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5 Causes of Sciatica and What You Can Do to Prevent it Sep 2nd, 2024

Your sciatic nerve runs from your lower back down through your hips, buttocks, and legs. When inflamed or irritated, this nerve causes the pain, numbness, and tingling of sciatica. Sciatica pain can range in intensity from mild to severe, and interrupt daily life, exercise, and sleep. Here at Expert Pain...

When Is an Epidural Injection the Best Choice for Your Neck or Back Pain? Aug 13th, 2024

If you have chronic neck and back pain, you know how debilitating it can be. It affects your daily activities, abilities to work, and overall quality of life. When conservative treatments like physical therapy, medications, and lifestyle changes don’t provide sufficient relief, an epidural injection might be the next step...

The Migraine Procedure: Drug-free Relief for That Intractable Pain Jul 26th, 2024

About 12-15% of the world population suffer from the pain of migraines, but only 1-2.2% of people have chronic migraines – defined as 15 or more episodes of migraine symptoms monthly. If you’re part of this population, you’re all too familiar with the intractable pain and possible auras, nausea, and...

What Happens During a Radiofrequency Ablation Procedure? Jun 28th, 2024

More than one in five American adults is living with chronic pain. And if you’re one of them, you know how it can erode your quality of life and make even the simplest tasks difficult to perform. Chronic pain is complex, and there’s no one-size-fits-all solution for effective pain relief. ...

How the Novel NALU Micro-IPG PNS system redefines the Chronic Pain Treatment Paradigm May 11th, 2024

The Novel NALU Micro-IPG PNS system is a revolutionary new therapy that successfully and safely treats chronic pain of multiple origins such as : Chronic back Post-surgical pain, chronic pain of the back and buttocks from Cluneal Neuropathy, sacroiliac joint chronic pain, chronic shoulder pain as a result of  surgery...

The significance of Fellowship training and Board Certification in Pain Medicine Mar 3rd, 2024

For patients today it is very hard to evaluate and consider the plethora of all sorts of medical providers in Pain Medicine, and find the appropriate physician who has the clinical skills and the training/experience to diagnose accurately and find treatment solutions for their clinical needs. Not all physicians are...

Pudendal Neuralgia Feb 4th, 2024

  Pudendal neuralgia is a painful condition caused by inflammation, compression, or entrapment of the pudendal nerve. Pudendal neuralgia is defined as a burning neuropathic pain in the distribution of the pudendal nerve, usually localized to the vulva, vagina, clitoris, perineum, and rectum in females, and to the glans penis,...

Painful Neuropathy and clinically effective evidence supported treatments Jan 13th, 2024

One of the most difficult conditions to treat, the burning, shooting agonizing chronic neuropathic pain, brings suffering patients to our Interventional Pain practice seeking diagnostic and treatment answers. Not all neuropathic chronic pain is the same. Different etiologies include: Painful Diabetic Peripheral Neuropathy, Ischemic Neuropathy, Idiopathic Peripheral Neuropathies, Spine related...

Radiofrequency Ablation : A back pain treatment that works Jan 3rd, 2022

Back pain is one of the most common reasons a patient comes to a physican's clinic and is one of the leading causes of suffering and disability worldwide. Although back pain etiology and treatments can vary, facet joint osteoatrhritis represents one of the most common reasons for back pain. Facet...

An Update from the Expert Pain Team about Care During COVID Mar 29th, 2021

The headlines tell us that there is light at the end of the COVID-19 tunnel, with vaccine distribution beginning in the next few weeks. But it will be several months before the majority of the population can be vaccinated, so it is critical that we do all we can in...

Dr. Skaribas Partners with Abbott on the NeuroSphere™ myPath™ App Feb 10th, 2021

Dr. Skaribas is excited to announce that he has been selected as a Limited Market Release (LMR) site for the NeuroSphere™ myPath™ App., the latest Spinal Cord and DRG Stimulation patient-centric innovation within the Abbott NeuroSphere™ Digital Care platform. This opportunity gives Dr. Skaribas and his patients early-access to this powerful and intuitive...

Conditions that Cause Leg Pain Nov 11th, 2020

When people experience pain in their legs, it can fall into two major categories: acute or chronic. Acute pain comes on suddenly and is often caused by injury or damage to the bones, tendons or ligaments in the legs. Among the most common causes of acute leg pain are broken...

