Due to the repetitive stress from poling, Nordic skiers can develop overuse injuries of both the elbow and/or the shoulder. The most common of these are medial epicondylitis and shoulder impingement syndrome.   The underlying cause of the development of these injuries is multi-factorial: poling technique, pole length, and poor strength and conditioning.  

Shoulder impingement syndrome is caused by underlying weakness of the rotator cuff and muscles around the shoulder blade.  This underlying weakness causes impingement or pinching of the rotator cuff between the humerus and glenoid (ball and socket of the shoulder joint), which can be further exacerbated by poor poling technique.  Therefore to prevent developing shoulder pain during your Nordic ski season, make sure you incorporate strength and conditioning of your rotator cuff and periscapular musculature.

Medial epicondylitis is an irritation of the tendon of the wrist flexors and presents as pain on the inside of the elbow.  This irritation is caused by repetitive stress to the tendon mainly from poor poling technique, but also from underlying weakness of the wrist flexor muscles.   Thus prevention of medial epicondylitis can be achieved through working on your poling technique and ensuring you have proper forearm strength.

See More Injury Prevention in Nordic Skiing: Knee Pain

See More Injury Prevention in Nordic Skiing: Lower Back Pain

See More Injury Prevention in Nordic Skiing: Technique

 

Jason Lunden, DPT, SCS specializes in the rehabilitation and prevention of sports-related injuries, with a particular interest in the biomechanics of sporting activities – running, cycling, skiing, snowboarding and overhead athletics. He has published on the topic of shoulder biomechanics and the rehabilitation of knee injuries and has a strong commitment to educating others. Jason serves as a physical therapist for the US Snowboarding and US Freeskiing teams and is a frequent, well-received local and national presenter on the topics of sports rehabilitation and injury prevention. If you have specific questions about how to strengthen, restore, and get back on the slopes and trails, contact us at Excel Physical Therapy, 406.556.0562 in Bozeman, Montana or 406.284.4262 in Manhattan, Montana. #excelptmt

Low back pain has been found to be more common in cross-country skiers, than non-athletic controls1.   Compared to skate skiing, low back pain is more prevalent in classic skiing because of the repetitive flexion-extension loading pattern of double poling.  In addition to making sure your technique is sound, it is important to make sure you have adequate core abdominal, hip, and spinal extensor strength.  So make sure you incorporate proper core and hip strengthening in to your training.  Furthermore, improving hip flexibility has been shown to decrease the rate of low back pain in Nordic skiers2.  Hip flexor flexibility is especially important, so make sure to incorporate hip flexor stretching as part of your normal routine.

1Bahr R, Andersen SO, Løken S, Fossan B, Hansen T, Holme I. Low back pain among endurance athletes with and without specific back loading–a cross-sectionalsurvey of cross-country skiers, rowers, orienteerers, and nonathletic controls. Spine (Phila Pa 1976). 2004; 29(4):449-54.

2Alricsson M, Werner S. The effect of pre-season dance training on physical indices and back pain in elite cross-country skiers: a prospective controlled intervention study. Br J Sports Med. 2004;38(2):148-53

See More Injury Prevention in Nordic Skiing: Technique

See More Injury Prevention in Nordic Skiing: Elbow & Shoulder Pain

See More Injury Prevention in Nordic Skiing: Knee Pain

 

Jason Lunden, DPT, SCS specializes in the rehabilitation and prevention of sports-related injuries, with a particular interest in the biomechanics of sporting activities – running, cycling, skiing, snowboarding and overhead athletics. He has published on the topic of shoulder biomechanics and the rehabilitation of knee injuries and has a strong commitment to educating others. Jason serves as a physical therapist for the US Snowboarding and US Freeskiing teams and is a frequent, well-received local and national presenter on the topics of sports rehabilitation and injury prevention. If you have specific questions about how to strengthen, restore, and get back on the slopes and trails, contact us at Excel Physical Therapy, 406.556.0562 in Bozeman, Montana or 406.284.4262 in Manhattan, Montana. #excelptmt

I have recently been thinking quite a bit about the importance of joint mobility, not strictly for function, but for joint health. In manual therapy, assessment of a given joint in the body always consists of consideration of joint mobility. Is there enough mobility? If not, why not? Does the joint itself have a motion restriction? Or is there perhaps some tissue outside the joint, like a tight muscle, that is limiting mobility? While it makes sense that a certain degree of motion is important for functional tasks, like bending your knee a certain amount to ascend stairs, mobility is also critical for joint health.

