cited as evidence of Peter's supposed pro-Jewish sentiment, but Ha-Levi's success did not necessarily reflect the general experience of the Spanish Jewry in this period which was often marked by discrimination and pogroms. Following Peter's death, Jews had to wear a yellow badge, as punishment for having supported him.


title: Peter of Castile

text: In the summer of 1366, Peter took refuge with Edward, the Black Prince, who restored him to his throne in the following year after the Battle of Nájera. The health of the Black Prince broke down, and he left the Iberian Peninsula. bringing with him two of Pedro I's daughters, Constance and Isabella of Castile, whom he had taken as hostages as assurers that Pedro would pay up. He married the princesses into English nobility, most famously Constance to his brother John of Gaunt, in order to make a claim on the Castilian throne.


title: Peter of Castile

text: Meanwhile, Henry of Trastámara returned to Castile in September 1368. The "cortes" of the city of Burgos recognized him as King of Castile. Others followed, including Córdoba, Palencia, Valladolid, and Jaén. Galicia and Asturias, on the other hand, continued to support Peter. As Henry made his way toward Toledo, Peter, who had retreated to Andalusia, chose to confront him in battle. On 14 March 1369, the forces of Peter and Henry met at Montiel, a fortress then controlled by the Order of Santiago. Henry prevailed with the assistance of Bertrand du Guesclin. Peter took refuge in the fortress, which, being controlled by a military order of Galician origin, remained faithful to him. Negotiations were opened between Peter and his besieger, Henry. Peter met with du Guesclin, who was acting as Henry's envoy. Peter offered du Guesclin 200,000 gold coins and several towns, including Soria, Almazán, and Atienza to betray Henry. Ever opportunistic, du Guesclin informed Henry of the offer and immediately bargained for greater compensation from Henry to betray Peter.


title: Peter of Castile

text: Having made a deal with Henry, Du Guesclin returned to Peter. Under the guise of accepting his deal, du Guesclin led Peter to his tent on the night of 23 March 1369. Henry was waiting. The historian López de Ayala described the encounter as follows: "Upon entering du Guesclin's tent, Henry saw King Peter. He did not recognize him because they had not seen each other for a long time. One of Bertrand's men said 'This is your enemy.' But King Henry asked if it was he and King Peter said twice, 'I am he, I am he.' Then King Henry recognized him and hit him in the face with a knife and they ... fell to the ground. King Henry struck him again and again." Having dispatched his half-brother, Henry left Peter's body unburied for three days, during which time it was subjected to ridicule and abuse.


title: Peter of Castile

text: Popular memory generally views King Peter I as one of the few monarchs who sided with an Islamic sultan (Granada), while also being a Catholic king. Granada paid Pedro I tribute. He helped them during several invasions and a coup. One of the rewards he was given by a sultan of Granada was the famous ruby, a reward for killing an usurper, that is now in the crown of England, brought back by The Black Prince of England along with Peter I's surviving two daughters (Constance and Isabella of Castile, who were legitimized). Not all of Peter's reputation comes from the works of the chronicler Pero López de Ayala, who after his father's change of allegiance had little choice but to serve Peter's usurper. After time passed, there was a reaction in Peter's favour and an alternative name was found for him. It became a fashion to speak of him as "El Justiciero", the executor of justice (the Lawful). Apologists were found to say that he had killed only men who would not submit themselves to the law or respect the rights of others. Peter did have his supporters. Even López de Ayala confessed that the king's fall was regretted by many, among them the peasants and burghers subjected to the nobles by late feudal gifts and by the merchants, who enjoyed security under his rule.


title: Peter of Castile

text: The English, who backed Peter, also remembered the king positively. Geoffrey Chaucer visited Castile during Peter's reign and lamented the monarch's death in "The Monk's Tale", part of "The Canterbury Tales". (Chaucer's patron, John of Gaunt, 1st Duke of Lancaster, had fought on Peter's side in his struggle to reclaim the throne.) The English Lake Poet Robert Southey was presented in 1818 with a copy of a five-act play by the novelist Ann Doherty, entitled "Peter the Cruel, King of Castile and Leon".


