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Some new info on running, overpronation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Matt22, Aug 26, 2007.

  1. Matt22

    Matt22 Member

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    To the Doctors of the Podiatry Arena,

    My name is Matt, and I was a competitive runner through high school and college. I went through a few years where I couldn't run due to a condition called overpronation. I was able to successfully accomodate the condition and get back into peak shape.

    In the process, I learned some new things about overpronation and running that I want to share with the rest of the community. Below I've attached a brief summary of what I learned. I hope that this is received well.


    Running in general

    1) All humans sprint with roughly the same form.
    2) As they slow down, they start to fall into one of three fundamental patterns
    3) Pattern 1: You bring foot out in front, land on heel or balls, absorb shock as your leg goes under you, and kick up with your lower hamstrings for propulsion. Most people run with this pattern. Shoes are designed for it.
    4) Pattern 2: You land with foot beneath you on the balls of your foot, and wait until the last moment to push off. The Pose community has popularized this and describes it as "falling forward." A lot of professional runners run like this.
    5) Pattern 3: You bring foot out in front, land on heel or forefoot, and absorb the shock almost immediately. You then rise off the ground as your leg goes beneath you, thus eliminating the kick. A lot of professional runners do this.

    Where overpronation comes from

    1) One cause of overpronation is a genetically short first metatarsal*
    2) An accepted test for whether you have this condition is to place the balls of your foot on a floor with the heel raised. If the ball of your foot does not reach the ground when your foot is in neutral position, then you have a short first metatarsal.

    How overpronation destroys a runner

    1) A short metatarsal causes the ball of the big toe to be out of place when the foot is in neutral position.
    2) As you put weight on the foot, the ankle tries to roll inward to put big toe in proper place.
    3) Ligaments along the inside of ankle prevent the ankle from rolling far. But over time, these ligaments can stretch and allow excessive pronation.

    How to accomodate overpronation

    1) The best way to accomodate overpronation is to run with the third pattern that I described.
    2) This is because ankles rotate inward most easily during the stage that your leg goes beneath you.
    3) Want to minimize weight sent to ankles during that stage.
    4) The third pattern minimizes this weight because you are rising off the ground during that stage.

    How I now run

    1) If I am running on hard ground, I wear New Balance stability shoes with Powerstep over-the-counter orthotics. I land on my heels and run with the third pattern.
    2) If I am running on grassy fields, I go barefoot and run with the third pattern. I land on the back of my forefoot followed immediately by heel.

    * The following source indicates that the first metatarsal is supposed to be shorter than the second. So what constitues a short first metatarsal? The test that I mentioned is also described in the source: w ww.latrobe.edu.au/podiatry/Metatarsallengthvariations.html
    Last edited: Aug 27, 2007
  2. DaVinci

    DaVinci Well-Known Member

    How many x-rays have you looked at? Notice that everyone has a shorter first metatatrsal? You actually need a first metatarsal that is shorter than the second for normal function. A short first metatarsal does not cause overpronation!

    "Overpronation" is so last century as terminology. We have way moved on from that and its understanding.
  3. Matt22

    Matt22 Member

    Lol, I was just about to edit my post, damn it!

    * About where you said that the term overpronation is outdated, I confess that I don't know what you mean.

    * About where you said that a short first metatarsal does not cause overpronation, well, that's a big issue. I don't think you can dismiss it just like that.
    Last edited: Aug 26, 2007
  4. Matt:

    I appreciate your enthusiasm for running. However, many of your observations are wrong. You are now posting on a website intended for medical professionals where you are making statements like an authority, which you obviously are not.

    I would suggest, if you wanted to ask questions of the experts on this site, then feel free to do so. However, unless you have done a research project on running biomechanics or have extensive knowledge of the scientific research on the subject of running biomechanics, you would be better off posting on a website that is geared toward the layperson, not one that is geared toward the medical professional.

    As an analogy, if you work on your car brakes for the first time and happen to fix them correctly and without problems, you wouldn't necessarily go onto the website for car repair professionals and tell them how to fix brakes on the cars they repeatedly worked on for the past 10-20 years......would you?? :eek:
  5. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I've lost count of the number of otherwise intelligent and highly interested and motivated runners and sportspeople who I have heard theories from along these lines over the years.

