foreign [Music] professor and head of the Department of Family Medicine and biobehavioral health and Associate Dean for Rural medicine at the University of Minnesota Medical School Duluth campus I'm your host for our program tonight on lower extremity foot knee and hip problems the success of this program is very dependent on you the viewer so please call in your questions or email them to ask at wdsc.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Sandy Stover a family medicine physician and faculty member in the department of family medicine and biobehavioral health at the Medical School Duluth campus Dr Patrick Hall an orthopedic surgeon with Orthopedic Associates of Duluth and Dr E Tolga hanhan a family medicine physician with Saint Luke's Lakeview Medical Clinic in Two Harbors it is membership drive time here at wdsc so we have a bank of phone Volunteers in the studio to take your questions and calls of support and now on to tonight's program on lore extremity knee foot and hip problems and our first question Dr hanhan it's already come in about osteoporosis of the hip what can prevent it from getting worse so osteoporosis is basically thinning of the bones if you want to think about it like that and how to keep it from getting worse there's a lot of things people can do if somebody is smoking if they're able to quit smoking that would be probably number one exercise is very important if we can keep our lower extremities healthy and moving that's good for the hip itself and uh and good vitamin D intake as well as probably some calcium can improve the health of the bones as well but if I had to pick one thing it would probably be exercise exercise is medicine and and it keeps your bones very healthy well continuing on hip problems Dr Hall you uh brought a example or of a hip prosthesis could you tell us a little about what we're looking at yeah this is an example of a hip replacement and the indication for a hip replacement is somebody who has end-stage arthritis and they've usually tried some form of conservative management that's either failed or hasn't succeeded in alleviating their symptoms adequately enough and so this just shows an example of what the parts look like and so there's a ephemeral part and an acetabular or a socket part and we basically just replace the surfaces of the joint so we remove the ball and then we resurface both sides of the joints so instead of burying weight through the the worn out articular surfaces you're wearing you're bearing the weight through artificial parts and they're made out of metal and plastic essentially it's a little more complicated than that some of the metal alloys and things but that's essentially what the bearing surfaces typically are made out of could you point out the parts that are in the leg and the parts that are in the hip sure so if we're looking at this we're going to kind of turn this so we can see it so let's actually maybe I'll hold it up for the audience if you can see it so this is the the bone of the femur so that's the leg bone and so the ball part comes off the leg bone and goes into the socket but we remove the ball part and replace it with this metal part here that um that goes down into the femur and then the socket part has two parts it has a metal shell that goes into the socket and then a plastic liner that snaps in and the metal ball articulates with the plastic liner and so that recreates a hip joint that functions just like a normal hip joint well I imagine we'll get additional questions about the hip the next question is for Dr Stover a caller wants to know after many years of planters warts or calluses uh wondering if there's some effective or magic way of of resolving it good question because that's one of the more common things to cause pain in the foot and if you have pain in the foot it's hard to walk normally which can cause pain in the knee or the hip as well the the issue is kind of two-sided so trying to prevent calluses from forming uh can mean that it's it's important to pay attention to the shoes themselves is there anything rubbing on there is a weight-bearing bone that's lost some padding from natural aging maybe a little more padding in the shoe could be helpful they're actually all the way up to the special orthotic shoes that can help accommodate to different changes in our feet as we grow as we age the warts are a little bit different in that they're actually something that's caused by a virus that will get right in that kind of upper upper layer of the skin in that in that thicker normal calcium area of the skin and if you do nothing about a wart it eventually will resolve on its own as the immune system finds it and like all all good immune systems can get the virus taken care of but it can take a while it can take several years sometimes and in that process the the body will callus around the wart and it's like walking on a stone in your shoe doesn't feel very good so you can shave off either calluses or warts with something like there's a brand name called the petty egg or some very fine shaving opportunities or some pumice stone kind of a thing but the best way to remove it is actually to to kind of uh you can use a little bit of either some a very mild acid that's that like Compound W which is a brand name for something over the counter or you can come see a physician who can do a little bit more deeper activation of the work so that the body recognizes and helps it resolve on and so on so long answer short good shoes or paying attention to blisters before they become problems paying attention to work to weight bearing and then checking in with your family physician just to get an idea about specific issues in your own feed thank you Dr hanhan can you tell us a bit about the early evaluation of an ankle sprain uh sure we see a lot of ankle sprains are very common uh