title: Peter of Castile

text: Peter had many qualities of those later monarchs educated in the centralization style. He built a strong Royal administrative force ahead of his times. He failed to counter or check all the feudal powers that supported his rivals, however illegitimate and opposite to the principles of aristocracy they represented themselves. But his moral superiority was reduced too by the violent means, including fratricides, by which he sought to suppress opposition; he at times was extremely despotic and unpredictable, even by the standards of his age. In this he was preceded by his father Alfonso XI, who since the crisis at the death of Alfonso X had faced multiple rebellions against royal authority.


title: Peter of Castile

text: The death of King Peter ended the traditional alliance of Castile and Navarre with England, which had been started by the Plantagenets to keep France in check. The alliance was later renewed by the Trastámaras and Tudors.


title: Peter of Castile

text: The great original but hostile authority for the life of Peter the Cruel is the "Chronicle of the Chancellor Pedro López de Ayala" (1332–1407). To put that in perspective are a biography by Prosper Mérimée, "Histoire de Don Pedro I, roi de Castille" (1848) and a modern history setting Peter in the social and economic context of his time by Clara Estow ("Pedro the Cruel of Castile (1350–1369)", 1995).


title: Peter of Castile

text: Strictly speaking, Peter was not defeated by Henry but by the opposing aristocracy; the nobles accomplished their objective of enthroning a weaker dynasty (the House of Trastámara), much more amenable to their interests. Most of the bad stories about Peter are likely to be colored by Black Legend, coined by his enemies, who finally succeeded in their rebellion. The Chancellor López de Ayala, the main source for Peter's reign, was the official chronicler of the Trastámara, a servant of the new rulers and of Peter's aristocratic adversaries.


title: Peter of Castile

text: The change of dynasty can be considered as the epilogue of the first act of a long struggle between the Castilian monarchy and the aristocracy; this struggle was to continue for more than three centuries and come to an end only under Charles I of Spain, the grandson of Ferdinand II of Aragon (Ferdinand V of Castile) and Isabella I of Castile (The Catholic Monarchs), in the first quarter of the 16th century.


title: Francis Chan

text: Francis Chan [陳恩藩] (born August 31, 1967), is an American Protestant author, teacher, and preacher. He is the former teaching pastor of Cornerstone Community Church, an Evangelical church in Simi Valley, California founded by Chan in 1994. He also founded Eternity Bible College in 2004, and served as its early chancellor until 2010.


title: Francis Chan

text: Chan has been a board member of several Christian and social justice organizations, including Children's Hunger Fund and Gospel for Asia. He has authored and co-authored numerous books including , a New York Times bestseller. Chan has also served as an ambassador for Care for Children.


title: Francis Chan

text: Chan was born in San Francisco to immigrants Pak-sum Chan [陳柏森], a former minister at the Leighton Road Baptist Church in Hong Kong, and Wan-bing Mui [梅韻冰], a “Bible woman of the Hong Kong Baptist Church, Caine Road.” He was their third child; his mother died during his childbirth, of “excessive bleeding”, leaving his father with sister Grace, brother Paul, and newborn Francis, who was named for the city of his birth and of the tragedy.


title: Francis Chan

text: Chan was sent to Hong Kong to be raised by a grandmother, a Buddhist for several years. During this time, his father married Amy Law [羅笑容] and gave Francis a half-sister, Gloria. In 1976, when Chan was eight years old, his stepmother Amy Chan died in an automobile accident.


title: Francis Chan

text: His father then remarried again, to Josephine Leung [梁克閲], who “raised [the] four children lovingly with Godly influence.“ In raising the four, his father and new stepmother had family support from his father's younger sister and her husband, Marion and William Wong, along with a large extended family and church family. He did not get along well with his father growing up but says that his fear of his father has helped him understand a level of fear of God. He also stated he didn't understand the love of God well until he became a father himself. In 1979, when Francis was twelve years old, he lost his father to cancer. As a high-school and then junior-college student, Chan was active in Christian youth groups, which helped develop his faith in Christ and his interest in ministry.