    Without wanting to kill your enthusiasm, there are literally dozens of causes for "overpronation" - which is a term we try not to use anymore, since it is very hard to define, and varies form one individual to the next. More importantly, although problems such as metatasus primus elevatus / supinatus can contribute to the subtalar joint moving into a more pronated position - variation in length is typically not an issue. That being said- 1st MT length issues may contribute to other problems such as hallux limitus/valgus etc. which will affect runners.

    I admire your enthusiasm, but have a good deep read of hundreds of pages of biomechanics content found on Podiatry Arena, and if your still think that your theory holds weight (and you can provide a logical explanation also), I'm sure many here will enjoy a robust discussion about it.

  6. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Overpronation is not a "condition". It is just an observation - and a crude one at that.

    That being said - it might have contributed, either in a small or large way, to whatever you actually did have.

    Remember, there are lots of runners that "overpronate" and never develop any foot or leg problems.

  7. Scorpio622

    Scorpio622 Active Member

    Is the human body built to run long distances??? Why are we the only animal on the planet that runs for miles without resting???

    I am about to commit podiatric heresy, but it is honestly how I feel....

    I don't like treating runners. Read again the intial post and then imagine treating this guy- he is an authority. I get exhausted treating marathoners and the like. Most, I can never make happy. i.e. "The right orthotic if fine but the left is not posted enough, could you send it back and add 1 degree" Two weeks later- "It now makes my knee hurt, could you take off 0.5 degrees........

    I am not a runner (beyond 3 mile jogs) and believe that you have to be a runner to treat runners. For many, long distance running is a psychological addiction in the OCD realm. For some, especially teenagers, its sublimation. I am not saying that ALL runners fit this description, but many do. I don't mean to insult the runners on the forum, so accept my apology if I have.
  8. Matt22

    Matt22 Member

    I'm considering the commonly accepted definition, where overpronation is when the ankle rotates inward upon weight bearing followed by collapsing of the arch and the first metatarsal moving forward.

    If I understood that statement correctly, you said that a short first metatarsal can cause overpronation, but it usually isn't an issue. My response to that is that it can become an issue over time.
  9. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    This is just highlights where you are getting into trouble. The ankle cannot pronate for a start. Anatomy 101.

    No you didn't understand me correctly. Metatarsus primus elevatus is a saggital plane issue affecting the 1st MT. It has nothing to do with absolute length.

    Perhaps you should do some reading around the topic before continuing on this thread, or at least provide some evidence that supports you position.

  10. Matt22

    Matt22 Member

    I didn't say that the ankle pronates. I said that the ankle turns inward, which happens during pronation. Source: http://www.steenwyk.com/pronsup.htm Additionally, saying that the ankle pronates has the same meaning as saying it turns inward in common running lingo.

    My assertion is simply that a short first metatarsal is a cause of overpronation. Which in turn, can cause metatarsus primus elevatus and supinatus. I mistakenly thought that you were saying the same thing as well.
  11. Craig Payne

    Craig Payne Moderator

    Nope. Thats were you got it very wrong. a short first metatarsal is not a cause of "overpronation" (we so over that terminology!). As Davinci pointed out above --- look at some x-rays and you will see that everyone has a first metatarsal that is shorter than the second. Its needs to be shorter for normal function to occur (as its head is larger, it needs to plantarflex more than the second, so has to be shorter or it can't do this).

    George Sheehan (a cardiologist and running philosopher) popularised this as a cause of overpronation in the early 70's running boom as every runner with an injury had a short first met. What he did not realise that every non-injured runner had one too (except the minority that had equal lengths or longer ones, but they had a different set of problems as a result; and the few that have really really pathological short firsts). I also recall a newsletter from Sheldon Langer in the late 70's or early 80's called the 'Myth of the Short First Metatarsal' (or something like that)
  12. Matt22

    Matt22 Member

    What about your website, which I cited? ww.latrobe.edu.au/podiatry/Metatarsallengthvariations.html specifically says that a first metatarsal that is too short can lead to overpronation. It even gives a test to determine what "too short" is, which I described in my original post.

    (It should be "www.latrobe..." but I erased a w because the link doesn't work when the post changes it to a url link)
    Last edited: Aug 27, 2007
  13. efuller

    efuller MVP

    How did you learn that your problem was overpronation? What measurements were made that determined you went beyond normal pronation to overpronation. There is no definition of overpronation in the medical literature.

    In the past, podiatry accepted there was a connection to foot pathology and STJ pronation. However, there was never a good explanation of the connection.