most commonly uh people kind of Will Roll their foot you know basketball games and things like that where people jump up it's a it's a very common injury and uh people come in with this kind of swollen ankle and it's very painful and they may be limping and our job is uh Physicians is to find out is it truly a sprain or do we suspect a fracture uh they're they're managed differently a sprain is I think a big deal actually it can cause uh chronic ankle problems when you know years down the road so those also have to be managed but they are managed a little bit differently thank you Dr Hall this question seems to be a bit about a range of motion of both legs around the hips a caller is concerned that sometimes the left leg can't quite meet over to the right leg somewhat the way it's as a caller put it magnets might repel each other is there something about the range of motion of the left leg coming over to the right that might imply a hip problem yeah it could you know if if somebody has had normal range of motion and their range of motion is decreasing for some reason it could indicate that there's some arthritis in the hip sometimes with arthritis at the hip one of the first signs is decreased range of motion so one of the things that people tend to to realize first is that they have a hard time putting shoes and socks on because they can't Flex their hip and rotate their hip enough to get their shoes and socks on and that's kind of an early sign there are other reasons to sometimes people have hip dysplasia and maybe they've got a abnormal hip joint that just doesn't move as well as the other one it can also happen from knee problems so when people start to wear out their knees oftentimes they wear out their knees asymmetrical so when you look at somebody from the front the normal leg alignment is to be a little bit knockneed and so in that configuration centers the hip and the knee and the ankle but when people wear their knees out oftentimes they wear out the inside first because that's where most of the weight gets transferred so so when they wear that the knees out in the on the medial part they start to become a little bit more bow-legged and when they do they notice that they can't bring their knees together as well so they could be could be a hip a knee or even a foot problem thank you for that Dr Stover a caller asks about post-polio exercises especially with lower body problems even to the point of not being able to walk what exercises could help the legs and the lower body that's a that's a very good question and it's a little complicated because the polio process when when that virus invades the body it causes some muscle damage and usually it tends to hit younger people but because young muscles are overall in good shape the body can compensate for years there comes a time though as well age that muscles just gradually do become a little less vibrant and in that process the old damage from the polio can become more apparent again so it's difficult to exercise tissue that's become damaged but it is important to consider how to balance out the the muscles that are there so that you don't over Tire or or like Dr Hall is talking about when there's an imbalance issue in the feet or the knees or the hips it transmits other places my best suggestion for post polio syndrome is to work with some of our wonderful Physical Medicine Rehabilitation people or physical therapists to kind of help in supporting the areas that aren't working quite as well and then working to support and exercise the parts that are still a vibrant muscle Dr hanhan a caller asks about Fallen arch of the foot what is it and how might you treat it uh so Fallen Arch is essentially lots of that natural Arch created by the plantar fascia I imagine we'll talk about that at some point tonight and so it's basically you know all of a sudden your foot kind of takes on that flatter shape and so what can be done about it I think one of the better things is supporting that arch of the foot we you can do that with Orthotics you can do that with custom insoles just very good shoes even running shoes can sometimes do it thank you Dr Hall this one's about running and forecasts for joint issues in hips and knees is running a marathon past 40 okay or is it a invitation for the problem you know I think running is okay after 40. you know a lot of people run and it's their passion and so in our office we have some physical therapists that are really good running experts and they they sometimes get people on the treadmill they watch the way they run they give suggestions but I think when you run on hard surfaces it is hard on the joints and so we recommend good cushion shoes good running shoes and replacing your running shoes periodically when they wear out so that you can help cushion the joints when you're running on hard surfaces and we see a lot of that around you know May and June around here because the marathon is usually in mid-june and so we see a lot of overuse injuries from running and some of it has to do with shoe wear some of it has to do with the surfaces it people run on but I think it's okay to continue to run and and be active but I think being smart about the surfaces that you run on maybe cross training somewhat so you're not always doing a lot of repetitive impact on your joints sometimes cross training by biking or doing something that's a little less less strenuous on the joints can be helpful so yeah so we recommend those things but yeah I think it's okay to keep running after 40. we have people that run the marathon you know in their 50s 60s and 70s even so yeah just just to stress that the notion about Footwear most of us probably do not replace our shoes enough I mean there's some recommendations that Runners should be replacing them every 250 miles which is not a lot of miles if you're an avid