title: Francis Chan

text: Chan graduated high school and went on to earn a Bachelor of Arts degree from Master's College, and a master of divinity degree from The Master's Seminary.


title: Francis Chan

text: After earning his seminary degree, Chan "landed a youth pastor position" in Chatsworth, California, at the Church at Rocky Peak. "Christianity Today", reporting in 2009, has Chan characterizing this as a period where his personal life was not lived consistently with his religious ideas, stating "Those were the worst years of my life... a sinful, hypocritical time." For reasons not explained further, Chan left that pastoral position for a job at a restaurant, waiting tables.


title: Francis Chan

text: Chan, his wife Lisa, and 30 others founded Cornerstone Community Church in 1994; within two months, the church had grown to have 100 attending. The church continued to see increases in attendance, and by the year 2000, it had received approval from local officials for building expansion to double its capacity, in support of a 1,600-member congregation. As of January 2008, Cornerstone was one of the largest churches in Ventura County, California.


title: Francis Chan

text: After a three-month leave from Cornerstone, ca. 2008, Chan said he felt convicted to sacrifice more for God. Chan had been giving away about 50% of his income, didn't take a salary from his church, and donated most of his book royalties, which totaled about $2,000,000, to various charities. All of it goes to organizations which rescue sex slaves in foreign countries. Furthermore, in 2008 it was reported that Cornerstone would give away 55% of its income to charitable causes.


title: Francis Chan

text: Chan started Eternity Bible College in 2004 as a ministry of Cornerstone Community Church, with 100 students. In 2008, Eternity launched an abroad program in Ecuador. As of 2009, the college had 47 graduates serving in various parts of the world.


title: Francis Chan

text: In June 2011, he stated he felt called to San Francisco, CA. He moved to Northern California and started a church planting network of house churches called "We Are Church".


title: Francis Chan

text: In September 2014, Chan joined the board of elders of Abundant Life Christian Fellowship; as of August 2016, he was no longer an elder at that congregation.


title: Francis Chan

text: In 2020, Chan moved back to Hong Kong, living and working in Sham Shui Po, the poorest area in Hong Kong and the neighborhood where his mother used to do ministry in the 1950s.


title: Francis Chan

text: In January 2021, Chan announced he and his family had returned to the US after his HK visa was denied. He has stated his intent to return to Hong Kong when possible.


title: Francis Chan

text: Chan frequently talks about "What the Bible is really saying" "and really living our lives that way." According to one author, he is not afraid of confronting "lukewarmness" in the Christian life.


title: Francis Chan

text: With regards to Communion, in January 2020, Francis Chan began to publicly investigate his stance on the real presence of Christ in the Lord's Supper, a lighter view of which is taught in the Reformed Protestant tradition (which Chan has been associated with in the past).


title: Francis Chan

text: Prior to this shift on the Eucharist, Chan had given a talk to Catholics at the (Neo-charismatic Protestant) Onething conference in 2018, and was prayed over by multiple Catholic priests. He spoke at the Fellowship of Catholic University Students' SEEK conference in February 2021.


title: Francis Chan

text: Chan is married to Lisa, a singer. They wed in 1994, and as of December 2014 they have seven children. Their eldest is singer Rachel Chan.


title: Three Blind Mice

text: "Three Blind Mice" is an English-language nursery rhyme and musical round. It has a Roud Folk Song Index number of 3753.


title: Three Blind Mice

text: A version of this rhyme, together with music (in a minor key), was published in "Deuteromelia or The Seconde part of Musicks melodie" (1609). The editor of the book, and possible author of the rhyme, was Thomas Ravenscroft. The original lyrics are:


title: Three Blind Mice

text: Attempts to read historical significance into the words have led to the speculation that this musical round was written earlier and refers to Queen Mary I of England blinding and executing three Protestant bishops. However, the Oxford Martyrs, Ridley, Latimer and Cranmer, were burned at the stake, not blinded; although if the rhyme was made by crypto-Catholics, the mice's "blindness" could refer to their Protestantism. However, as can be seen above, the earliest lyrics don't talk about harming the three blind mice, and the first known date of publication is 1609, well after Queen Mary died.


