Today we are going to be talking about foot health. It's something I have a deep passion for and have been doing for about seven plus years in my clinical practice. So my belief is that foot health is the largest blind spot in all of medicine, certainly the biggest blind spot within orthopedic and sports medicine. We're going to go through the different factors and concepts that are both common today in foot health care, but also then the corrective measure that I employ with my patients. And hopefully, you know, help you begin to see how far off sort of conventional mainstream care is today. So the goal with foot health and the answer in general terms to have a healthy foot, healthy foot that can move, healthy foot that can feel, healthy foot that's not in pain. Is alignment and strength. This is just like every other part of the body, right? The overall direction we want to be. headed in when we're talking about how do we create health in the foot comes down to two basic components that are closely related and they are alignment and strength. What we do now in sort of conventional mainstream care not just podiatry so one thing kind of just at the start is I'm not I'm not a I'm gonna try really not to sort of bash any particular individual doctors this is not a problem of just the podiatry profession although it is a huge problem within that profession but it's also MDs orthopedic sports medicine people it's It's chiropractors, it's physical therapists, it's people like myself. It's, it's really across a very wide spectrum. So it's not specific to a certain profession or a, or a specific, um, type of practitioner, um, but what is done now sort of in the mainstream with how we treat the feet, both in terms of sort of quote unquote preventive, quote unquote, common sense care, but also in terms of treating disease and treating pain is we deform and progressively weaken the feet. We don't do this to any other part of the body, right? But this, the, the mainstream care is constrict, deform, prop up and progressively weaken. Okay. So what we're going to do is start with what I, uh, consider arguments from first principles, right? So what this means is regardless of what we see out in the real world or in studies, which we'll go over, uh, starting with first principle arguments, meaning if we just sort of, if we're an alien coming to earth and we look at, you know, the human foot and we go, okay, like, what do we think's going on here? The kind of arguments that lay the groundwork for, uh, logical and intuitive, um, approaches. So the number one idea is form and function. This is a common concept in physiology and biology. You see it a lot in evolutionary, evolutionary biology. Form and function is this idea that the shape or form of a body part in this case. Tells us something important about the function of that body part Feet and I'm and obviously I'm talking about the human foot the human foot is Designed to support itself Feet are designed to support themselves If we start by looking at baby feet We have in both my offices we have prints of baby feet One of my son and at North's foot an ankle. We have dr. Ray's daughters Their their baby feet prints up in the office to show people the shape of a human foot before it gets in shoes is widest out at the tips of the toes and Sort of wedge or triangle shaped back to the heel That is the form of the human foot And if we look at cultures where people don't wear shoes or don't wear constrictive shoes, the foot stays like that. Widest of the tips of the toes, sort of triangle or wedge -shaped back to the heel. So that is the form of the foot. Now with form and function, we go, okay, the form of the foot is a triangle, roughly speaking, right? It's a tripod. Tripods, we all understand, are inherently stable. That's why stools can be a tripod and you can sit on them. You don't need, you don't need to sit like on a, so the contrast would be like sitting on a log where there's no empty space beneath where you're sitting. It's just a column. Whereas a tripod has empty space underneath it, which is with just three struts. The empty space does not cause weakness, right? The strength comes from the counteracting collection of forces that the three struts are creating of the tripod. Tripods are inherently stable. We also, in terms of form, have arches. We have three arches in our foot, one that goes along from the heel to the big toe, one that goes from the heel to the little toe, and one that goes from the little toe to the big toe. Now, this is a little bit easier to see visually, but that tripod formation is also a tripod of arches. So we understand that tripods are stable. We understand that arches are very stable. That's why we build bridges with arch architecture. And we actually have in the foot a tripod arch form. And so what this tells us about fungal, again form and function as a first principles argument is that the function of the foot is designed to support itself right the foot is made to be stable inherently intrinsically right so that's number one we just look at how a human foot is shaped and it tells us something about what it is supposed to do next first principles argument is when we look at what we do to the arch of the foot in mainstream medicine primarily with the use of orthotics and arch supports again we don't need to know anything about the studies about our supports just yet if we just look at the logic of propping up an arch from underneath with stuff this is a method that we would not apply and that we do not apply to any other arch anywhere in the universe, right? Arches are strong because of their shape. They're meant by design to have empty space underneath them. That's the whole point of an arch. Propping an arch up from underneath sounds intuitive when you're told, oh, your