1 00:00:03,400 --> 00:00:07,600 We're going to try not to talk about highly technical things, 2 00:00:07,600 --> 00:00:09,600 but once again, thank you for giving us this half hour. 3 00:00:10,000 --> 00:00:15,000 So first a little intro why we're each going to kind of tell 4 00:00:15,000 --> 00:00:21,600 a little story of a patient that we have and I find we both of us 5 00:00:21,700 --> 00:00:25,300 with physical therapy and and in Podiatry, treating people every 6 00:00:25,300 --> 00:00:27,800 single day with plantar fasciitis. 7 00:00:27,800 --> 00:00:29,900 And I want to give an example of a woman that I was seeing 8 00:00:29,900 --> 00:00:32,500 recently. She's a 35 year old female. 9 00:00:32,800 --> 00:00:36,700 She came in and she had been dealing with heel pain for three 10 00:00:36,700 --> 00:00:40,600 years and she kept on hoping that it would go away. 11 00:00:41,400 --> 00:00:45,400 Initially started when she was trying to work out for exercise 12 00:00:45,400 --> 00:00:48,000 to shed a little bit of weight after having a couple of 13 00:00:48,000 --> 00:00:51,100 children and it never got a never went away. 14 00:00:51,600 --> 00:00:54,800 And so part of her reason for keeping active is, she was 15 00:00:54,800 --> 00:00:56,800 trying to lose weight. And when you have really bad 16 00:00:56,800 --> 00:00:59,400 healing, you can't do anything. It's debilitating. 17 00:00:59,800 --> 00:01:02,300 So for me, when I was able to treat her, send her over to 18 00:01:02,300 --> 00:01:04,400 physical therapy. Therapy, do some different types 19 00:01:04,400 --> 00:01:06,100 of treatments. I think she had some shock wave 20 00:01:06,100 --> 00:01:09,200 therapy and things like that getting her into Orthotics, she 21 00:01:09,200 --> 00:01:11,800 could be active during her recovery. 22 00:01:11,800 --> 00:01:14,000 So that's kind of why I like to help people. 23 00:01:14,000 --> 00:01:16,900 And Joe you had a marathon patient right recently. 24 00:01:16,900 --> 00:01:19,300 Yes I have a marathon patient right now she's at the mid 25 00:01:19,300 --> 00:01:23,200 14-mile running to distance. It's just I'm becoming having 26 00:01:23,200 --> 00:01:25,400 foot pain. She's in physical therapy, were 27 00:01:25,400 --> 00:01:28,000 taking care of the foot pain, but we still going to keep her 28 00:01:28,000 --> 00:01:29,900 cardio up. So we're having our do things 29 00:01:29,900 --> 00:01:32,000 like swimming getting on the bike. 30 00:01:33,400 --> 00:01:36,900 For that two hour mark and keeping that heart rate where it 31 00:01:36,900 --> 00:01:40,000 is, so she can keep her cardio while she's still training and 32 00:01:40,000 --> 00:01:42,100 still getting better so she can get back into the Running part 33 00:01:42,100 --> 00:01:44,200 of it. Yes, I think that's key is 34 00:01:44,200 --> 00:01:47,900 keeping people active so they can either lose weight or run 35 00:01:47,900 --> 00:01:50,600 their Marathon or you do not have to switch boards. 36 00:01:50,600 --> 00:01:53,600 But I do tell people once in a while, you know, if you have a 37 00:01:53,600 --> 00:01:55,700 for example, other things like a stress fracture. 38 00:01:55,900 --> 00:01:59,400 That might be a good opportunity to kind of learn another sport 39 00:01:59,400 --> 00:02:01,000 like swimming or something else like that. 40 00:02:01,000 --> 00:02:04,400 If it's to debilitating So let's get right into it. 41 00:02:04,600 --> 00:02:08,600 The two types of heel pain that we're talking about I would say 42 00:02:08,800 --> 00:02:14,700 90% maybe 95% are something called plantar fasciitis and 43 00:02:14,700 --> 00:02:19,000 achilles tendonitis. Now the reason we're talking 44 00:02:19,000 --> 00:02:25,400 about heel pain generically is because both of these, if you 45 00:02:25,400 --> 00:02:28,800 look this is the heel bone or the calcaneus both of these 46 00:02:28,800 --> 00:02:32,600 insert into the heel, the plantar. 47 00:02:32,800 --> 00:02:38,700 Sure inserts into the bottom in the Achilles inserts into the 48 00:02:38,700 --> 00:02:41,000 back. So in my opinion, to pretty much 49 00:02:41,000 --> 00:02:45,600 the same thing and they're treated very, similarly y, you 50 00:02:45,600 --> 00:02:49,700 get one versus the other, maybe a flip of the coin, there might 51 00:02:49,700 --> 00:02:52,500 be some what we call biomechanics, or how your foot 52 00:02:52,500 --> 00:02:55,900 structure is or how tight you are, but a lot of people they 53 00:02:55,900 --> 00:02:58,800 come in with plantar fasciitis and then maybe later on. 54 00:02:58,800 --> 00:03:01,600 They'll develop achilles tendonitis and I think the big 55 00:03:01,600 --> 00:03:05,800 culprit is the back. Back of the calf and no one ever 56 00:03:05,800 --> 00:03:09,500 complains of back of calf pain. And when I bring up, you know, 57 00:03:09,500 --> 00:03:14,100 working the back of the calf or working your core, or working 58 00:03:14,100 --> 00:03:19,000 your quads, or your glutes, or your other things more up, or 59 00:03:19,000 --> 00:03:21,400 more proximal, everyone wonders. Why? 60 00:03:21,400 --> 00:03:25,500 It's because the foot is just a symptom of what's Happening, 61 00:03:25,500 --> 00:03:27,400 higher up. And so that's why it's 62 00:03:27,400 --> 00:03:29,700 essential. If you really want to get rid of 63 00:03:29,700 --> 00:03:32,400 it and avoid injury, you have to work on everything else. 64 00:03:32,400 --> 00:03:35,100 Hi Up. And you're all it is is how your 65 00:03:35,100 --> 00:03:37,800 body moves over your foot. So if your body is moving over 66 00:03:37,800 --> 00:03:41,800 abnormal, abnormally, that needs to be fixed specifically in your 67 00:03:41,800 --> 00:03:44,000 pelvis. That's a big area or hip range 68 00:03:44,000 --> 00:03:48,000 of motion. Another thing that people should 69 00:03:48,000 --> 00:03:51,000 know of some they actually have degeneration of the tendon. 70 00:03:51,000 --> 00:03:54,800 So you can see here this is a thickened tendon and it develops 71 00:03:54,800 --> 00:03:57,000 Scar Tissue. That's called a bulbous. 72 00:03:57,000 --> 00:03:59,700 Looks like a bulb. A bulbous change in the 73 00:03:59,700 --> 00:04:02,100 Achilles. Now if you think about it, if 74 00:04:02,100 --> 00:04:05,400 you have a A piece of string and you tie a whole bunch of knots 75 00:04:05,400 --> 00:04:08,900 in it that string is going to reduce in length because it 76 00:04:08,900 --> 00:04:12,900 takes up space those knots and it's the same thing in the 77 00:04:12,900 --> 00:04:16,600 Achilles and the same thing of the fashion you're going to see 78 00:04:16,600 --> 00:04:20,800 later on when I talk about the ultrasound it gets thicker if 79 00:04:20,800 --> 00:04:25,400 it's thicker it inherently gets shorter when it gets shorter, 80 00:04:25,400 --> 00:04:29,300 it's going to put more strain on those on those tissues. 81 00:04:29,300 --> 00:04:32,600 So in my opinion I think about 80 percent is due to tight. 82 00:04:33,500 --> 00:04:36,500 Tightness in the back of the calf that then leads to Achilles 83 00:04:36,500 --> 00:04:39,100 tendonitis, or plantar fasciitis, for some patients 84 00:04:39,100 --> 00:04:44,400 that can be caused by flat feet over pronation increasing your 85 00:04:44,400 --> 00:04:46,600 activity. The big, the big story I get is 86 00:04:46,600 --> 00:04:50,900 people, they go to Disney and they don't have plantar 87 00:04:50,900 --> 00:04:52,900 fasciitis, and they come back with plantar fasciitis, 88 00:04:52,900 --> 00:04:55,100 basically, because they've been on their feet for six or eight 89 00:04:55,100 --> 00:04:57,500 hours a day and they're in flip-flops. 90 00:04:57,800 --> 00:05:00,800 And then the, yeah, and on cement and they're walking a 91 00:05:00,800 --> 00:05:03,800 whole bunch, or they're starting to Work out there trying to do a 92 00:05:03,808 --> 00:05:06,800 marathon or half-marathon and then they get it and it never 93 00:05:06,800 --> 00:05:09,700 calms down if you get help right away, it can calm down and it 94 00:05:09,700 --> 00:05:14,000 can you can get help. What I was talking about in 95 00:05:14,000 --> 00:05:18,600 terms of the Imaging, you can either do an ultrasound or an 96 00:05:18,600 --> 00:05:20,300 x-ray. We always get x-rays first to 97 00:05:20,300 --> 00:05:24,400 see if there's any bones for, but it's not as important in my 98 00:05:24,400 --> 00:05:29,000 opinion, if you have a Spur, not a Spur shows that you have 99 00:05:29,000 --> 00:05:33,500 traction on either the faccia or on the Achilles. 100 00:05:33,500 --> 00:05:37,000 So basically this is an example of the right plantar fascia. 