-----Why Do I Have Chronic Tendonitis? Found insideI've got bursitis in my shoulder and a partial plate in my mouth. Define a heterosexual person, and the first thing you say about him won't be that he's straight. Right?” I nodded. “You're right. Of course. It's been 7 years now and it is still going. However, these injuries can also affect younger people who often partake in new or repetitive activities, are already injured, and/or have chronic weakness in their shoulder. This does not mean all movement needs to stop. Found insideA client has bursitis in the subacromial bursa. A nurse determines that the client understands teaching when the client says: 1. “I will apply moist heat to my shoulder for 20 minutes three times each day.” 2. “I will lift 30lb (13.5kg) ... Initial studies show clinically significant decreases in shoulder pain when compared to sham acupuncture treatments. Arthritis. Found insideThe thought of it awakened the bursitis in his right shoulder. “What'll I do there? Don't they raise wheat or something like that? ... My business is with numbers.” “An accounting position seemed inadvisable on the off chance Redman's ... Top 5 causes of hip pain. If your initial symptoms are significant, your doctor may give you a cortisone injection on your first visit. Also write down any new instructions your provider gives you. Found inside – Page 1An old seaman walks away from the vessel and heads south—memories tugging at his mind. It is a momentous journey but when he ... With the duffel on his good shoulder (the other aching with bursitis) he headed toward the purser's office. Found inside – Page 201My shoulder has been aching. I wonder if I'm old enough to get bursitis. Enough kvetching, though. I have been sleeping fitfully this week, and my wisdom tooth has stopped aching. This morning I got a call from Donald Stauffer, ... The condition can occur when something injures or damages the tendon of the rotator cuff. Know why a test or procedure is recommended and what the results could mean. Stand with your injured shoulder next to the wall. It is common, treatable, and often heals within months. Leaning for long periods of time on the elbows can also irritate the bursa and lead to shoulder bursitis. However, for those who are experiencing severe or chronic pain, shoulder injections can help manage their pain while undergoing other treatments like physical therapy. Elbow Bursitis Treatment - For the first 24-48 hrs after the initial onset of elbow pain or the visible swelling due to elbow bursitis (olecranon bursitis) it may be appropriate to apply ice and then immobilize and rest the elbow (This should hopefully help minimize the initial swelling). Surgery is sometimes needed to treat shoulder bursitis. Found inside – Page 670In my opinion , the conclusion sought by the General Counsel is entirely too remote , and it would be unreasonable for employees to draw such an inference of a discharge threat . C. Alleged discrimination against Marie Sutton Sutton's ... If these are overly taught then they can become inflamed and create a chronic pain that can be difficult to shift. Shoulder bursitis symptoms are typically worse at night after a long day of activity, or in the morning when the shoulder has been still for a long period of time. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder. A bursa is a slippery, sac-like tissue that normally allows smooth movement around bony prominences, such as People with other health conditions like rheumatoid arthritis, gout, and diabetes are also more at risk. They offered a huge variety of different services, ranging from setting broken bones to handling routine immunizations, and it was a huge relief. – Shoulder Pain- General. Icing the elbow for the first 48 hours after symptoms begin can reduce swelling. Rather than one joint working in isolation with limited movement, the shoulder enjoys a wide range of motion – the widest of any joint in the body. Gradually increase the demands you put on your body. Symptoms of bursitis can be similar to those caused by arthritis, diabetic neuropathy, frozen shoulder, tendonitis, gout and many other conditions. Cortisone shots and surgery may also be used to treat the condition. In the acute phase, you should rest your shoulder. Infection can become serious and should be treated urgently. And it's predictable that it will continue to hurt. Found inside – Page 297Then I smiled at Laura one more time before I drove away. DOES IT SEEM surprising that I left so quickly, that I made so little fuss? After all, considering that I had been in love with, obsessed with, Laura for most of my life, ... This information is not intended as a substitute for professional medical care. Subacromial Bursitis (shoulder bursitis). Services Provided by, Our Opioid Therapy Statement And Management Tool, How To Treat Shoulder Bursitis: 9 At-Home And Advanced Treatments, 5 Frozen Shoulder Symptoms: Early And More Advanced Signs. From eyelashes to keep dust and debris