Shoulder Problems – with Angel J. Garcia
/in Podcast/by dmiddaughDr. David
Hey there. I'm Dr. David, welcome to the show. I've got a great guest here, friend of mine. His name is Dr. Angel Garcia. He's a physician here in El Paso, sports medicine specialist. One of the best in the southwest. Certainly, the best in El Paso and I let him tell you more about all that. But I just want to welcome you to the show. Thank you for listening, and welcome on here. Dr. Garcia. How are you?
Dr. Garcia
Good. Thanks for having me.
Dr. David
Yeah, absolutely. We sure appreciate it.
Dr. Garcia
So, my name is Angel Garcia, was born in Puerto Rico moved to El Paso when I was about five years old. Been here since then. Went to Bel Air High School, part of the health magnet there, first graduating class. After Bel Air, went to Baylor for my undergrad, got my degree in psychology. And then from there I went to San Antonio for Med School, Medical University of Texas Health Science Center, San Antonio for medical school.
Graduated there, came back home for residency at Texas Tech in Family Medicine, and then after completing the residency in family medicine, stayed at Texas Tech for a fellowship in sports medicine, to better serve the patient population that I was interested in treating.
What drew me to family medicine was more of the… being able to see the whole family, treating the whole family, but I really love the musculoskeletal system working with athletes, and dealing with those type of issues and trying to provide a different perspective then what was provided by surgeons.
Not that, you know, surgery has its place, but for the vast majority of problems can be solved without surgery. And I was wanting to be able to help my patients more. So, I decided to do the sports medicine fellowship at Texas Tech.
Dr. David
That's awesome. Were you one of the first classes there at Texas Tech because they are pretty new?
Dr. Garcia
For sports medicine. We were the first class for sports medicine at Texas Tech. They had, you know, different program throughout the state. But my wife and I really want to stay here in El Paso with family.
Dr. David
Cool, cool, awesome. I love El Paso. So, you've got your own company here and let's just where we're at right now we're recording from Dr. Garcia's office. So, tell me about your company, what's the name and where's it at?
Dr. Garcia
So, yeah, when I left residency and fellowship, I really wanted to just kind of go out on my own, you know, not working for the man. So, we opened up a clinic El Paso Center for Family Sports Medicine. Initially we were at another location on Lee Trevino. But we recently just moved, we got a new building, trying to expand our services. So now we're on George Dieter and physicians, right next to diagnostic outpatient imaging and across the street from foundations hospital. So, it's a pretty cool location. So far, people are really liking the new building.
Dr. David
I know, I just got a tour when I walked in and is swanky looking. I mean I think of just modern. The floors are just beautiful, everything is, it smells like that new car smell.
Dr. Garcia
Still breaking it in, still moving in. But slowly but surely. Yeah.
Dr. David
So, I don’t know if you mentioned, but when did you start your practice?
Dr. Garcia
So, we've been in practice, I’ve been in practice for about seven years now, outside of residency and fellowship, but if you take that into account that has been about 10 years.
Dr. David
Nice, awesome. And then you mentioned that you did the fellowship and the residency and all that. Just so that people understand the difference, because I don't think the general population understands. I think they think you go to medical school, you become a physician, and residency and fellowship kind of just loses meaning after that. Could you explain a little bit more about what that means?
Dr. Garcia
So medical school, everyone kind of receives like the same kind of groundwork knowledge for general medicine. Then you had to start picking what specialty you're wanting to go into. So, whether you want to do dermatology, ophthalmology, or you know disorders of the eye, or if you want to focus on skin, if you want to become a surgeon, if you want to become a heart specialist, then those require more training than just what's in medical school.
Once you graduate medical school, you can become a general practitioner, but you're not necessarily a specialist of in of any sort. So, OBGYN had to do a residency in OBGYN. Cardiologists have to go to fellowship to study the specifics of the heart. So, after medical school, you have this kind of groundwork that you have to build on, and then depending on what specialty you're wanting to do, that's the fellowship or residency that you go into. Residencies can vary from three to seven years. Family Medicine is a three-year residency. Most of the primary care residency are two years. So, pediatrics is also three years, psychiatrists two years the surgical subspecialties can be anywhere from four to five years.
