151. Foot Health, Transition Protocol to Minimalist Shoes & Footwear in Athletes | Irene Davis, PhD, PT

Welcome to Medicine Redefined, a podcast focusing on helping you reclaim ownership of your health. I'm Dr. Darsha, and I'm Dr. Altamasharaja, where your hosts, hair to challenge conventional practices and uncover the stories behind pioneers shaping the future of medicine. Our conversations not only focus on the individual level to dissect common practices for health optimization, but also zoom out to enhance systemic change. Join us as we look to break the status quo, move the needle forward, and put the help back in healthcare. Hey everyone, real quick, we are excited to share that we launched our newsletter. It contains high yield insights from our guests and tips and tricks from us. We want to put the health back in healthcare and invite you to do the same by giving you the necessary information to live your best lives and provide value to those around you. Make sure to head to medicineredefined.com, where you can input your email and stay up to date. Okay, time for the episode. We are rejoined today by Dr. Irene Davis. Dr. Davis was a recent guest on episode 144, where we spent a lot of time discussing the importance of barefoot or minimalist training and even incorporating barefoot activities in everyday life for optimal foot and musculoskeletal health. In this episode, we build on that conversation by talking about how to transition to barefoot training or minimalist footwear. Following all the excitement about the new carbon footplate by Nike, which supposedly improves running economy and performance by up to 4%, we wanted to get Dr. Davis's take on this, as well as the implications to consider if incorporated into your training. And then we discussed footwear and athletes, and being mindful of the purpose of shoes, hint protection over aesthetics. As a reminder, Dr. Davis is a professor in the School of Physical Therapy and Rehabilitation Science in the Morsani College of Medicine at the University of South Florida. She has extensive experience working with running athletes, studying foot mechanics and foot health, and was a founding director of the Spaldon National Running Center in the Department of Physical Medicine Rehab at Harvard Medical School. She received her bachelor's in exercise science from the University of Massachusetts and physical therapy from the University of South Florida. She earned her master's degree in biomechanics and her PhD in biomechanics as well from Penn State University. She's the current president of the American College of Sports Medicine and has a deep passion setting the relationship between lower extremity structure, mechanics, and injury. Now, with that further delay, please enjoy this part to discussion with Dr. Irene Davis. All right, round two with Irene Davis. Thank you so much for coming back and talking about a topic that is really near and dear to my heart. I can't believe you want it. You want me back again, but I'm happy to be here, Dars. Hey, if I could have a podcast solely on barefoot shoes and minimalist footwear, I probably would. And then it would just be us to probably just co-hosting that. Yeah, that would be really fun. Yeah, it's funny. So over the weekend, I was celebrating in Philadelphia. It was my birthday, actually. And happy birthday. Thank you. A couple of tequila shots with my friends. And she's asking me about fitness and I just go up to her shoe and I just look at it and I'm examining every aspect of it. And I'm just like, man, I am really, really into this stuff. So I love having you here. You're obviously the expert. And so, yeah, thanks for coming back for round two. Sure. All right. Let's do it. Yeah, let's do it. So for the guests, again, round one was episode 144. So not too long could go at all. So if anybody wants to understand the basics of what minimalist footwear is, what it means to be barefoot, highly recommend going back to check out that episode. I mean, we did cover a lot. So actually right now, we're going to cover some audience questions, some follow-ups that they had after listening to the first episode. And so not in any particular order and maybe we'll transition this into what we'll be talking about, which is more about footwear and the athletic population. But let's first start. One of our interns had a question about where you should even buy these shoes, right? So I'll start that. I bought these online, but are there even shoe stores that you can go to that will help assess your feet and then even put you in a barefoot or minimal issue? So that's a very good question. They were very difficult to find in shoe stores for a very long time. And most people had to purchase them online, you know, and then there's always the issue of fit. And I know in our clinic, when I was at Spaulding National Running Center, we had a whole range of sizes of different brands of minimal shoes so people could try them on. And then we'd order them online. So a lot of it has been done online. I do want to say I'm going to put a plug in for there's a barefoot shoe expo in Chicago on May 5th. I have it. I actually tweeted about that today. So if and you can go there and actually sit down and try on shoes, which is really nice. But there are shoes, there are stores that are starting to have some of these minimal shoes. And I mean, I could name some local ones, but I don't think that's going to be helpful. I think you really just have to have to check them out and see if they do. I mean, some of the stores like REI and some of the more adventure kind of, you know, that have that kind of equipment and that kind of a spin will have some of these minimal shoes. And the standard shoe, when you go into a standard shoe store, I still believe, and I haven't been in one in a very long time, but I still believe they're going to look at you, they're going to run you on the treadmill, they're going to give you a motion control shoe. And I just, and we talked about that last time. I know we went through, I did go back and listen because I didn't want to repeat myself on this, on this episode. And I thought, wow, we went through a lot of stuff very quickly. But you know, there was that study, and for those who, you know, didn't hear the episode one, and there's studies that have actually debunked the idea that you need to match shoes to the foot type. We need to let our feet do what they're supposed to do and get out of their way and just be there to protect the feet. That's really what shoes have always been for until 50 years ago. And I remind this audience that shoes were completely minimal before 50 years ago. But we all have lived during those 50 years. So for us, it's the norm, but it's one of the most abby, normal things that we do wearing shoes like that, along with sitting in some moldy things. So, you know, I'm not sure I'm answering a question, you can't, there are some stores that, it's actually a shoe store in West Virginia that only sells minimal shoes. So there are places like that, but they are hard to find. There's sometimes, I think in Boston, in Newberry Street, there was a V-Borm store, so you could get the five fingers and some of those shoes. If you can find a store that sells the meryles, then you're going to be able to find, you know, the Meryl Barefoot shoes. The V-Vo Barefoot shoes are a little bit more difficult. They're actually, they're made in England, they come from England. They're a great shoe. I think that's one you love. Yeah. Yeah. I want my second V-Vo pair now. Have you actually found them in a store? Do you buy them online? I had to buy them online, yeah. Yeah. So, I mean, there are places that do sell them, but they're harder to find than a standard shoe. But I would not go, if you're thinking about a minimal shoe, I think you need to make sure that you have the right perspective when you go into a shoe store because they are going to try to sell your shoe likely based on your foot type. I shouldn't say a blanket statement because there may be some that don't, but I think there are some that still do that. Yeah. No. 100%. I think, do you have any tips for when somebody goes into a shoe store, how to be more convincing of yourself to say, you know, I don't want to get convinced by the opposite salesperson to say, oh, I need an orthotic or I need this type of shoe. What can they go into the shoe store knowing to really help the associate help understand, you know, this is what I wanted to show. They can say that they understand that