    That said some foot problems can be related to pronation of the subtalar joint. Pronation is a rotational motion and rotational motions are caused by moments or torques. Therefore the cause of pronation has to be a moment. Moment is equal to force times distance. The center of pressure is the average point of force under the foot. The position of the center of pressure relative to the projection of the STJ axis on to the ground gives the magnitude of pronation moment from the ground. Muscles can also cause a pronation moment. All moments are added together to provide a net moment. A lot of shoe modifications in antipronation shoes are directed at altering the location of center of pressure.

    A shorter first metatarsal does correlate with decreased pressure under the metatarsal. The lower pressure under the metatarsal will tend to shift the center of pressure more laterally which would increase the pronation moment from the ground. Therefore, metatarsal length is one of many factors that contribute to pronation moment from the ground. Variation in STJ axis position from one individual to another is, in my opinion, much more important factor than metatarsal length. That is why people were right in dismissing your original assertion.

    Matt, when I first read your post, I was thinking Brian Rothbart. He is a podiatrist who tried to lecture the rest of us on the list with a very similar line of logic to yours. You should search the archives to see the reception he got.

    Eric Fuller
  14. Matt22

    Matt22 Member

    Thanks for the Rothbart reference. I will seach for him on the podiatry website. In the meantime...

    If I understood you correctly, you stated that a first metatarsal that is too short can be a cause of overpronation. Likewise, in my original post, I also said that it is one cause.
  15. Matt22

    Matt22 Member


    If I understood him correctly, Rothbart was advocating the use of placing a medial wedge under the first metatarsal joint. I have tried this before*, and not only did it not work, but it made my overpronation worse. (By "worse" I mean that my ankle turned to a greater degree and my achilles hurt more)

    *Once on my own, and once by the doctor who made my custom orthotics
    Last edited: Aug 27, 2007
  16. Stanley

    Stanley Well-Known Member


    I was around at the time of the theory of the short metatarsal, and it is based on Dudley J. Morton's book. Morton was an anatomist at Columbia University, and his theory was that certain people had a triad of foot of a 1. Short metatarsal, 2. Hypermobile first metatarsal, and 3. Posteriorly displaced sesmoids. This was called Morton's foot or toe. (Don't get confused with Morton's neuroma, as this was Thomas G. Morton)
    He felt that this was an atavistic trait and thus he explained its existence.
    He had a close friend, Richard Schuster D.P.M. who incorporated this into his theories of putting the foot in a less pronated postition in midstance. He felt that the foot was like a three legged stool, and if one leg was short, the stool would tip inwards. The three legs according to Schuster was the first metatarsal, the fifth metatarsal, and the calcaneus. Therefore, if the first metatarsal was too short, the foot would roll in like the stool. One of Schuster's patients was George Sheehan M.D.who was the medical editor of Runner's World (the largest running magazine in the US at the time of the running boom in the late 1970's), and due to his writing, podiatry became the preeminent profession for treating runners.
    Anatomically, the first metatarsal is always shorter than the second metatarsal. At the time, to determine how short the metatarsal was, the measurement was performed on x-rays. A bisection of the first and second metatarsals shafts were made, and the distance from the intersection to the ends of the metatarals was compared. The results of this was that 1/3 had a short first metatarsal, 1/3 were even, and 1/3 had a long first metatarsal.
    In the 30+ years that this theory first came out, there have been improvements in biomechanical theory of the foot. The deficiency in Schuster's theory was that he ignored propulsion, as he felt that patients spent a minimal amount of time at this part of the gait cycle during the course of a day. The propulsive phase is better addressed with the Sagittal plane theory of Danenberg.
    Schuster worked mostly on weekend athletes that did not require as much attention to propulsion, and his midstance concept worked well for this population. In fact at his peak, he was in People magazine, and he had a 3 month waiting list.
    You being a better class runner would have problems with this theory, as you have noted, since propulsion is critical.
    Podiatric biomechanics is still evolving, and there are many theories that can explain what happens. That is what this listserve is about. Some of us feel that you have to understand the forces on a foot; others look at position; others use Danenberg's theories; others do not make orthoses, but rather work on muscles; others believe that the foot is only part of a larger system; and others use a little of each. A consensus will eventually be reached to everyone's betterment.
    I hope this helps to fill in the blanks.