title: Three Blind Mice

text: The rhyme only entered children's literature in 1842 when it was published in a collection by James Orchard Halliwell.


title: Three Blind Mice

text: Robert Schumann's Kreisleriana #7, which is arguably about a cat (Murr), appears to be based upon "Three Blind Mice", but in a predominantly minor key. "Three Blind Mice" is to be found in the fugue which is the centerpiece of #7.


title: Three Blind Mice

text: Joseph Holbrooke (1878–1958) composed his Symphonic Variations, opus 37, based on "Three Blind Mice". Also, Joseph Haydn used its theme in the Finale (4th Mvt) of his Symphony 83 ("La Poule") (1785–86); one of the 6 "Paris Symphonies", and the music also appears in the final movement of English composer Eric Coates' suite "The Three Men". "Three Blind Mice" was also used as a theme song for The Three Stooges and a Curtis Fuller arrangement of the rhyme is featured on the Art Blakey live album of the same name. The song is also the basis for Leroy Anderson's 1947 orchestral "Fiddle Faddle".


title: Three Blind Mice

text: The British composer Havergal Brian (1876–1972) used the tune as the basis of his orchestral work "Fantastic Variations on an Old Rhyme" (1907–08). The work was originally intended as the first movement of a satirical "Fantastic Symphony" (Symphony No.1), a programmatic work, based on the nursery rhyme. The second movement was intended as a scherzo for pizzicato strings, depicting the souls of the departed mice going to heaven and the third movement was a Lament for the dead mice. Both these movements are lost. "Festal Dance" (1908) formed the finale, depicting the wild dance of triumph of the farmer's wife in which passing references to the tune can be heard. Having been performed separately, the first and last movements became independent works around 1914.


title: Three Blind Mice

text: The theme of the second movement of Sergei Rachmaninoff's Piano Concerto No. 4 (1926, revised 1928 and 1941) was criticized as resembling "Three Blind Mice".


title: Three Blind Mice

text: A calypso version of the tune with new lyrics by Monty Norman was recorded by Byron Lee and the Dragonaires for the film "Dr. No", and is featured in its soundtrack as part of the track "Kingston Calypso". The reworked rhyme alludes to the three black assassins whose deadly march through the streets of Kingston, Jamaica opens the film. Other Jamaican versions include dancehall artists, like Josey Wales and Brigadier Jerry.


title: Three Blind Mice

text: In a 78 RPM CD of "The Whale who Wanted to Sing at the Met", Nelson Eddy, sang a round of the song before the actual short performance.


title: Three Blind Mice

text: The line "See how they run" appears in The Beatles' "Lady Madonna" (1968) and Redeye's "Games" (1970–1971).


title: Three Blind Mice

text: In 1969, a version of the rhyme, with slightly changed lyrics and in D minor rather than in a major key, was recorded by Mike Oldfield as part of the duo The Sallyangie, with his older sister Sally, within the song "Chameleon" on the duo's only album, "Children of the Sun". In the song, Oldfield sings the rhyme (among other lyrics) as a lower counterpoint vocal to his sister, who sings completely different lyrics on a different, slower melody, in a high voice. Also in the same year, Sesame Street adapted the song to "B is for Bubble".


title: Three Blind Mice

text: Published in 1904 by Frederick Warne & Co., an illustrated children's book by John W. Ivimey entitled "The Complete Version of Ye Three Blind Mice", fleshes the mice out into mischievous characters who seek adventure, eventually being taken in by a farmer whose wife chases them from the house and into a bramble bush, which blinds them.


title: Three Blind Mice

text: Soon after, their tails are removed by "the butcher's wife" when the complete version incorporates the original verse—although the earliest version from 1609 does not mention tails being cut off. The story ends with them using a tonic to grow new tails and recover their eyesight, learning a trade (making wood chips, according to the accompanying illustration), buying a house and living happily ever after.