Spinal Cord Stimulation for Neuropathic Pain Nov 4th, 2020

The body’s nervous system can be thought of as a “hub and spoke” model, where the hub (the brain) serves as the central control room that sends and receives messages from the spokes, the nerves in the spinal cord, skin, muscles and other parts of the body. When there is...

Interventional Treatment Options for Back Pain Oct 28th, 2020

The human spine consists of 24 separate vertebrae interspaced with cartilage, plus the two bones of the sacrum and coccyx. Supporting these bones are 23 discs, more than 30 muscles and tendons that provide spinal balance, stability and mobility, and three major ligaments that prevent excessive movement of the vertebrae....

Oh, My Aching Feet! Oct 21st, 2020

Under normal circumstances, an injury such as a broken bone or sprained ankle will heal on its own with appropriate care such as casting, rest, elevation, etc. Once healed, there are generally no long-term effects. Or as some would say, “I’m as good as new.” Sometimes, however, the thin fibers...

Sacroiliitis: Pain in the You-Know-What Oct 14th, 2020

The COVID-19 pandemic has forced us all to change the way we live and work. And for many of those working from home, the changes have been literally painful. That’s because as much as we love working in our pj’s on our laptops in bed or on the sofa, this...

All Types of Pain are Not the Same Oct 7th, 2020

When our bodies hurt, we don’t usually stop to think about the kind of pain we have, we just want relief. But to pain medicine specialists, accurately diagnosing the kind of pain the patient is experiencing is key to developing an effective treatment plan. In order to treat pain correctly, the physician...

Shouldering the Pain: Causes and Treatments for Aching Shoulders Sep 30th, 2020

When people complain about shoulder pain, many assume that the rotator cuff is the source of their pain. But unless you are a major league pitcher or quarterback or have spent a career in a job that requires repeated overhead arm motions, the cause of the pain could be something...

Causes and Treatments for Degenerative Arthritis Sep 25th, 2020

September is Pain Awareness month in the United States and has special significance for the estimated 32.5 million adult Americans who suffer from painful osteoarthritis.[i] Sometimes also referred to as degenerative arthritis, osteoarthritis occurs when the cushioning cartilage that lines the body’s joints breaks down. As it worsens, it can...

Exercises to Relieve Joint Pain Sep 18th, 2020

For patients with pain in their joints, the thought of exercise can be, well, painful. Yet exercise is critical to relieving pain. That is because exercising painful joints helps replenish necessary lubrication to joint cartilage and can reduce stiffness, inflammation and pain. In addition, for those with pain in weight-bearing...

LinQ™ Procedure Offers New Hope to Patients with SI Joint Pain Sep 11th, 2020

Although upwards of 80 percent of Americans suffer from lower back pain at some point in their lives, sometimes the pain is not coming from their spine per se. Sometimes it may come from the sacroiliac joints where the lower spine and pelvis connect. The two sacroiliac joints are located at...

Tennis Elbow: Causes, Symptoms, and Treatments Sep 4th, 2020

What Causes Tennis Elbow?  Although it is referred to as tennis elbow, this condition is not exclusive to tennis players. Lateral epicondylitis, better known as Tennis elbow, is a muscle strain injury that is typically caused from overuse. A repeated contraction of the muscles in the forearm that are used...

What is Diabetic Neuropathy? Aug 26th, 2020

Nearly half of patients who have diabetes suffer from some kind of neuropathy. Diabetic neuropathy is nerve damage caused by high glucose levels. It is common and serious for patients who have diabetes. While diabetic neuropathy can cause issues with the digestive system, blood vessels, and heart, it most often...

Sacroiliac Joint Dysfunction Aug 18th, 2020

Sacroiliac Joint Dysfunction (SJD) also known as Sacroilitis, is a condition that directly affects the sacroiliac joints that reside in the lumbar region of the spine. These joints sit right where the spine and pelvis connect with several ligaments supporting them. Studies show that almost everyone will experience lower back...

DRG Therapy for Complex Regional Pain Syndrome Aug 13th, 2020

Dorsal Root Ganglion therapy, DRG for short, is a neuromodulatory therapy which treats chronic pain. Dorsal root ganglions are collections of nerve cells that reside on both sides of each vertebrae at the dorsal root of the spinal nerve. There are approximately 1500 neurons at each dorsal root ganglion. They...