Dr. David
So, what's the difference between a residency and a fellowship?
Dr. Garcia
So, residency is your primary specialty, so internal medicine, psychiatry, pediatrics, family medicine. Fellowship is when you want to take an aspect of that, and sub specialize. So, you get further training in the heart. Your further training in the GI tract. You get special training and different surgical procedures.
In my case, we got more training in the muscle skeletal system, more common sports type injuries, management of those injuries. Just dealing in more specifics on a smaller area, that you can become more specialized in, as opposed to this broad topic of, Family Medicine, where you have tons of medical elements that you study. The fellowship focuses on one of those, and you go into that a lot more in depth.
Dr. David
So, you're, that's like super specialist. My understanding is, it's like the most specialized that you can get in a specific body area or subject within the medical field.
Dr. Garcia
Right. And that's where the fellowship comes in. Some people will do multiple fellowships to get specialize in very minutiae. So, like the eye doctor can become a specialist of the retina. So, there are different things like that. Orthopedic surgeons who will become specialists in just the hand. So, that's the point of fellowship. It is just to focus on one or two areas and expand your knowledge on that as supposed to just kind of generally brush.
Dr. David
So, we are going to get into our topic of the day, one of the favorite things for you to talk about is shoulder problems. And, you know, it's definitely a commonly injured body part for people in sports. So, tell us about shoulder problems, what got you interested in that?
Dr. Garcia
So, it's basically what got me interested in sports medicine in general is just trying to deal with, you know, common ailments that athletes, and I use the term athlete loosely, you know, you don't have to be a professional athlete or anything like that to have shoulder pain.
Dr. David
Be like a weekend warrior.
Dr. Garcia
Weekend warrior, you know, or even just recreational. Just dealing with aches that I myself had, you know, I had a shoulder injury a few years back when I fell and dislocated my shoulder. You never realize how important the body part is until it hurts. So, helping people deal with shoulder issues is something that I enjoy just as my general sports medicine practice and trying to provide a non-invasive or non-surgical approach to something that can be pretty debilitating. And try to approach it from a vantage point that is just not isolated to the shoulder, but like the whole body in general.
Sometimes people will have neck pain that presents in the shoulder. Or they could have the elbow that is the cause of their shoulder pain. So, it's not just the shoulder that you have to look at. You have to look at the whole individual. And sometimes when you go to, you know, other specialists and tell them you have shoulder pain, they don't necessarily evaluate the other things that could be masking as shoulder pain, and people go undiagnosed, or misdiagnosed for several years. So that's one of the things of why I was wanting to get into that so that I can help patients get to the right diagnosis. And the right treatment sooner.
Dr. David
Yeah. That's awesome. That's so cool. And so, how long have you been focusing on people with shoulder problems? I mean, was that been your whole career pretty much it was an after the fellowship more so?
Dr. Garcia
More so after the fellowship. I didn't do as much during my family medicine residency. But the little I did do was what sparked my interest to do the fellowship. So, in my fellowship, and then the time since then, so for the past seven, eight years, have been really, really focusing on shoulder issues.
Dr. David
Now you said that you help people out with avoiding surgery or alternatives to surgery more. So is what he said. What are some of the common problems with shoulders that you see like some of the more specific diagnoses?
Dr. Garcia
So, the most common would be, you know, rotator cuff injuries. That's, that's kind of a catch all phrase, sometimes, but that's, you know, definitely the most common shoulder problem that that we see. And rotator cuff issues don't necessarily have to be caused by any, you know, real significant injury or trauma. Someone could just reach for something really quickly or, awkwardly rotate their arm a certain way and they develop inflammation of the rotator cuff or a sprain.