Blue Mountain State: The Rise of Thadland is a 2016 American comedy film directed by Lev L. Spiro and starring Darin Brooks, Alan Ritchson, and Chris Romano. It is based on the Spike (now Paramount Network) series "Blue Mountain State". Picking up where season 3 of the series left off, the plot follows Alex Moran, now in his senior year, who must throw an epic party for Thad, who has recently been drafted into the NFL, in an effort to get him to buy the Goat House from the new Dean of sports.


title: Blue Mountain State: The Rise of Thadland

text: Following the cancellation of the series in early 2012, rumors of a reboot of feature-length film circulated. As the show gained a cult following, members of the cast, including Ed Marinaro and Page Kennedy, hinted at a possible project. On April 8, 2014, the film was officially announced, with the creators launching a Kickstarter to raise funds; filming took place in North Carolina in late-2014. The film was released on February 2, 2016 by Lionsgate.


text: Alex Moran has begun his senior year at Blue Mountain State. Since the team is predicted to not do as well this season, he decides to dedicate his final year more to partying.


text: Meanwhile, a new dean threatens to take over the Goat House, the party location for the school's football team, Alex reaches out to Thad Castle, who has recently been drafted into the NFL, to buy the house. Thad agrees he will, but only if Alex throws a party in his honor and it meets his wild expectations. The party, full of drugs and amusement rides, gets out of hand, but Thad is impressed nevertheless.


text: The auction begins for the house, and Thad bids five million dollars on it (having outbid himself from three million). Alex celebrates having "his" house back, and Thad confronts him on only thinking of himself when agreeing to create Thadland. Thad angrily banishes Alex from the Goat House.


text: Alex, in a dream, sees a potential future where Sammy is dead, Thad, now a middle-aged wash-up, is living in the Goat House, having never left, and Alex is now his house boy. Horrified, Alex wakes up in the middle of a deserted field. He walks to a nearby road, where he flags down a car driven by his old teammate, Craig Shilo. The two go to Thadland together, which is still running as a shell of its former self, with derelict amusement attractions and multiple deaths as a result of partying too much. Alex finds a drugged out Sammy, who has eaten Billy as a form of vengeance.


text: At a press conference about Thadland and Coach Marty Daniels' poor personal behavior, Daniels angrily tells the reporters and Dean Oliviares off, admitting to everything he's done and denying any regret for it.


text: In the basement of the Goat House, Alex confronts Harmon about a balloon-based drugs and what is inside of them. Harmon reveals that the drugs are a fermented gas derived from the house's septic tank. A disgusted Alex uses his authority as captain to coerce Harmon to shut the tanks down, to which he complies. Upstairs, Alex finds Thad and Mary Jo, both of whom are high due to the drug. Alex confronts him about his supposed wealth and asks why he can waste his time at a party at a college campus rather than attending practice with his professional team. Thad tearfully reveals that his contract was voided due to his bad behavior upon receiving his money, and that all of his wealth was fake. Alex, enraged, asks why he did that, and Thad produces a handgun, declaring that if he couldn't have his wealth, he wanted to die because he was out of money and had no friends. Alex refuses to help Thad kill himself, but instead has another plan.


text: In the basement, Dick Dawg, Thad's cousin, begins to rig the septic and gas tanks to explode, but is confronted by a drugged Sammy; the two fight, with Dick Dawg easily overpowering Sammy, who is knocked unconscious by falling debris. The house begins to crumble, prompting everyone inside to evacuate. Upstairs, Alex and Thad embrace, with Thad asking him to remember his story. Alex leaves with Mary Jo, which Dick Dawg carries the unconscious Sammy out of harm's way. The Goat House explodes.