101 00:05:37,600 --> 00:05:41,000 This is the heel in, this is the fashion, this little fibrous 102 00:05:41,000 --> 00:05:43,900 thing. If you pull hard enough on this 103 00:05:43,900 --> 00:05:47,400 bone, it's going to create a Spur out here, that's called 104 00:05:47,400 --> 00:05:51,900 Wolff's law, your body, it responds to pulling over a 105 00:05:51,907 --> 00:05:53,800 period of time. So the goal is to reduce that 106 00:05:53,800 --> 00:05:58,000 polling or that traction but what happens with the faccia, if 107 00:05:58,000 --> 00:06:00,200 it's been there for a while, you can see this thickness, the 108 00:06:00,200 --> 00:06:03,500 distance between the two A's and then the distance right here 109 00:06:03,500 --> 00:06:08,500 between the two ways, this it looks darker looks black and 110 00:06:08,500 --> 00:06:10,700 it's thicker. That's chronic. 111 00:06:11,300 --> 00:06:15,000 Your fashio says it gets thick and over time if you're looking 112 00:06:15,000 --> 00:06:17,600 at an ultrasound in a patient that just has plantar fasciitis, 113 00:06:17,600 --> 00:06:19,800 it's going to look the same thickness in the same color. 114 00:06:20,000 --> 00:06:22,900 If it's been there for a couple of months, it's going to get why 115 00:06:22,900 --> 00:06:26,200 it's going to get black and it's going to get thicker. 116 00:06:26,600 --> 00:06:30,300 And that means there's chronic effusion or swelling inside of 117 00:06:30,308 --> 00:06:32,100 that tissue. And you may need a different 118 00:06:32,100 --> 00:06:33,800 type of treatment to get rid of that. 119 00:06:33,800 --> 00:06:37,200 The longer it is, I usually use three months, if you've had it 120 00:06:37,200 --> 00:06:39,000 for three months, you're going to probably need some of the 121 00:06:39,000 --> 00:06:41,200 more advanced treatments, if it's less than three months. 122 00:06:41,800 --> 00:06:44,200 You know, you came in sooner but most people don't come in right 123 00:06:44,200 --> 00:06:47,400 away. This is a lengthwise evaluation 124 00:06:47,400 --> 00:06:49,700 of an Achilles. You can see this little black 125 00:06:49,700 --> 00:06:51,900 line. So it's looking right down the 126 00:06:51,900 --> 00:06:56,200 Achilles and this has a little bit of a tear right in that area 127 00:06:56,300 --> 00:06:59,600 and then it's thicker. Once again this thickness is 128 00:06:59,600 --> 00:07:02,700 kind of like scar tissue in that doesn't allow it to be as 129 00:07:02,700 --> 00:07:05,500 flexible and that needs treatment and you know, get 130 00:07:05,500 --> 00:07:06,700 kill. He's is a hard area because you 131 00:07:06,700 --> 00:07:08,700 can't really do a cortisone injection to that because it 132 00:07:08,700 --> 00:07:10,900 could cause a rupture. And so that's those are kind of 133 00:07:10,900 --> 00:07:13,400 the Yeah, they aspects of the energy so just going to talk a 134 00:07:13,407 --> 00:07:14,500 little bit about stretching here. 135 00:07:15,000 --> 00:07:17,800 So stretching is key and that's what we kind of promote. 136 00:07:17,900 --> 00:07:20,400 When the patient comes in will ask them what they're stretching 137 00:07:20,400 --> 00:07:21,800 program is. And they're probably have 138 00:07:21,800 --> 00:07:23,500 nothing at all. They just know, I just go 139 00:07:23,500 --> 00:07:25,300 running. I just go exercise and I don't 140 00:07:25,300 --> 00:07:28,300 have time for stretching so most of the patients that are here 141 00:07:28,300 --> 00:07:30,300 from physical therapy because they don't stretch. 142 00:07:30,500 --> 00:07:34,300 So we'll go over a nice routine of good stretching will make 143 00:07:34,300 --> 00:07:35,900 sure that they know the stretching, they have the 144 00:07:35,900 --> 00:07:38,300 stretching of the pictures word, so they can work on their own 145 00:07:38,300 --> 00:07:41,100 stretching along with that, we do the foam rolling. 146 00:07:41,500 --> 00:07:43,100 Make sure their pelvis is aligned, make sure all the 147 00:07:43,100 --> 00:07:46,800 joints are working, so that the whole leg is working for the 148 00:07:46,800 --> 00:07:49,000 foot and the foot is working for the legs. 149 00:07:49,500 --> 00:07:52,300 So, Joe talked a little bit about your habits. 150 00:07:52,300 --> 00:07:54,200 Let's say someone has Achilles or plantar fascia. 151 00:07:54,500 --> 00:07:57,800 How many minutes do they need to dedicate to stretching or here's 152 00:07:57,800 --> 00:08:00,500 an example of a foam rolling? How much time are they gonna 153 00:08:00,500 --> 00:08:02,800 have to? We usually film about two 154 00:08:02,800 --> 00:08:06,100 minutes per muscle area. So they're going to get on their 155 00:08:06,100 --> 00:08:08,600 Catholic and go back and forth and get to work it out for a 156 00:08:08,600 --> 00:08:10,900 good, two minutes different angles so they can take their 157 00:08:10,900 --> 00:08:12,000 foot. They're going to Is the foot 158 00:08:12,000 --> 00:08:15,200 angle back and forth like their Comic-Con was like running in 159 00:08:15,200 --> 00:08:16,800 and out. Try to hit the different fibers 160 00:08:16,800 --> 00:08:20,700 of each of those muscles. How many times a day it's up to 161 00:08:20,700 --> 00:08:22,000 them. At least once or twice. 162 00:08:22,000 --> 00:08:24,000 But if you know they're exercising, run, we want to do 163 00:08:24,000 --> 00:08:26,700 before and after would just to keep everything nice and loose 164 00:08:26,700 --> 00:08:28,700 and shouldn't hurt. Is it okay to hurt? 165 00:08:29,100 --> 00:08:32,500 It's Gonna Hurt, it's just that determining. 166 00:08:32,500 --> 00:08:35,100 What kind of heard it is a bad hurt that we have to hold off? 167 00:08:35,299 --> 00:08:37,799 If it's a good working her that's still okay? 168 00:08:37,799 --> 00:08:40,200 And after we can ice and stem or whatever they want to do to kind 169 00:08:40,200 --> 00:08:44,000 of calm down, And then how about those those those the the people 170 00:08:44,000 --> 00:08:46,000 run pushing against the wall, the runners stretch here, 171 00:08:46,000 --> 00:08:48,900 letting your heels go. Down the E Centric, contracture, 172 00:08:49,500 --> 00:08:52,600 explain that a little bit, those types of stresses of nice. 173 00:08:52,600 --> 00:08:55,200 Good, lengthen and stretch. I usually tell them not to 174 00:08:55,500 --> 00:08:57,400 stretch to the point where it's painful. 175 00:08:57,500 --> 00:09:00,200 It shouldn't be too painful, but should get a good comfortable 176 00:09:00,200 --> 00:09:03,200 stretch out of it. Yeah, I think a lot of times you 177 00:09:03,200 --> 00:09:05,500 go to see a doctor and they'll just recommend stretching 178 00:09:06,000 --> 00:09:07,600 Primary Care. You go to your primary care. 179 00:09:07,600 --> 00:09:09,900 They're going to recommend a shoe insert, maybe a new shoe 180 00:09:10,300 --> 00:09:12,900 and then stretching and time. Andres icing and fed doesn't get 181 00:09:12,900 --> 00:09:14,500 better. Then the probably send you to 182 00:09:14,500 --> 00:09:20,000 physical therapy or to see a podiatrist, I think foam rolling 183 00:09:20,000 --> 00:09:24,400 is in deep tissue, work is key. And then if so, I basically foam 184 00:09:24,400 --> 00:09:27,400 rolling, is that two to three minutes on each muscle group. 185 00:09:27,400 --> 00:09:29,800 Maybe I say ten minutes in the morning, ten minutes at night, 186 00:09:30,200 --> 00:09:32,100 that's what eyes. And then during the day you can 187 00:09:32,100 --> 00:09:35,400 do your stretches like if you're at work or if you're at a stair 188 00:09:35,400 --> 00:09:37,500 or something else like that. But you have to become part of 189 00:09:37,500 --> 00:09:39,700 your routine. Now, even when they recovered, 190 00:09:39,800 --> 00:09:41,100 do they have to continue doing this? 191 00:09:41,500 --> 00:09:44,000 Yeah, they'll keep them out of the doctor's office and other 192 00:09:44,000 --> 00:09:45,300 PC. Keep working. 193 00:09:45,300 --> 00:09:46,700 Keep stretching keep foam rolling. 194 00:09:47,100 --> 00:10:01,600 Yeah I think a lot of people all the time and you can speak 195 00:10:01,600 --> 00:10:04,300 better to that but everything gets kind of tight and then 196 00:10:04,300 --> 00:10:06,300 people start working out. I go to Disney or something like 197 00:10:06,300 --> 00:10:07,600 that. And they Wonder well how come I 198 00:10:07,608 --> 00:10:10,400 developed heel pain or something like that for sure? 199 00:10:10,900 --> 00:10:14,600 Yeah. Okay, talk about this here, 200 00:10:14,600 --> 00:10:16,500 what's this? All right, so another way we can 201 00:10:16,700 --> 00:10:19,500 adapt the tissue or a kind of break up that strategy called 202 00:10:20,300 --> 00:10:22,500 fiberglassing. So, we have tools and see the 203 00:10:22,500 --> 00:10:24,900 tools up here. Use the tools that people love 204 00:10:24,900 --> 00:10:27,900 to hate because they hate it when we do it, but they love it 205 00:10:27,900 --> 00:10:29,400 after it, because they feel so much better. 