Not all rotator cuff issues are necessarily tearing that require surgery, a lot of times it's a muscle strain or inflammation of a muscle that just needs the right type of treatment. Most of the time that treatment consists a lot of going someone like you and getting physical therapy.
Sometimes, when I tell my patients it's a simple fix, but it's not a quick fix. The exercises aren't very elaborate, you don't have to have a lot of weights or a fancy gym because people always say, “Well, I don't have time to go to the gym.” Well, you don’t have to go to the gym, you can learn about some of these exercises, you can just use your door jamb for exercising the muscles of the rotator cuff. But the key is arriving at that right diagnosis. So that the appropriate treatment can be applied.
Dr. David
And one of the other diagnoses that I commonly see, related to rotator cuff tears, and the way that I look at the body, it's more of a spectrum and on the lower end of the spectrum of rotator cuff tears like the extreme end, on the other end would be like nerve impingement. So, there's something wrong with the ball and socket joint. Do you get a lot of those people as well?
Dr. Garcia
Yeah, it's definitely a spectrum. It's the impingement, I think, is one of the more overlooked. And the reason why is because, a lot of the studies that we use, or a lot of the diagnostic studies that people use nowadays, don't involve, unfortunately, the physical exam.
So, x-ray, a lot of people will focus on X-ray when people have shoulder pain and like, “Whoa, you have nothing.” Meaning that yeah, there's not a break. You may have a little bit of arthritis, but the X-ray is normal. Until the patient's like, “Well, why do I have this pain?”
Well, one you know, muscle doesn't show up on X ray. Second, test that is commonly used is the MRI. The MRI is great for looking at tears. It's great for looking at signs of inflammation. Maybe some calcifications in the tendon that cause irritation. But it doesn't allow for you to examine the muscle in movement. And impingement is one of those things where movement is what triggers the symptoms.
So yeah, the MRI may come back negative, because impingement you're holding still in an MRI, you can't move. So, there's no way to, appropriately diagnose impingement using MRI. So, impingement is more of a clinical diagnosis in terms of certain exams that you do within the visit that trigger that symptom.
That's one of the things that, sports medicine specialists learn in fellowship are those provocative tests to elicit that symptom, that can't necessarily be visualized with the most common modalities that we have.
Dr. David
Yeah, that's exactly I wanted to ask you next is, what are you doing? You specifically as a sports medicine shoulder specialist, what are you doing that's different than, say a general doctor, like what kind of knowledge, or hands on test do you do that they wouldn't necessarily know to do?
Dr. Garcia
In family medicine, when I was doing my residency. The basic exam that I got was, do they have full range of motion of the shoulder, or are they tender to a particular spot. For impingement, and other shoulder issues, there's a slew of tests that can be done to test the rotator cuff.
There's one is called the job's maneuver where you know, you're putting pressure on the arm and external rotation pushing kind of up towards your head. The other one that's called for impingement is the nearest test so you kind of put your thumb facing down and then you kind of elevate your arm close to your ears. So near to the ear.
Hopkins test is another test that checks for impingement where it's kind of like you hold your arm out in front of you, bend your elbow and just kind of rotate your arm down towards the floor, as you move across your body.
So, there's different tests that specialists have been trained to do that that weren't part of my, my residency training. And a lot of times you got to use multiple tests to isolate the issue, because the longer an issue goes on, other muscles start to get affected, they start to ache and can give you a false positive on some test and kind of lead you to another direction when it's all coming from the impingement.
It's just that it's gone on for so long that the other muscles around it are irritated because they're having to pick up the slack. So, it's a combination of all those tests. Sometimes I'll do an ultrasound. So that's one of the few, or I think the only one, that you can actually visualize the impingement because you're actually visualizing the muscle and then you move the joint, and then you can see the impingement on ultrasound. So that's, that's another modality that we can use.
Dr. David
Wow. That's awesome. What type of symptoms should people be looking for when they have a shoulder problem? When should they decide to come and see you versus waiting and seeing if it'll pass?