Spinal Cord Stimulation for Neuropathic Pain Aug 5th, 2020

Spinal cord stimulation (SCS) has been recognized as the most commonly used form of pain management treatment after nonsurgical treatments have failed for patients. This treatment has been used and studied for hundreds of years and made its debut in medical publications in the 1960s. SCS has a high success...

What are NSAIDs and How are They Used? Jul 30th, 2020

Inflammation is the body’s response to injury or irritation. As a self-defense mechanism, inflammation can be key to determining what is wrong, although reducing that inflammation is crucial to managing your pain.  Instead of prescribing opioids or narcotic pain medications, many physicians recommend taking NSAIDs to relieve aches and pains. ...

Treating Chronic Foot Pain Jul 21st, 2020

Ask anyone who has ever suffered foot pain, either from something as simple as a pair of ill-fitting shoes or from a disease such as diabetes, and they will tell you that painful feet can severely impact one’s quality of life. This is especially true for those who suffer from...

Prevent Golfer’s Shoulder and Elbow Pain Jul 15th, 2020

Amid our nation’s pandemic, many recreational activities have had to be put on hold. One that has been deemed to be fairly safe, however, is golf. Given that it allows for physical distancing and that golf courses are taking additional measures to sanitize their club houses, carts and other equipment,...

What Lower Back Pain Might Mean Jul 8th, 2020

There is a reason that upwards of 80 percent of all adults will experience lower back pain at some point in their lives.[i] Much of it has to do with the anatomy of the lower (lumbar) spine. This area bears much of the weight of the upper body before transferring it...

What is a Pain Management Specialist? Jul 2nd, 2020

In science, as more and more information about a specific topic is learned, it often leads to subspecialties. Consider the field of physics. There are astrophysicists, nuclear physicists, molecular physicists, and so on. The same is true in medicine. Within the field of cardiology, there are general cardiologists, cardiac surgeons,...

Successful Treatment of Charcot‐Marie‐Tooth Chronic Pain with Spinal Cord Stimulation Jul 1st, 2020

Abstract Charcot-Marie-Tooth (CMT) disease is one of the most common hereditary neuropathies affecting one in 2500 people in the United States. CMT disease is associated with moderate to severe chronic extremity pain. We present the case of a young man with chronic intractable lower extremity pain associated with CMT disease...

How Chronic Pain Spreads Jun 29th, 2020

Serious sailors know that a small amount of rust on a boat can become a much bigger problem if it is not addressed quickly. The same applies to pain. Left untreated, it can become worse, become chronic and sometimes spread to other areas of the body. Chronic pain is generally...

When Surgery Fails to Relieve Back Pain Jun 22nd, 2020

Patients who live with chronic back pain are often desperate for relief, and understandably so. Back pain can impact their ability to do basic daily tasks, such as working, driving and shopping. The pain can make it difficult to enjoy spending time with family and friends and can often lead...

Degenerative Arthritis Jun 11th, 2020

The human body, like even the most fine-tuned automobile, cannot avoid the effects of aging. Wear-and-tear causes parts to break down over time. But like a classic car, there are ways to keep the parts of the body that have worn out running smoothly—well into the “golden years.” Degenerative arthritis...

Joint Injections for Neck Pain Jun 1st, 2020

Nobody likes a pain in the neck…literally. Neck pain often radiates to the head, jaw and upper extremities including the shoulders and arms. In some cases, it may simply be the result of a muscle spasm (“a crick in the neck”). But sometimes it occurs as a result of nerve...

Treatment Options for Lower Back Pain May 20th, 2020

When people suffer from back pain, it usually occurs in the lower back, known as the lumbar region. This area tends to bear the brunt of our daily twisting and turning, bending and lifting. It is also where the weight of the upper body comes to rest when we are...

Common Causes of Knee Pain May 15th, 2020

It is estimated that the average, moderately active person will walk about 110,000 miles during their lifetime.[1] That’s the equivalent of eight round-trip walks from Houston to Alaska.[2] Although most people will never make that trek once, yet alone eight times, they will still put their knees to work walking,...