206 00:10:29,500 --> 00:10:31,100 So, basically, we are digging into the muscle. 207 00:10:31,100 --> 00:10:33,800 We're breaking up while the fibers and we're stretching it 208 00:10:33,800 --> 00:10:37,700 out, so we'll do it at different angles at different points, it 209 00:10:37,700 --> 00:10:40,600 will do it action, but movement, sometimes just so we can break 210 00:10:40,600 --> 00:10:43,000 up those five or so we can get The muscle working better. 211 00:10:44,000 --> 00:10:49,400 It's what technologically, what is it doing to the tissue? 212 00:10:49,400 --> 00:10:50,600 Is it lengthening? It? 213 00:10:50,600 --> 00:10:52,500 Is it helping it to repair? Or what is it? 214 00:10:52,500 --> 00:10:54,700 Doing all the mom. So basically we're breaking up 215 00:10:54,700 --> 00:10:57,600 the scar tissue, increasing the blood flow, and we'll do it at 216 00:10:57,600 --> 00:11:02,000 different points of the joint angles so that we can hit 217 00:11:02,000 --> 00:11:05,700 different areas of the muscles. Yeah, and so what Joe's talking 218 00:11:05,700 --> 00:11:08,900 about on that ultrasound when I showed you that it was thicker, 219 00:11:09,500 --> 00:11:12,700 I guess you could call that scar tissue or a thickened tissue and 220 00:11:12,700 --> 00:11:15,700 then he takes this any, any rubs it on that area. 221 00:11:16,400 --> 00:11:19,600 What I find is that when you do treatment such as this or shock 222 00:11:19,600 --> 00:11:24,200 wave, it can actually thin down over time, that swelling goes 223 00:11:24,200 --> 00:11:27,200 down from within that tissue and it can thin it down to more of a 224 00:11:27,208 --> 00:11:29,200 normal level. But just like, scarring, 225 00:11:29,200 --> 00:11:31,200 anywhere else. For example, if you have a 226 00:11:31,200 --> 00:11:34,000 surgery or if you have a cut it's going to be initially, 227 00:11:34,000 --> 00:11:38,700 swollen thick and scarred. And then over about six months 228 00:11:38,700 --> 00:11:42,200 to a year it's going to remodel and it's going to get That 229 00:11:42,200 --> 00:11:45,800 thinner little line, you're always going to have a scar but 230 00:11:45,800 --> 00:11:49,200 the whole goal is that it's not as swollen and part of the 231 00:11:49,200 --> 00:11:51,800 problem is we never stopped in a. 232 00:11:51,800 --> 00:11:55,300 We are always busy, I find especially kids. 233 00:11:55,300 --> 00:11:58,800 You know, we don't see this as much in kids but like we're 234 00:11:58,800 --> 00:12:00,600 going from one sport to another sport. 235 00:12:00,600 --> 00:12:04,200 Were either sitting down or very active and no one gives anything 236 00:12:04,200 --> 00:12:06,500 a chance to kind of rest and recover. 237 00:12:07,000 --> 00:12:12,100 So it's an issue. How important our shoes Joe She 238 00:12:12,100 --> 00:12:15,000 was our key. So we have pronate and supinate 239 00:12:15,000 --> 00:12:17,200 has in neutral feet and most Runners. 240 00:12:17,200 --> 00:12:20,100 Even there if they've been doing multiple marathons, really don't 241 00:12:20,100 --> 00:12:22,400 know about their feet. You'll find a particular sneaker 242 00:12:22,400 --> 00:12:25,000 and they'll just go with it and more likely are in pain. 243 00:12:25,100 --> 00:12:27,800 But once we see them will evaluate their foot to see if 244 00:12:27,800 --> 00:12:30,700 which, what type they are. And there's different shoes that 245 00:12:30,900 --> 00:12:34,000 fit for different kinds of fees, especially for runners on the 246 00:12:34,000 --> 00:12:36,100 top, right? You'll see the new balance, you 247 00:12:36,100 --> 00:12:39,700 see the yellow band in there and that's a guys, it's a pronated. 248 00:12:39,700 --> 00:12:42,500 So it's an anti pronate. So it's a bar It's somewhat like 249 00:12:42,500 --> 00:12:45,800 let your foot came in as much and that will cause the 250 00:12:45,800 --> 00:12:49,100 pronation pain cause deep and right up to the hip pain for 251 00:12:49,100 --> 00:12:52,000 these Runners. The one on the bottom is more of 252 00:12:52,000 --> 00:12:54,700 a neutral, you can see where it's just basically nice, good 253 00:12:54,700 --> 00:12:58,300 Soul, nice cushion, soft as someone that has it more neutral 254 00:12:58,300 --> 00:13:01,300 foot and needs that needs to be able to select just like through 255 00:13:01,300 --> 00:13:04,700 when they're going through the running process and that's after 256 00:13:04,700 --> 00:13:07,000 afterwards when you feel nice. And so again it's a nice good 257 00:13:07,500 --> 00:13:09,400 sandal like that. It just makes you feel good. 258 00:13:09,600 --> 00:13:12,100 Yeah, I keep it real simple. One asked me. 259 00:13:12,100 --> 00:13:14,000 Hey Doc, am I gonna have to wear ugly shoes? 260 00:13:14,000 --> 00:13:15,600 The rest of my life. I say. 261 00:13:15,600 --> 00:13:19,800 It's for now. It's not forever, okay? 262 00:13:20,100 --> 00:13:24,000 And I say when you're at home, if you don't want to wear shoes, 263 00:13:24,000 --> 00:13:27,400 I like either a new foe or there's a Hoka sandal something 264 00:13:27,400 --> 00:13:30,100 with a really good arch support when you're when you're at home 265 00:13:30,300 --> 00:13:34,300 or it's a better alternative to a flip-flop. 266 00:13:34,300 --> 00:13:36,600 Now, you can tell something's good when you give it to your 267 00:13:36,600 --> 00:13:38,400 mom. So when my mom came and visited 268 00:13:38,400 --> 00:13:43,300 me, she had bunion surgery and I put her in these things and she 269 00:13:43,300 --> 00:13:45,600 absolutely love them. It could be from the cushion, 270 00:13:45,600 --> 00:13:48,200 could be from the arch, but there's a lot of things. 271 00:13:48,200 --> 00:13:51,600 These shoes are great. Now, specifically, I want to 272 00:13:51,608 --> 00:13:54,100 talk a little bit about a little to get a little technical here, 273 00:13:54,900 --> 00:13:57,900 a lot of shoes. You can see here, it's thicker 274 00:13:57,900 --> 00:14:01,500 at the heel than it is at the toe. 275 00:14:01,800 --> 00:14:04,000 And it has this little curvature thing here. 276 00:14:04,300 --> 00:14:06,600 So, this is kind of like a little rocker in the front of 277 00:14:06,600 --> 00:14:09,000 the foot. And this is a probably, a five 278 00:14:09,000 --> 00:14:12,700 to seven millimeter drop what that Ins is the height here, 279 00:14:13,000 --> 00:14:15,100 down to there is about five millimeters. 280 00:14:15,500 --> 00:14:18,700 This works well with someone, with Achilles tendonitis and 281 00:14:18,700 --> 00:14:22,100 finer fasciitis, because if you have a group called a zero drop 282 00:14:22,100 --> 00:14:27,000 shoe or it's exactly the same height that's going to put more 283 00:14:27,000 --> 00:14:29,400 pressure on the back of the Achilles now. 284 00:14:29,400 --> 00:14:33,200 Even though I do recommend a lot of shoes that are zero drop, I 285 00:14:33,200 --> 00:14:36,000 find that when you're recovering from one of these conditions, 286 00:14:36,000 --> 00:14:38,600 you tend to do better with the shoe with a little bit of a heel 287 00:14:38,600 --> 00:14:40,100 in it. Is that what you find as well 288 00:14:40,100 --> 00:14:41,100 for sure? Yeah. 289 00:14:41,700 --> 00:14:45,600 Some of my achilles patients I'll ask them. 290 00:14:45,600 --> 00:14:48,500 Have they changed their shoes and then someone will go from 291 00:14:48,500 --> 00:14:51,400 the zero drop two and another sneaker or Nike sticking with a 292 00:14:51,408 --> 00:14:54,300 higher heel bed and that's what's probably given the issues 293 00:14:55,000 --> 00:14:57,100 are going to a higher arch for actually lower. 294 00:15:21,500 --> 00:15:23,900 Look down and see where you're at, in terms of shoes. 295 00:15:23,900 --> 00:15:29,500 Can they go to? Like I said O, My People sneak 296 00:15:29,500 --> 00:15:32,200 around Mama, we have a script will write down the script, it 297 00:15:32,208 --> 00:15:34,500 will validate the foot. They look at the script. 298 00:15:34,500 --> 00:15:37,000 They look at the sneakers, they'll choose they'll give them 299 00:15:37,000 --> 00:15:39,300 three or four options and that's how we usually do it. 300 00:15:39,300 --> 00:15:41,800 Yeah, the real key is you want to go to a place that We're 301 00:15:41,800 --> 00:15:44,900 going to watch you walk and they'll be able to get something 302 00:15:44,900 --> 00:15:46,900 that's appropriate for you. You know. 303 00:15:46,900 --> 00:15:49,200 I can't emphasize when you're when you're starting to deal 304 00:15:49,200 --> 00:15:50,800 with heel pain. If you're if you're just in the 305 00:15:50,800 --> 00:15:54,100 beginning it's about its shoes as key. 306 00:15:54,200 --> 00:15:55,900 And you may say oh I have tons of shoes. 