Joint pain is often accompanied by some loss of joint mobility. While it may be possible to get by with a small loss of motion this may be taking its toll on your joint. Taking a joint though it full available motion is critical to providing nutrition to a joint. Nutrients and metabolic waste products are housed in a joint’s synovial fluid and are moved in and out of a joint through motion. Each joint has a position, either fully bent or fully straight, that provides the most narrowing of the joint space. This position in physical therapy is called the close-packed position which allows the joint to excrete waste products. This in turn provides room to draw nutrients into the joint through the joint capsule. When one loses the ability to close-pack a joint it can lead to a slow degenerative process resulting in conditions like osteoarthritis and pain.

This principal applies to the smallest joints at the tips of the fingers, to the joints in the spine, as well as to larger joints like the shoulder and knee. If you have a joint that seems to be getting stiff consider having this assessed by an orthopedic professional. Preserve the motion of your joints and you will be taking an important step to promoting good joint nutrition and health.

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About Matt Heyliger, DPT: Matt completed his Doctorate in Physical Therapy at Eastern Washington University in Cheney, Washington. During his clinical experience with the Sports Medicine and Extremities team at The Orthopedic Specialty Hospital in Salt Lake City, Matt was exposed to a wide variety of surgical and non-surgical conditions and developed a solid foundation for the assessment and treatment of orthopedic conditions related to the extremities. Prior to completing his Doctorate of Physical Therapy degree, Matt obtained his Bachelor’s Degree in in philosophy at the University of California, Santa Barbara.

 
Matt has developed a specific interest focus in biomechanics and how impairments at one level or joint affect other body structures. More specifically, he has a particular interest in the relationship of cervical/thoracic spine mechanics and upper extremity conditions. Matt is an avid rock climber, telemark/backcountry skier and mountain biker. Matt regularly practices yoga and enjoys frequent adventures in the mountains with his wife and their Alaskan Malamute.
 
Matt treats patients out of the Excel Physical Therapy offices in Bozeman and Manhattan, Montana offices. You may schedule an appointment with him at 406.556.0562 (Bozeman) or 406.284.4262 (Manhattan).

Excel PT Matt Spire Climbing Injury Screens Facebook JpegClimbing unquestionably takes a toll on the body and many if not all climbers end up dealing with some type of injury each season. When our bodies tell us a break from climbing is mandatory, we often make the mistake of not correcting the biomechanical factors that made us vulnerable to injury in the first place. Often times these predisposing factors are easy to correct with proper assessment and the right treatment plan.

Screening includes:

Each screening will be approximately 15-20 minutes long so please be prompt.

Sign up online at the following link: www.spireclimbingcenter.com/onlineregistration

Scroll to Events and select the FREE Injury Screening link and fill out the appropriate information.

Matt Heyliger, DPT is a physical therapist with Excel Physical Therapy and an avid rock climber.

 

 

 

 

There is no doubt that leg length differences (LLDs) exist, but a lack of agreement exists about diagnosing the condition, their functional importance, and how to treat them.  How many of us have been to the physical therapist, massage therapist, or chiropractor and were told that our legs were not of equal length?  Lying face up on the exam table, we ponder what to do about this recent revelation.

Most experts agree that 0.5 centimeters (1/8 inch) or less of leg length difference is not significant.  Furthermore, most clinicians agree that mild to modest discrepancies should not be corrected in the absence of pain or dysfunction.  If it doesn’t hurt, then don’t fix it.  But what if the difference is causing problems?  How reliable is a clinician’s assessment of your LLD?

LLDs can be either anatomical or functional.  An anatomical LLD is present because of a structural (bone; cartilage) difference, comparing one leg to the other.  For example, an individual may have broken a bone in his or her leg at a young age, creating a disturbance in the growth plate, ultimately leading to an alteration in that bones final, mature length.  A functional leg length occurs when a limb only presents longer or shorter because of being forced into this position by changes in muscles or other soft tissues of the low back, hips, or feet.   Tight muscles in the right side of your low back can draw up the right leg, making it present as shorter. 