Dr. Skaribas Finds Success in Telehealth Services May 5th, 2020

Dr. Skaribas has been having great success in caring for patients using our virtual Telehealth services. He is certainly making the most out of this current situation! If you would like to schedule a Telehealth Appointment, please click HERE. For New Patients: We will be seeing new patients in office who have an appointment....

Cervical Radiculopathy: Causes and Symptoms May 4th, 2020

Cervical radiculopathy occurs when nerve roots in the cervical spine (the seven vertebrae in the neck) become pinched or irritated. Some patients experience numbness, tingling or weakness; others report pain that ranges from a dull ache to a burning, shock-like sensation. The pain occurs from the neck and radiates into the shoulder,...

Causalgia: Another Name for Complex Regional Pain Syndrome II Apr 22nd, 2020

Patients who experience chronic, severe burning pain in a limb due to an injury to a peripheral nerve may have once been told that they suffer from causalgia. Today, the condition is more often referred to as Type 2 Complex Regional Pain Syndrome (CRPS II). Peripheral nerves run from the brain...

Neuropathic Pain Types Apr 14th, 2020

Neuropathic pain is often the result of nerve damage or a malfunctioning nervous system that sends pain signals to the brain even if there is no trigger, such as an injury or inflammation. In some patients, sensory signals simply get crossed and are interpreted as pain. Neuropathic pain can present as...

New Hope for Migraine Sufferers Apr 7th, 2020

Anyone who has endured the intense, throbbing pain of a migraine knows that these headaches can be truly disabling. They can cause nausea, vomiting and hypersensitivity to sensory triggers like light and sound. Even a slight movement of the head can cause excruciating pain. Some people even report experiencing visual...

Vertiflex: A Treatment Option for Spinal Stenosis Mar 31st, 2020

Another Option for Treating Spinal Stenosis It has been estimated that 95 percent of the population has degenerative changes of the spine by the time they reach the age of 50,[i] with upwards of 500,000 Americans suffering from symptoms related to spinal stenosis.[ii] Spinal stenosis occurs when the spinal canal starts...

Neuropathic Pain: Things to Know Mar 16th, 2020

What is Neuropathic Pain?  When damage or dysfunction is caused to the nervous system, the nerves are unable to function properly which can cause pain. This is called neuropathic pain. The pain stems from the nerves inability to transmit sensations to the brain, resulting in a sense of numbness or...

Chronic Pain and the Central Nervous System Mar 4th, 2020

Chronic pain is pain that is ongoing or lasts longer than 6 months. And while this pain can be debilitating and affect your daily life, it can also cause other serious health issues and affect the central nervous system.  How Pain Signals Work in Your Body Your brain and spinal cord work...

ATTENTION: Flu Season Safety Feb 27th, 2020

With the flu season still in effect, and the coronavirus posing a threat, Expert Pain reminds all its patients and the public the following 3 very basic rules of profylaxis:

What is Adult Degenerative Scoliosis Feb 20th, 2020

Degenerative adult scoliosis, also known as adult onset scoliosis, is when the facet joints and intervertebral discs deteriorate and lead to a curve in the spine. This side-to-side curve occurs over time as a person gets older. Commonly, it begins after the age of 40, and is more frequently seen...

Peripheral Neuropathy: Diagnosis & Treatments Feb 5th, 2020

Peripheral neuropathy is the term used for disorders that are caused by damage to the body’s peripheral nervous system.  The peripheral nervous system connects nerves from the brain and spinal cord to the rest of the body. Including, but not limited to, the arms, legs and feet, joints, eyes, nose,...

Pain and Stiffness Caused by Arthritis Feb 3rd, 2020

Arthritis is the swelling and tenderness of the joints. It is a term used to describe over 200 types of joint conditions. Two of the main symptoms that are associated with arthritis are pain and stiffness.  Arthritis Pain Arthritis pain can be debilitating. In fact, the CDC reports that over...

Osteoporosis and Compression Fractures Jan 22nd, 2020

As we age, our bones get weak, thin, and prone to diseases such as osteoporosis. Osteoporosis is a medical condition where your bones become fragile and weak. This is typically because of hormonal changes, loss of tissue, or calcium and vitamin deficiency.  Osteoporosis can go unnoticed for years, silently affecting...