307 00:15:55,900 --> 00:15:59,200 I particularly don't like some of these cuter shoes, the 308 00:15:59,200 --> 00:16:01,500 Skechers, the Nikes, the things like that, they have really kept 309 00:16:01,500 --> 00:16:04,500 up with the technology, whereas the New Balance, the Saucony, 310 00:16:04,900 --> 00:16:07,600 the A6 and things like that. They have a better shoot. 311 00:16:07,600 --> 00:16:10,600 Now, for those patients doing to come in and say, you know, you 312 00:16:10,600 --> 00:16:14,500 know, Joe, I tried I'd 10 shoes in my heel, still doesn't feel 313 00:16:14,500 --> 00:16:16,400 better. What do you tell them? 314 00:16:16,600 --> 00:16:20,100 That's when I you should promote doctor Pelt, 04 Orthotics. 315 00:16:20,100 --> 00:16:22,300 And, you know, we'll take them, see how the taping feeling if 316 00:16:22,300 --> 00:16:24,100 that feels. Well, go see, dr. 317 00:16:24,100 --> 00:16:25,800 Kelso for Orthotics, and we're from there. 318 00:16:25,800 --> 00:16:28,500 Yeah, Joe that's the key is like if you've tried 20 pairs of 319 00:16:28,500 --> 00:16:31,600 shoes and the shoes of hurts, and it only hurts on your right 320 00:16:31,600 --> 00:16:33,500 foot because your right foot as pain pressure to the problem 321 00:16:33,500 --> 00:16:36,000 isn't the shoe don't go buying more shoes and don't you can 322 00:16:36,000 --> 00:16:38,800 spend like thousands of dollars on Amazon trying to buy every 323 00:16:38,800 --> 00:16:42,600 single thing don't do that. Save a lot of time and a lot of 324 00:16:42,600 --> 00:16:46,400 money by seeing someone. So, how about activity, 325 00:16:46,400 --> 00:16:48,700 modifications, if your want to stay active? 326 00:16:49,800 --> 00:16:51,300 Sure. So, if the running or the 327 00:16:51,300 --> 00:16:53,300 walking part hurts, this other ways of doing it. 328 00:16:53,300 --> 00:16:57,300 So, you're walking or running on the cement or Tire, you can get 329 00:16:57,300 --> 00:16:59,400 you onto a treadmill or you can go to a track. 330 00:16:59,400 --> 00:17:01,600 That's a lot softer. That'll help out a little bit. 331 00:17:01,600 --> 00:17:04,400 You can do some cycling cycle, will keep you going but I won't 332 00:17:04,400 --> 00:17:06,900 put a lot for stir that through your foot. 333 00:17:07,400 --> 00:17:10,000 Strengthen your core is always key and then for some people if 334 00:17:10,000 --> 00:17:12,300 they're running, if they're doing a marathon and they can't 335 00:17:12,300 --> 00:17:14,599 really put a lot of weight, we'll get him, the pool and 336 00:17:14,599 --> 00:17:17,400 we'll do some In the pool that will burn them out real quick. 337 00:17:17,400 --> 00:17:19,500 We'll give them the all the exercise but it won't put all 338 00:17:19,500 --> 00:17:23,300 that force on that foot and there's a special pred know that 339 00:17:23,300 --> 00:17:26,700 they make right. The that was a cup of G-Force if 340 00:17:26,700 --> 00:17:29,700 you're for yeah and you're pretty much sit in a saddle and 341 00:17:29,700 --> 00:17:32,500 then it you can take off 50% of the way, 30 percent of the 342 00:17:32,508 --> 00:17:33,800 weight. And you can still get that 343 00:17:33,800 --> 00:17:37,000 cardio that you like that's a good option if you're having a 344 00:17:37,008 --> 00:17:39,700 lot of pain. Now, how about if someone let's 345 00:17:39,700 --> 00:17:43,000 say Joe someone has pain when they get up in the morning but 346 00:17:43,000 --> 00:17:44,900 when they do their stretches and things like that, everything 347 00:17:44,900 --> 00:17:47,500 goes Away. Can they be as active or how do 348 00:17:47,500 --> 00:17:49,500 you determine how active you can be? 349 00:17:50,100 --> 00:17:52,100 Yeah, they can be a source is the pains gone. 350 00:17:52,100 --> 00:17:53,600 Let them do what they're workout. 351 00:17:53,600 --> 00:17:55,800 It is and it's all by space on the pain. 352 00:17:55,800 --> 00:17:58,200 If the pain increases that we have to slow down a little bit. 353 00:17:58,200 --> 00:18:01,600 Yeah, I always say if you're limping and if you're changing 354 00:18:01,600 --> 00:18:04,300 your gate, or if you're going to injure yourself because of 355 00:18:04,300 --> 00:18:07,200 because you're a cheap accommodating, how you're going 356 00:18:07,200 --> 00:18:09,400 to injure yourself, you're gonna have to go see Joe, you're going 357 00:18:09,400 --> 00:18:11,800 to throw your hip off. You're going to throw something 358 00:18:11,800 --> 00:18:13,400 else off because you're changing your gate. 359 00:18:13,500 --> 00:18:16,300 If it's that level you're going to have Switch your activity 360 00:18:16,300 --> 00:18:19,700 temporarily until you get calm until you calm down. 361 00:18:21,500 --> 00:18:23,700 So I'm going to talk a little bit about some of the initial 362 00:18:23,700 --> 00:18:25,900 treatments. I'm not going to go into detail 363 00:18:25,900 --> 00:18:29,600 about all of those like hundreds of treatment, but a few things, 364 00:18:29,600 --> 00:18:32,400 if you're trying to deal with this, something that you may not 365 00:18:32,400 --> 00:18:35,700 have heard of is something called a contrast bath, and 366 00:18:35,700 --> 00:18:38,900 everyone knows about like taking the bottle of water and rolling 367 00:18:38,900 --> 00:18:41,700 on the bottom of the foot or a bottle on the back of the calf 368 00:18:41,800 --> 00:18:44,300 of ice water. But a contrast bath, if you've 369 00:18:44,300 --> 00:18:47,600 never tried it, you take a bucket of ice water in a bucket 370 00:18:47,600 --> 00:18:49,400 of hot water. You know, you don't want to burn 371 00:18:49,400 --> 00:18:53,300 yourself and You five minutes in the ice water, five minutes in 372 00:18:53,300 --> 00:18:55,700 the hot water, and then 5 and Ice. 373 00:18:55,700 --> 00:19:00,900 You always start and end in the ice water and what that does is 374 00:19:00,900 --> 00:19:04,100 it, basically restarts reboots the computer. 375 00:19:04,100 --> 00:19:06,500 So it's going to cause the ice is going to cause 376 00:19:06,500 --> 00:19:09,100 vasoconstriction. Meaning it's going to shrink 377 00:19:09,100 --> 00:19:12,700 down the the hot water is going to vasodilate, it's going to 378 00:19:12,700 --> 00:19:15,800 swell and then it's going to shrink down again, it's kind of 379 00:19:15,800 --> 00:19:20,100 shocking the area to help increase the blood flow, all of 380 00:19:20,100 --> 00:19:22,200 its blood flow getting to that area. 381 00:19:22,200 --> 00:19:24,700 So if you want to think about it, if you want your body to 382 00:19:24,700 --> 00:19:28,800 heal itself, you have to have adequate blood flow and there 383 00:19:28,800 --> 00:19:30,800 are things that can restrict the blood flow. 384 00:19:31,100 --> 00:19:31,900 Okay. And that's what we're going to 385 00:19:31,900 --> 00:19:35,900 talk about anti-inflammatories. I don't do more than two weeks 386 00:19:36,300 --> 00:19:39,600 of an anti-inflammatory. It can be used temporarily. 387 00:19:39,600 --> 00:19:45,800 If you like okay I II once in a while you do a prednisone, not 388 00:19:45,800 --> 00:19:47,100 too much. I'm not too much of an 389 00:19:47,100 --> 00:19:49,200 anti-inflammatory person. I think you should work on the 390 00:19:49,200 --> 00:19:50,400 treatments of getting rid of the pain. 391 00:19:52,500 --> 00:19:54,900 I want to talk a little bit about offloading. 392 00:19:54,900 --> 00:19:58,600 Now, the reason I want to talk about this is because if you 393 00:19:58,600 --> 00:20:02,000 want to stay active, you're going to have to take the 394 00:20:02,000 --> 00:20:06,900 tension off the faccia or off the Achilles and there are 395 00:20:06,908 --> 00:20:09,300 different levels of pain reduction. 