minimal shoes actually really strengthen feet. And that they really have a goal to strengthen their feet that minimal shoes promote more of a softer for foot strike landing. And that that's kind of the goal that they have in mind. And to know other shoes are really going to do that. If they say that I've got a zero drop shoe, well, they still have cushioning and we know that cushioning promotes a rear foot strike pattern because they will say that. I would just be very resolute and say, I really am looking for a minimal shoe. I want to try it. I understand the risks. I understand this has to be done slowly, like any exercise program that you would undertake. You undertake it slowly and gradually, like, you know, just and so you understand that because that's what they're going to probably say is people get hurt in these shoes. And again, I don't want to vote poorly on on all, you know, shoe stores because there may be some that are really very progressive in their thinking and are open to whatever people want. Whether they want a cushion shoe or minimal shoe, I would hope that most are would be open to that. Yeah. So let's say someone is now putting on the minimal issue at the store or at home that they bought online. Are there any guidelines or rules that you look at for saying this is a better fit minimal issue? I know you said that transition can be a little bit difficult and we just kind of have to let our feet get used to it. But is there anything that you really look at? So you want to make sure, I mean, it's like any other shoe fit. You want to make sure you have a little bit of length at the toe because you foot slides forward as you walk in, especially as you run. And you want to make sure it's nice and wide so it allows your foot to spread. And then you just want to make sure it fits your foot well. So this is where I think the minimal shoe brands, this is why I like to stay brand agnostic. I love all my minimal shoe vendor or companies and have good relationships with all of them. They all make them over different lasts, last is the model that you make a shoe over. And so they're going to be shaped a little different. And I just know that some people say, you know what, that Vivo really fits my foot well. And someone else will say, I love the zeros or I love the marbles. I've had all three of them and I like them all. So I think it's a matter of trying it on and seeing how it feels. Yeah, I would agree. I tried the zeros as well and I definitely loved both the Vivo and the zeros. I haven't tried the Merrill yet. Yeah, each provide their own different comfort and kind of a different situation. I think your feet, you know, definitely get used to it over time. So yeah, I totally, totally echo that. And if you're into the five fingers, just to just want to say, because there's still some people that like them, just make sure that you're patient because those toe pockets take time to adapt and mold to your toes. When you, they're hard to get on first. And you know, everyone's toes are a little bit different, especially little toes. So sometimes it's hard to get in on, but they will kind of mold to your foot and be more comfortable if you really want to go that route. Yeah. And then do you have a preference about the type of socks someone wears? Because I've been really wearing toe socks actually, especially with running to avoid any friction or blisters because when I initially started with barefoot running, I was getting some blisters and, you know, calluses on my feet. So I don't know if that's something you've also looked at. You know, people have their own preferences about socks I have found. Some people love the toe socks because some people don't like them. Some I actually, like I play pickleball in my minimal shoes and I wear no socks. I typically don't wear socks with my shoes, but that's not to say that you shouldn't. You certainly can. So I think it's just, I think that's really a personal preference. Okay. Got it. And then on the opposite side of that spectrum of barefoot shoes and ones that we love, are there any shoes? This was another question. Any shoes that or habits that you avoid at all costs, whether it might be heels, cushion shoes, et cetera. Do you remember me saying never say never and never say always? Oh, yeah. So there are times when I wear heels because I'm still a girl and I like them. And a little bit of a fashionista, not a huge fashionista, but, you know, go into a wedding, those kinds of things. So I wear heels. One of the things I definitely avoid when I'm looking at dress shoes are really pointy shoes. I've never liked them and I don't ever. So for me personally, I completely avoid those. I never buy shoes with cushion because once you get away from cushion, you don't like it. It's very, I mean that. It's very true. Yeah. It's people once you, once you, it's just you don't want to go back. So, you know, I try to find shoes that are, if I'm looking at just regular shoes, I mean, certainly you can buy minimal shoes that are for work. But sometimes you like a little more variety, whatever. I always look for a shoe that is really wide, that doesn't have much of a heel. And is, you know, the wide is really important because it's more shaped your foot plus I have a wide foot. So even that, I have to count, accommodate that. Anyways, so yeah, I mean, even with boots, I try to get boots, they're, they're coming out with minimal snow boots and minimal hiking boots, where they've got the tread that you need, but not the support, right? And it does come up over the ankle a little bit, like a little bit higher, but they're very flexible and very minimal. Snow boots that are really warm but very flexible without a big thick heel. We want some protection from the ice in the snow course. So, you know, there's a little bit of moderation in there. It's not like you have to be completely extreme all the time. I know people though that are very dedicated to this barefoot life and actually go out in the snow in their bare feet. Wow. And I, yeah, I'm a little nervous about that because when your feet become numb, you lose that protective sensation and you can injure yourself without knowing it. I'm not, I don't advocate for it. People do it, I say it's great, but I also know people that hike, that hike barefoot completely barefoot. I've done mild hikes. I can't say I've done intense hikes with barefoot. Just feeling the rocks have been kind of advantageous when they're not, you know, crazy. I've never ran in snow. I should clarify that. I just walked in snow to work and things like that in barefoot and there's not much of that. So, I have. Wow. It's just because it's just easy convenient. I love wearing them in the hospital. So, I'm just like, you know what? I'm just going to get through the snow and it's going to be cold for me. I'm in with no shoes. I mean, no shoes. Oh, absolutely at all. I'm talking completely barefoot. Yeah, yeah, yeah. I mean, I hike in my barefoot shoes. I'm looking to see if I hike in my regular barefoot shoes, but I don't do like heavy-duty hiking. But I am now hoping to find a pair of shoes that are, you know, more for hiking, minimal, but more for hiking. I'm talking about with completely barefoot. Oh, wow. Be barefoot. They walk in the snow completely barefoot. They're just purists. And I think that's a little crazy. Even our ancestors, that's why shoes were developed is to protect our feet. Right. Right. Right. But, you know, people like to take things to the extreme and all about that. There is this new trend, I think, on social media where people have been cutting out the bottom of their souls. And so, they're actually just walking in their barefoot, but having a shoe cover on top. So, I don't know. I guess. Yeah. Yeah. I haven't heard about that one. That's, that's, that's, it's probably called soling or something. It was probably a name for it. Maybe. So, they've given some. Yeah. Because I've been asked about that around the hospital being the quote unquote barefoot nut. So. Yeah. So, one of the most popular questions we've had is really about the protocol to transition from what people have been on for 50, 60 years of their life, maybe even, you know, 30, 40, to these, this, this barefoot minimalist shoe. So, I know I don't believe there's specific guidelines or protocols out there and to each its own, but let's say somebody has a really thick and shoe, very high heel to toe drop. Do you still recommend somebody go directly to barefoot shoes and then using time as the limiting