What are Stem Cells & How are They Used? Jan 15th, 2020

Over the last few years, technology, research, and success rates involving stem cells & regenerative medicine have skyrocketed. This treatment type holds a great deal of promise to help patients who suffer from chronic pain conditions.  What are Stem Cells? Stem cells are the only type of cell in the...

Causes, Diagnosis, and Treatment of Chronic Neck Pain Jan 2nd, 2020

A pain in the neck – a quiet literal condition. Neck pain is one of the most common complaints and aches that doctors hear. Fortunately, neck pain is rarely the sign of a more complicated condition.  Your neck supports the weight of your head and is flexible, making it prone...

Myalgia: Causes, Symptoms & Treatments Dec 24th, 2019

Muscle pain is common, and can originate in any muscle of the body. The medical term for muscle pain is myalgia. Myalgia can be described as muscle pains, aches, and pain associated with ligaments, tendons, and the soft tissues that connect bones, organs, and muscles. Causes of Myalgia Myalgia can...

How is Spinal Stenosis Diagnosed? Dec 11th, 2019

What is Spinal Stenosis? The spine consists of bones called vertebrae. The job of these bones is to provide stability and support for the upper body. Nerves run through the openings in the vertebrae and transmit signals from the brain to the rest of the body. If the surrounding bones...

Difference Between Acute and Chronic Pain Dec 4th, 2019

When it comes to your pain, there are two different types of pain: acute and chronic. All pain is uncomfortable, unwanted, and unpleasant.  No matter the type of pain, it can range from mild to severe and all pain has the ability to reduce your quality of life and prevent...

Serial ganglion impar blocks in a patient with nutcracker syndrome refractory Dec 2nd, 2019

Serial ganglion impar blocks in a patient with nutcracker syndrome refractory to left renal vein transposition Abstract Background: Nutcracker syndrome is a rare disorder caused by compression of the left renal vein, usually between the aorta and the superior mesenteric artery. It typically presents with left-sided abdominal pain and hematuria....

Failed Back Surgery Syndrome Nov 27th, 2019

Failed back surgery syndrome (FBSS) is the term used for continued pain a patient has after an unsuccessful back surgery. The patient is usually referred to a pain management specialist to treat existing pain.  The goal of spinal surgery is to decompress a nerve root or to stabilize a painful...

The Facet Joint Injection Procedure Nov 20th, 2019

Facet joints are small, bony joints that sit along the spine. They are paired up from the neck to the lower back area. When the joints get inflamed, they cause pain that can be severe. The pain can be acute or chronic, caused by a variety of conditions.  The pain...

How Does Cold Weather Affect Pain? Nov 14th, 2019

As leaves begin to fall and you break out a jacket and your sweaters, it is safe to say that colder weather is on the horizon. People have very different opinions on the colder temperatures – either they love it, or dislike it. However, regardless of your personal feelings, a...

Minimally Invasive Procedures to Reduce Back Pain Nov 6th, 2019

Chronic pain affects millions of Americans each year. Back pain is not only uncomfortable, but it can be debilitating and cause damage to other parts of the body. Living with back pain interferes with the quality of life on a regular basis and can be incredibly limiting. Back pain can...

Sciatica: Causes, Symptoms, and Prevention Oct 30th, 2019

If you suffer from sciatica, you know how painful it can be. It disrupts your daily life, affecting everything from sitting in the car to standing in the kitchen to make a meal.  Sciatica is a term used for any pain or symptom that causes numbness or sensation like tingling...

Managing Chronic Pain Without Opioids Oct 25th, 2019

There are a lot of options for treating pain without the use of narcotics. The opioid epidemic is spreading across the nation at frightening rates. Many state laws are cracking down on opioid prescriptions to prevent excessive prescribing. However, this leaves many chronic pain patients feeling lost and confused about...

Stretches to Reduce Chronic Pain at Home Oct 22nd, 2019

Living with pain does not have to be “the norm.” In fact, incorporating a regular stretching routine into you daily activities can not only help relieve pain, but it can prevent pain from becoming persistent.  Seeing a physical therapist or a specialist all the time to guide you through stretching...

