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  Fundamental MedicineTeresa Gryder, ND

What to Do for a Shoulder Injury

9/13/2018

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Shoulders are complicated. They're not like the hip, with a deep socket that makes them stable. The socket for the shoulder is a shallow divet on the front face of the shoulder blade, and the parts are held together by a collection of sinew, muscle and bone known collectively as the shoulder girdle. The shoulder has the biggest range of motion of any joint in the body, and because of this it is more vulnerable to injury.

The bones of the shoulder girdle are the shoulder blades and collar bones. The breast bone is considered part of the axial (midline) skeleton and serves as a kind of keystone in the arch of the shoulder girdle, keeping the shoulders wide. The shoulder blades are big flat bones that slide around on your upper back. They are held in place by sheets of fascia and the muscles that attach to them. The sinew of the girdle is fascia, tendons and ligaments. When these strong connective tissues are disrupted the whole thing falls apart. When all the parts are strong we can swing from trees like other primates, do hand stands and push-ups, reach forward to do fine work with our hands, throw a spear or a ball, swim long distances and reach the finest liquor on the top shelf. You may never realize, until you injure one, just how many things a shoulder does.

There are many ways to hurt your shoulders. You can tear the labrum, which is a disc of cartilage inside the joint that provides padding and a connection point for some tendons. You can injure the rotator cuff, which is a set of four small muscles and their tendons that comprise the deepest part of the joint capsule and help prevent dislocations. The supraspinatus tendon is one of the most commonly injured parts of the rotator cuff, and the injuries accumulate with age. We also are more likely to have arthritis and impingement syndromes with age. There are lots of muscles outside the rotator cuff that can get torn up. You can stretch or rupture the ligaments that hold the collar bones in place, most commonly the AC (acromioclavicular) ligament but there are others. You can tear the big muscles of the shoulder or you can even completely dislocate the ball from the socket, which can damage lots of things including nerves and blood vessels. You can make such a mess of your shoulder that you think you will never be able to pick up your own arm again, but unless you have ruptured tendons, it may heal on its own. You can even function without some of the tendons; the body has redundancy and it adapts. Given time and the ingredients for healing, our bodies can do amazing things.

I am a whitewater kayaker. Kayaking is almost as hard on shoulders as throwing or swimming. Not only are your shoulders part of the propulsion linkage for paddling, but they are used for balance in bracing, and for righting yourself when you flip over by using the Eskimo roll. I have injured my shoulders many times, and I have supported a lot of friends and patients as they go through shoulder injuries and surgeries. The most recent time I was injured I thought it would require surgery. I took 6 months off from kayaking (which was a long time) and my return to the river was gradual. After a year I was getting after it—without having surgery. People who get surgery rarely have outcomes better than that. Shoulder injuries are painful and slow to heal. The good news is that they usually do, you just have to be patient enough and keep moving.

Most people will go see their primary care doctor when the injury is painful, interferes with daily activities or favorite sports, and doesn’t get better fast enough. If you go to a doctor for your shoulder, you should get a proper shoulder exam. The doctor should test your strength and range of motion with a bunch of strange challenges. They’ll tell you to push out. Pull in. Lift your elbow against my hand. Pat your belly. If the doctor doesn't do a thorough exam, go to another doctor. The shoulder is complicated, and not every doctor is an expert on it. A person who knows the anatomy of the joint and how to examine it will be able to diagnose the injury better than all the fancy imaging in the world. This is called a clinical diagnosis, and with shoulders a good clinical diagnosis is more useful than imaging. With a good exam and clinical diagnosis you get better information about the prognosis and treatment for your shoulder than what you can get from an MRI, but again, this all depends on your doctor having knowledge and exam skills specific to the shoulder.

If the injury is severe and you have good insurance, your doctor may send you for an MRI and refer you to a surgeon for a consult. If you go this route, odds are good that the surgeon will want to operate. After all, that is what they do. This is when you should slow down and take some deep breaths. Do not rush under the knife. It is common to be told that you should get it done immediately. Take that statement with a grain of salt. If a tendon is completely ruptured, the muscle will dissolve away if it is not reattached soon, so that is a reason to get it done now. If that's not the case then get a second opinion. Odds are good that the second opinion will be different from the first, and if that is the case, you can go with the one you trust more, or get a third opinion for a tie breaker.