arch needs support. But then you think about it for a second, you go, what other arch needs this type of support? And the answer is none. There is no other arch that we support in the same way that we try to support the arches of the feet. Propping stuff up from underneath defeats the whole purpose of an arch. And we know that arches are strong from an engineering and physics perspective, okay? And we can see this through engineering. We can see in natural archways. We can see that the apparent logic used to justify arch supports now for decades and generations is flawed on its face. It doesn't make any sense, okay? And I think the key is people will say, oh, well, the foot arch is different. The foot arch is not quite an arch or something like that. And it's just, it's simply not true. Again, we go back, form and function. It's a tripod arch. Nothing about the stability of a tripod, the stability of three arches oriented in a tripod would suggest that it needs to be propped up from underneath, okay? So we don't do this to any other arch in the universe. We also don't do what we do to the foot to any other part of the body, all right? So third argument here under the first principles category, number one, form and function. Number two, we don't prop up any other arch anywhere with stuff from underneath except for in the foot. Number three is we don't do what we do to the foot to any other part of the body, all right? So not only is the sort of support in constriction model of the foot, illogical in terms of sort of physics and arch engineering. It's also illogical in comparison to how we treat all other parts of the body. So when you have knee arthritis or or knee pain, meniscus, injury, whatever, the number one most evidence -based, most basic recommendation is to strengthen the muscles around your knee. This is, as far as we can tell, basically indisputably accurate as far as being beneficial. You have knee pain, number one thing, strengthen your knee, strengthen your quads, strengthen your hamstrings. If you have back pain, again back pain is a little more complicated but just in general, strengthening your core, you know, may not be everything but definitely doesn't hurt. Again, the key is the first reaction to dysfunction is strength because all things being equal, if you are just stronger, you can compensate better for any particular underlying issue. If you have a shoulder problem, the first thing you do is physical therapy to improve the strength of your rotator cuffs, of your surrounding and accessory shoulder muscles. The point is, every other part of the body, the first thing we do is try to strengthen it because that is what we should do. And yet in the feet, the first thing that is often done is constriction and weakening. It does not make any sense. Now next is, and this is the last one, the fourth, starting from first principles and looking at just the inconsistencies of the foot, is the unique role of fashion. Again, when we look at the unique way in which feet are treated, there is no other part of the body that is burdened with fashion ideas and fashion concepts in the way that the foot is. It is not unique in the sense that obviously there are fashion concepts that adorn all of our, like all over our body, whether we are wearing a specific type of shirt or obviously there is jewelry, there is body art, which is changing our body, but that is very much explicit. That is on purpose. We are changing our body, whether with a piercing or a tattoo or something, gauging your ears. You are changing physically the structure of your body. That is all very intentional. A shirt does not deform your shoulders. or it should most of them don't. Regular shirts don't deform your body. Regular pants don't deform your body. Most shoes deform your feet and these are all because of fashion concepts. So the the role of fashion is uniquely burdensome and uniquely deforming to the feet in today's world. There are other examples corsets being one in you know in I think it's I think it must be Victorian Europe right so corsets as a way to change the shape of a woman's body right those were physically deforming to the rib cage into the spine they were done explicitly for aesthetic reasons. Obviously you know not many people were in corsets today so in terms of modern Western culture shoes are uniquely burdensome as far as a fashion item on our body. and they deform the feet in a way that no other piece of fashion deforms our body. Imagine if we had pants and that the normal pants like the Levi's, all the sweat pants, all of the athletic pants, all of your dress pants had tight bands built into the pants that around your knees so that when you wore the pants normally your knees were pulled together and sort of touching in the middle right kind of pulling you into a knock need situation. And that's just how things were right we decided someone decided 500 years ago that that was what was aesthetically pleasing we want our knees to be knocked in together so we start making pants that pull our knees together and we get to today and everyone is just you know everyone just says well hey like that's just what pants that's just what pants are like we can't get around that like that's how pants are shaped uh what about all these knee deformities we keep treating people for right and doing surgeries on well that's hereditary um you know your mom had deformed knees and your dad had deformed knees and that's why you have deformed knees it's not because you all wore pants that knocked your knees in together um but of course if we were to look at other societies that didn't wear pants that knocked everyone knees together we wouldn't see these knee deformities the point is we take for granted what fashion sort of instills in us right pants aren't shaped like that right