factor for the protocol, or do they have to even go through different varying degrees of shoes until they get to a barefoot shoe? So there's a couple of questions wrapped up in that question. And one of them is kind of how you transition in terms of just transitioning, you know, like how do you, how you go from running a little bit to a lot and then how do you get to the shoe? I think it's kind of part of what you're, you're asking. Yeah. I, I think that my preference, especially if you've got a runner, if you have a runner and they don't want to cut their running down, then you can't, let me, let me back up. I'm sorry. Back up and say, my preference, my ideal way to do it is to start someone walking in the minimal shoes and then until they, and once they get to, you know, walking 30 minutes frisky, then start them running in the minimal shoes and run a little bit and then slowly increase their mileage up until, and one of the very like easy ways, if you are healthy, this is someone who doesn't have planar fasciitis, let's say, you get them walking in the minimal shoes, get them walking briskly for 30 minutes, take that 30 minute time block and break it into three times through periods of 10 and you walk nine and then run one. Walk nine, run one, walk nine, run one, then you've just run three minutes in the shoes. It's not going to do it. It's probably not going to bother you at all. And then you start to add, you start to slowly replace your walking with your running. So walk eight, run two, walk eight, two, eight, two, and do that for a few days. Don't run every day, you know, consecutively take some days off. And how you progress that really depends on you and how weak your muscles are and, you know, just, you know, whether you've had a history of foot related problems. So you've got to listen to your body. That's probably the biggest message I can give you is when you're transitioning, if you have a tweak or something feels just pack off. Because one of the biggest risk factors for injury is training for race, because people don't want to back off, right? So take it slowly, listen to your body and then slowly replace your walking with running until you're running 30 minutes. Once you're running 30 minutes, then start to increase your time and increase your, and then you can start increasing your speed a little bit and you can start doing some hills and you start progressing at that point. Again, though, not giving yourself rest, you know, like every other day to begin with and then two days to build up to what your goal is for your running. Gotcha. Now, we have people who don't want to give up their running, they're running 40 miles a week and they don't want to do it, but they want to transition to the minimal shoes. With those individuals, what I, again, it's something preference, but if they're feeling that way, what I would do with them is I would say, all right, I want you to take your minimal shoes with you and for the last quarter mile, I want you to run with your minimal shoes and then just slowly increase your running with your minimal shoes in that way. The problem is that you're going to be running differently in both shoes. This is why I don't like it. You're mixing your running mechanics, right? Or as if you do it the other way, you start from scratch and you get on the ball of your foot and you don't, you're not going back and forth and back and forth. You do from walking to running, but remember last time I said that's natural, it's natural and on your heel and then so you're always doing the right running mechanic if you start that way. I don't start with like a fixed shoe, go to a thinner, thinner, thinner because there was a study done that looked at a minimal shoe, a partial minimal shoe, and a regular shoe. I think they used a Nike Air Pegasus as a regular shoe. They used a, maybe it was the balanced minimalist that had some cushion in it and then they had like the V-Brums. I think that was the three and what they, and they looked at their mechanics and what they found is the mechanics of running in a partial minimal shoe were similar to running in a regular shoe and different than running in the minimal shoe because when you have cushioning you're going to land on your heel, which changes all the mechanics. That's why I don't do that, it's not going to, it's not going to change anything until they don't have the cushion, so let's just not give them the cushion. Gotcha. Okay, and what about let's say they're non-runner just everyday walkers or just standing around, it's, I'm assuming it's just completely safe to transition and then even maybe use it for half a day and then increase the time. Yeah, so that's walking, so remember that when you run, you're landing, first of all, you're changing your foot strike pattern, so now you're changing the way you're loading the foot, so the calf is going to get more, the Achilles tendon, even your metatarsals. Like, the reason why we had so many metatarsals stress fractures early back in the 2010 period is because people's intrinsic muscles, remember all those muscles in the arch I talked about last time, they were so important to the deformation and the control of the deformation of the arch. And those muscles are not trained and you land, you end up putting a lot of load on the metatarsals, because they're not being guarded by the muscles. And so if you don't have good, strong feet, your metatarsals are going to get loaded more as well. And so it's really important to have that strength built up before. In fact, if you're going to transition to running, I also recommend augmenting it with some doming foot core exercise, you can look them up on the internet, we usually find that. And single and double egg heel raises and jump roping. Jump roping too. Jump roping, you get the eccentric, concentric, eccentric, concentric, do this little bit of power in that. So if you just do doming and do some progressive doming like do doming and then doming and hopping and just really working those muscles, the arch that heel raises and then the jump roping, just those three exercises and kind of progress it along with your progression into running. That just helps to build that base. If you're super weak and haven't done any running at all, then I would probably start with that before you start running. Right. If you're not trained. This is why you have to titrate it depending on where you're starting. Now if we're going to do walking and you don't have a history of plantar fascia, you've got a healthy feet, maybe a little weak because you have them supported, then you can actually put minimal shoes on and start walking, but again, you don't want to walk five miles because those minimal shoes are going to put greater demand on your feet. The reason those muscles get bigger, every single study that's been done, looking at the effect of minimal shoes on the feet, have shown the feet get stronger. Right. The reason they feel you get stronger is because there's more demand on them. Right. So you don't want to go out and do it to a five mile walk the first time you wear them. So wear them gradually, well, you know, work into them. Now, let's take the person who's been wearing orthotics for a long time. They still don't have any foot pain, because there's a lot of people that put orthotics in their shoes and they just keep them in there, even after they don't even remember why they have them. Right. And they don't even remember what they were prescribed for. And so with those individuals, you want to wean them out of the orthotics first. Okay. And so we need them out first with the regular shoes that they have. Start weaning them off in the orthotic. We know that when you wear orthotics, there was a study that showed that 12 weeks of orthotic use reduces the muscles of the arch, the size of them by 10 to 17 percent in three months. So you can imagine some of this worn them forever. And I don't know that it's a linear relationship, but I'm sure that they're weak. So I think it was someone who's been wearing orthotics. I would also get them doing some strengthening muscle exercises prior to doing a lot of walking. But walking is much lower demand. Running it's you landing on one foot, you're landing a different way on the ball, your foot, and you've got two and a half times your body weight. Walking, you don't have a flight phase, you always got at least one foot on the ground. So it's just and the impacts so that peak load and running is about two and a half times your body weight. So if you're