text: Mary Jo sympathetically consoles Alex about the house he fought so hard for, to which he responds that it's "just a house." The Dean celebrates his so-called victory over Alex but begins to hyperventilate from the excitement. Before Alex can confront him, Harmon, in the guise of providing oxygen, gives Oliviares a puff of his drug. The dean begins to hallucinate and promptly begins humping Holly, likely costing him his reputation and job. In a line-up, Alex, Mary Jo, Larry, Donnie, Harmon, Shilo, and Radon all toast to Thad's memory.


text: In March 2013, Ed Marinaro stated in an interview with Class Act Sports that he was working on a Blue Mountain State film. He continued to hint on Twitter at some 'behind-the-scenes' work being done on said movie. In early March 2014, Page Kennedy started hinting at Blue Mountain State reunion project on Instagram, Vine and Twitter along with Darin Brooks, Kelly Kruger, Alan Ritchson, Sam Jones III, Frankie Shaw and Romanski.


text: On April 8, 2014, "Blue Mountain State: The Movie" was officially announced. On April 15, the production launched a Kickstarter campaign, much like the hugely successful 2013 campaign by "Veronica Mars" to get the cancelled show made into a feature film. The project's goal was to raise $1.5 million by May 15 in order to fund the film. There were rewards for donating to campaign, such as personalized tweets from the cast (for donating $10), shot and pint glasses with the BMS logo ($20), and a speaking role in the film (for a $10,000 donation).


text: On May 11, 2014, the Kickstarter goal of $1.5 million was reached. On May 15, 2014 the Kickstarter campaign ended, with the final funds raised being $1,911,827 from 23,999 backers.


text: In May 2014, it was announced Jay Chandrasekhar would be the director of the film. However, on September 28, 2014, Lev L. Spiro was hired as the new director of "BMS: The Movie". The crew started filming in late 2014 on location in Wilmington, North Carolina.


text: Originally slated for a September 2015 release, the film was pushed back due to issues with the studio and distribution. Writer and producer Eric Falconer said the film originally received an NC-17 rating from the MPAA, but certain scenes were edited in order to get the film down to an R rating. On January 14, 2016, the film's trailer was released, along with Falconer setting a February 2, 2016 release date.


title: Chrysler Pacifica (minivan)

text: The Chrysler Pacifica is a minivan produced by the Chrysler division of Stellantis. It is unrelated to the discontinued crossover and concept vehicles by the same name and replaced the Chrysler Town & Country for the 2017 model year. It is positioned as the higher-end Chrysler minivan, above the Dodge Grand Caravan until 2020 and above the Chrysler Voyager (rebadged as the Chrysler Grand Caravan in Canada) since 2020.


title: Chrysler Pacifica (minivan)

text: The minivan is produced with two powertrains, a 3.6-liter gasoline-powered engine and a plug-in hybrid. The plug-in hybrid version has a 16-kWh lithium-ion battery that can propel the car up to on electric power alone. The gasoline-only version of the Pacifica minivan went on sale in mid-2016, while the plug-in hybrid version became available in early 2017.


title: Chrysler Pacifica (minivan)

text: In June 2013, it was reported that Chrysler was preparing to produce a new generation of its Town & Country minivan at the Windsor Assembly Plant, with production set to begin in 2015 and a release for the 2017 model year. An industry analyst reported that the new version would possibly be a crossover utility vehicle in the vein of the Pacifica.


title: Chrysler Pacifica (minivan)

text: In 2015, FCA CEO Sergio Marchionne announced that it would invest $2 billion in developing a new minivan, and overhauling the Windsor Assembly Plant to facilitate its production. A company issued plan of future vehicles revealed that a new Town & Country would begin production in February 2016 for the 2017 model year, and that the final-generation Dodge Grand Caravan would be maintained in parallel with the new Town & Country as a lower-cost option during the 2017 model year, after which it will be discontinued. Marchionne has been against "duplicate[d] investments" in product development—a strategy reflected by his reduction of badge-engineering between FCA US's domestic marques. On November 3, 2015, FCA filed to have its trademark registration on the Pacifica brand renewed; FCA's Head of Passenger Car Brands Timothy Kuniskis denied that this was related to any new products, and that it was standard industry practice to continue renewing its trademarks because "you don't want to lose names. Establishing new names is expensive."