Runner because of the wear and tear and the cushioning that might not be available anymore in the older and the cushioning kind of kind of crunched down after a while they're not as effective so well Dr Stover this question is actually about two feet and if someone is having bunions on both feet would the surgery be recommended on both feet at the same instant and that's a good question the issue with bunions is where that that first knuckle on the foot that's basically with the big toe gets enlarged it's actually is turning in it makes it look like it's getting larger there's some wear and tear in the joint it thickens a little bit and bunions are a little bit of family related it's not something that's really due to Footwear that we have it's it's something that's more of a inherent changes that are going to occur in a body and if there's no pain in the bunions or if you can get shoes to accommodate that change in that bulge you don't really want surgery because the issue with bunion surgery is is that that natural change that's happening in individuals who get bunions is going to happen again even post-surgery the change can occur so if there's no pain you don't need surgery if there is pain that's affecting your gait like we've been talking about it'll affect your knees and your hips too then you want to talk with someone about getting it I the problem is it's it's essentially it affects the bone enough almost like a fracture that you have to be off that foot for a while so to do both at once would make it very difficult to get around so the recommendation is one at a time but it's another good conversation to have with a physician about is this the right time for you as an individual is there is waiting a little bit giving you more time to avoid a second surgery Dr hanhan we have a question about peripheral neuropathy what are current recommended treatments for peripheral neuropathy of the lower extremities yeah so peripheral peripheral neuropathy is basically nerve damage if you want to think about it like that and it's it's a big deal for the lower extremities in particular uh if if you really think about the body the feet are as far away as you can possibly get from our spine which is where these kind of nerves come out of so feet are affected by the peripheral neuropathy and I think the uh the question is why do you have a peripheral neuropathy the most common reason in our country is from diabetes and so uh it's all about diabetes care so making sure that the diabetes is well controlled there are medications that can kind of if the neuropathy is painful which is the case for some individuals there's some medications that can be used for that but it's basically supportive one of the dangers of peripheral neuropathy is you may not be aware of some foot damage that's actually happening for example you could be walking with a rock in your shoe not even know it so we tell our folks with peripheral neuropathy to make sure they're looking at their feed in on a regular basis Dr Hall could you help our viewers understand the difference between knee pain that's in front of the kneecap and knee pain that might be behind the kneecap and my might be explaining those yeah I mean sometimes it's hard to distinguish where the pain is coming from when people have anterior knee pain a lot of times knee problems come from the patellofemoral joint or the extensor mechanism so it can be overuse and stressing the extensor mechanism of the knee and you can get some quad tendonitis or some patellar tendinitis and those usually present with anterior knee pain that's palpable when people have patellofemoral arthritis that means arthritis in the joint between the kneecap and the femur that also presents with anterior knee pain and crepitation if the joints are starting to wear out a lot of times those conditions are aggravated by going up and down stairs or squatting down to pick something up off the floor because it accentuates your use of the extensor mechanism of the knee so people who have those kinds of problems can usually walk on level ground pretty easily but when they have to walk up hills or stairs that's when they notice it the most and that's because they they really use that extensor part of their knee more when they when they do those activities and so it's probably important to come and have it evaluated start with some X-rays and then maybe even an MRI if there's some question about what's causing it for our viewers you mentioned crepitus could you indicate on your knee model where that crepitus is coming yeah this is a not a a new model this is a knee model with a knee replacement in it but if you look at this knee model this shows the patella and what's really not shown here is the muscles but you can see the the kneecap connects down to the tibia through What's called the patellar tendon and so the crepitation happens between the patella and the femur when the knee is flexed and extended and really what you're what you're hearing is that crunching and grinding Sensation that you hear when two uneven joint surfaces rub on one another and so that indicates that there's some wear and tear of the patellofemoral joint thank you Dr Stover a caller wants to know the caller has rain nodes and while sleeping what could be done to not wake up with cold tingling hands and Reynolds is actually something that's that's not happening because of temperature outside or inside although it can be triggered by cold temperature but it's a vascular problem some people will wear a wool kind of gloves on at night to help retain heat in the hands a little bit better that's probably my favorite way to do it but overall that with Ray knows you may want to check with your doctors to make sure there's no other process going on in the body that could be leading to that Dr hanhan a caller asks why might legs