396 00:20:09,300 --> 00:20:12,600 I'm going to start with the kind of the most severe so if your 397 00:20:12,600 --> 00:20:16,900 pain level is 8 9 or a 10, what we call an on that visual analog 398 00:20:16,900 --> 00:20:18,500 scale. Basically you look at the 399 00:20:18,500 --> 00:20:21,600 frowning face and a happy face. And if you're if you're 400 00:20:21,600 --> 00:20:24,600 basically a limping around, you're going to probably need to 401 00:20:24,600 --> 00:20:27,900 be in a walking boot for a short period of time or if you have a 402 00:20:27,900 --> 00:20:29,200 tear or something else like that. 403 00:20:29,200 --> 00:20:31,600 Now the key I you see so many people they come in with the 404 00:20:31,600 --> 00:20:34,600 boot but then they complain of hip pain or back pain or 405 00:20:34,600 --> 00:20:36,700 something else like that. That's why I just want to take a 406 00:20:36,700 --> 00:20:40,100 moment to talk about this thing. This is called an even up. 407 00:20:40,100 --> 00:20:44,100 So if you ever get a boot or if you ever see someone that has a 408 00:20:44,100 --> 00:20:47,700 boot in there, limping around you have you can use an even up 409 00:20:47,700 --> 00:20:50,300 or you can use your shoe with a little bit of a heel so you can 410 00:20:50,300 --> 00:20:52,200 just Mine on Amazon is called even up. 411 00:20:52,300 --> 00:20:56,800 So that's the worst amount of pain, the next, the next kind of 412 00:20:56,800 --> 00:20:59,700 the if you're if you're only in moderate pain, there are two 413 00:20:59,700 --> 00:21:03,200 options. What is called an air cast in? 414 00:21:03,200 --> 00:21:05,800 The other one is called a velocity brace and I want to 415 00:21:05,808 --> 00:21:09,000 explain both of these. The purpose of these are to be 416 00:21:09,000 --> 00:21:12,100 used temporarily, okay? Just like the boot. 417 00:21:12,100 --> 00:21:15,800 You're not using these forever, the are past. 418 00:21:15,800 --> 00:21:20,300 It has a bladder of are in the bottom and a bladder of are in 419 00:21:20,300 --> 00:21:23,700 the Back of the Achilles. So as you're walking, it's 420 00:21:23,700 --> 00:21:26,400 pushing the air back and forth with a little tube and it's 421 00:21:26,400 --> 00:21:30,200 massaging the back of the Achilles to increase blood flow. 422 00:21:30,800 --> 00:21:34,000 And it's as you push here, it's taking pressure off the heel so 423 00:21:34,000 --> 00:21:37,000 it can be used both for plantar fasciitis, and achilles 424 00:21:37,000 --> 00:21:40,100 tendonitis, this isn't my first go to that. 425 00:21:40,100 --> 00:21:42,300 These are for people that have quite a bit of pain and you do 426 00:21:42,300 --> 00:21:46,600 this, I would say for two to four weeks, For patients that 427 00:21:46,800 --> 00:21:50,200 that need more stability to avoid pronation. 428 00:21:50,700 --> 00:21:55,200 This is called a velocity brace. It's kind of like an afo. 429 00:21:55,200 --> 00:21:59,200 An afo is an ankle, so it involves the ankle and a foot 430 00:21:59,200 --> 00:22:01,600 and it's an orthotic. So it has a little orthotic 431 00:22:01,600 --> 00:22:05,300 piece in the bottom, and it also has an ankle brace. 432 00:22:05,300 --> 00:22:09,400 So this won't allow people to invert or E vert. 433 00:22:09,400 --> 00:22:13,500 It won't allow that pronation to happen and it puts less strain. 434 00:22:13,500 --> 00:22:16,100 So specifically patients. Have posterior tibial, 435 00:22:16,100 --> 00:22:19,300 tendonitis or tendinitis on this tender on the inside or a lot of 436 00:22:19,300 --> 00:22:21,000 flattening, they're going to work. 437 00:22:21,000 --> 00:22:23,600 Well in this, another reason that this works well is because 438 00:22:23,600 --> 00:22:27,600 it works in one unit. And what I say is my expectation 439 00:22:27,600 --> 00:22:31,800 is about 30% of the pressure is going to go into the lower leg. 440 00:22:31,800 --> 00:22:34,600 So it's going to attenuate or take the pressure off the back 441 00:22:34,600 --> 00:22:38,200 of the Achilles and off the faccia, input it into the lower 442 00:22:38,200 --> 00:22:40,400 leg. It's a lot easier to get used to 443 00:22:40,400 --> 00:22:43,500 this. That it is a big bulky boot. 444 00:22:43,800 --> 00:22:46,400 These are both. 'The only used I would say two 445 00:22:46,400 --> 00:22:49,700 to four weeks when you're in the recovery period, I don't use it 446 00:22:49,700 --> 00:22:54,400 for a long, long time. Once people are feeling better 447 00:22:54,800 --> 00:22:57,200 than I'm going to transition them to an orthotic. 448 00:22:57,700 --> 00:23:01,400 In the way I use Orthotics is I use it to correct posture? 449 00:23:01,600 --> 00:23:02,300 Okay. Go ahead. 450 00:23:03,300 --> 00:23:04,600 So our thoughts are different types. 451 00:23:04,600 --> 00:23:07,900 You can try an over-the-counter insert and there are different 452 00:23:07,900 --> 00:23:11,200 ones once again, if you're going to get an insert, please don't 453 00:23:11,200 --> 00:23:13,400 hope dr. Scholl's isn't listening but 454 00:23:13,400 --> 00:23:16,400 don't get a doctor, Scholl's. They're overpriced, and they're 455 00:23:16,400 --> 00:23:19,700 not doing anything where I would recommend is going to sneak 456 00:23:19,700 --> 00:23:22,100 around mama. And what you're going to find is 457 00:23:22,100 --> 00:23:24,500 you're going to find an over-the-counter insert. 458 00:23:24,500 --> 00:23:27,400 There's like a spend Co something that's more rigid 459 00:23:27,400 --> 00:23:29,900 because when it's rigid, it's actually doing something 460 00:23:30,400 --> 00:23:32,400 patients, can start with an over-the-counter one. 461 00:23:32,600 --> 00:23:36,200 But the main key, and I want to explain this for everyone is, 462 00:23:36,200 --> 00:23:40,300 when you have an orthotic, they did some research and they found 463 00:23:40,300 --> 00:23:44,600 that with the faccia, the higher, the orthotic Contours, 464 00:23:44,700 --> 00:23:48,300 as to the foot, the better, it takes the strain and stress off 465 00:23:48,300 --> 00:23:50,700 the fashion and what you'll find is a normal. 466 00:23:50,700 --> 00:23:54,400 Insert is going to be a big gap between there in that Gap. 467 00:23:54,400 --> 00:23:57,500 Still allows pronation and it doesn't take as much strain off. 468 00:23:57,500 --> 00:24:00,400 That's the reason we do a custom one because it basically sits 469 00:24:00,400 --> 00:24:04,000 right with the arch and it that takes more of the strain off and 470 00:24:04,000 --> 00:24:06,600 you just can't do that with an over-the-counter because you 471 00:24:06,600 --> 00:24:08,800 don't have an over-the-counter foot and no one does. 472 00:24:09,200 --> 00:24:11,700 But for a lot of patients in over the counters, a good way to 473 00:24:11,700 --> 00:24:14,100 start. And if that's not enough, then 474 00:24:14,100 --> 00:24:15,900 we'll move some Into a custom orthotic. 475 00:24:15,900 --> 00:24:19,100 And that's, and that's, and they're made to be used, maybe 476 00:24:19,100 --> 00:24:20,700 not the rest of your life. Everyone asked me to have to 477 00:24:20,700 --> 00:24:22,300 warm the rest of my life. Probably not. 478 00:24:22,500 --> 00:24:24,200 You're going to wear them until you feel better. 479 00:24:24,200 --> 00:24:27,200 And then for certain types of activities that could aggravate 480 00:24:27,200 --> 00:24:29,900 your plantar fascial, anything else you want to say about 481 00:24:29,900 --> 00:24:32,200 these? How about a patient that has the 482 00:24:32,200 --> 00:24:34,600 Orthotics. But there's still having pain 483 00:24:35,000 --> 00:24:36,500 and if I tape them, they feel better. 484 00:24:37,100 --> 00:24:38,900 Yeah. I think taping is great and I 485 00:24:38,908 --> 00:24:42,900 don't tape you guys tape. I think what taping does is it 486 00:24:42,900 --> 00:24:47,000 holds everything in proper Ian, I a lot of a lot of doctors what 487 00:24:47,000 --> 00:24:50,300 they do is if they have a custom orthotic already, then that 488 00:24:50,300 --> 00:24:52,800 custom orthotic isn't contouring enough so you may need something 489 00:24:52,800 --> 00:24:55,400 that's even higher. Yeah in the big problem for us 490 00:24:55,400 --> 00:24:58,000 going to high is that it's not going to be comfortable. 491 00:24:58,300 --> 00:25:00,600 But doing a higher one is going to feel even better. 492 00:25:00,600 --> 00:25:03,600 That's why that taping feels good that extra support but you 493 00:25:03,600 --> 00:25:05,100 can't take for the rest of your life. 494 00:25:05,100 --> 00:25:06,500 No. Do you still have to kind of get 495 00:25:06,500 --> 00:25:10,400 that, get that area down. You may need a higher contouring 496 00:25:10,400 --> 00:25:12,400 or thought because there are a lot they are there. 497 00:25:12,400 --> 00:25:14,600 A lot of places around the they say it's a custom orthotic. 498 00:25:14,800 --> 00:25:17,500 But it's really not. They see how it's made for you. 499 00:25:17,500 --> 00:25:19,900 You step in a box or something else like that, the way we do it 500 00:25:19,900 --> 00:25:22,900 as perfect a 3D scanner and we make it specifically for you. 501 00:25:22,900 --> 00:25:24,500 So you have to go to a place. Yeah. 502 00:25:24,500 --> 00:25:25,500 Are they going to be more expensive? 