  17. Craig Payne

    Craig Payne Moderator

    I hope not :rolleyes: :rolleyes: It will be a boring subject to teach and Podiatry Arena will be out of business :eek: :eek:
  18. Matt22

    Matt22 Member

    Thank you, Stanley, and everyone else for your feedback. In summary of this thread, here are the points that have been brought forth:

    * The term "overpronation" has fallen out of use in the medical community.
    * Overpronation (for lack of a better word) has many causes.
    * It is normal for the first metatarsal to be shorter than the second.
    * Variation in length may not be an issue to everyone
    * Overpronation may not be an issue to everyone
    * The "first short metatarsal theory" was brought to light by Morton and was popularized in the seventies. From what I've seen in everyone's input, the medical community DOES accept the theory that a too-short first metatarsal can lead to overpronation.
  19. Matt22

    Matt22 Member

    If I understand the Sagittal plane theory correctly, Danenberg advocated raising the heel to make use of the windlass effect. My experience with that has been negative. While raising the heel does tighten "things" up, it also puts more load to ankle upon weight bearing. My ankle is even less stable when my heel is raised than when it is not.
  20. efuller

    efuller MVP

    I didn't say it in so many words, but it is minor factor. You can have a short 1st metatarsal that is plantar flexed and therefore bears normal load. You can have a relatively long metatarsal that is dorsiflexed or not stiff that bears less load.

    The relative lack of load on the first metatarsal is the "cause" of a more lateral location of center of pressure. The length of the metatarsal is a factor in the amount of load. This "cause" excludes feet that "overpronate" because of muscular contraction which is independent of metatarsal length.

    Eric Fuller
  21. Matt22

    Matt22 Member

    I agree that when you first take a step, a longer first metatarsal will direct the load outward towards the fifth metatarsal and the outer edge of the foot.

    You also said that a short first metatarsal that is plantar flexed can still bear a normal load. However, if I raise my heel off the floor, my first metatarsal does not reach the ground (and hence carries no load) unless I pronate my foot so that my fifth metatarsal comes off the ground and my first metatarsal reaches the ground. As I do this, my ankle rotates inward.
  22. Stanley

    Stanley Well-Known Member

    Matt, I don't want to talk for Dr. Danenberg, :eek: but it is my understanding that he feels that if there is a restriction of the body's ability to progress, then there will be compensations causing problems. He will then address these problems individually on the patient. He uses an F-scan and slow motion videotape analysis to help in finding these restrictions. In the case of a tight calf muscle he will manipulate the ankle joint and the fibula to increase the range. If he finds that the first metatarsal joint is the cause of the restriction, he will make an orthosis to allow the first metatarsal head to drop. This is the exact opposite of the Morton's extension you were alluding to. I don't want you to think that this is all that Dr. Danenberg does, as he has many more techniques for these and other imbalances.
    Raising the heel when it is not indicated will cause several problems. It will decrease the functional range, so there is less time for the forces from the calf muscles to be applied to the pushoff. It will also cause you to flex the knee causing patellar tendonitis (pain below the knee cap which you easily get when you train at a pace more than a minute per mile below your training pace). I have also seen better runners develop hamstring problems from this. When I used the Schuster devices, which automatically would put material under the first metatarsal head, I had the opportunity to treat some very good local runners. This device made the runnners slower, so I would raise the heel to compensate for the shorter stride length that was being caused by it. I had nothing but problems with this. Switching to the first ray cut out has not resulted in these problems.
    The key thing is to have your problem evaluated and treated properly.
    I hope this helps to explain it.


  23. Matt22

    Matt22 Member

    Those have been my observations as well.

    The first ray cut out is an interesting idea. As I try it, I see that the range of pronation is reduced significantly. However, the dropped first metatarsal directs a lot of the load towards the big toe. Hence, my foot is held in a state of pronation. My concern is that during running, too much of the impact would go directly to my ankles.
  24. Great minds... :rolleyes:

    Matt you are showing a lot of interest and not a little aptitude for a lay person. Are you by any chance a physio or Dr having a dabble in biomechanics? As the good Prof Kirby states you are talking to a bunch of rather well qualified and specialist people with the air of another academic seeking to instruct rather than a lay person seeking to learn (which BTW Is not really what this forum is for). Your observations are interesting and relevant (though lacking in research and understanding) and at about the level of expertise i would expect from a 2nd or third year podiatry student rather than a member of the GU (or indeed a qualified podiatrist).