Dr. Garcia
That's a great question because you know, everyone's going to have aches and pains. It's part of life. You tweak muscles here and there. When it starts affecting your activities of daily living, if you're having trouble getting dressed, or putting on your shirt, women having issues striking the bra, reaching for a cup in the cupboards, or doorknobs.
When it's affecting your activities of daily living, and the symptoms have been going on for about a week or two. Most muscle strains heal within a week or two timeframes. But if it's severe pain, if it's pain that's keeping you up at night. If there's any significant weakness or neurological issues, numbness, tingling, burning, then I would definitely come in sooner.
But if it's just a pain to the shoulder, without significant reduction in your daily living, you know that 7 to 10-day window is usually good enough for most muscle strains to kind of go away. But if it's persisting past that, that definitely seeing someone would be beneficial.
Dr. David
Yeah, one of the common ones that I hear about all the time is picking up the full pot of coffee, to pour their coffee people always say “Gosh, that kills me every morning! That’s how I know my problem still hasn't gone away!”
Dr. Garcia
It could be something as simple as that. I've had one person that couldn't get their toothpaste on because they would have to reach up into the medicine cabinet to get it. Just that motion of moving their arm up the few degrees was killer.
Dr. David
Oh, cooking is another one, like chopping up a lot of vegetables or you know, whatever it is they're chopping, that force repetitive, I hear a lot of people complain about that.
Dr. Garcia
Yeah, that too. The people who are able to enjoy their golf, they are finely attuned to when their swing goes awry because of the shoulders bothering them.
Dr. David
Yep. And in the sports world, people lifting weights, all the time run into shoulder problems. Especially with like doing overhead exercises or anything with any shoulder specific exercises. Bench-press, I hear about all the time.
Dr. Garcia
So, for people who are who are on the more athletic side, do more performance. Being akin to your body is key. If there's a gradual loss of weakness on one side to the other, that wasn't there before. In someone who trains a lot needs to be dealt with soon, because those slight weaknesses can actually be a sign of pre-significant muscle damage and someone who's very well built.
So, someone who has that, or notices that you should be seen pretty quickly. For those who are wanting to work out form is key. You can be doing the right exercise, but if your form is not right, you are going to hurt yourself.
Dr. David
I see that all the time. I agree 100%. So, do you have any other helpful information that you want to share with people in El Paso about shoulder problems, that they may not otherwise know? Like, it's not common knowledge or something that unique that you end up telling patients a lot.
Dr. Garcia
What I tell patients in particularly, because I'm a huge believer in diet and exercise. And a lot of people think that one day they have to go to the gym or have a lot of fancy equipment to do the exercises. But in terms of the shoulder, they are very basic, simple exercises that for the actual intrinsic rotator cuff muscles don't require a whole lot of heavy weights or machines. It's, it's mostly a lot of range of motion and an appropriate range of motion.
Just because you go to the, and I get this a lot for people when I try to refer them for physical therapy is like, “Why, I go to the gym three, four times a day. I'm already doing exercise.” Yeah, you're doing exercises but you're doing exercises one for more of a general kind of well-being of the body, and usually more geared towards muscle building or muscle toning.
The exercises for shoulder injury, or any musculoskeletal injury are more geared to taking away the inflammation, or muscle strain from the smaller intrinsic muscles that oftentimes get overlooked when you're going to the gym. Curling or bench pressing, that are focused more on the larger muscle groups.
Physical Therapy is something that focuses on the intrinsic muscles, that helps stabilize the joints better, that don't necessarily make you look, it doesn't add to the curb appeal. But it just helps mitigate the pain by assuring more proper alignment of the muscles and joints.
Dr. David
Yeah. I always have people that, whenever I talk to them about working on their rotator cuff muscle, I tell them this, you'll feel somewhat of a burn but it's not going to be like if you go work out your biceps are triceps, and then you never going to have the muscle burn where you look in the mirror and flex and rise like, look at this rotator cuff back here. It's just popping out like that.