503 00:25:25,500 --> 00:25:26,800 Yeah. But these over-the-counter ones 504 00:25:26,800 --> 00:25:29,200 the last maybe six months and you have to change it. 505 00:25:29,800 --> 00:25:35,500 So and then I want to talk a little bit about questions about 506 00:25:35,500 --> 00:25:38,300 doing a cortisone injection and then there's a new type of 507 00:25:38,300 --> 00:25:43,000 therapy called Shockwave. So, the way I think about it is 508 00:25:43,000 --> 00:25:47,100 it, if you're in a lot of pain, if you're limping around, if 509 00:25:47,100 --> 00:25:50,000 you've had this and you just can't function in life. 510 00:25:50,100 --> 00:25:53,000 And so basically, if you're looking at an eight, nine or ten 511 00:25:53,000 --> 00:25:57,000 pain, You can't tolerate Shockwave, you can't tolerate 512 00:25:57,000 --> 00:25:59,200 Physical Therapy, you're going to be living around. 513 00:25:59,200 --> 00:26:02,000 You can't do anything. So for patients, like that, if 514 00:26:02,000 --> 00:26:06,700 it's in the heel, I will do a cortisone injection, okay? 515 00:26:07,300 --> 00:26:11,500 If it's under eight, if it's seven or below and then if I do 516 00:26:11,500 --> 00:26:14,900 an ultrasound and I see that it's thicker, that's where I'll 517 00:26:14,900 --> 00:26:18,200 recommend the shock wave now, I don't do this. 518 00:26:18,200 --> 00:26:21,900 Usually first line meaning. What I do first is I say, change 519 00:26:21,900 --> 00:26:24,400 your shoes, try the inserts, try the ice, You can try the 520 00:26:24,400 --> 00:26:27,800 anti-inflammatories if that doesn't work, then what I tend 521 00:26:27,800 --> 00:26:30,800 to do is I switch to the shock wave, and the physical therapy, 522 00:26:30,900 --> 00:26:32,200 okay? People start with the foam 523 00:26:32,200 --> 00:26:34,800 rolling and then if that doesn't work, then they go into the 524 00:26:34,800 --> 00:26:36,300 shock wave in the physical therapy. 525 00:26:37,300 --> 00:26:38,700 What? How this works? 526 00:26:39,000 --> 00:26:40,400 There are two types of shock waves. 527 00:26:40,800 --> 00:26:42,800 But you see, this little thing that looks like a bullet. 528 00:26:43,800 --> 00:26:47,500 This bullet runs back and forth, and it hits this piece of metal 529 00:26:47,800 --> 00:26:52,100 in a create something called radial shockwaves, okay? 530 00:26:52,200 --> 00:26:56,100 There's two different devices we have One that's focused in one. 531 00:26:56,100 --> 00:26:58,600 That's radial, I'm just showing you the radio one, this is the 532 00:26:58,600 --> 00:27:00,100 one that we've had for a number of years. 533 00:27:00,600 --> 00:27:03,600 But what does it do? Basically areas that are 534 00:27:03,600 --> 00:27:07,100 chronically, injured like the fashion in the Achilles tendon, 535 00:27:07,500 --> 00:27:09,200 they get thick and they get scarred. 536 00:27:09,200 --> 00:27:11,600 And if you know anything about Scar Tissue, it doesn't have the 537 00:27:11,600 --> 00:27:15,100 best blood flow. The flow is bad. 538 00:27:15,300 --> 00:27:18,000 And what what, you try to do with your breasts and technique, 539 00:27:18,100 --> 00:27:22,100 or there's another Physical Therapy modality called dry 540 00:27:22,100 --> 00:27:26,400 needling, and That, what that does is that tries to increase 541 00:27:26,400 --> 00:27:29,600 the blood flow to the area. So your own body heals it. 542 00:27:30,100 --> 00:27:31,500 Okay. And that's what this does. 543 00:27:31,800 --> 00:27:34,700 I whack the heck out of it and it increases the blood flow. 544 00:27:34,700 --> 00:27:37,200 So during the course of treatment with shockwave, you 545 00:27:37,200 --> 00:27:39,900 can't do any anti-inflammatories Motrin ibuprofen. 546 00:27:39,900 --> 00:27:42,800 You can do Tylenol, two days before and two days after, and 547 00:27:42,800 --> 00:27:46,400 we do between three and six sessions in what that does is 548 00:27:46,400 --> 00:27:48,400 that increases the blood flow to the area. 549 00:27:48,700 --> 00:27:51,600 And it's Matt, it's almost like magic and it takes away the 550 00:27:51,600 --> 00:27:53,200 pain. There are some other Advanced 551 00:27:53,200 --> 00:27:55,600 ones. Well like platelet-rich plasma 552 00:27:55,600 --> 00:27:59,000 or amnio injections, we might do those if there's a tear or 553 00:27:59,008 --> 00:28:01,500 something else we specifically see on the ultrasound but this 554 00:28:01,500 --> 00:28:04,300 is our go-to for treating. I used to do ton of cortisone, 555 00:28:04,300 --> 00:28:06,500 but what I found with cortisone, I had a patient today. 556 00:28:06,500 --> 00:28:11,300 I did a cortisone, he had a four weeks ago and he was feeling a 557 00:28:11,300 --> 00:28:13,300 little bit better for about two to three weeks. 558 00:28:13,300 --> 00:28:15,300 And then all of a sudden, all the pain came back. 559 00:28:15,300 --> 00:28:18,900 The reason for that is cortisone, only lasts about 560 00:28:18,900 --> 00:28:20,700 four. Four to six weeks depending on 561 00:28:20,700 --> 00:28:22,500 what type you put in. We do a combination of a 562 00:28:22,508 --> 00:28:26,300 short-acting and a Long acting and then what I find is, what it 563 00:28:26,300 --> 00:28:28,800 wears off. If you don't change the tissue 564 00:28:28,900 --> 00:28:31,800 or the structure with the foam rolling and the physical therapy 565 00:28:31,800 --> 00:28:35,400 in the offloading, it can come back, not for everyone but it 566 00:28:35,400 --> 00:28:36,700 can come back. But what this does is it 567 00:28:36,700 --> 00:28:39,600 actually heals the tissue. What's been your experience? 568 00:28:39,600 --> 00:28:42,300 With this drone we're seeing a lot more patients, those truck 569 00:28:42,300 --> 00:28:44,900 where they usually like it. They'll come in will do the 570 00:28:45,400 --> 00:28:48,300 stretching and the check out the pelvis, getting all the joints 571 00:28:48,300 --> 00:28:51,600 working, and we're just work with their pain level and 572 00:28:51,600 --> 00:28:54,200 getting them better. Yeah, I think it's A real 573 00:28:54,200 --> 00:28:56,800 practice changer, especially in the Achilles on the back and the 574 00:28:56,808 --> 00:28:59,400 Achilles you can't do cortisone because it could cause a 575 00:28:59,400 --> 00:29:01,100 rupture. So we really didn't have any 576 00:29:01,100 --> 00:29:04,600 options besides doing a surgery. If there's a big bump back there 577 00:29:04,900 --> 00:29:08,900 or something else. Now with patients that are not 578 00:29:08,900 --> 00:29:11,000 coming from a podiatrist that have heel pain. 579 00:29:11,000 --> 00:29:14,300 What I'll do is I'll show them the book by Don Pelt. 580 00:29:14,300 --> 00:29:17,300 Oh and open up the page which Shockwave so they can read about 581 00:29:17,300 --> 00:29:20,300 shock wave that I'll do you give them the card so they can called 582 00:29:20,300 --> 00:29:22,500 on and see if they can do the shockwaves for them. 583 00:29:23,000 --> 00:29:25,500 Yeah. I I can't, I can't it's really 584 00:29:25,500 --> 00:29:27,800 been a practice changer. There's been an only a few 585 00:29:27,800 --> 00:29:30,500 things subbing in this remote on over 10 years now. 586 00:29:30,800 --> 00:29:33,300 But this has been a practice changer and it's something 587 00:29:33,300 --> 00:29:35,700 that's it tended to start. I'll tell you a little history 588 00:29:35,700 --> 00:29:39,000 of it. Shockwave, it started in Germany 589 00:29:39,700 --> 00:29:41,600 and it was used to break up kidney stones. 590 00:29:41,700 --> 00:29:44,100 So what they did is they put people in big things of water 591 00:29:44,300 --> 00:29:46,900 and they still use it to this day and they shoot these sound 592 00:29:46,900 --> 00:29:50,500 waves with his huge shock wave machine and it broke up the 593 00:29:50,500 --> 00:29:52,800 kidney stones. But what they found is that 594 00:29:52,800 --> 00:29:55,600 people with chronic back I mean, because a lot of times back pain 595 00:29:55,600 --> 00:29:58,100 is caused by the tightness in the muscles, their back pain 596 00:29:58,100 --> 00:29:59,700 went away and they're like, hmmm. 597 00:29:59,700 --> 00:30:01,400 I wonder why their back pain went away when were treating 598 00:30:01,400 --> 00:30:04,600 their kidneys and then the machines got smaller and 599 00:30:04,600 --> 00:30:06,900 smaller, and instead of putting people in water, now we put 600 00:30:06,900 --> 00:30:10,100 ultrasound gel on it and what we're finding and it's not just 601 00:30:10,100 --> 00:30:12,100 using the foot. It's used pretty much everywhere 602 00:30:12,100 --> 00:30:15,300 in your body for area of chronic inflammation to help it 603 00:30:15,300 --> 00:30:17,700 naturally reduce it and I think the reason they do it more in 604 00:30:17,700 --> 00:30:20,800 Germany, is it might because I think it's covered by Insurance 605 00:30:20,800 --> 00:30:23,600 there and they're more natural than we are here. 606 00:30:23,600 --> 00:30:25,200 We're Like running the surgery there. 