be aching while walking there's so many reasons some questions I'd have in in mind would be what part of the leg uh you know um probably all of us have had leg pain for all kinds of different reasons I don't run very often but when I do I get some leg aching the next day just because I'm not used to it but yeah there's the leg is pretty complex so sounds like worth an examination and history and physical I think so okay thank you and very briefly Dr Stover are there insert cushions for alternatives to replacing the running shoes that's a good question I was actually thinking about where we were talking um ideally that the shoes are built with a cushion that's in the rubbery part as well as on the insert part so the shoes are good running shoes are complex but I have replaced using gel pads and gotten more weight more wear out of a shoe well very well as mentioned at the beginning of our program it is membership week here at wdsc doctors on call is such a special and unique local show but requires your support to make it happen each week we'll be back after learning about why your donations to wdsc are so important [Music] thank you welcome back to doctors on call let's get back to questions on our topic lower extremity knee foot and hip problems Dr Hall this question regards leg length is it common to have a leg get longer after a robotic total knee replacement and the caller mentions for instance a half inch longer well you know sometimes people just normally have a leg length discrepancy so you know if you were to take you know a bunch of people at random and accurately measure their leg lengths a lot of people have a small leg length discrepancy and they don't really know it and so until it gets to be a little bit bigger like maybe a half an inch or more it's typically a lot of times goes unnoticed um so after a knee replacement sometimes the leg does appear or feel a little bit longer especially with a big deformity so you can imagine if somebody has a big bow-legged deformity and then you correct that deformity and straighten the knee out it does add length and so somebody who's been used to walking on a shorter leg for a long period of time and then has that deformity correct it is going to feel like that leg is longer because they're used to walking on it feeling short and so it it may be something like that it's really not that common to to end up with a big leg length discrepancy from a knee replacement because the most of the knee replacement systems are designed to put the same amount of bone or the same amount of space back with the prosthesis that was removed from the bone during the knee replacement so there's different reasons why somebody might feel like one leg is longer than the other or why they might have a leg length discrepancy but I think with a knee replacement it's it's unusual to end up with a large leg length discrepancy thank you Dr Stover this question is about what scan could be done next a caller's had two hips replaced and a history of bone cancer in the back hips are now starting to feel painful and the caller wants to know what kind of scan could be done next that's a good question because the metal that can be in Replacements can be distorting in things like a CT scan depending on the kind of metal there may still be an opportunity to do something like an MRI it depends on the kind of metal but something else that's that's very interesting to use in in Orthopedic care is an ultrasound for soft tissue issues it won't help with the bones but you can look to see if there's been a tendon that's become inflamed or looking a little bit more at areas of swelling and what they're coming from there's there are some other kinds of scans like pet scans that look at for cancer things like that so that's kind of depends again on what part you're really interested in looking at what part is hurting Dr hanhan a caller asks about a deep vein issue contributing to lymphedema and what activities could be avoided if one has lymphedema perhaps to make it better yeah so lymphedema is a term where lymph tissue which is part of our immune system builds up in one extremity and it could happen in really any of your extremities and it's very challenging to deal with there's no very easy solution for Lymphedema there's a lot of products that are made that can kind of squeeze the extremity and and try to push some of that fluid back and out of the extremity just for comfort and so what should be avoided uh probably anything that hurts but in general we should try to keep our our extremities moving the more our legs move for example the more our muscles will pump that tissue back so one thing that should probably be avoided is just sitting still for long periods of time Dr Hall this question is about the knee sounding like cellophane after the knee replacement it's not painful but the patient hears it yeah that that can happen it's usually caused by some synovial tissue or Scar Tissue build up around the patellar component it doesn't typically happen right away after a knee replacement but happens maybe six months to a year later sometimes and it usually it can sometimes be a really audible sound you know kind of a crunching sound there's a name for it it's called patellar clunk syndrome sometimes and oftentimes the solution to that problem is to do a knee arthroscopy and go in and trim out the the tissue that builds up around the patellar component and that happens sometimes I I wouldn't say it's real frequent but maybe you know one or two percent of the time and it almost always responds to a knee arthroscopy to trim that tissue out I've had patients that have had that even twice you know maybe you know maybe early on and then later on in life even with some of the scar tissue that builds up and the knee is arthroscopy almost always solves that problem Dr Stover could