a hundred pounds, that's 250 pounds, where's walking is like 1.1, 1.2 or 120. So it's much less. This is why walking is lower risk. So if you've had orthotics, though, you're I'm going to assume the feet are weak and I want to strengthen them a little bit and take it slow, we nod to the orthotics. Let's go a little farther. You're so you've got someone who has had planar fascia, has a history of planar fascia itis. May also be an orthotics, you still have to wean them out slowly, but for those individuals, you really want to take it, take it slow, strengthen them, make sure that when they're using their, if they have any pain, you want them, you want to stop, you want to back off. I am just, I tend to be very conservative with pain. Some people say, oh, you can, you can push through the pain. In my opinion, pain is our gift. So warning sign that says, this is too much for the tissue at this moment. And so I think that, you know, in any case, I think you need to just back off a little bit from the, when you have pain, yeah, yeah, yeah, yeah, 100% and I wish I had this conversation with you before I even went to the barefoot, you know, shoes because I started running two, three miles and once the pain came, it was impossible to almost regress from there. That was the biggest issue that now I still have that pain and I'm really trying to learn how to retrain my cadence and my, you know, with rest and really just trying to optimize so that I can still continue to use barefoot shoes for, you know, all my athletic training, which leads me to my next question, is there any value when it comes to gate retraining? So even using video feedback and when you're trying to transition somebody, maybe it's more of an athlete at this point, but is there any real value with that or you really don't need it? I think there's value when it comes to running. I mean, I think if you start out barefoot, your feet in the sensory input tell you what you need to do. Like we don't need to be taught how to run, right? You watch little kids, they, they, it evolves naturally. It is not a sport. We've made it into a sport, but it was, it's one of our activities, repertoire is of activities that we have, we can walk, we can jump, these are things that we naturally can do and that's what running is and we don't really need to teach anybody how to run. But there are people who, even in walking, right, I've seen people, even the walking evolves naturally, I've seen people walk who need to be, who could really benefit from some training in their walking and that, and when you walk that way over and over again, you can end up with loading your knees or your ankles in a, in a way that eventually wears them down and, and you have problems. It's the same with, with running. So when people say, oh, why, I, I can make you more skillful, yes, you can make running more skillful. But running is not, again, I don't think it's, it's not a skill. It's something that we have innate in us is one of our activity levels, activities of daily living we need. So we do a lot of gate retraining, as you know. And I think that you have to retrain gate based on a rationale. So you don't want to take someone's gate and go, I'm just going to willingly change it. And so the, the kinds of things that we change gate about have to do with like, maybe they're alignment. So let's say their knees are, are coming in like, like they're knee valgus, like they're not need. And we know that that particular alignment increases the risk of fatale femoral or knee cap into your knee pain related injuries. And so when, and we've shown that prospectively, retrospectively in our research, that gives me a rationale. I see it in the person, they have that problem. No matter how much you strengthen them, that's not going to change their mechanics. We've already shown that as well. So you need to, because what retraining does is it addresses the software. See, the hardware, which is your muscles, and then you have your software, which is the motor pattern. And so you have to, you know, you have to address that motor pattern and get them to change their mechanics. Now it, when people came to the clinic and we felt like they needed to adjust their, we needed to do some retraining because of the problem that they had and the what we saw in their mechanics, if they were leaning on their heel, we always transitioned them to a four foot strike. And some people will say, I mean, you're treating everyone the same and not personalizing it. And I would argue with that because we personalize it by the strength thing program we give based on the where the weaknesses are. The other parts of the retraining that we do, whether it's, it could be a lean, it could be toe out, it could be supination. There's lots of things. And we, we tailor our retraining for that. But I believe the foundation of running is landing on the ball of your foot. And that's just my philosophy. And I have a very strong reason based on, you know, I think science and based on what we've seen just historically, I mean, if you, there are Greek bases from BC that depict man running and he's on the ball of his foot, right? So there's lots of, and we talked last time about why we think the ball of the foot is the way to go. So when I see somebody running on their heel, in my view, it's as abnormal as walking on your toes, you know, you have toe walkers, right? That's what I think. Now, if someone's happy running on their heel, I'm not going to change them. It's, you know, because people have this idea that this is the way we're supposed to run. And it's really because of the footwear, but, but, but if someone's injured, my goal is well aligned soft landings. I want them as well aligned as possible because then the loads will be distributed more equally throughout the body than if you're malaligned, right? And the softer you land, the less the impacts on the body, which is going to be good. We know the forefoot striking is these softest landings, the best way to soften someone's landings to get on the ball of their foot, and then I address the other gate deviations if there are them. So, so when you talk about retraining for just forefoot striking, it's usually a part of our full retraining program. If someone comes in perfectly aligned and all it is is forefoot training, we can still do some retraining there because sometimes people land to plan or flexed. Sometimes they reach out too far still because they're so used to, you know, reaching way out, even though, you know, a forefoot check usually brings the foot under, it doesn't with all people. Some people tend to reach and even the minimal shoes will, because they're so used to being out on the outside of foot. So we do retraining, like for example, this one here, we'll ask the person to imagine that there's a bar that they're trying to get their foot under. And so they need to keep, they can't have it at tilted, they have to keep it straight and you get that visualization that those kinds of things. So we can retrain people to a forefoot strike and try to optimize the forefoot strike. It's a long answer to your question, but I think if people went out and just ran barefoot, they probably would be pretty close to a pretty good forefoot strike on their own. No, I think it's really helpful because I think it transitions well to, honestly, the rest of what we're going to be talking about here, which is a really athletic performance and athletes and the footwear that they use. So you know, talking about that, we know that different sports will have different types issues, right? So we have to wait winter with maybe a somewhat of a wedge or maybe even flat, a little bulkier to have that weight down to really have that grip on the platform. We'll have basketball and tennis shoes, which, you know, I always grew up as a tennis player, which has more cushioning more towards the, I wouldn't even say cushioning more tread that way. You're not skidding and making holes through their shoes and that provides more lateral movement. And then you have running shoes, right? Which are more trying to make you efficient and more of an anterior posterior matter, which we see marathon runners use. So when selecting for as an athlete, when selecting for these different shoes, you know, I know our bias is going to be towards still learning how to be more barefoot. But when you get to the NBA level or you get to the professional level, what are some of these components about the shoe that companies are maximizing or that athletes are