away from our eyes, to fingernails that prevent damage to our distal phalanx, each of us is born with a comprehensive set of safeguards that shield us from pain and discomfort.. Those expecting hip bursitis to go away on its own may not always get what they wish for. With so many moving parts, shoulder injuries and pain are one of the more common upper body pain conditions. Yep. Found inside – Page 1450The Witness : As far as my knowledge is concerned . ... have you treated of shoulder bursitis , treated or 1452 observed the treatment in hospitals ? On an inhale, lift both shoulders towards your ears and pause at the top of the inhale. Found insideI scrambled to my feet, the bursitis in my hip hurting fierce as I ran up onto the porch. Bob hadn't barricaded the door; it whipped inward when I slammed my shoulder against it, staggering me as I burst through. Bursitis is inflammation of a bursa. Applying ice packs in a 20-minute on, 20-minute off schedule for the first 24 hours may also provide significant (if chilly!) For many patients, a few weeks of these measures will be enough to treat shoulder bursitis. If you are looking for shoulder bursitis treatments in Arizona, give the pain specialists at Arizona Pain a call. A therapist will generally add new exercises to your therapy sessions as you improve. You may want to complete these shoulder bursitis exercises for both shoulders to stay balanced in your range of motion. It feels like somebody is stabbing me in the area. For instance, if you play sports like baseball or work in a setting that requires you to lift, raise, or use your arm repeatedly, take a break. Found inside – Page 14You'll stand taller when wearing this simple, effective shoulder brace. ... Welcome relief for bursitis and arthritis sufferers F6566 Knee Strap $6.99 LOOK SLIMMER INSTANTLY! ... CHARGE TO MY: (CIRCLE ONE) Card Expires: MO. The rotator cuff is a group of four muscles and their tendons that surround the … Start new exercises or sports slowly. Try the following measures to prevent bursitis: Call your healthcare provider if you have any of the following: Tips to help you get the most from a visit to your healthcare provider: Cedars-Sinai has a range of comprehensive treatment options. Try the following measures to prevent bursitis: Warm up before exercising or before sports or other repetitive movements. As with the condition itself, shoulder bursitis treatments may be minor (changes to your routine) to more involved (full-blown surgical intervention). Even though they are sold over the counter, it is important to take them only as directed. In some cases, immobilizing the arm completely with a sling may be necessary. Gradually increase the demands you put on your body. Found inside – Page 13On the days when my workload was lighter, I'd leave work early and sleep the rest of the day. ... How could bursitis be related to insomnia? ... How could the pain travel from my shoulder to my neck and to my hands in a matter ... During physical therapy, a specialist will try to improve the range of motion in your shoulder. These are best done after a diagnosis, though, and under the guidance of your doctor. A 501(c)(3) non-profit organization. In some cases, shoulder bursitis develops some time after the injury occurs, perhaps in response to the healing process or as a result of restricted movement. Always follow your healthcare professional's instructions. Polymyalgia rheumatica is an inflammatory condition that causes pain in Stand facing a wall (the front of your body should be touching the wall). Inflammation in this area causes pain when the arms lift overhead. Your shoulders are packed with bones, muscles, tendons, and ligaments. Whichever stretches you complete, take your time and be patient with your healing. Avoid doing the things that cause pain, such as reaching or stretching beyond your comfort zone. Found inside – Page 70'I think you can paint him now' DOCTOR," he said to the interne when he walked back, "you're not trying to scrub my patient away are you? You wouldn't want me to have to go out on the street and find a new one. These are low-impact stretches that can be done every day. Two common shoulder problems are arthritis and bursitis. Found inside – Page 466... hidden in bread and had to go to the dentist and Irene has now a bursitis in the synovial bursa at the left shoulder. ... gives a concert on Saturday) then we'll have my mother at home until Thursday when I leave to the chalet. Found inside – Page 12The “ Premier " is too light in the stroke to be satisfactory in my opinion. ... _as applied to sprains , Synovitis and Bursitis , Dr. A. B. Clark , of New ... The good news: "Pain almost always goes away with targeted exercise and stretching," says Dr. Elson. Bursitis is also associated with other problems. Gently pull the towel upward with your other hand to stretch the affected shoulder and upper arm. These are some of the possible reasons why you may be experiencing shoulder blade pain. Of