there be a relationship between back surgery and subsequent burning on the top of a left foot or itching on the bottom of a right foot and the when there's issues related to the back that requires surgeries often to release pressure that's kind of come across one of the nerves that leaves the spinal spinal cord and then feeds the leg muscles and the sensory system in the legs and so the back surgery itself doesn't always completely resolve its main it's intended to help improve function but sometimes there's still some inflammation to the nerves that feed those areas and the other Sensations that come with our nerves are things like burning itching sometimes a feeling of cold prickliness or a light tickly sort of sensation and so those kinds of Sensations are best dealt with by using a positive alternative sensation sometimes creams can do that or a slight electrical stimulation so that again that's something that can be dealt with if it's a bothersome so people find that it's present but it doesn't really bother them so there's a requirement that something be done as long as there's good muscle function and strength in the legs Dr hanhan a patient has a collar has broken a bone in the foot back in August in Fairly good health it's still hurting at times and getting swollen what are you considering or what might be done so a bone in the foot that has broken and so we're about four months out and if it's still a Troublesome it's worth you know thinking about if the bone healed properly that's kind of my biggest question you know feet are very important if you think about the stress the the feet kind of carry of or weight so that's worth a look let's say for the sake of argument that it did heal properly but the patient the person still ends up with some kind of tenderness and comes some swelling from time to time you know you can develop arthritis from broken bones once they've healed and so and that can pass on to the joints right around the the break itself um but it's probably worth getting it looked at to see if the bones are where they should be thank you and Dr Hall this caller wants to know about why knees might be aching only at night um yeah that's a good question some people complain of aching at night it can be from stress that that happened during the day and a lot of times during our day we're not you know paying attention to our knees because we're focused on the tasks that we're doing during the day and sometimes they that when patients go to bed they just feel it more at night so it could be it could be a result of the the activity during the day um so I'm not really sure how to answer that question other than to say that sometimes it's related to activity and sometimes just people notice it more at night and Dr Stover this question is regarding advice after cortisone injection a caller wants to ride the exercise bike but is uncertain if she can what might be the recommendations around activity after cortisone shot so cortisone is a steroid so it's an anti-inflammatory it's often accompanied by a little bit of Lidocaine which is an anesthetic and if those two are given together the knee will often feel quite a bit better in that first 24 hours I think my biggest recommendation to people if there's been a cortisone shot is not to overdo it in that first day when you're when you've got a little bit of that anesthetic on board and doing too much can then increase the reason that the inflammation is there in the first place I think it's also helpful to think about what kind of exercise you're looking at working with a physical therapist or a physician to kind of design the right thing for the knee to strengthen the the need to support whatever the problem is going on in there but in the first 24 hours a light exercise is good and important to do you just don't want to jump in to a more aggressive form until you've had a chance to build the strength back up in the knee Dr hanhan what are current treatments for symptomatic peripheral neuropathy so the neuropathy question again so there's a lot of various options that there's various medicines a lot of nerve agents are used one of the issues with nerve agents is uh oftentimes they can make people kind of feel fatigued or run down so those are somewhat limiting so if some people can tolerate those medications some people cannot uh and then as Dr Stover suggested there's some cream creams that people can use uh and uh there's a lot of options out there I mean a lot of them have been tested and some of them have not that doesn't mean they don't work uh so it's just worth experimenting uh with all the different options Dr Stover a few callers are asking about inserts for their shoes and whom they might consult about fitting them well and that's a good question so um there's kind of two sorts of inserts that we've talked about tonight there are uh kind of inserts that are custom made by an orthotist uh that that uh can be helpful for something like an arch support or some people have heel issues related to tendonitis in the foot and that should be fitted by someone a podiatrist or an orthotist who specializes in making inserts you can buy commercial products that are more cushioning so as opposed to supporting a structure it's cushioning the pounding that we were talking about earlier that can put wear and tear on on the joints that are further north and so the gel pads that have been a nice technology have been around long enough to know before gel pads we almost mostly had foam they didn't hold up as well as the as the gel pads do so trying out gel pads that are commercially done can be helpful there really isn't one place I'd go to get specific advice unless you're doing the the inserts to to correct something or to support something that's changing in your foot um I hope I think that that's probably my and Dr Hall regarding