looking for to really give them that boost in the specific movements that they need? I think it depends on the sport, so it can't answer that for any, like so, for let's take basketball, for example, you know, they're coming down landing and they, that one of the very common injuries is ankle sprains as you come down and land, right? So they've made these shoes with really high and very stiff. They're almost like ski boots now, right? But again, here we go with now you're going to end up with weakening the ankles because you've now added all the support to the ankle so that, you know, so it's like you walk a fine line with these things, right? If you put all the support in the ankle, then they're going to lose that ankle strength and they're still going to be, you still can sprain your ankle in a pair of those shoes. You just lose that strength to be able to withstand some of those loads. So it's a double edged sword, I think. The more you do to a shoe, because as I said last time, the more you add to the shoe or the equipment, the more you take away from what the body has to do and the body's naturally not going to do it. The body wants to be efficient, right? If you put, you know, a jet propelled engine or jet propulsion in the midsole of a shoe, people are not going to push off as hard, they're not going to have to, they're going to rely on that. It's just like cushioning in the regular running shoe. You rely on that cushioning so much that when the cushioning dampens out in the three to four to five hundred miles, whatever it is, and that's when you start to have the knee pain that you always get, right? I'm not saying you, but the person that's calm, and then they get a new pair of shoes and it goes away. It's because they have not taught their body how to cushion and relying on it. So in all of these shoes, like I agree with you, we need, like for example, in soccer, you want to have cleats that are going to dig into the ground, you need some of that, right? It's because of the sport. Although there are some kids that play, the in third world countries that play soccer very well in their bare feet. They're bare feet. So do we really, I mean, if we were only had our feet, would we then develop them to a greater degree than that we would need all this extra stuff that we think we need? Now, a court is a little different because it depends on what kind of court you're playing on, right? If you're playing on concrete, you need something, you don't want to be doing that with your bare feet because you're going to get burns, et cetera. And I think shoes really do need to protect our feet. It's just like a skiing. We need to protect our ankles, but guess what happens? The stress goes to our knee, we'll tear our ACLs. So it seems like there's always a trade-off with this. And this kind of moves into performance. I know you wanted to talk about performance. I think it's a good, maybe a good segue into performance because the Nike 4% shoe has been shown to reduce the times in these high-level races now. And there is an advantage, and science has shown there's an advantage, and it's a combination of these plates and the foam. It's the foam that has the energy return. The plates just give you this kind of a foundation to push off of, and maybe add spring. But it's not, it's the energy return is really mostly coming from the foam. And that's been shown by some of the work done at UMass. And so, you know, the problem is once you have that, so hard to bring, you can't put the genie back in the bottle. Right. Now, everybody wants a 1% shoe, and here's the problem. Here's the problem with it. I think there's other problems. One of the problems is that as long as Nike has the patent on it, no one else can have a shoe like that. So only if you're running for Nike, can you have that advantage that becomes problematic. But that's eventually, eventually that won't be a problem because you can only hold that for so long. There are problems, I believe, with those plates, those carbon fiber plates. It was a study that came out. It was a case series of five individuals with the regular stress factors, right? And that following transition to these type of shoes with the carbon plates, and when you think about it, there's got to be some tuning of the foot to the shoe so that they're both moving with the same rebound that you probably get a little bit from that carbon plate. And if you don't, it can provide these abnormal forces between the shoe and the foot. I don't know what the mechanism is for these stress factors, and this was the first paper to come out. But I think it's interesting. Let's just say it's interesting, right? There was, I have a really, I'm going to say beautiful, not really beautiful, but very demonstrative picture of what those shoes, the changes in the mechanics of those shoes can create. So, I got this from someone from World Athletics, it was an elite runner. He is banking a turn, so he's going around a turn, and his foot that's on the inside is actually going into pronation, right, it's being forced into a person. And because those shoes have a large, they're very thick, so a lateral ground reaction force, I want to try to show this, and a large moment arm here, the physics of that creates a moment into aversion, right? And flare, which is a big flare in the forefoot, with a vertical ground reaction force and a big flare, that also increases the moment for the biomechanist nerds, or maybe he are watching, but increases the torques on the foot, and the foot is, I mean, the ankles nearly on the ground is rolled over so far. And I just wonder, what are going to be, now, when we have all of these increased loads on the foot, torques on the foot, what's consequences of this in terms of injury? And if you remember, my mantra from our previous time together was, the closer we are to the way that we are adapted to move the last service for injury. So you start adding all of these things that create these abnormal motions, but it is, I mean, there's definitely a question to be answered here, how do we apply this sort of minimal approach to other sports? My husband just asked me about his golf shoes, like he wants to get some golf shoes, right? And, you know, does he, does he golf in the minimal shoes, which he's, can he has done that? He's been golfing in the minimal shoes, but he doesn't have that sort of grab of the ground that he wants, and so, you know, and I do know that zero, vivo, all of them are thinking about this. I know zero and Steve Sashin has worked with some female NBA players, but the problem is that, you know, they can't, they can't wear a shoe that's not the shoe that they're sponsored by. Sponsored by. But even for practice and stuff, he is, he's worked with some of them, and he's been thinking a lot about how we can take this minimal approach to other footwear, which I think is part of the question, and how much do we, how far do we go to improve performance, which is your question, especially with other sports? Terms of weightlifting, I know lots of weightlifters that weight lift in minimal shoes now. So, but as I mentioned last time, you don't want to do that really quickly either, because now you've got a huge load, not just your own load, but the load of the weight. I don't know how you did anything, yeah, yeah. Dr. Davis, do you mind, so the 4% what is that in reference to just for the listeners who made it? Yes, people were 4% more efficient. That's how it got the 4% name to it. A classification that shoe is often called AFT, advanced footwear technology, because there are other shoes that have plates in them, and there are shoes that have some of these characteristics. So, you're going to see it throughout a lot of different footwear now. Dr. And so, you talked about how the foam and their cushioning, what was so specific about the foam is the material of it that you still love. Something about the material, and that's their secret sauce, right? There's secret sauce in that foam. The thing about the foam, though, is that it wears out very quickly, and I mean, there's what, 300, I don't know how much they are now, but they're $300 a pair, something like that, and you know, you might get a marathon out of them, and then that's it. So, some people will train in the regular shoes and run in those shoes, which I don't think is a great idea, because I think the mechanics are different. I don't think we understand quite yet how different they are. And some people will just train in them as well, but just get numerous