they aren't built like that and if they were right we would have really extreme physical problems with knee alignment and arthritis and all sorts of issues right but to not see that the pants are what would be causing the problem is crazy and again in shoes and their impact on the feet to not see that what we to not see how we deform the feet in shoes as a primary cause of foot issues is it is it is a form of blindness that is that is difficult to wrap your head around and we're gonna talk more about that later but we cannot ignore the role of fashion ok so from first principles before we get in physiology before we get into studies before we get into my clinical experience and all the other stuff that that really kind of grounds this in the real world just from first principles we have form and function The foot is shaped in a certain way that really tells us something about what it should do and how it's built. We don't do what we do to the foot arches to any other arch ever. We also don't do what we do to the feet to any other part of the body. And we also don't burden any other part of the body with fashion in the same way we do with feet, okay? So just those things right off the top, right? We're already onto something here, right? What we do to the feet is totally insane. And yet it continues. So I mentioned at the top, strength and alignment. Strength and alignment is what we're doing and what I'm doing with patients and obviously in broad strokes. That's basically the direction we're moving everyone in. So what does that look like clinically? What does strength and alignment look like clinically? Number one, it looks like this. It is wearing a foot shaped shoe that allows for normal foot movement, maintaining proper alignment and promoting strength. When we talk about alignment, the number one thing that we start with with everyone, whether or not you have problems in your toes or not, is we start with big toe alignment. Your big toe is a part of how your arch is supported. Your big toe is a part of your arch support. Having your big toe in the proper position, which is straight off the foot, not deviated in toward the little toes. Again, look at a baby's foot, straight off the foot so that the tip of your big toe is the widest point at the front of your foot. Widest point toward the midline on the front of your foot. That is big toe alignment. And what that does is it creates arch support along your medial longitudinal arch, which is your main arch. When people talk about arch of the foot, they're talking about arch of the foot. talking about your medial longitudinal arch right there are three of them but that's the main one as far as what people refer to it maintains that tripod position it acts like a kickstand and creates that wider tripod so that your arch doesn't flatten and fall in or collapse I don't like to use word collapse it's very dramatic there are obviously instances of collapsed arches but most people are told oh your arch is collapsing and it's mostly just that they're you know flattening out because their toes in a bad position so alignment and strength alignment starts with big toe alignment your big toe is disproportionately important for foot function right it is like your thumb on your hand right no one would argue that your thumb is disproportionately important compared to your other four fingers for hand function right the opposable thumb provides a level of dexterity that no that the four other fingers in a single, any single finger can't match. Your big toe is similar to your thumb. It is disproportionately important for the form and function of your foot to be in the right position. Now, by aligning the bones and aligning the toe specifically, what you're also doing is you're moving the muscles that attached all of those bones. And this gets us into muscular support, right? So by moving the big toe and maintaining proper alignment of the big toe, you are increasing what I call structural support, right? Support just by nature of alignment, right? This is like a tripod. Now there's muscles connected to all these bones. So as you align the toe, you're also aligning the muscles. And this provides better muscular support. There's an idea in muscle physiology. And my major in undergrad was exercise and support science. And this is very, very basic stuff, right? This is muscle physiology 101, which is that there's something called the length to tension relationship. And that says that a muscle produces its maximum force output when it is basically in the middle of its length distribution. So when the muscle is very, very shortened, it's not as strong. When the muscle is very, very lengthened, it's not as strong. When it's in the middle of that length, that is when it's its strongest, when it can produce the most force. So by realigning the bones, by realigning the toes, we're putting the muscles in a better starting position. to produce more force. So conventional shoes today and the mainstream foot care would have you deform your foot in a way that over stretches your muscles and thereby decreases the possible force that they could produce. Not to mention the fact that they're also progressively weakening them, right? So there's this that creates weakness, but also a bad position, an overstretched position that creates less force production and less and less strength. So hallux alignment or big toe alignment is important, not just for that tripod position, but also to put your muscles in the best possible length to tension relationship so that when they are used, they can produce an adequate amount of strength. Having your big toe on alignment also increases blood flow and circulation to the front of the foot, which can be very important for healing any type of injury. It can be important for neuropathy, it can