Clinically, physical therapists can pick up a LLD by looking at your leg lengths in standing and lying down with the use of visual inspection and tape measurement.  There have been several studies looking at the accuracy of LLD clinical assessment and the evidence seems to point towards our ability in picking up these discrepancies.  However, clinical accuracy is limited.  I can say “Mrs. Jones, your left leg is around 1 to 1.5 centimeters longer on the right.”  I cannot say “Mrs. Jones, your left leg is exactly 1 centimeter longer on the right.”  Only obtaining an x-ray or CT-Scan of the legs can give you a fairly accurate number on LLD.

Most of us are walking around with some type of LLD, which is more likely functional, rather than anatomical.  Don’t be surprised if someday you are told that one leg is longer or shorter than the other.  In the presence of pain, a LLD can be addressed by placing a heel lift in the shoe or adding to the sole on the outside of the shoe.  Use caution when correcting a LLD.  A good rule of thumb is to correct for no more than ½ of the suspected LLD and only make an alteration of 3 to 5 millimeters at one time.  Wait several weeks to month a month before trying additional lift height.  Your physical therapist or other health care professional can assist you in this process.

To reach David Coletta, MPT, CMPT with any LLD questions, please contact him at “david at excelptmt dot com” or call our Excel Physical Therapy Bozeman office at 406.556.0562.

Do you have patellofemoral knee pain? A recent study by Christopher Powers et al. in the Journal of Orthopaedic & Sports Physical Therapy suggests that knee angle during quadriceps strengthening exercises affects patellofemoral joint stress. Because excessive joint stress may contribute to patellofemoral pain, the author’s purpose was to determine which exercises were minimally stressful to the knee.

                                                                                                       

During the squat exercise, joint stress was the least in the standing position, and increased as a subject descended into the squat position, peaking at 90 degrees of knee flexion. In an open chain seated leg extension exercise the joint stress was variable depending on the type of weight used, however joint stress was generally greater when the leg was fully extended.

 

The authors suggest that a squat exercise from standing to 45 degrees knee flexion coupled with an open chain seated leg extension from 90 degrees to 45 degrees knee range of motion is the best combination to minimize patellofemoral joint stress and therefore strengthen the quads without increasing pain.

 

We can help you if you suffer from patellofemoral knee pain. Call us at 406-556-0562 (Bozeman) or 406-284-4262 (Manhattan). 

Plantar Intrinsic Training

by Matt Heyliger, DPT, Excel Physical Therapy

Over-pronation (the inward roll of the foot while walking or running) is a common contributing factor in the development of several lower extremity injuries including plantar fasciitis, Achilles tendinopathy, patellafemoral knee pain and other overuse conditions. Recent research addressing the contributing factors to the development of plantar foot pain (pain at the bottom of your foot) has emphasized the importance of training the muscles of the foot to keep the arch from collapsing inward. It has been proposed that the intrinsic plantar muscles of the foot play a similar role in arch preservation as the core muscles play in the stabilization of the trunk and spine. This concept provides a great foundation for direct treatment of conditions associated with over-pronation.

 

A recent study by Mulligan and Cook, published in the journal “Manual Therapy,” presented this concept and sought to test if the performance of a series of exercises (named “Short Foot Exercises”) directed at isolating the recruitment of the plantar foot muscles could decrease pronation after four weeks of training. They discovered a small, but significant difference in arch height and these differences were preserved after eight weeks without continued training. While these exercises are tedious and initially challenging, our patients here at Excel Physical Therapy are responding well to these exercises. If you have been dealing with plantar foot pain and are not responding to other therapies or orthotics, consider training the “core” of your feet with Short Foot Exercises.

 

Be sure to contact a licensed health professional before starting any exercise plan and for a thorough evaluation or diagnosis of your issue. We can help. Call us in Bozeman at 406.556.0562 or in Manhattan at 406.284.4262.

 

About Matt Heyliger, DPT:

Matt completed his Doctorate in Physical Therapy at Eastern Washington University in Cheney, Washington. During his clinical experience with the Sports Medicine and Extremities team at The Orthopedic Specialty Hospital in Salt Lake City, Matt was exposed to a wide variety of surgical and non-surgical conditions and developed a solid foundation for the assessment and treatment of orthopedic conditions related to the extremities.
Matt is an avid rock climber, telemark/backcountry skier and mountain biker. Matt regularly practices yoga and enjoys frequent adventures in the mountains with his wife and their Alaskan Malamute.