In most cases doctors will suggest physical therapy before considering surgery. Surgery is something to avoid unless it is really necessary. Shoulders can be badly hurt and refuse to work at all, and then later recover completely, or completely enough that you can do everything you want to do. So do not give up. If you decide to do physical therapy, do the exercises and keep after it. Over time you will learn more exercises and graduate to harder ones. Save the instructions and make a notebook of shoulder exercises for yourself. The same exercises you use to rehabilitate after an injury may be useful in the future for prevention.

If you decide that surgery is indeed what you must do, shop around for the best shoulder surgeon in your region. Surgeons will usually tell you that they do not know what they will do to your shoulder until they stick a camera in there and start working on you. But each surgeon has a slightly different approach. Ask about the procedures that they do most, and their strategies with regard to the shoulder. Find out as much as you can about their approach and philosophy and compare surgeons with each other. Surgeons don’t always communicate very well—they may prefer their customers anesthetized. Get someone to go with you to your consults to make sure you get the information you need. Find a surgeon you trust.

If you decide to avoid the knife and heal up your shoulder yourself, it's important to be gentle with yourself. Healing up from an injury usually takes less time than healing after a surgery, but for shoulders both are slow because there’s not a lot of blood circulating inside the shoulder joint. PT’s can offer expert advice about what kinds of exercises to do. Your average personal trainer could do you harm.  Therapeutic shoulder exercises usually involve bands or light weights, and having good posture really helps. You will want informed recommendations on diet, botanical medicine and other alternatives to enhance healing. I can offer those things and provide referrals for injection therapies (prolo or PRP), hydrotherapy and other treatments as needed. Depending on your injury it could be 6 months before you feel comfortable returning to your usual activities, and a year or more before you are all the way back up to speed. Definitely keep exercising however you can, because keeping yourself fit supports your body's efforts to fix any injured parts.

Keeping moving is always key. It's OK to rest a body part for a little while when it's hurting from an injury, but move the rest of you, and move the hurt part as soon as you can stand to.  If you keep a shoulder still too long it can freeze in place and it is excruciating to break a frozen shoulder free. Learn the exercises to strengthen the small muscles of the rotator cuff and the big muscles of the shoulder girdle and do them properly. Develop routines for moving your shoulder through its entire range. Swing like a monkey, do push-ups and other intense exercises only when your shoulders are ready.

If you need help or encouragement in making decisions about surgery, or for healing a shoulder whether they operated or not, I would be glad to assist. I can help you find the right shoulder surgeon if you need one, and come with you to appointments to be your medical advocate.  I have a great protocol for surgery prep to increase your odds of an excellent outcome, and I can set you up with a recovery protocol specific to you and your needs. While PT’s specialize in exercises and conventional doctors give meds and do surgery, I can help with all the other ways to support healing. You can use the contact form on this website or contact me directly for more information.
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On Spiritual Practice and Loving Life

3/26/2017

 
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What do you practice in your life?  I believe it was the Mahatma Gandhi who said that bit about how your thoughts become your actions and on down the line…. It was about how you create yourself by what you choose to think and believe.  A practice is anything that you do regularly, even ritually.  A morning cup of coffee is a common practice.

​If it is true that what you do becomes who you are, it is worth putting some thought and intention into your own personal practice.


There are a lot of yoga practitioners out there.  I count myself as one.  I practice at least a little yoga every day.  For me it is the avenue by which I came to recognize and respect my own body, which was necessary before I could begin to care for it.  I was in denial of my body for many years.  In my 20’s, though I looked fit, I could not touch my toes without bending my legs.  One cannot gain flexibility without a regular practice, because it is a gradual process.  And one cannot be truly strong without flexibility; if you can’t use the full range of your body’s movements, your strength is hobbled.  I believe this applies to flexibility of the mind, too.  If once lacks mental flexibility, one cannot learn.

Many say we should all develop a spiritual practice.  This is about choosing at least some thoughts and actions that are oriented toward our highest values and goals.  A cup of coffee might not satisfy this.  Having some small fraction of each day that is dedicated to the big picture, to the people and things that we most love, is a simple way to remind us that we are part of that Wholeness that is the World.  Regardless of your belief system—and even if you are firmly atheist or mildly agnostic—you will benefit from such a practice.  The research tells us that you will live longer, be less depressed, and be more likely to request life-extending medicine when your time is short.  You will love life more.