these, shoulder bursitis, also called rotator cuff tendonitis or impingement syndrome, is arguably the most common. Bring someone with you to help you ask questions and remember what your provider tells you. Know how you can contact your provider if you have questions. Symptoms are extreme burn and electrification. I began looking around for an awesome clinic that offered a wide range of services, and to my surprise, I was able to find a few places that I was really impressed with. The cold helps … When shoulder pain strikes, we quickly understand how important (and well-used) the shoulder joint is. I think it may be shoulder bursitis but I don't want to go to a doctor because I think they don't take their job seriously. Bursitis may go away over time with self-care. Ask if your condition can be treated in other ways. Frozen shoulder (also called adhesive capsulitis) is a common disorder that causes pain, stiffness, and loss of normal range of motion in the shoulder. These are low-impact stretches that can be done every day. I think I would like to push for surgery because I have heard that bursitis is uncurable and … Pain is not normal, start the conversation today. That's just how Tendonitis works. Shoulder pain can also be a sign of a more serious injury to your rotator cuff, a small tear or hole called a rotator cuff tear. These include arthritis, gout, tendonitis, diabetes, and thyroid disease. The rotator cuff is a group of muscles that surrounds the shoulders, giving it support and allowing it a free range of motion. In the area of the hip and pelvis there are several bursae, which may be subject to bursitis. The most significant downside is that cortisone injections may weaken tendons. Weekly updates on conditions, treatments, and pain medicine. If your pain between shoulder blades won’t go away after a few days or it’s severe, see your doctor as soon as possible. … © 2021 Cedars-Sinai. Once the inflammation and pain subsides somewhat, shoulder bursitis stretches can help restore (and increase) your range of motion for better shoulder health. – Rotator Cuff Tear. Arthritis is a very common condition. The shoulder is the most mobile joint in the body. If an infection is suspected, your doctor may also prescribe antibiotics. It's simple. More interventional techniques are discussed after. Take a strap or a belt between your hands, wider than your shoulders and with your palms facing down. If your job requires kneeling or reaching overhead repeatedly (i.e., cleaning floors or hanging drywall), you are at a higher risk for shoulder bursitis as well. After the pain is gone, simple exercises or physical therapy may help you return to normal, pain-free activities. A physical therapist can work with you to correct any underlying mechanical issues that may have caused your inflammation. The most common causes of bursitis are injury or overuse. Tendonitis is acute (short-term) inflammation in the tendons. It may go away in just a few days with rest and physical therapy. Tendonitis results from micro-tears in the tendon when it's overloaded by sudden or heavy force. The other forms of bursitis can be a … © 2000-2021 The StayWell Company, LLC. If hard and soft tissues interact directly during movement, they create friction that eventually leads to inflammation in their bursae, or bursitis. Bursitis in the shoulder can develop on its own when something irritates, damages, or infects the shoulder's bursa. Infection may also cause it. Shoulder bursitis is a common ailment for many people, with symptoms ranging from a minor inconvenience to completely debilitating pain. 3) Start to bring in gentle heat. Typically, you’ll combine rest with other at-home shoulder bursitis treatments. At-home shoulder bursitis treatments are often adequate to treat shoulder bursitis symptoms and heal your pain and inflammation. Found inside – Page 139the raft is going to flare up the bursitis in my left shoulder , I'm thinking that too , when Mr. Tennessee Shirt who's stumbling beside me says , What if a shark got hold of Talbot after he got hold of it ? The doctor may refer you to a rheumatologist, an orthopedic surgeon or a physical therapist for specialized treatment. In some cases, joint injections to relieve pain and inflammation may be recommended, but this is not considered a first-line treatment and is generally only utilized when conservative measures have failed. The exercises may include passive exercises, such as lifting your arm up and down. Start new exercises or sports slowly. Found inside – Page 436If I have terrible bursitis in my shoulder when I am conducting , I change the baton to the other arm . ... has problems and one can lose oneself in doing this thing that's so necessary for one to do , it doesn't take the problem away . Take breaks often when doing repetitive tasks. Found inside – Page 8Comfortable elastic back support gently holds your shoulders, helps you stand straighten Look slimmer! ... 