title: Chrysler Pacifica (minivan)

text: Chrysler debuted the new vehicle on January 11, 2016, at the 2016 North American International Auto Show. Rather than being named the Town & Country, the new vehicle was branded as the Pacifica. The decision to drop the Town & Country brand was made primarily to distinguish the new vehicle from previous iterations; Director of Chrysler brand product marketing Bruce Velisek explained that the Pacifica was meant to "change the entire paradigm of what people know about minivans in the segment". Among its differences from the previous Town & Country is a new platform, and a design carrying a sportier appearance inspired by crossovers—a market segment that had cannibalized minivan sales—in an effort to disassociate the vehicle from other minivans with a boxier build. Chrysler also changed the minivan's sliding doors: they will be aluminum and hands-free, opening automatically when the fob holder waves under them.


title: Chrysler Pacifica (minivan)

text: The starting price of the 2017 Pacifica was . This was less than the starting price of the 2016 Town & Country. The base model plug-in hybrid, called "Premium", started at and the high-end "Platinum" model started at .


title: Chrysler Pacifica (minivan)

text: The production of a plug-in hybrid version was the first of its class in the United States, and according to chief engineer Kevin Mets, meant to create an electric vehicle that could feasibly be a family's "primary vehicle". The Pacifica Hybrid has a 16 kWh battery pack qualifying it in the US for the full federal tax credit and also to other incentives at the state and local level. In June 2017, Chrysler recalled 1,600 Pacificas to fix the electronics.


title: Chrysler Pacifica (minivan)

text: On November 7, 2017, Waymo announced that it had begun testing driverless cars without a safety driver at the driver position using the Pacifica plug-in.


title: Chrysler Pacifica (minivan)

text: The AWD option was made available in June 2020 for 2020 Touring-L models equipped with the AWD Launch Edition package. The Pacifica is currently the only minivan in the North American market to feature a traditional AWD system as the fourth-generation Toyota Sienna has switched to the E-four system with the rear wheels driven electrically.


title: Chrysler Pacifica (minivan)

text: Starting with the 2020 model year, the low-end "L" and "LX" models have been separated from the Pacifica nameplate and are now sold under the Voyager nameplate in the United States. This marked the return of the Voyager nameplate to the Chrysler model lineup, in which it was last used in 2016, and the North American market, in which it was last used in 2003 in the U.S. and 2007 in Mexico. In addition to the L and LX trim levels, an "LXi" model is available to fleet customers.


title: Chrysler Pacifica (minivan)

text: In the 2021 model year, Canadian sales of the model started under the Chrysler Grand Caravan nameplate with trim level designations carried over from the outgoing Dodge Grand Caravan (as opposed to the former base Pacifica) and no equivalent to the LXi model. This marked the return of the "Chrysler Grand Caravan" nameplate which was last used in 2007, primarily in South American markets.


title: Chrysler Pacifica (minivan)

text: The Voyager was restricted in the United States to fleet buyers for the 2022 model year. It continues the pre-facelift design and includes a long list of features and equipment with only two options: (1) the "SafetyTec Group" (Advanced Brake Assist, Pedestrian Emergency Braking, Full-Speed Forward Collision Warning Plus, Uconnect 5 NAV with 10.1-inch Display, ParkSense Rear Park Assist System with Stop, and Blind Spot Monitoring with Rear Cross-Path Detection System) and (2) the "Fleet Security Group" (Two additional key fobs and SiriusXM Guardian trial).


title: Chrysler Pacifica (minivan)

text: A restyled 2021 Chrysler Pacifica was introduced at the 2020 Chicago Auto Show in Chicago, Illinois. The 2021 model year Pacifica featured new exterior styling and is now available with all-wheel-drive (AWD) for gasoline-powered models. The Pacifica Hybrid versions use front-wheel-drive.