 

My Personal Bout with Acute Neck Pain: Recovery ~ Part 2 of 3

Recovery

As a physical therapist specializing in treatment of the spine, I had a great deal of experience with the physicians at Bridger Orthopedic & Sports Medicine.  This seemed like a good place to seek advice and help for my agonizing condition.   I called Christine, a patient care coordinator at Bridger, and she was kind enough to get a same day appointment for me with Dr. Speth and Bryce Wiley, PA-C.  They performed a very thorough evaluation and determined that I most likely had a cervical radiculopathy.  I was in for a cervical MRI the next day and Bryce called to inform me that the imaging revealed a left C5/C6 disc bulge with compression on the C6 nerve root.  There was also some cervical arthritis present in the mid to low neck.

Again, the patient care coordinators (Christine & Shane) quickly scheduled me for a cervical steroid injection with Dr. Slocum at the surgery center, just below Bridger Orthopedics & Sports Medicine.  Dr. Slocum was kind enough to come downstairs between seeing patients and perform a transforaminal steroid injection in the neck.  During the procedure, I took the opportunity to dissect what was going on.  Some of my patients go through spinal injections and they will often ask me if it is painful.  Now I was about to find out.  I’m sure the experience is different for all people, but my procedural pain was considerable, though quite brief.  Dr. Slocum injected around C6 on the left and for about 5 to 6 seconds I felt all of the pain that I had experienced over the last week and a half condensed into my neck, shoulder blade, and arm.  Within a few minutes there was some relief.  Dr. Slocum explained that the injection could take 1 to 2 weeks for the full positive effect, but I would experience an initial decrease in pain within the first day, which might not last.

The next morning I woke up and felt 90% better.  I could move my neck, lie down comfortably on my back, and work on patients without concentrating on my own pain.  Slowly, by the next day this reduction in pain slid backwards to about 50% better.  I had a problem.  Two days later, I was to be on a flight to Chicago for a much anticipated PT continuing education course.  Bryce prescribed me another round of oral steroids and more hydrocodone for pain relief.  I made it to Chicago, wearing a soft cervical collar on the airplane to support my neck. 

I arrived at my continuing education course tired, now only 40% better, and unable to sit during the presentation.  I was truly blessed to be traveling with Jason Lunden, one of our sports specialist PTs from Excel PT, and sitting next to another experienced PT named Effie.  During the first break she looked at me and asked if I was OK.  She got the full story.  Effie said “I can help you.”  I immediately explained how serious this problem was and that I probably was not appropriate for hands-on PT treatment.  She assured me that her specialty was in spine.  Sounds familiar.  Effie performed left sided cervical and upper thoracic joint mobilizations, soft tissue techniques to the shoulder blade and shoulder muscles, and traction to the neck.  These techniques were more aggressive than I would have chosen for my patients, but I was willing to try anything and I trusted her.  After 10 minutes of treatment, my pain was reduced greatly and I practically fell asleep on the table.

Effie treated my neck again on the following 2 days of class and, by the time I returned home to Bozeman, the symptoms were improved to 75% of normal.  I continued under the care of Megan Peach, at Excel PT, and I reached 95% improvement over the next month with physical therapy treatments 2x/weeks.  The remaining 5% of symptom reduction and full strength in the left arm took 2 to 3 more months of performing my exercises independently.  

Click Here to read David’s Personal Bout with Acute Neck Pain: Lessons Learned ~ Part 3 of 3

Click Here to read David’s Personal Bout with Acute Neck Pain: The Onset ~ Part 1 of 3

My Personal Bout with Acute Neck Pain: Lessons Learned ~ Part 3 of 3

Lessons Learned

I believe that there was a silver lining or a purpose to why I experienced this cervical radiculopathy.  As health care practitioners, we sometimes lose perspective on the severity of what our patients are dealing with.  The terrible pain, decrease in function, and loss of sleep will be hard to forget.  I gained valuable familiarity with the use of a Saunders Cervical Traction Unit and other treatments that are best for an acute and sub-acute radiculopathy.  I also became more personally familiar with the use of different medications to treat this condition.

Perhaps the most valuable lesson learned was an appreciation for how important good physical therapy and excellent physician specialty care are.  I would not be where I am today without the tremendous care from Megan and Effie (my physical therapists), Dr. Slocum, and the doctors at Bridger Orthopedics and Sports Medicine.  Hands on manual therapy, exercises, diagnostic imaging, and epidural steroid injection were all very helpful to me.