be important for Morton's neuromas. Aligning the big toe also promotes joint health of that big toe joint especially. So one of the main downstream effects we see with bunions, for example, is arthritis. Again, going back to the pants that cause knock knees, right? If we had pants that pulled our knees in together just automatically, we would have much worse arthritis and we already have a lot of arthritis in knees. So promotes joint health just through alignment. Hallux alignment and big toe alignment also promotes glute activation and knee alignment because if your big toe is in the right position, it prevents overpronation, which means flattening of the arch. So it prevents flattening of the arch, which prevents your knee from falling toward your midline, which prevents your hip from internally rotating and stretching and elongating your glutes. So big toe alignment and activation of your arch actually helps to align your knee and activate your glutes because your glute activation and your arch activation in your foot are very, very tightly connected and they're along the same tensegrity network so that when one is strong, the other is when one is working well, the other can work well too. Now, we use correct toes, toe spreaders to achieve big toe alignment. We're going to get into shoes here in a second, but wearing wide shoes is a must. But for most people who have been wearing narrow shoes for a long time, just switching We're going to get into shoes here in a second. into wider shoes, generally is not enough because what you do is you maintain the deformity of your toes that have occurred from the narrow shoes. So we need something to actively push back your toes into a better alignment, right? As opposed to just removing the cause, which we need to do, we need to remove the cause and get active realignment by wearing a toe sputter that pushes the big toe out into its best alignment and natural shape. These are like braces for your toes. A lot of people will sort of grow out of them. Some people, if whatever their issue is progressed to a certain amount of severity, you'll need active toe alignment and correct toes indefinitely. But in either case, they're like braces where we're holding and actively realigning your toes. holding them in place, holding them in a better alignment for structural and muscular strength and then using your foot so that your muscles and tissue remodel and grow stronger around the proper alignment and so this is another key where especially with a lot of physical therapists we'll do a bunch of foot strength exercises in the PT office barefoot and then say okay great good job you know we're gonna get this plantar fasciitis healed do a bunch of foot strengthening stuff barefoot and then go inside of a shoe that deforms constricts and props up the foot and really is counter to everything you just did strengthening wise so we want that alignment to maintain itself while we are active because when we're active is when the remodeling and the actual changes in your body happen so you can't just wear toe spreaders at night that's passive you're not weight -bearing you're not getting muscle remodeling you need active big toe realignment and then be on your feet for progressively increasing amounts of time to the point where you are have your toes spread and using your foot for days and weeks and years on end because most people come to me after decades of wearing shoes that scrunched their toes together so we need a lot of time often to to reverse these things permanently the great thing is that almost everyone has short -term relief right within a month or two people almost always feel better and then there's this longer project of getting these these big big changes over a longer period of time because they've taken a long time to develop last thing about big toe alignment is that the conventional mainstream treatment for foot problems either promotes misalignment as normal Again, the sort of well, that's just how shoes are shaped, right? that kind of line or So it either promotes the misalignment as normal like oh, yeah, there's nothing wrong with your foot being You know your toes being scrunched together That's what feeder. That's what feet look like, you know Or it completely ignores The role of big toe alignment all together All right people there's a serious conversation in foot medicine is we have no idea why bunions occur the hereditary, right? Your mom had them you had them. It's genetic not it completely ignoring the fact that You know you and your mom both wore shoes that are shaped like bunions right completely ignoring the fact of environmental influence The we have no idea why bunions occur is one of the biggest examples of just head in the sand thinking I can think of in all of medicine. Look down at your feet. Are your shoes shaped like a bunion? Yes or no. That's a very good starting point to begin this sort of journey. Because if they are, your foot can't support itself because the form has been distorted. It won't function correctly. And then you'll need a bunch of other stuff to make up for the main issue, which is that your toe is not in the right place. So that's toe alignment. It has a huge influence on everything, right? Even if you have an ankle problem, we're going to talk about toe realignment. If you have a plantar fascia problem, we're going to talk about toe realignment. If you have knee problems or hip problems, I might talk to you about toe alignment. So it's not about your toes per se. It's not about how your foot looks per se. It's about how the alignment and form of your foot directly affects the function of your whole lower limb. So that's big toe alignment. Now let's talk about muscle strength. Your foot's full of muscles, like every other part of your body. Muscles operate on