pairs of them. So, that's one of the disadvantages. I think their next step is going to be able to make a foam that provides that same energy return, but it's more durable. And, you know, I don't doubt that we can be more and more creative with the innovations to make people fast, provide more energy returns what we're doing. I just disagree with the approach. I, you know, we stopped it with swimming. We stopped it. We did not allow that material that the swimsuits. And yet, we allow it with the shoes. Yeah, I think like we have this fascination with speed, right? And we often times relate speed with health, but people need to realize that two are not together, right? I mean, we want to increase our VO2 max for longevity purposes. We want to stay in this zone to cardio state. And, you know, there's been a marathon boom, especially since Kipchogi, you know, in 2019, set under two hour mark. And, yeah, I believe he was wearing the carbon fiber footplate. And then since then, you know, there's really been this big running boom. I see so many people trying to sign up for half marathons, five Ks. And now every holiday party, or, you know, St. Paddy's Day here in my town, they did a four-miler, right? And so, they're getting a lot of people to sign up for these things. And I think when you go online and you look at what the best are doing, because we're all trying to be the best, we quickly see what they're wearing and try to replicate it. Without realizing, like you said, the trade-off is, I don't think we're really actually focusing on health, but more than anything, it sounds like marketing, you know, overall, these trends from every single sport are focusing on adding more and the new gimmicks, which, you know, maybe help performance a little bit if everyone's doing it as the game's getting faster, but more from a protection standpoint. Yeah, and there have been some studies that have shown that not everybody benefits from them, and equally. And it may be that you've got to be at a certain, and I think we need more studies to really fully understand this, but you may need to be at a certain level to really get that last bit of advantage. And if you're just a regular marathon or so many people are just, you know, they run for fun, basically. They're not being sponsored or it's not competitive. They just want to be able to do it. That kind of thing. Are they going to get advantage out of it? It just because the elite do does not necessarily mean that someone who's a lower-level runner is going to get that same advantage. I think it's something to keep in mind. And I just, again, when I speak to people from world athletics, they're concerned. They are concerned about all the technology. They are. And they're concerned because they want the person who's up on the podium to be there because of their own abilities, and not because of being augmented. And that's the problem. That's the problem. And that's why we didn't allow those swimsuits. But, you know, the footwork companies have got much deeper pockets, and I think they're a harder industry to fight. So that's why I say the Juni model. Yeah, I do wonder if they're going to create a separate category, almost like they do with bodybuilding, where you can be natural versus, you know, antibox steroids, and what you're not, and compete in two different categories, and, you know, pick a general one. Are you in favor of that? I'd definitely be in favor of that. I think that's not a bad idea. I should suggest that. That would be awesome. What else here? So, yeah, what's interesting, too, is, you know, ultimately, I really wanted to talk about the carbon fiber footplate. And so, you pride in me some of these studies, and so it seems like in 2018, there was a study, too, which kind of highlights what you're talking about with that efficiency. And so, just to bring it back to running a mechanics, it seems like the cadence decreases, right, but you're still taking a longer stride lane. And so, when people need to think about that, the cadence is almost that tempo. Stride lane is, you know, the swing of your legs from one foot to the next. And so, if you're going longer on that stride lane, decreasing the tempo, or the tempo, saying the same, or decreasing, you're going to be more efficient. Is that good, right? So, yeah, I think so. Okay. Yeah. Fantastic. Is there anything else that you wanted to provide in regards to these carbon footplates, anything else that we can go down? You know, I just, I think that we need to be careful. I think we need to proceed carefully in terms of innovation and creativity, and I think, as I said, everything's a trade-off. You know, it's, it's probably easier to run a marathon in a pair of cushioned shoes than it is barefoot. And so, in, so, you know, there's a, you know, cost savings in terms, there's a payoff in terms of that. Because you have to do more work, right? Right. You have to do more work. You have to do the cushioning. But I think that's what sports should be about. I don't think it should be about what's being augmented. So, that's why I'm, and my focus has always, I mean, of course, I, I love to watch performance. Don't get me wrong, and I love to see my, my patients perform well because that's their goal. But my goal is always getting people running injury free. And performance isn't, mine isn't what I'm thinking about. I'm thinking about, can I get them running in a way that their mechanics are going to be optimized and they can run as much as they want. And then they can perform as, you know, you're not going to perform well if you're injured anyways. But um, yeah. Yeah, for sure. I think growing up as a tennis player too, there's always these philosophical conversations about performance and who's the greatest, right? And so it seems like we're always just trying to defy human limits. I mean, you even look at the tennis racket from like the early 1900s to now and the strings, the aerodynamic, the physics behind these inventions is absolutely incredible to where these players are, you know, just playing at a different level than they even were 10, 20 years ago. And I think every sport has kind of moved in some sort of direction that way. But yeah, I totally agree. I'm very much in favor of that hard work and letting the human natural, natural human capabilities kind of take over and really trying to augment it from that standpoint of what we can do with basic training and our own training. So I totally agree. Yeah, and you want kids and we think about, we talked about how the Holy Grail is kids. Yeah, right. We want kids to start out using all their body in the way that their body was designed to be used and not adding all this other stuff. And even kids are probably jumping on that bandwagon. I don't know how many parents are buying kids, so it's kind of shoes, but, um, yeah. And then, you know, the, um, you know, we've talked a lot about running, but I am a big advocate of, of making sure that people move in multi directions. And I don't think we talked much about that last time. No, I don't think we have talked about the planes, yeah. Yeah. And I think it's really important. Like, running, I've studied running and I think running is one of our natural, as I said, is one of the things that we've all to do. But when we were running, Darce, we were running on, we were chasing animals. We were running right and left and we were at a start with stopping and starting and we're doing sort of high interval training in a sense, like sprinting after them and stopping and we try to carve them out of their, their herd so that they were by themselves and then go after them and it was a very different kind of running, right. Then the running that we do today and that kind of running, um, we probably, you know, we're probably not running, though, even though even with bare feet or minimal shoes, we're not running in the way that we were adapted to run, you think about it, right. So it's important, like, with kids, do you have children? Did you tell me you've... I do not. No, ultimately. No, you don't. Oh, that's right. He was the one, right. But, you know, with kids, you really want to make sure that you promote that multi-directional movement because there's an individual named Stu Warden, he's in Indianapolis and he's done a lot of work in bone and he showed some data meeting recently where he was looking at the bone, measures the bone strength in children, adolescents who only run and who those who run and do multi-directional sports. And there was a significant