607 00:30:25,200 --> 00:30:27,300 They do everything they can to avoid surgery because they have 608 00:30:27,300 --> 00:30:30,300 public health and it takes forever to get a surgery. 609 00:30:30,300 --> 00:30:31,900 So that's why they have some of those other options. 610 00:30:32,800 --> 00:30:34,700 There were a few questions that people ask. 611 00:30:34,700 --> 00:30:37,100 So I'd like you, if you're listening here and you have any 612 00:30:37,100 --> 00:30:40,800 other questions, put it in the chat box right now and we're 613 00:30:40,800 --> 00:30:43,100 going to start answering the questions that were sent over 614 00:30:43,100 --> 00:30:46,500 previously and then we'll answer the other ones that people are 615 00:30:46,500 --> 00:30:50,800 putting it to us right now. So I'll ask you Joe, is it best 616 00:30:50,800 --> 00:30:55,000 to avoid impact exercises? Like aerobic exercises, while 617 00:30:55,000 --> 00:30:57,700 you're healing it all depends on your pain level. 618 00:30:57,900 --> 00:31:00,300 If you're able to do the exercise without causing 619 00:31:00,300 --> 00:31:03,700 increased pain, then it's okay if you're doing the exercise and 620 00:31:03,700 --> 00:31:06,000 causing more pain, that means you the tissues being 621 00:31:06,000 --> 00:31:08,500 overwhelmed, you got to cut it down and that's where we can go 622 00:31:08,500 --> 00:31:11,000 to the cycling. You get the swimming, you got 623 00:31:11,000 --> 00:31:13,300 the elliptical. That's not pounding as much, but 624 00:31:13,300 --> 00:31:15,200 still give me an aerobic capacity. 625 00:31:15,600 --> 00:31:20,900 Yeah, and I would say, try doing the shoes And the the offloading 626 00:31:20,900 --> 00:31:24,700 with, either an orthotic, or something else to see how it's 627 00:31:24,700 --> 00:31:27,800 doing, or even one of those braces like that are cast, that 628 00:31:27,800 --> 00:31:30,600 you mentioned to me, that perfect, you could probably stay 629 00:31:30,600 --> 00:31:36,300 being active with that. So how do you know what the 630 00:31:36,300 --> 00:31:39,800 balances between pain and exercise therapy for achilles 631 00:31:39,800 --> 00:31:42,600 tendonitis. I don't, if you have any ideas 632 00:31:42,600 --> 00:31:46,300 here, the pain. So it's there's good pain in 633 00:31:46,300 --> 00:31:48,400 this bad pain. If you're in that bad pains 634 00:31:48,500 --> 00:31:50,500 Zone. Once again, you're over texting 635 00:31:50,500 --> 00:31:52,600 that tissue and it's not going to get better. 636 00:31:52,600 --> 00:31:55,300 So we going to cut it back here with otix global you're 637 00:31:55,300 --> 00:31:57,900 stretching. The scraping, comment down in 638 00:31:57,900 --> 00:32:03,000 the build from there. Perfect question, 3 plantar 639 00:32:03,000 --> 00:32:06,400 fasciitis versus achilles tendonitis treatment, any major 640 00:32:06,400 --> 00:32:09,500 differences any studies and this was a saint by one of the 641 00:32:09,508 --> 00:32:10,800 colleagues from physical therapy. 642 00:32:10,800 --> 00:32:12,800 I usually treat them pretty similar in terms of PT 643 00:32:12,800 --> 00:32:15,900 treatments in terms of plantar, fasciitis. 644 00:32:16,000 --> 00:32:18,600 I think there are almost exactly the same. 645 00:32:19,000 --> 00:32:23,400 The only difference is, I think plantar fasciitis responds, much 646 00:32:23,400 --> 00:32:26,900 better to orthotic therapy than achilles tendonitis. 647 00:32:27,400 --> 00:32:30,400 Achilles tendonitis, there's no, not really Many studies about 648 00:32:30,400 --> 00:32:35,100 responding to to orthotic therapy. 649 00:32:35,300 --> 00:32:38,000 I find that Achilles tendinitis tends to respond a little bit 650 00:32:38,000 --> 00:32:40,400 better to heal lips. So putting a he lifts in there. 651 00:32:40,500 --> 00:32:44,400 Taking the pull off temporarily, that works for Achilles 652 00:32:44,400 --> 00:32:47,500 tendinitis also treatments in terms of what I do. 653 00:32:47,500 --> 00:32:50,300 I don't do cortisone on Achilles, I can do it on plantar 654 00:32:50,300 --> 00:32:54,200 fasciitis, the Shockwave is all the same, all the other icing 655 00:32:54,200 --> 00:32:56,800 anti-inflammatories, PT is pretty much the same, anything 656 00:32:56,800 --> 00:32:59,000 else that you do different for both of you. 657 00:32:59,200 --> 00:33:02,700 I usually go after the hip if the hip has really poor range 658 00:33:02,700 --> 00:33:05,300 emotion when they're walking or running their always hitting in 659 00:33:05,300 --> 00:33:08,300 that same spot on the heel. So I Really Work the hip get 660 00:33:08,300 --> 00:33:10,500 that range of motion better. So they have multiple angles 661 00:33:10,500 --> 00:33:13,000 when they're walking, they're moving to different spots. 662 00:33:13,400 --> 00:33:19,100 Perfect. So, Joe which shoes are better 663 00:33:19,100 --> 00:33:22,900 or worse for it. We can address that but yeah, 664 00:33:23,700 --> 00:33:26,800 there's so many shoes out there. Once we evaluate the foot, we 665 00:33:26,800 --> 00:33:28,700 figure out your opponent is super neutral. 666 00:33:29,300 --> 00:33:32,200 And we sent you over to the Seeker stuff, they'll get the 667 00:33:32,200 --> 00:33:34,500 shoe on for him and from there we can evaluate, which you can 668 00:33:34,500 --> 00:33:37,600 works for best for you. Yeah, and Joe, does it ever go 669 00:33:37,600 --> 00:33:39,800 away? Does it ever go away? 670 00:33:40,900 --> 00:33:42,800 It should. But if you don't do your 671 00:33:42,800 --> 00:33:44,300 stretching, you don't do all your exercise. 672 00:33:44,300 --> 00:33:45,400 You don't do what you're supposed to do. 673 00:33:45,400 --> 00:33:48,300 It's going to creep back and basically just going to keep on 674 00:33:48,300 --> 00:33:50,900 doing it or you can come back to us and we can figure out again. 675 00:33:51,400 --> 00:33:55,100 Yeah, I so I guess there's two ways of thinking about this 676 00:33:55,100 --> 00:33:57,900 question. It might go away and then come 677 00:33:57,900 --> 00:33:59,800 back. If it's Coming back. 678 00:33:59,800 --> 00:34:01,700 It tends to be something structural that you're going to 679 00:34:01,708 --> 00:34:03,700 need physical therapy for meaning. 680 00:34:03,700 --> 00:34:07,400 You may have a pelvic issue, you may have a stability issue, it 681 00:34:07,400 --> 00:34:10,100 might be a tightness issue. That's not addressed, maybe new 682 00:34:10,100 --> 00:34:12,800 orthotic issue, something else like that, but it should go 683 00:34:12,800 --> 00:34:15,699 away. So, long away coming back, it's 684 00:34:15,699 --> 00:34:17,500 usually because of that, I usually say, it's like an 685 00:34:17,500 --> 00:34:20,699 incident meaning, you went to Disney, you went on a long walk. 686 00:34:20,699 --> 00:34:23,699 You're starting to train for something very commonly people 687 00:34:23,699 --> 00:34:26,600 at train or starting to be more active, trying to lose weight, 688 00:34:26,800 --> 00:34:29,000 the Cavs, get tight, not usually day one. 689 00:34:29,100 --> 00:34:31,800 Wanted to day three. But after a few weeks and they 690 00:34:31,800 --> 00:34:34,400 start to have foot pain, it's because the tightness normally 691 00:34:34,699 --> 00:34:37,000 and then the other for you if you're listening to this and 692 00:34:37,000 --> 00:34:40,000 you've had this for years and it's never gotten better. 693 00:34:40,000 --> 00:34:42,000 It's probably because you haven't had treatment or the 694 00:34:42,000 --> 00:34:43,699 right kind of treatment. I find many patients. 695 00:34:43,699 --> 00:34:47,000 They come as a second opinion, they've like seen a doctor a 696 00:34:47,000 --> 00:34:50,199 number of times, but they just say, okay, I'll do 3 cortisone 697 00:34:50,199 --> 00:34:52,699 injections in an orthotic and if you can't get better, you can't 698 00:34:52,699 --> 00:34:54,300 get better. You know, you have to really 699 00:34:54,300 --> 00:34:56,900 advocate for yourself. There are some Advanced 700 00:34:56,900 --> 00:35:00,700 treatments, but I do have a certain Number of patients that 701 00:35:00,900 --> 00:35:03,600 just might need a surgical procedure or something more 702 00:35:03,600 --> 00:35:05,800 involved. I think I've done this maybe one 703 00:35:05,800 --> 00:35:08,500 surgery in the last three years. There's not really surgery isn't 704 00:35:08,500 --> 00:35:10,600 the option, okay? Isn't the best option but there 705 00:35:10,600 --> 00:35:12,000 are other people that can help you. 706 00:35:12,000 --> 00:35:15,100 So you have to kind of advocate for yourself and try to get 707 00:35:15,100 --> 00:35:16,600 help. Yeah. 708 00:35:17,300 --> 00:35:19,400 And there are some other questions were going to address 709 00:35:19,400 --> 00:35:22,500 here before we finish up here for patients, who get custom 710 00:35:22,500 --> 00:35:24,600 orthotics. How long do they usually last? 711 00:35:24,600 --> 00:35:28,900 What do you tell them? So custom orthotics. 