the use it or lose it principle. If you do not use the feet of your muscles, if you do not use the muscles of your feet, they will get weaker. Again, we don't do what we do to the feet, to any other part of the body. We have to use our feet if we want them to be strong. If we never use our feet, they will never be strong and they will continue to get weaker and weaker. This is where people who are put in arch supports at a young age are continually being put in more and more dramatic and supportive arch supports. There's no end to it because is you prop up your foot with something, it weakens to a point where then the thing that you originally used doesn't do the job anymore and then you need more support to the, now it's support the weakened foot and then that gets weaker and then you need more support to support the further weakened foot. And it goes until either there's sort of a catastrophic, you know, issue with your foot and you either get a surgery to treat something that was totally preventable in the first place or you come and see me and we begin to work sort of unwinding a lot of these things. So muscle strength, right, depends on alignment, but strength itself is progressive use. The one of the concepts that I take my patients through is that with a lot of these changes, especially initially with foot health, one of the main things that's happening is that we're just doing a strength training program for your feet. Okay. That's not all of it, but that's a big portion of it. And thinking of it that way, I think helps people wrap their heads around like what it is and why it is we're doing all of this stuff that we're doing. Right. So why are we slowly increasing our correct toes use? Why are we slowly and carefully increasing how much we, uh, wear naturally shaped shoes? Why are we doing foot strengthening exercises? Because we are progressively strengthening all of the muscles in the feet because they have been chronically weakened in most people. Now, just like with any other strength training program, right? If you want to deadlift more, you cannot just put 400 pounds on the bar and go to the gym every day and just keep trying to pick up 400 pounds. Right. Um, now everyone understands that intuitively. It's kind of funny, right? When you kind of characterize it that way, that's not how strength training works, right? You have to start with where you are at and then very progressively, little by little, add more and more challenge so that your body can meet the challenge, adapt, become stronger, and then meet a slightly greater challenge and then so on and so forth as you get stronger and stronger. The main mistake that people make when doing this type of approach on their own, which says you can do it on your own, but the main mistake that people do is they do too much too fast. They go from wearing Hoka's or Nike's with custom orthotics and they say, Oh my gosh, like everything in this YouTube video, uh, from Dr. McClanahan, like makes so much sense. I'm going to start, I'm going to start just going barefoot and then they go barefoot and then they start running barefoot. And then it's way too big of a change all at once by and mechanically, which relates to this other issue or, or, or sort of phenomena that I see very, very commonly, which is people in general, both patients, which, you know, in some sense, we're all patients because we all have feet, but patients and doctors, I think doctors don't understand this either, but all people, we all tend to vastly underestimate the degree to which our feet are deconditioned. Right. Imagine if you never picked anything up with your left hand, you just never used it, right? It was always in a glove that kind of squished it, squished the fingers together and it, and it never was used to grip anything. And then you were surprised when you tried to use your left hand for something and it didn't work. Of course, we wouldn't be surprised. We've never used it. Why would we expect it to work? With the foot, we tend to, with the conventional approach, never ask our feet to do very much and then are surprised when there's dysfunction in pain and surprised when they don't work. We underestimate vastly the degree to which our feet are deconditioned. People's feet are generally speaking, coddled and, and, and never asked to do a challenge, um, and it results in a profound level of weakness and muscular dysfunction where people can't even move their toes, right? Because they've never moved their toes. So the progressive strength training component can really needs to start. And this is what I think I'm good at. And I think, you know, why it's worth seeing someone about this as opposed to, you know, if you're struggling and trying to do it on your own is really starting from where you are at, right? If, if, if you have really profound muscle dysfunction and weakness and deformity in your foot, everyone can get better, everyone can get better alignment and everyone can get better strength, right? But we have to start with where your foot's at. And just like, quote unquote, going barefoot is not a good idea for someone with that level of with a lot of, it's not a good idea for many people because their, their dysfunction is so profound and their weakness is so great. Related to muscle strength is arches. We already kind of went over the architecture of arches, but your muscles are really what are the contractile force that hold the arch together and hold the arch in its arch form. Again, use it or lose it. If you don't ever put force and stress through an arch, it will atrophy and weaken. So one of the big misconceptions that I hear constantly and that is just patently false is that people will say, oh I have flat feet. That's why I have pain. My doctor told me I have flat feet. That's why I'm in