increase in the bone strength in those who did add the multi-directional sport. Running is not a good bone development activity, right. You know, it's very repetitive and your bone only responds after why your bone gets numb to the impacts and it just doesn't respond. And it happens very quickly. So running is not a good, you know, bone stimulating activity. Things like gymnastics and, you know, volleyball and things where you're moving around, those are much better. And I think about it with the muskis, the muscle system as well, you know, that muscles need to be challenged in lots of different directions. I tell you, you know, I do a lot of biking and when I go out and play pickleball and I haven't done it in a little bit, I'm sore and in muscles in different ways because you're stopping instead. It's like tennis. Have you played pickleball? Oh, yeah. I cannot wait to come to Tampa. I'm so excited to play. Yep. Oh my gosh. Yeah. Well, I'm just I'm a newbie. So don't I'm not my head. So we'll have to play. We're working to just get it over the net back and forth and make it sure we can do it. But move, you know, you're just I said that we need to be moving adults. We tend to move very, you know, a lot of drugs. Yeah, but it's like in one direction. We don't, and kids are playing and they're always, and we watch them watch a playground. They're running here. They're running there. We don't do that. Unless you're on like a soccer league or even basketball, you're moving around a little bit. We have to do that. And I think it's really important. I don't think kids should just be involved in track. And the more I've learned about that, the stronger I feel about that, I think it's a great don't it's our most natural activity, our most natural, I guess exercise, but it shouldn't be our only because we used to run really differently too. Yeah, I totally agree. I think in there's a book called Great by Angela Duckworth or so good they can. I talk about these principles actually in one of my talks about how when you look at some of the greatest athletes, look at Roger Federer, the Robin, the dolls, who else LeBron James, Michael Phelps growing up, they were multi-sport athletes and that carryover effect that they had from sport to sport only made them even better. Because of everything you're talking about, the strength, the agility, the adaptability, the quickness, everything. Yes, yes. And you know, our kids have gotten into specialization now where they aren't, a lot of them are not. They're doing springing and even just even soccer. Yeah, just doing one sport. It's not good either because you're not working your upper extremities as much. So, you know, I just think we've gotten to this whole specialization and parents want their kids to be Olympic athletes. And they're all going to be Olympic athletes when they're seven years old. And I think the important thing is really getting them to move in lots of directions. And for us as adults to remember that we do need to do that as well. Yeah, yeah. Well, Dr. Davis, I want to dovetail on the idea of how in athletes, they actually might be weakening certain joints and certain footwear is causing actually weaker muscles. But in order to be, again, at that top level, every percent counts when it comes to that lower extremity chain and being able to jump and have that strength. When you work with athletes, is there anything that you recommend when it comes to just training in the weight room or when it comes to what they're doing outside of their actual sport? Should they be back in barefoot shoes or should they be training in barefoot shoes aside from being on the court? So most of the athletes that I have worked in for at least for the past 12 years now have been runners. So, you know, but we believe strongly that they need to have a good strong base and they should be in the gym and they should be working. We are very big advocates of plyometrics and dynamic activities, but progressively loading them. I think as physical therapists, we don't load our, now I'm going to talk about athletes and patients in general. We don't load them enough. I think we're too, too tentative with our patients. So I think we need to be aggressive when we need to really challenge them in very dynamic activities. So our focus is really more on functional movements, dynamic, you know, like I said, like plyometric kinds of things, adding loads to that. But we also recommend that they get in the gym and they get on a good, you know, multi joint program to keep everything fit. Because I think strength, as I was talking about where strength doesn't change your mechanics, but the strength is important for maintaining your endurance. So to speak. So for example, if you're weak, then your mechanics may actually break down. It's not like they're going to, if you strengthen the muscle, it's not going to improve your mechanics. So if someone has knee valgus, for example, and I strengthen the muscle that pulls their knee out, it's not going to make their knee pull out until I add the software component to it. But if you're weak and the tendency is to come in, they'll call it inward more and more as they get more and more fatigued. So having that, that basis, a really good basis strength, even in runners, I mean, they don't want to be big and bulky, but at the same time, you want to, they want to be strong. So that's the kind of program that we develop with with our runners. I see. Gotcha. Okay. Very cool. I want to also transition now towards shockwave therapy, something that we see a lot of therapists actually use in their clinic and medical doctors may be referring them out. But we know there's pretty good data for when it comes to a keelies and plantar fasciitis. Is that something that you recommend that you would utilize in some of your patients that may be developing some sort of injuries, really using shockwave therapy or do you believe kind of more in a different approach to when it comes to retraining and getting injury free? Yeah. So I think of it as treating symptoms. So it's kind of like ultrasound, like, you know, giving ultrasound to try to treat the tissue up and try to treat the symptoms, giving somebody a, you know, steroid or that's what I think of with shockwave is it's a way to treat the symptoms. But I'm always thinking about what is the ideology? What is the actual cause? So like, there are studies I've shown randomized control trials that show that it helps with plantar fasciitis and the keelies tend nice. So some of those kinds of problems. But if you don't address the underlying cause, you're just going to end up back in the doctor's office with that problem again. So that's how I, that's how I think of it. Definitely fair. So awesome. Okay. So I also want to transition now to an older population, which I know we're both kind of passionate about talking about because being a physical rehab doctor, a lot of our patients are over 50, a lot of falls that we see. And we just mentioned throughout this whole episode about how we have to get our young children adapted. But with the advent of sports and specialization, it's not really happening as much the awareness is not there. You live in these shoes for 50, 60 years. And now when somebody hears about barefoot shoes, obviously it's very tough maybe to change that lifestyle component behind it. But what are some of the risks? I mean, even athletes, there was a picture of LeBron James' his feet. I saw like two, three weeks ago on the internet. And they are really, I don't like claw toes, hammer toes, whatever you want to call them, his feet were essentially mangled from playing for 20 years now in tight shoes. And so I can only imagine the effects of, I'm not sure how much that can get better without surgery or, you know, but talking about those risks, what are some of the things that you've seen, you know, in your clinic when it comes to older population that have just been wearing tight shoes for a very long time? Oh, I mean, you see all kinds of problems. You'll see that the helix valgus is a very common deviation. It's much more common in women. This is women tend to wear more tight shoes than men do. And then once the toe comes over like this, right, over here, it starts to lose its optimal length tension related. This is your abductor halisus that springs it out. And once it gets over like this, it has a hard time functioning, right? The abductor halisus to pull it back out. And so it just becomes, so then the adductor becomes the predominant one, it