4633 Drake Building Colorado Springs, CO 80940 CHARGE TO MY: (CIRCLE ONE) NAME ADDRESS Account No: CITY & STATE ZIP Signature: ... My doctor diagnosed it as bursitis and arthritis, as well as disc degeneration in my neck, causing pain under my shoulder blade. The following five at-home treatments are a great place to start to ease pain while keeping a good range of motion. If your elbow bursitis was caused by constant, repetitive overuse – such as playing tennis or golf – consider modifying its frequency and the way you perform the activity. 4 Arizona locations to better serve you. This means limiting the activity that lead to the inflammation. The body is a miraculous thing— it has built-in protection systems to keep organs, bones, and other vital mechanisms safe. Note: only perform these stretches after getting approval from your doctor. These control both pain and inflammation. Other exercises include lifting light weights to strengthen your rotator cuff tissues. Impingement refers to soft tissues when they become trapped between two bony surfaces. clinically significant decreases in shoulder pain, 875 N Greenfield Rd #110 What bursitis feels like. Shoulder impingement usually takes about three to six months to heal completely. More severe cases can take up to a year to heal. However, you can usually start returning to your normal activities within two to four weeks . Surgery is rarely needed to treat bursitis. Ligaments and tendons further stabilize all four joints, attaching muscle to bone (tendons) and bone to bone (ligaments). Found inside – Page 797Whipple Humane Horse Collars shoulder - showing why your sore horses easier ... mingle Hock , Bursitis it with the soil and liberate the plant DEPARTMENT OF ... Repeat five to ten times. These drugs help reduce the swelling and pain. Shoulder bursitis is a condition that develops in the fluid-filled sac (bursa) found between the rotator cuff and shoulder blade. Found insideClive ducked behind his shoulder again. But Ken held his hand steady as he could. ... Ken and Aris talked about their own problems; prostrate for Ken, rheumatism, gout and bursitis for Aris. But JD wouldn't get off the painting. Moving too quickly or ignoring extreme pain can only prolong the healing process or exacerbate your shoulder bursitis, so proceed with caution. – Biceps Tendon Injury at the Shoulder (Tear/Tendonitis) Shoulder Procedures ». Found inside – Page 162I personally can attest to this painful woe , which affected my shoulders after overdoing it with hand weights . Often , it is exercise - related ... If you want to heal faster , try massaging oil into the tender spots as well . Baseball players, tennis pros, and golfers are frequently diagnosed with shoulder bursitis. She typically recommends massage and a course of physical therapy, which focuses at first on easing tight tissues by stretching them. Found inside – Page 30I'll have to scrub the carpet, and I can barely walk on my feet! ... Both my feet and ankles are arthritic, my right knee has gout, and my right shoulder has bursitis. ... I huffed away, boiling mad at Mother's insensitivity. ... That means you won’t have to stay in the hospital overnight. Found inside – Page 30My momma's bedroom light went out also, but it was not dark outside because the stars brightly shined. I tried to get comfortable, ... He whispered back over his shoulder, “Hey Santa, it appears that a little girl is homeless.” “What? This may help address any issues in the shoulder that are caused by misalignment of the vertebrae anywhere along the spine, but especially in the upper portions. Your pain and swelling should go down in a few days. Your doctor will start your shoulder bursitis diagnosis by asking about your medical history and conducting a physical exam. Found inside – Page 1450The Witness : As far as my knowledge is concerned . ... have you treated of shoulder bursitis , treated or 1452 observed the treatment in hospitals ? Rest and gentle exercises can speed up recovery. All rights reserved. Bursitis of the shoulder (impingement syndrome) occurs when there is swelling and redness between the top of the arm bone and the tip of the shoulder. During this procedure, hair-thin needles are inserted at specific points in the body depending on what condition is being treated. Our trustworthy, compassionate doctors are ready to help you! Some doctors do this after they aspirate the bursa. pain relief. At this point, your pain will begin to switch from sensations of inflammation to feelings more akin to stiffness. This can be done using a small incision with a special, minimally invasive probe called an arthroscope. Cushion “at risk” joints by using elbow or knee pads. The shoulder bursa acts as a cushion for a tendon in your rotator cuff that connects bone to bone. This entire structure consists of four joints. If it doesn't, a primary care doctor will focus on reducing pain and inflammation and preserving mobility. In some instances hip bursitis will absolutely go away on its own, however, without