pain. What can you do about it? Oh well nothing you know just where arch supports for the rest of your life. And then the net literally the next patient I see will say, yeah I have high arches. And my doctor told me, yeah I have high arches. That's why I'm in pain. Okay well what they say was the solution. Well there is no solution just where arch supports for the rest of your life. Think about how illogical that is. A doctor is telling people, hey you have low arches, flat feet. That's why you have pain. Wear an arch support for the rest of your life. And then that same doctor is telling people, hey you have high arches. That's why you're in pain wearing arch support for the rest of your life. This doesn't make any sense It doesn't make an ounce of sense, right? Low arches do not cause pain high arches do not cause pain weak arches cause pain With my patience, I do not care how high your arches I do not care how low your arches I care how strong your arch is people are shaped very differently There's a huge amount of Variety in the specific shape of the foot the height of the arch There's very very very rare extreme examples where the bony formation is is Sort of a an issue that can't just be Reminied with strength, but these are extraordinarily rare and people with completely normal feet have been led to believe that they're somehow like Catastrophically flat and deformed and there's nothing you can do about it So just never go barefoot and wear this arch support this this $800 custom arch support that you'll need to get done every You know two or three years forever Okay, it's completely incorrect low flat arches do not cause pain high Arches do not cause pain weak arches cause pain How do we Make a week. How do we make a weak arch stronger? We use it Right propping propping up a weak arch with something from underneath outside of the foot right propping up with something external Only promotes more weakness. Okay, this is what I just have to keep saying it over and over again because you have to break through the bad logic that we've all been trained in if You want something to be stronger you have to use it conventional shoes promote disuse because you're propping up and constricting the foot with something else something outside of the foot you need your foot to support itself in order for it to get stronger you need your foot in the proper alignment for it to work well enough to become stronger to support itself let's talk about shoes shoes are shaped like bunions this is the truth it's undeniable you don't need an evidence -based study to prove it just look down look down at your feet if you don't know what a bunion is take a look at a picture it's where the big toes deviated in toward the little toes basically where the foot becomes more pointed in the front why because shoes are pointed in the front this goes back to what we talked about with toe alignment Not everyone has bunions, not everyone with foot pain has a big toe misalignment. The point is that when your feet are inside of shoes that are shaped like bunions, nobody's foot can function normally because the, because from the very start, the form is distorted and the function will be distorted. There's a whole cascade of biomechanical effects that follow from big toe misalignment. You scrunch the toes together so that you ruin the tripod orientation of the foot. You distort the arches and then the foot falls inward over pronates and you say, ah, see, we must need arch support because the foot can't support itself. Right. But what you've done is deformed it and then proved that deforming it makes it not work. You have not proved that having arch supports is helpful. Right. So if you start from a bad place and then say, oh, well, this justifies the use of all these other bad ideas, right? You're just compounding your mistake, right? As opposed to saying, let's just start from a good place. Let's start with the toes aligned. Let's start with the foot in its, in its true form, right? The tripod arch orientation. And then you don't need something propping up your foot and then you don't need, you know, your heel elevated. So there's a whole cascade of biomechanical dysfunction that, again, tends to be compounded with more and more mistakes, more and more cushion, more and more constriction, more and more propping up, more and more elaborate arch supports, more and more disuse, more deformity, and more weakness in shoes, conventional shoes, right? So what I'm talking about is dress shoes. I'm talking about cowboy boots. I'm talking about really any formal shoe. I'm talking about most athletic shoes. I'm talking about Brooks. I'm talking about Nike. I'm talking about Adidas. Everything except for a few. that we'll talk about a small part of the market, feet are not pointed in the front okay but shoes are so there's a there's a fundamental mismatch there and that's the number one issue with shoes now shoes also have other features that shoes also have a raised heel where your heel is elevated above the level of your toes this is called a drop. Why this exists is purely a fashion phenomena high heels were in fashion shoes and they were brought into athletic shoes for no other reason other than that's what people were used to there is no foot health reason to have a raised heel there is no biomechanical advantage in fact there's many disadvantages to having a raised heel it's because that's what people were used to and if you're used to wearing high heels and you put yourself in a flat shoe you can get some Achilles irritation because high heels shorten your calf muscles Like physically shorten it so that you have a shorter Muscle and then when you go into a flat shoe it gets elongated and stretched and you can create some issues now That's again why we clinically would go slowly with people