pulls it in more and more and more. So, I mean, that's a very common one. When you have weakness of your intrinsic muscles, that's when you start to get this clawing of the feet, right? And, you know, a lot of those athletes, I remember being at UVA where they put every single athlete got an insult. They just always automatically. And I know that in their heart of hearts, they thought they were doing the right thing. But do you, when you're taking away the demand of those foot muscles for over many, many years, I mean, when you will go to communities where people are, don't wear shoes at all, you don't see these kind of mangled feet. And I'm not going to say always there's probably some examples, but in general, you don't see it. You don't see it. Those DVA, you know, I show in one of my presentations a feed of children who grew up in a closed Christian community, kind of like the Amish and they will go barefoot a lot. And when you look at their toes, you know, I used to think 10 degrees of howlex valve, this was normal. If you took a goniameter and looked along the metatarsal and then the toe, 10 degrees is normal. No, these kids are all straight. They're like this. Their toes are like this and they all have, they all have space between their toes. That's normal. Our feet are not diamonds, right? They're trying for real toes to triangles, but we force them into being like diamonds. So yeah, when you do that for many, many years, it's hard to undo that. I agree. You know, when you've got people who are older, it's not so hard to get people out of thick shoes and to minimal shoes. It's just, it takes, it takes more time. The older you are, the less plastic you are, the less, well, you have, doesn't mean you still can change, but it takes you longer, you know. And so you just have to give it a little more time, but there's no reason why elderly people can't transition to minimal shoes. And I think it's really the way to go because the studies have shown, as I mentioned last time, that balance is better. I think falls are less, I know that falls are related to weak feet, right? And we know that when you are in minimal shoes, you have stronger feet. So if A, it would be, we'll see kind of thing. I mean, this sort of inductive or deductive reasoning, I would think that falls would be reduced. I'm not sure if there's a study yet to show that. So, you know, I think there's a real application. The other thing that happens as we age, and we lose our strength, because we do, is that we lose our strength distally first. So we lose our strength, our muscle strength, and power, and our feet, and our lower legs first. So if we could be in minimal shoes, that's going to help maintain that strength, right? So that's, there's another good reason, even, you know, balance, proprioception, all of those things will also maintain the strength of the feet and people as they reach. Yeah, we may have touched on this in round one, but is there any sort of data to talk about proprioception in the older population and that really increasing in their position in space when they go with barefoot or minimal shoes? I do know that balance and there's been different measures of balance that sort of indicate that better proprioception is improved when they're in minimal shoes. Okay, yeah, very cool. Yeah, I'm just thinking about my parents and how to get them over to minimal issues and also think about training them in planes. You know, they've been very active going to the gym lately, but it's now about how do I bury that up thinking about the next 10, 20 years for them? I have to play pickleball. That's true. I mean, it's a great sport for all ages, but you know, yeah, getting to play pickleball, because it's a great sport. My dad plays tennis, so it should be an easy transition. I used to play tennis, not probably not as well as you did, but I used to play tennis. I used to love to play tennis. I found that transition to pickleball hard. I can't take my first start, they missed the ball, because I thought I had a longer racket in my hand. You know what I mean? Yes. That ball bounces so differently, bounces so differently. My husband's was a racquetball player, so he's got his own kind of transitional issues, but it's been really it's been fun to get out there. So that's what I would recommend that they do. Absolutely. That's awesome. Yeah, no, it is a different game. I should I should recall that statement. I being a tennis player, I was putting spin on the ball with pickleball. It's a lot harder to do that, and so the hand-eye coordination of that net swing movement is very different for sure. She playing at the net with a whistle ball. It doesn't really just bounce off the racket like you would expect it to. And the wind takes it. Oh my gosh, when it's windy, the wind really takes it all. Well, that's awesome. Well, I am definitely excited to move down here in a couple of months or down to Tampa. So Dr. Davis, I think big takeaway for me here is really understanding the trade-offs. I think that has been the biggest thing from round one and round two is that, you know, while we can increase our athletic performance, and while these 4% shoes might make a difference, we have to understand our own goals as human beings and when it comes to health and things like that. And this has been a recurrent theme that I've heard from many of our other guests is before you actually go out and venture on to something and try something new. Make sure you go back, check your ego, and look at what is your true goal? And are you doing something that's going to hinder you and impede your progress? Or are you actually going to be doing something that keeps you safe but still maintains or even helps you a little bit? And so, you know, for me, this has really helped me even thinking about the sports that I play, pickleball, tennis, basketball, and how to even just look at shoes and not go overboard with the fancy marketing that is so convincing to so many of us. So with that, Dr. Davis, I just want to thank you so much, again, for coming on here. I know Altamash has said that he couldn't make it. He really had a lot of good questions. He'll listen to this and get some insight out of it too, so. I enjoyed the discussion because I think we were able to get into some things in a little bit more depth than we were maybe last time. We covered a lot of things. So hopefully, hopefully, the audience will appreciate some of the answers to some of the questions and all of that. But thank you so much. I've really enjoyed speaking with you too. And please keep spreading the word because as I said, the more people that spread the word, I think the more the word will be spread. Yes, yes. We absolutely will, Dr. Davis, and yeah, thank you again for coming on and shedding light on this topic. Last but not least, just want to ask you, where can our listeners find you? Where are you most active on social media? Mostly active on Twitter, on X. So that's probably the best place. Okay, we'll do. And then we'll post our videos and stuff on there too. So people who may, you know, I've heard of say certain words. Dr. Davis used a lot of hand movements. So YouTube is also a great place to watch this podcast to really get in depth understanding of the biomechanics. So awesome. Well, Dr. Davis, thank you so much. Thank you. You take care. Thank you for listening to another episode of medicine redefined. As a reminder, our newsletter is officially rolled out. And if you'd like more actionable tips and tricks delivered right to your inbox, please be sure to visit the website and input your email. And you will have it delivered to your inbox every Sunday afternoon. Please also check out our social media platforms, where you can find more content like this. And you can follow us on Instagram, Twitter, and TikTok at Med Redefine. We also want to thank our team for the production of this podcast, specifically Ethan Jew, Harita Yipri, Zaniligmani, and Sarah Han. And lastly, please remember that important disclaimer that everything in this podcast is for educational purposes only. It does not cost you the practice of medicine, nor should it be considered a medical device. No physician, patient, relationship is formed. And anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal position or coach regarding any specific health related issues. However, if you enjoy the show, please be sure to subscribe, review, and share it with anyone who you think will gain value from this. And until next time, thank you for listening.