712 00:35:29,200 --> 00:35:31,600 Once again, you have to have the sneaker and shoe to fit with it, 713 00:35:31,600 --> 00:35:33,900 if you have the wrong shoe with the Orthotics, that's not going 714 00:35:33,900 --> 00:35:37,500 to help as much. What we're talking three to five 715 00:35:37,500 --> 00:35:40,600 years, depending on how it was built, how was made? 716 00:35:40,800 --> 00:35:42,700 And you have to where you have to do. 717 00:35:42,700 --> 00:35:44,700 All your stress is all the stuff you do to keep it going. 718 00:35:45,000 --> 00:35:46,100 Yeah. Orthotics are kind of like 719 00:35:46,100 --> 00:35:48,300 glasses, right? I can't I don't wear my glasses 720 00:35:48,300 --> 00:35:50,100 when I'm doing the webinars, but I'm not wearing these. 721 00:35:50,100 --> 00:35:53,000 I can't see far away but if I'm wearing them, I can see far away 722 00:35:53,000 --> 00:35:54,400 it. So it corrects for mechanical 723 00:35:54,400 --> 00:35:56,900 instability in the foot and it's the same thing with an orthotic 724 00:35:57,300 --> 00:35:59,300 in the way I kind of explained. It is if you're doing Out of 725 00:35:59,300 --> 00:36:02,600 walking, a lot of standing, you're probably going to feel 726 00:36:02,600 --> 00:36:05,100 better in them. Now, you may only need them for 727 00:36:05,107 --> 00:36:07,100 a period of time to heal that injury, though, once you're 728 00:36:07,100 --> 00:36:09,500 better, if you're an athlete, you can probably try to ditch 729 00:36:09,500 --> 00:36:10,900 them. But if you have a really really 730 00:36:10,900 --> 00:36:13,500 collapsing foot, you're just going to feel better in them, 731 00:36:13,500 --> 00:36:17,000 some patients just feel better because they're so collapsed for 732 00:36:17,000 --> 00:36:20,500 them. There was some comments here 733 00:36:20,500 --> 00:36:23,400 about a book, I'll show you guys how you can get these books if 734 00:36:23,400 --> 00:36:27,500 you want. I have them as a download and 735 00:36:27,500 --> 00:36:29,800 then in the at the PTA Greendale, they have them 736 00:36:29,800 --> 00:36:32,500 sitting there as well. So when patients are getting 737 00:36:32,500 --> 00:36:34,800 shopping, this is a question here, when patients are getting 738 00:36:35,200 --> 00:36:38,000 shock wave therapy in an attending Physical Therapy. 739 00:36:38,300 --> 00:36:42,700 Should they modify the exercise and all my opinion, if they're 740 00:36:42,700 --> 00:36:44,700 getting Shockwave? It's usually for, let's say, for 741 00:36:44,700 --> 00:36:48,200 the heel, I'll have them. That session work, more on the 742 00:36:48,200 --> 00:36:52,000 calf region, okay? Or working on the poor stability 743 00:36:52,000 --> 00:36:55,600 or something else like that because if it's way too painful. 744 00:36:55,600 --> 00:36:59,900 But frankly, if you do Shockwave that day, Would just the next 745 00:36:59,900 --> 00:37:02,100 day, you should be better. Shockwave doesn't usually have 746 00:37:02,100 --> 00:37:05,100 much pain for a few days after it doesn't another thing about 747 00:37:05,100 --> 00:37:09,000 Shockwave, Shockwave is an instantaneous, like, cortisone 748 00:37:09,000 --> 00:37:11,200 injection of cortisone, you get the cortisone, you're better 749 00:37:11,700 --> 00:37:14,200 Shockwave to. It actually has to create new 750 00:37:14,200 --> 00:37:17,400 blood vessels, and blood flow to the area and that takes six to 751 00:37:17,400 --> 00:37:19,300 eight weeks. So, just for you. 752 00:37:19,300 --> 00:37:22,800 So, you know, so from day one of shock wave to you actually start 753 00:37:22,800 --> 00:37:27,000 seeing the results is six weeks. And so if we do three sessions 754 00:37:27,000 --> 00:37:29,600 as you six weeks after that's when it started, And it works 755 00:37:29,600 --> 00:37:32,700 for like three or four months afterwards and it's not 756 00:37:32,700 --> 00:37:34,200 instantaneous. So that's where you have to 757 00:37:34,207 --> 00:37:37,700 control the load so people can kind of Be Active with that as 758 00:37:37,700 --> 00:37:40,200 well. Another question here, I wear 759 00:37:40,200 --> 00:37:43,100 slippers at home, I think that may be part of my problem. 760 00:37:43,700 --> 00:37:45,800 Can you be more specific on what I can wear? 761 00:37:46,100 --> 00:37:50,700 What can they wear at home? So a good sandals of once again 762 00:37:50,700 --> 00:37:53,300 I said I'm down to see Grandma. They have always good sandals 763 00:37:53,300 --> 00:37:56,100 over there, they have good arch. Support a lot of cushioning them 764 00:37:56,100 --> 00:37:58,600 in the much better in the house. You come into the house, you 765 00:37:58,600 --> 00:38:00,900 take your shoes off, you're going to do sandals and you 766 00:38:00,900 --> 00:38:03,400 could pick out. Yeah I think there's a couple of 767 00:38:03,400 --> 00:38:07,200 Brands Spangled hasn't okay. One who follows have a good one. 768 00:38:07,400 --> 00:38:10,200 Hoka has a good one and you can just wear shoes though. 769 00:38:10,200 --> 00:38:12,300 If you have a you get a second pair of shoes, I have a whole 770 00:38:12,300 --> 00:38:14,900 shoe and wear that at home, and I think you're going to be, 771 00:38:15,300 --> 00:38:17,200 you're going to be much better with that. 772 00:38:18,400 --> 00:38:21,200 So I think we answered all the questions. 773 00:38:21,700 --> 00:38:25,800 I put a little link here for the the replay and resources. 774 00:38:25,800 --> 00:38:28,700 So if you're watching this, we're going to post this. 775 00:38:28,700 --> 00:38:30,900 You can use your phone and kind of scan it and it'll go to a 776 00:38:30,900 --> 00:38:33,700 blog post. And then you can also go to the 777 00:38:33,700 --> 00:38:36,600 Greendale PT and contact them. They can give you a copy of this 778 00:38:36,600 --> 00:38:37,600 video. If you want to listen to it 779 00:38:37,600 --> 00:38:40,200 afterwards. There's a couple of resources I 780 00:38:40,200 --> 00:38:43,400 make available on my blog after build a.com. 781 00:38:43,400 --> 00:38:46,100 It'll there's one thing on a heel and wanting to kill. 782 00:38:46,100 --> 00:38:48,800 He's the one that Joe was referring to. 783 00:38:48,800 --> 00:38:50,200 I'm just going to open it up right here. 784 00:38:50,200 --> 00:38:51,400 Look at that. Doesn't even open up. 785 00:38:52,700 --> 00:38:56,900 You have to have an Achilles with a capital A and it's a 786 00:38:56,908 --> 00:38:58,800 little course, I put together. So it basically has a book. 787 00:38:58,800 --> 00:39:02,800 You can download a quick start guide, icing and contrast oofos, 788 00:39:03,000 --> 00:39:06,700 shoes recommendations and then basically down here it's kind of 789 00:39:06,700 --> 00:39:09,200 cool because I put your how do you treat achilles tendonitis, 790 00:39:09,700 --> 00:39:12,900 deep tissue, massage and loosening exercises actually 791 00:39:12,900 --> 00:39:15,300 recorded this at Greendale PT a number of years ago. 792 00:39:15,500 --> 00:39:18,000 Trigger point tools. What To do when you get up in 793 00:39:18,000 --> 00:39:20,800 the morning this is kind of fun. So it patients we talk about 794 00:39:21,300 --> 00:39:25,100 core belly, breathing, doing a stretching routine before you 795 00:39:25,100 --> 00:39:26,600 get out of bed. This is to help that first step 796 00:39:26,600 --> 00:39:29,500 out of bed. Talk about Shockwave or E Pat 797 00:39:29,900 --> 00:39:33,200 and amnio injections and then things like that. 798 00:39:33,200 --> 00:39:36,500 So there's other resources. So I take a lot of pride in 799 00:39:36,500 --> 00:39:38,600 doing these things. It's been a lot of fun and I 800 00:39:38,600 --> 00:39:41,700 really appreciate all the help over at Greendale PT. 801 00:39:41,700 --> 00:39:44,500 So it's been great. I think we've answered all the 802 00:39:44,500 --> 00:39:46,300 questions. I don't really see any other 803 00:39:46,300 --> 00:39:48,600 questions here. If you guys have any more, you 804 00:39:48,600 --> 00:39:52,200 can post it. Otherwise we're going to stop 805 00:39:52,200 --> 00:39:52,500 this.