This ordeal has helped me to be a better physical therapist when treating the neck.  I value the experience over any class or formal education in my past.

Click Here to read David’s Bout with Acute Neck Pain: The Onset ~ Part 1 of 3

Click Here to read David’s Bout with Acute Neck Pain: Recovery ~ Part 2 of 3

Our patients have found this information interesting so we are sharing the following article from the Wall Street Journal’s Health Journal:

 

How Your Knees Can Predict the Weather

Granny was right: Scientists find link between achy joints and the forecast

By

Melinda Beck
 
Oct. 14, 2013 7:12 p.m. ET

The Wolff family of Paramus, N.J., was eyeing the gathering clouds and debating whether to cancel a planned park trip when 6-year-old Leora piped up with an idea: “Let’s call Grandma. Her knees always know when it’s going to rain!”

Leora’s grandmother, Esther Polatsek, says she started being sensitive to the weather in her 20s, when a fracture in her foot would ache whenever a snowstorm approached. Now 66 and plagued by rheumatoid arthritis, Mrs. Polatsek says she suffers flare-ups whenever the weather is about to change.

“It’s just uncanny. Sometimes it’ll be gorgeous out, but I’ll have this awful pain. And sure enough, the next morning it rains,” she says. “It may be just a few drops, but it makes my body crazy.”

Do weather conditions really aggravate physical pain?

It is one of the longest running controversies in medicine.

Weathering the Pain

You can’t change the forecast, but you can lessen its impact.

  • Take a pain reliever or anti-inflammatory in advance if a storm or cold weather is forecast.
  • Dress warmly in the cold, including thermal socks, gloves and a vest.
  • Keep out drafts at home by sealing doors and windows and carpeting floors.
  • Apply heat to aching joints.
  • Use a dehumidifier to avoid spikes in dampness.
  • Consider visiting a warm, dry climate, although the benefits may wear off after a prolonged stay.
  • Maintain a healthy body weight.
  • Stay active, keeping muscles strong around damaged joints.

Hippocrates in 400 B.C. noticed that some illnesses were seasonal. The traditional Chinese medicine term for rheumatism (fengshi bing) translates to “wind-damp disease.”

But modern scholars have gotten inconsistent results in studies that tried to match weather patterns to reported pain symptoms—leading some to dismiss the connection as highly subjective or all in sufferers’ minds.

“People’s beliefs about arthritis pain and the weather may tell more about the workings of the mind than of the body,” concluded the late Stanford psychologist Amos Tversky in the mid-1990s, after comparing the pain reports of 18 rheumatoid-arthritis patients with local weather conditions for a year and finding no connection.

Still, other studies have linked changes in temperature, humidity or barometric pressure to worsening pain from rheumatoid arthritis and osteoarthritis, as well as headaches, tooth aches, jaw pain, scar pain, low-back pain, pelvic pain, fibromyalgia, trigeminal neuralgia (a searing pain in the face), gout and phantom-limb pain.

 

Bill Balderaz had a rheumatoid-arthritis flare-up last year—just before a surprise storm hit Ohio. Jason Joseph

Scientists don’t understand all the mechanisms involved in weather-related pain, but one leading theory holds that the falling barometric pressure that frequently precedes a storm alters the pressure inside joints. Those connections between bones, held together with tendons and ligaments, are surrounded and cushioned by sacs of fluid and trapped gasses.

“Think of a balloon that has as much air pressure on the outside pushing in as on the inside pushing out,” says Robert Jamison, a professor of anesthesia and psychiatry at Harvard Medical School. As the outside pressure drops, the balloon—or joint—expands, pressing against surrounding nerves and other tissues. “That’s probably the effect that people are feeling, particularly if those nerves are irritated in the first place,” Dr. Jamison says.

Not everyone with arthritis has weather-related pain, says Patience White, a rheumatologist at George Washington University School of Medicine and a vice president of the Arthritis Foundation. “It’s much more common in people with some sort of effusion,” an abnormal buildup of fluid in or around a joint that frequently occurs with inflammation.

Many patients swear that certain weather conditions exacerbate their pain. Consequently, orthopedists, rheumatologists, neurologists, family physicians, chiropractors, physical therapists—even personal trainers—report an increase in grousing among their clients when the temperature drops or a storm approaches.