I personally have been mulling on these ideas of a practice because I now have a medical practice as well.  What is the core of my practice?  It is evolving.  Perhaps the most important thing I can do for my patients is to help them to notice the great blessings that abound as long as we live.   The irritants of daily life are passing things, often irrelevant in the longterm.  I practice meditation, gratitude, kindness, the four agreements, and also being in nature.  My church the is river, sky, mountain, snows of winter and buds of spring.  Science shows that being in natural environments lowers blood pressure and stress hormones, but I believe it does more than that.

I also practice Feng Shui.  Not in any traditional way, but in the deeper concept.  Feng Shui taught me that the physical things that surround me either facilitate or impede my practice.  I strive to make every item in my space a reminder of all I have to be grateful of, and what I am striving for.  If physical things get in my way, I move them.  If they are not moveable, I move other things to improve the flow.

So now you know my practice.  What is yours?  I look forward to hearing about it.
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I am an ALLY

8/27/2015

 
I just completed a training at NCNM and what I learned is that there ARE other people in the community who are impassioned about social justice. Sometimes, when I'm walking down the street, and the people around me are completely closed off from each other, I wonder. I feel good every time that I am the one to stop and ask if someone is OK, offer a hand with something, or otherwise step up to be part of the kinder gentler world that civilization is supposed to bring.

I feel our common humanity more deeply than I fear our external differences. I do not care what color you are, or what you think is sexy, or which religion you think is the right one.  What I care about is joy.

So presume only that I will take you as another human, doing the best you can. I hope you will see that I am no different.
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New Location: Macadam Building, John's Landing

3/30/2015

 
I'm pleased to announce that my new office is nearly ready.  There are still a few pieces of furniture to bring in, and some new equipment on order.  This is the waiting room, and that thing on the wall (left side) is a water fountain that makes a delightfully relaxing sound.  My office is the one with the light coming in on the right.  More photos to come.
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Healthcare in America is Mostly Sickcare

9/10/2013

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What I hear is that most everybody in America is frustrated about healthcare.  Maybe you have good insurance, but then the doctor doesn't listen, or the treatment doesn't work.  Maybe you're on pills and don't know what they're for.  Maybe you don't have insurance and flat out can't afford to get help.  Maybe you think something's wrong but don't want to confirm it because then you'd have to deal with it.  We all worry, and it's not easy to sort out what to do.  Doctor Google can be misleading, and sometimes terrifying.  The assortment of supplements at the store is overwhelming.  Everybody thinks they know what will help you, but they don't know your whole story.  They don't know the half of it.  It's not an easy situation.

I offer a win-win deal: I will take a thorough history and get to know you enough to have an idea how the parts of your life are affecting you.  Then I educate you about your options, including alternative and conventional therapies.  In the end, using real information you choose what you want to do.  Conventional medicine is the best answer for some situations and conditions.  Naturopathic medicine helps as long as you are willing to do more than pop pills and sit on the couch.  If I can't help you, I will help you find someone who can.  I consider it my job to provide you with current, personalized, unbiased information, not to keep you a slave to some treatment that only I can offer.

My personal slant is scientific.  I realize that many people consider Naturopathy to be quite "alternative".  Considering what has happened with pharmaceutical medicine, an alternative is much needed.  Naturopathic Medicine (as I use it) is a combination of traditional healing (forgotten in the age of pharmaceuticals) and the application of new knowledge about how our choices affect body function and healing.  Conventional medicine is not keeping up with the changing times. A simple change in your diet or lifestyle could do you more good than a drug that you take for the rest of your life (and save you a gazillion dollars).   Making informed, gradual improvements to your diet and lifestyle will save you money, increase your quality of life, and help you stay away from the doctor, the pharmacy, and the hospital.

If you are one of those skeptics who has avoided alternative medicine because you don't think naturopaths have any real training, come see me for a free 15 minute introduction. I would like to tell you how a science-minded skeptic like myself can embrace Naturopathy.  I can show you some of the great research that supports nonpharmaceutical and nonsurgical approaches to health.  There's plenty of it.