investigating and addressing its underlying root cause, we can’t guarantee the hip bursitis won’t return at a later date. Physical therapy will aim to restore flexibility to the joint capsule, then to strengthen it. Choose a doctor and schedule an appointment. Arizona Pain was founded on a single premise–provide world class care that we would want for our own mom or dad. The primary suspects for this type of pain are the bursa or the tendons of the gluteal muscles that attach onto the bone on the outside of the hip. In less than a week, the knee is typically back to normal (sans a little swelling if you retain a lot of fluid). Further cushioning and easing your movements are small, fluid-filled sacs called bursa. This usually subsides after 48 hours. As your shoulder heals, you can exhale and lower the arms behind the body (making them as wide as needed to keep the arms straight), then inhale to bring them back up and overhead to the front. You may want to complete these shoulder bursitis exercises for both shoulders to stay balanced in your range of motion. Found inside – Page 797Satisomy of a horse's shoulders . faction or money back . ed until the soil ... the plant Hock , Bursitis DEPARTMENT OF ANIMAL INDUSTRY , DETROIT , MICH . Until you see a physical therapist, refrain from anything that irritates your shoulder. Bend your elbow at a 90-degree angle. There are a variety of shoulder bursitis treatments at home and shoulder bursitis exercises that can help ease symptoms and treat pain and inflammation. Bursitis is inflammation of a bursa, a closed, fluid-filled sac that works as a cushion and gliding surface to reduce friction between tissues of the body. Shoulder bursitis can worsen without physical therapy treatment. Shoulder bursitis is best understood in the context of shoulder anatomy. Found inside – Page 75“Go on, Sheriff. ... it's the two chocolate brownies I had after dinner—well, okay, three, but I'm having some indigestion that won't go away. ... “I got a little of that bursitis back in my left shoulder, but other than that I'm fine. Here’s what you can expect. Bursitis of the shoulder is a painful inflammation in the shoulder joint. ... We all know that if the injury was healed, the pain would go away but what about the opposite situation? Repeated cortisone injections should be considered with care. Hold for five seconds, then slowly lower. Because of its extensive range of motion, it’s susceptible to injury and pain. Also in the acute phase, ice can help calm inflammation and offer acute pain relief. After the first 24 hours, warming pads and hot baths can help keep blood flowing in the shoulder capsule and also provide significant pain relief. Bursitis of the shoulder is treatable at home or by a doctor. Symptoms are often relieved using the RICE method: rest, ice, compression, and elevation. More specifically, the following treatments may help with shoulder bursitis: Anti-inflammatories: Aspirin or ibuprofen can reduce swelling and discomfort in the shoulder. | KC Bone & Joint. All Rights Reserved. Also know what the side effects are. Found insideSince Gage and the girls are here to look after you, I thought I'd go now. I won't be long. ... you need and drop it off before I go shopping. That way you and the girls can start baking right away. ... My bursitis is acting up. In some cases hip bursitis pain may never go away. We use a team approach with cutting edge treatment plans as we ask one simple question with every patient. Chiropractic care uses spinal manipulations to safely realign the spine. If the pain in your shoulder won't go away no matter what you do, you might have a problem called shoulder bursitis. Warm up before exercising or before sports or other repetitive movements. Schedule an appointment today and be seen by a double-board certified pain doctor. Found inside – Page 393... a ten - dollar bill , an autumn leaf , and sympathetic words , “ I too have slept with someone else's boot in the corner of my smile . ... then three years later she was hospitalized with an attack of bursitis in her shoulder . Regardless of treatment, shoulder bursitis recovery time will vary depending on the severity of your symptoms and any underlying health conditions. Rotator cuff injuries. Acupuncture uses the principles of traditional Chinese medicine to clear up blocked channels in the energy meridians of the body. Unbearable shoulder pain from shoulder bursitis by: Anonymous I am 19 and ran college track for a semester before the bursitis behind my left shoulder blade became unbarable. Once the inflammation and pain subsides somewhat, shoulder bursitis stretches can help restore (and increase) your range of motion for better shoulder health. Sometimes, inflammation in the bursa and tendon lead to shoulder impingement. What to do: Drape a towel over the unaffected shoulder, and grab it with your hand behind your back. Tense muscles can weaken over time and cause additional health complications like poor posture. Shoulder