the knee and we're familiar with abbreviations like ACL for example what is more commonly injured the anterior or the posterior cruciate ligaments and why oh so by far the anterior cruciate ligament so the ACL is a common injury in sports it usually happens with a twisting hyperextension type injury but the PCL is a much stronger ligament and so it's harder to injure the PCL it usually takes a higher energy injury oftentimes it's a motor vehicle accident where somebody hits the dashboard with the front of their knee or they fall really hard on the front of their knee so it takes a lot more Force to disrupt the PCL and I bet you we see ACL ACL injuries probably 10 times more frequently than PCO injuries thank you for that Dr hanhan a power lifter weighs a 350 pounds and is it the lifting or the weight that might be causing aching in the knees virtually all the time that's a great question um weight and knees have an inherent relationship right so the more somebody weighs the more we're asking of that knee joint and so weight is really tough on knees and if and so if if people are overweight if they're able to lose weight that can be very good for the knees and Dr Stover a caller would like to know about the effectiveness of Voltaren gel for arthritic knees that's a really good question because that's been a more recent kind of addition to the things we can do for inflammation and it's actually very effective so it has to be something that's aching that's that's closer to the surface so for a deep hip pain not not just over the side where the trochanter is but the hip pain it won't work as well but for the knee or for tendons on the top of the hands or the feet for elbows that can be super very effective it's important though to remember not to use too much of any one kind of drug because there are side effects to anything but following directions on the label or with Physician's directions are important and this question is about tendinosis and tendocinovitis or tinocinovitis affecting severe pain in the in the leg and in the heel and whether um if this has been going on for three years is there some surgery involved or more time for me sure so tendonitis and tenosynovitis are slightly different areas where inflammation is occurring the synovium is is referring more to the kind of the coating the tender of the of that joint area and so if it's affecting the heel it makes me think of the Achilles tendon could be strained it's part of a unit that goes all the way from the toes up to the back of the calf so anywhere in that system that tightens it can set the rest of the system off so doing stretch they're doing appropriate and and kind of slow and steady stretching in that area can be very helpful if the if something's been going on for three years that chronic nature of it can sometimes sort of it's sort of is like a coal that continues to burn in that area and so you have to find a way to change the stresses on that are pulling on that area to kind of cool that off so it has a chance then to be stretched and to heal up so I we kind of talked about physical therapy a couple of times today but they are they are experts in helping under design an exercise program for individuals that meet the needs of an individual problem in a joint system Dr Hall what are the treatments for a torn Achilles tendon well there's really two treatments either operative or non-operative I think if the tendon is torn and it's pretty well approximated you can put that in a cast or a boot and slight plantar flexion and oftentimes they'll heal if it's torn and really retracted or separated by a large gap that oftentimes will fix those surgically by suturing it together and bringing those two ends together so that they're reapproximated and will heal kind of together instead of with scar tissue in the Gap so those are really the two options either non-operative treatment by immobilization or surgery to fix the tendon does the patellar tendon also tear the way the Achilles tendon tears it can you know it's it it's it's uh you know connects the bottom of the kneecap to the tibial tubercle which is that bump in front of the knee and so that's what connects the quadricep to the tibia and so with you know extreme strain injuries to the patellar tendon it can rupture and more commonly I think the quad tendon is is more commonly ruptured but anytime those happen it disrupts the extensor mechanism of the knee and if you don't fix it it can lead to a lot of disability because that's a pretty important part of your knee to be able to function and you know walk and go up and down stairs and all of those things that you need to do and Dr hollab a brief final question can the knees get to the point where surgery won't help if it's bone on bone for both knees well if it's bone on bone for both knees that means you've worn through the cartilage on both sides of the joint and so usually when it gets to that point it's pretty painful and that's about the time we start to recommend knee replacement surgery so we try some of the conservative things like injections and medications and just activity modifications local pain relief modalities and just kind of avoiding the things you know are going to aggravate it but once people have failed conservative treatment and they're bone on bone that's when we talk about knee replacement surgery so thank you yeah great well I'd like to thank our panelists Dr Sandy Stover Dr Patrick Hall and Dr E Tolga hanhan please join Dr Ray Christensen next week for a program on men's health and kidney stones when his panelists will be Dr Josh Engels yard Dr Nick Johnson and Dr Paul Sanford thank you for joining us tonight this type of programming can only happen with viewer support you can keep all the shows on wdsc wrpt healthy when you become a supporting member [Music] foreign [Music] [Music]