Dr. Garcia
Because people go to the gym to focus on muscle building or improving their physique. The exercises for rotator cuff, the emphasis is not on improving the physique. It's on improving your pain, which will down the line allow you to improve your physique by letting you do the exercises that you're more wanting to do. But these exercises are needed to help prevent injury when you're doing those other more strenuous, heavy lifting exercises.
Dr. David
For the rotator cuff muscles, just to talk about that a little bit because that's a super common problem area for a lot of shoulder problems. There's four of them. We don't have to go to the names you can certainly Google them, but they all pull in different directions. They help to connect the ball on to the socket in the shoulder joint. And so, as a physical therapist, finding the exact direction in motion, that is the weakness or that is the main problem area or knowing which rotator cuff tendon is injured is also part of the problem. When we talk about doing shoulder exercises, rotator cuff exercises, it's not always like the same one that's going to help every person.
Dr. Garcia
Right? Because with their being the four major muscles that make up the rotator cuff, not everyone's going to be injured in the same muscle. And like you said, each muscle has their own action. One of the muscles rotate your arm outside, and another one rotate inside, another one lifted above your head. And then depending on what degree you're in, multiple muscles are working at the same time to give you that same benefit.
So that's what we talked about, when we talked about what exams to do for shoulder pain. Evaluation is trying to isolate that muscle in a particular movement or test that elicits that symptom.
The same exercises don't work for everybody, because not everybody injures the same rotator cuff muscle. Even though we dump it in the catch all phrase of rotator cuff injury. But rotator cuff injury can be a slew of different things. Because there are the four major muscles and then you have all those other smaller intrinsic muscles or ligaments that that can be injured.
Dr. David
Biceps tendon, I always hear about that.
Dr. Garcia
I see that bicep tendon is pretty common. You got ligaments that are combined but hold the humerus, and the shoulder together, are really small ligaments that that can be a cause of posterior shoulder pain, or pain on the backside of the shoulder that aren't necessarily muscle related. It's a ligament that attaches or holds two joints together. So yeah, every rotator cuff injury is different and therefore needs a different set of exercises to work through.
Dr. Garcia
Yeah, yeah. Cool. Well, this has been great. Talk about the shoulder today. So, do you have anything else that you think you want to share with El Pasoans about shoulder problems, or your company, or just in general about anything else you help us with?
Dr. Garcia
So, I mean, we're here, like I said, on the corner of Georgia Dieter and Physicians 11851 Physicians Dr. to help you with any sports medicine or musculoskeletal injuries. We also offer a vast array of other things, to general found medicine issues. So, we see anywhere from kids to adults.
For people who do a lot of working out trying to lose weight. We offer a weight management, education and help with weight management in terms of medication and diet, nutrition counseling. For people who have problem areas that they want to get rid of love handles or things like that. We have some aesthetic procedures that we offer SculpSure is a non-invasive way to lose the fat in those problem areas that aren't responding to diet and exercise.
It's not a substitute for diet and exercise. It's just for people who had those polar bears that they just can't get rid of that we can give you that added assistance with the with the SculpSure.
Dr. David
Amen to the problem areas. I know very well about that. Well cool. So, if someone El Paso wants to learn more about your clinic, Dr. Garcia, or even maybe make an appointment. What's the best way for them to get in touch with you?
Dr. Garcia
They can call us here at the clinic, 915-493-6646. We have a Facebook page and they can just search El Paso Center For Family Sports Medicine. They can reach out to us on our website, and they can actually book through our website at www.elpasocenterfamilyandsportsmed.com. There's a link there that you can actually book online if for whatever reason you're trying to book an appointment after hours or over the weekend. So those are the main ways to get a hold of us.
Dr. David
Awesome! Great information today. Thank you so much for taking the time to talk with us really appreciate it. I think El Pasoans are going to benefit from this, time and time again as this podcast is available.
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