bursitis can occur in anyone at any age but most commonly affects older adults. Found insideI rubbed at my bursitis-prone shoulder and glared across the table at the gargoyle. We'd been at this for more hours than I wanted to calculate, and I was no closer to setting fire to that bit of tinder-dry grass now than I had been ... All rights reserved. Phoenix, AZ 85024, Range of motion that is restricted by pain, Swelling and redness in and around the shoulder joint. Oftentimes, performing shoulder strengthening exercises with the arm by your side rather than overhead can be a way to continue strengthening the shoulder without aggravating symptoms that occur with overhead motions (like the exercise in your example). During the surgery, the inflamed bursa, some of the bone and any spurs are removed to create a larger space for the rotator cuff tendons. Found inside – Page 64My momma's bedroom light went out also, but it was not dark outside because the stars brightly shined. I tried to get comfortable, ... He whispered back over his shoulder, “Hey Santa, it appears that a little girl is homeless.” “What? It's important that you follow all of your therapist's advice during treatment. Elbow Bursitis: Will It Go Away on Its Own? 1. It Rarely Gets Better. If nothing changes, shoulder bursitis will, at best, stay the same. If you think you might have bursitis, it’s a good idea to visit your doctor (or a rheumatologist who specializes in joint disorders) in order to rule out other causes for your pain. Range of motion exercises increase flexibility, strength, and movement in your arm and shoulder. Found inside – Page 396For straight - away work there is the No. ... They go ahead of it . ... My 18 - yearHOCK OR BURSITIS old mare is trouble with a bad case of scratches ... After I started our family, I realized that I needed a great place to take our kids if they were ever injured or ill. Slowly begin to turn your body so that the raised arm is flat on the wall, but your body is opening away from the wall. Found inside – Page 29019:11—To my great surprise, we've turned up a little more on “Oh, The Elephant Never Forgets”: “All three of the ... Pony fall in Milwaukee Sentinel (April 15, 1937: “He fell on his shoulder—a distance of about four feet—and was so ... This includes car accidents, falls, or blows to the shoulder in contact sports. These conditions can occur alone or in combination. Shoulder bursitis most commonly occurs in people older than 40 years of age and/or have bone spurs on one of their shoulder bones. Practice good posture. Learning more about shoulder bursitis can help treat and manage your pain better. If there is fluid on the shoulder, this fluid can also be analyzed to confirm a diagnosis (or rule out other conditions). The pinched tissues limit movement in your arm. Natural Bursitis Treatment & Relapse Prevention. Stop when you feel a good stretch then breathe there for ten breaths. Raise the arm with the injured shoulder with the elbow bent at a 90-degree angle and place it on the wall (palm facing the wall). Three bones meet to make up the shoulder: The shoulder joint itself is a ball-and-socket joint that is part of the larger anatomy of what is known as the shoulder girdle (or shoulder capsule). The thin sacs allow soft tissues like your tendons to freely and safely move over the hard surfaces of your bones and joints. Gilbert, AZ 85234, 2340 East Beardsley Road Suite 110 Press the back of the hand against the wall and hold for five seconds. If, other than pain, there are no other physical symptoms, your doctor may recommend imaging to rule out other causes. The tendon swells, which places pressure on the bursa near it. To relieve bursitis of the shoulder, avoid doing the things that cause pain. Check it out! Typically, the first few days are particularly bad (redness, swelling, bruising sensation, stiffness). After much research, I discovered that there are basically 3 explanations as to why the pain in your elbow just won’t go away and keeps coming back. On an inhale, keep your arms straight but raise your arms above your head. If you have concerns or questions about shoulder bursitis, contact a physical therapist for answers. If your bursitis does not go away after 6-12 months, your doctor may recommend surgery to repair damage and relieve pressure on your bursa. I wanted to create a blog all about how to find a great health care clinic, so that you don't have to worry. Trochanteric bursitis brings warmth, swelling and pain to your outer thigh that can spread down to your knee. Found inside – Page 78Nelson Tank Heater -Two weeks Free Tria + TE ANK THE Risto SAVE - THE - HORSI BOOK FREE Don't Cut Out A SHOE BOIL , CAPPED HOCK OR BURSITIS R OV We DUVES ... Application of heat will help you loosen you up and speed healing. The condition can also be treated with anti-inflammatory medications such as Motrin or Advil. Depending on the severity, this inflammation can completely shut down mobility in your shoulder.