There are plenty of reasons to seek alternatives when facing the gauntlet of what insurance will buy for your health.  It's not cheating to get a second, or third opinion about any persistent health problem.  Before you take the toxin, or submit to the knife, it is wise to be sure that is what you need to do.

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Be Skeptical

8/31/2013

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In this day and age, it is necessary to second guess every information source.  So much "information" goes by that it becomes difficult to sort out what is advertising and what is not.  Even reporting about scientific research can completely skew the issue.  It doesn't pay to be gullible.

The problem is that we are wired to be gullible.  We humans would much rather trust in some comfortable authority figure and believe what they say, than to do all that research and work ourselves.  Figuring out the truth takes time...and sometimes the truth is elusive.  We just don't know everything yet.  We'd rather just believe.

Modern first-world culture is divisive and argumentative.  People agree to disagree more often than agreeing in substance.  As in other parts of our public arena, in the healthcare debate the shouting overwhelms reasonable conversation. Conventional treatments espoused by governments and establishment medical business may not be supported by the research. The policy came about when someone had to make a decision by a deadline using the best information available. We all do it.  We have to go on what we know, even if it is incomplete or incorrect. More information comes along, but established policy stays the same.  This is the downside of bureaucracy. Proponents of established methods will say that this must work because it is the rule, and don't worry about finding out the truth.

Alternative treatments are espoused by a wide range of practitioners and patients.  Often alternative treatments have little or no science backing them up.  Proponents say this works because they have seen it work, and maybe it did.  Just because there is no science doesn't mean it isn't true. Proponents also commonly claim that the science backs them up when it does not.

The Skeptic doesn't believe anything just because an authority said so.  The Skeptic asks questions, and studies the important questions, so as to be able to know if someone is speaking from a position of knowledge and perspective, or blowing a lot of hot air.  The Skeptic realizes that real information or falsehoods can come from any side, and runs every morsel through an internal fact-checker.  The truth is a moving target, and the skeptic is ever on the hunt.
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I passed boards!  ...And rowed the Colorado through Grand Canyon

10/23/2012

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After taking boards in August, I went on a series of adventures.  As you may know by now, my favorite form of outdoor recreation is boating down whitewater rivers.  I got to run the Rogue River here in Oregon for the first time, and returned to Arizona for another trip down the mighty Colorado River through Grand Canyon.  Our Grand Canyon adventure was 21 days long; a very long time to be away from cars, money, electricity, and everything else modern.  I love that.  On both trips I was rowing a raft.  I enjoy rowing in part because it strengthens my core and makes me feel awesome.  I had let myself get soft while studying for boards, and I feel much stronger after these trips.

While we were away my board results came in.  My mail was on hold so it wouldn't pile up in the mailbox.  When we got home I fell to the project of unpacking and cleaning up.  My partner asked me "Are you going to open the mail?" and finally I did.  I expected to pass, but the way those exams are, you never know for sure until you get the results.  Thankfully, I passed with room to spare.  I'm done running around on major multi-day river trips for now, and well rested to tackle the paperwork involved in starting up my practice.  Here goes!!!
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I'm Moved

6/12/2012

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Well folks I've relocated my kit and caboodle from SE to SW Portland.  I remember reading somewhere, years ago, that moving incurs stress equivalent to a death in the family.  I hope that's not true because I've moved so many times it would be like having lost my whole family more than once.  I think that would be worse.  Still, it's stressful.  Even now I am looking for my slippers, my clippers, my this and that.  Nothing is normal for a while after a move.  But it's getting better.
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Graduation Date Coming into View

12/6/2011

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I have just one more term to go, with two clinic shifts and an excellent elective (advanced gynecology).  I'll have time to get in shape again!  I have gotten soft from sitting in class so much.  I thought I was going to be taking boards this coming February, but I'll be taking them in August, most likely here in Portland.  I've started to enjoy Portland more in the last year.  I met some great people and started to kayak the incredible whitewater in the region.  It's going to be hard to leave.  I love Portland and my friends and patients here, but I am not a city girl.  I need to get out to where I can walk in the forest and play in the snow, and hear the sounds of nature instead of buses, trucks, trains and neighbors.
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    Author: Teresa Gryder

    Integrative Physician and Student of Life, Medicine, and the River.

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