What is Complex Regional Pain Syndrome? Oct 14th, 2019

Imagine a medical scenario when severe burning pain develops in an area of your body and starts spreading over a limp usually traveling to the opposite extremity or in other parts progressively becoming incapacitating and taking over your life.  Enter the mysterious clinical world of complex regional pain syndromes. Complex...

What is Dorsal Root Ganglion Stimulation? Oct 3rd, 2019

The Dorsal Root Ganglion (DRG) is a small bundle of nerve structures (neurons) connected to the spinal nerves of each vertebra along your spine. The DRG is critical in processing pain signals and transmitting them to your brain. They have a particularly important role in how you experience pain. The...

Treatment Options for Chronic Migraines Sep 26th, 2019

Approximately 12% of Americans suffer from migraines. However, only 1% of the population suffers from chronic migraines. A chronic migraine is defined as a severe headache occurring 15 or more times a month, for more than three months.  When diagnosing chronic migraines, it is important to know the exact number...

What is a Pain Management Doctor? Sep 17th, 2019

If you live with chronic pain or suffer from an incident where you find yourself in pain, chances are, you’ll be referred to a pain management specialist. The International Association for the Study of Pain (IASP) offers one of the most widely accepted descriptions of pain: “Pain is an unpleasant sensory...

Spinal Cord Stimulation: How it Works Sep 12th, 2019

Spinal cord stimulation therapy is a pain treatment that masks the pain signal before they reach the brain. A device similar to a pacemaker is implanted in the body and delivers electrical pulses to the spinal cord. This is an option for patients who suffer from chronic pain, leg, or arm...

Psychological Evaluation for Those Receiving Devices for the Treatment of Pain Aug 2nd, 2019

Abstract To date, spinal cord stimulators and intrathecal pump delivery systems represent the most common implantable devices in pain medicine. Pre-surgical psychological evaluations have been recommended since their very first use. The psychological status of any patient is an important factor in determining the success of the surgical use of...

The Neuromodulation Appropriateness Consensus Committee on Best Practices Jan 22nd, 2019

The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation Abstract Introduction The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for...

Effectiveness of Cervical Spinal Cord Stimulation for the Management of Chronic Pain Sep 24th, 2014

Abstract Introduction Scientific evidence supports spinal cord stimulation (SCS) as a cost‐effective treatment option that, for many disease states, should be employed earlier in the treatment continuum. Reimbursement for SCS in the cervical spine has recently been challenged based on supposed lack of clinical literature. To refute this assumption, we...

Interim Results From the Partnership for Advancement in Neuromodulation Pain Registry Feb 14th, 2014

Abstract Objectives The objective of this study was to present results from a multicenter registry designed to obtain longitudinal clinical outcome data for patients implanted with a neuromodulation system for the management of chronic pain of the trunk and/or limbs. Materials and Methods Interim data from 579 patients across 40...

Occipital peripheral nerve stimulation in the management of chronic intractable occipital neuralgia May 10th, 2011

Abstract Introduction Occipital peripheral nerve stimulation is an interventional pain management therapy that provides beneficial results in the treatment of refractory chronic occipital neuralgia. Herein we present a first-of-its-kind case study of a patient with neurofibromatosis type 1 and bilateral occipital neuralgia treated with occipital peripheral nerve stimulation. Case presentation...

Ultrasound imaging and occipital nerve stimulation Apr 1st, 2010

Abstract Objectives: Occipital nerve stimulation (ONS) is a peripheral nerve stimulation (PNS) technique that has been used with success in the management of intractable chronic daily headaches (CDHs) and occipital neuralgia (ON). The technique involves the placement of a stimulating surgical or percutaneous electrode over the occipital nerves within the...

Computed tomography-guided pudendal nerve block. Aug 1st, 2000

Computed tomography-guided pudendal nerve block. A new diagnostic approach to long-term anoperineal pain Abstract Objective: To show the value of computed tomography (CT) in selectively blocking the pudendal nerve in patients with long-term anogenital pain of uncertain etiology. We report a technique to selectively block the pudendal nerve using CT...

Anatomy and pathophysiology of the sacroiliac joint Apr 5th, 2000

Abstract The sacroiliac joint as a source of chronic pain has been a subject of debate for a long period of time. This controversy stems from the inherent anatomic location of the sacroiliac joint. Adjacent spinal structures may cause pain to be referred to the sacroiliac joint, thus making a...