“I can tell you emphatically there are certain days where practically every patient complains of increased pain,” says Aviva Wolff, an occupational therapist at the Hospital for Special Surgery in New York City, and Mrs. Polatsek’s daughter. “The more dramatic the weather change, the more obvious it is.”

Both the Weather Channel and AccuWeather have indexes on their websites that calculate the likelihood of aches and pains across the country, based on barometric pressure, temperature, humidity and wind. Changes in those conditions tend to affect joints even more than current conditions do, says AccuWeather meteorologist Michael Steinberg, which is why the Arthritis Index shows more risk the day before a storm or a sharp drop in temperature is forecast.

Some sufferers say their joints can be more accurate than meteorologists. Rheumatoid-arthritis sufferer Bill Balderaz, 38, president of a digital-marketing firm in Columbus, Ohio, recalls feeling “the worst arthritis pain I’ve ever had—I could barely move” one day last year, even though it was sunny and clear. By midafternoon, a land-based hurricane known as a derecho with 80 mile-per-hour winds unexpectedly buffeted Ohio and three other states, traveling 600 miles in 10 hours and knocking out power for 10 days. “The storm caught everyone off guard. It was clear one minute and then the skies opened up,” Mr. Balderaz says.

Tests on animals seem to bear out the impact of weather. In one study, guinea pigs with induced back pain exhibited signs of increased pain by pulling in their hindpaws in low barometric pressure.

Cold weather seems to raise the risk of stroke, heart attacks and sudden cardiac death, some research shows. Heart-attack risk rose 7% for every 10 degrees Celsius (18 degrees Fahrenheit) drop in temperature, according to a study of nearly 16,000 patients in Belgium, presented at the European Society of Cardiology last month. British researchers studying years of data on implanted defibrillators found that the risk of ventricular arrhythmia—an abnormal heart rhythm that can lead to sudden death—rose 1.2% for every 1.8 degrees Fahrenheit drop, according to a study in the International Journal of Biometerology last month.

Once blamed on physically demanding tasks like shoveling snow, the increased heart risk due to cold may be due to thickening blood and constricting blood vessels, researchers think.

And rising humidity may cause joints to swell and stiffen. In fact, tendons, ligaments, muscles, bones and other tissues all have varying densities, so they may expand or contract in different ways in changing conditions, Dr. Jamison says.

In people with chronic inflammation from arthritis or past injuries, even slight irritations due to the weather can aggravate sensory nerve cells, known as nociceptors, that relay pain signals to the brain. That may explain why some people with neuropathic pain and phantom-limb pain also report weather-related flare-ups.

“Fibromyalgia patients seem to be the most sensitive,” says Susan Goodman, a rheumatologist at the Hospital for Special Surgery. She also notes that while some people seem to be extremely sensitive to weather, others with similar conditions aren’t, for reasons that aren’t clear. That may explain why many studies find no clear association, she says.

Some weather conditions seem to relieve pain. In one study, the warm, high-pressure Chinook winds common to western Canada lessened patients’ neuropathic pain, the kind brought on by disease or injury. For other patients, the same climate increased migraines and sinus headaches.

Some pain sufferers say they feel better in warm, dry climates where weather conditions seldom change. When she went to Israel in the 1990s, “I felt like I was 20 years younger when I stepped off the plane,” says Mrs. Polatsek, the rheumatoid-arthritis patient.

But studies haven’t consistently borne out the benefits of one climate over another. “There really is no place in the U.S. where people report more or less weather-related pain,” says Dr. Jamison. He surveyed 557 arthritis sufferers in four cities in 1995 and found that more than 60% believed the weather affected their pain—regardless of whether they lived in San Diego, Boston, Nashville, Tenn., or Worcester, Mass.

Visiting a warm, dry climate may bring temporary relief, Dr. Jamison adds. “But if you live there full time, your body seems to acclimatize and you become sensitive to even subtle weather changes.”

Write to Melinda Beck at HealthJournal@wsj.com

From Wall Street Journal : http://online.wsj.com/news/articles/SB10001424052702304500404579127833656537554

"Here is the picture of me taken at the Franz Josef Glacier in New Zealand, seven months after 2 rotator cuff surgeries and physical therapy by Jason." --Nancy Dodd

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