title: Chrysler Pacifica (minivan)

text: Unlike previous AWD Chrysler minivans, the AWD Pacifica retains the Stow 'n' Go seating. It is the first Fiat Chrysler Automobiles vehicle to feature the new Android-based Uconnect 5 infotainment system with a standard 10.1-inch high-resolution touchscreen display and wireless Apple CarPlay and Android Auto smartphone integration, as well as Amazon Alexa capabilities, as well as SiriusXM Satellite Radio and high-speed data connectivity. USB-C high-speed data and charging ports are standard equipment, and TomTom-based GPS navigation are optional. The "FamCam" rear camera system can display an image of rear passengers in place of a conversation mirror.


title: Chrysler Pacifica (minivan)

text: A new Pinnacle trim level adds "Pinnacle" badging on the front doors, unique leather seat trim, quilted leather pillows for the second-row seats, and unique exterior styling cues.


title: Chrysler Pacifica (minivan)

text: The Pacifica uses a new revision of the 3.6-liter Pentastar V6 engine, and is produced with two powertrains: gasoline-only and plug-in hybrid, the latter marketed as Pacifica Hybrid. The plug-in hybrid version uses a 16-kWh lithium-ion battery, located under the floor under the second row of seats (the hybrid is not available with all-wheel drive, eight-passenger seating, Stow'n'Go seating or vacuum), with an all-electric range of before switching back to using the gasoline engine. The battery can be fully recharged in two hours using a 240-volt plug-in system. The gasoline-only version of the Pacifica minivan went on sale in mid-2016; the plug-in hybrid version, in 2017. Chrysler expected the plug-in hybrid model to achieve a fuel economy of at least 80 miles per gallon equivalent, and on December 1, 2016, the EPA announced the minivan achieved 84 MPGe.


title: Chrysler Pacifica (minivan)

text: The Pacifica Hybrid operating in hybrid mode has the highest fuel economy of any minivan available in the American market . The following table presents the official EPA fuel economy ratings for all powertrain variants of the Chrysler Pacifica.


title: Chrysler Pacifica (minivan)

text: The 2017 Pacifica was tested by the Insurance Institute for Highway Safety (IIHS), and its top trim received a "Top Safety Pick+" award:


title: Chrysler Pacifica (minivan)

text: The 2022 Pacifica was tested by the Insurance Institute for Highway Safety (IIHS), and it received a "Top Safety Pick+" award:


title: Chrysler Pacifica (minivan)

text: In April 2016, Chrysler launched a television advertising campaign for the Pacifica entitled "Dad Brand", featuring comedian Jim Gaffigan and his children. In October 2016, Chrysler launched a social media-oriented campaign known as "PacifiKids", featuring videos in which unsuspecting families shopped for the vehicle at a dealership staffed entirely by children. The Pacifica has also been used in cross-promotional campaigns for the films "The Secret Life of Pets" and "Incredibles 2".


title: EuropaCorp

text: EuropaCorp S.A. (stylised in opening logo as EUROPA CORP.) is a French motion picture company headquartered in Saint-Denis, a northern suburb of Paris, and one of a few full service independent studios that both produces and distributes feature films. It specializes in production, distribution, home entertainment, VOD, sales, partnerships and licenses, recording, publishing and exhibition. EuropaCorp's integrated financial model generates revenues from a wide range of sources, with films from many genres and a strong presence in the international markets.


title: EuropaCorp

text: Over 14 years, EuropaCorp has produced and co-produced over 80 films and is now distributing over 500 titles after the integration of the RoissyFilms Catalogue. The studio is mainly known for its expertise in the production of English-language films with strong earning potential in the international marketplace. The company developed and produced the successful "Taken" trilogy and the "Transporter" series. The company began producing TV series in 2010 through "EuropaCorp Television" which had already adapted EuropaCorp's popular "Taxi" film franchise.


title: EuropaCorp

text: Since 2018, the company has faced tumultuous times following rape and sexual assault accusations towards its chairman and majority owner Luc Besson.