    Could you tell us a little about yourself? We might be able to help you more if we knew where you were coming from.

  25. Matt22

    Matt22 Member

    Twenty two years old, engineering student at University of Michigan. Got hooked onto running during senior year of high school. Sophomore year of college started getting achilles and pf problems. Next three years tried every avenue and read every article that I could. Last spring finally started to put pieces together. Past summer got back into peak shape.
  26. Engineer. That explains it. Do a Podiatry degree. We need more people with engineering backgrounds! ;)
  27. Matt22

    Matt22 Member

    Lol, thanks.
  28. Stanley

    Stanley Well-Known Member

    Matt is this problem unilateral or bilateral? Which calf muscle is if any is tight, and which hip if any is tight?


  29. Matt22

    Matt22 Member

    I only have pronation issues in one direction. I do have some supinatus, but no problems that result from it. No tightness in calves or hips.
  30. Stanley

    Stanley Well-Known Member

    Sorry Matt, I meant to say, which hip is high when standing? :eek:
    Also, if you had Achilles problems, then this side should be tighter in the calf muscles. :confused: Did you have the Achilles on one leg or both?


  31. Matt:

    I commend you for trying to increase your knowledge in podiatric biomechancis. In all seriousness, you should, as Robert stated, consider podiatry as a profession considering your interest in running biomechanics. I ran a 2:31 at the Boston Marathon when I was your age (1979) and went to podiatry school in 1979 (at your age) after matriculating from UC Davis as an Animal Physiology major. We need people with engineering backgrounds in podiatry since most podiatrists do not have a good concept of biomechanical or engineering terminology, whereas it would be second nature to you considering your undergraduate background.

    For your information, I have worked closely with engineers on a few research projects (UC Davis Mechanical Engineering Department, Penn State Biomechanics Lab). As an engineering student you will have an advanced knowledge of mechanics compared to most podiatrists, but will be lacking in podiatric and orthopedic terminology and will also be greatly hampered by your lack of anatomy knowledge and clinical experience. I am providing you with the following references of presentations/papers I have done with the UC Davis and Penn State engineers since these papers may interest you the most.

    Ruby P, Hull ML, Kirby KA, Jenkins DW: The effect of lower-limb anatomy on knee loads during seated cycling. J Biomech, 25 (10): 1195-1207, 1992.

    Lewis GS, Kirby KA, Piazza SJ: A motion-based method for location of the subtalar joint axis assessed in cadaver specimens. Presented at 10th Anniversary Meeting of Gait and Clinical Movement Analysis Society in Portland, Oregon. April 7, 2005.

    Lewis GS, Kirby KA, Piazza SJ: Determination of subtalar joint axis location by restriction of talocrural joint motion. Gait and Posture. 25:63-69, 2007.
  32. This is where you run into problems learning only a few "models". If you've got a hammer everything looks like a nail (or if you've got a micro wedge everything looks like a primus metatarsus elevatus ;) ). Or if you've got the concept of mortens foot everything looks like a short 1st met.

    In you're origional post you said

    As part of the overpronation (shudder) is caused by short 1st mets explanation.

    now you tell us

    So you are happy that your STJ is pronating in order to get the big toe joint on the ground because it is short. Could also be because your forefoot is inverted on your rearfoot and your (short) 1st met is dorsiflexed?

    Which one it is, or rather how much of each, has implications in terms of treatment.

    And have you considered the location of your STJ axis? The degree and quality of movement in your Mid tarsal joint? The tension in your plantar fascia? The action of the tibialis anterior in swing phase? The clues derived by the wear patterns on your shoes?

    Whilst i admire your tenacity and the depth of your study without the breadth of knowledge your diagnostics are suspect. Otherwise it's like trying to paint a picture with only one colour. You may be accurate but you WILL be incomplete.

  33. Matt22

    Matt22 Member

    Left hip is higher than right. Used to have pain on left hip as a result. As for achilles problems, when I first started having problems with overpronation (almost three years ago now), both of my achilles were hurting. I used to stretch all the time, so I didn't have tightness back then.

    ^ I've been mostly pain free for the past two years or so. Not because the problems disappeared, but because I had all but stopped running. Now I can run just fine, so I'm all set.
  34. Matt22

    Matt22 Member

    Thanks Kevin, I appreciate it.
  35. Matt22

    Matt22 Member

    I'm not happy about that at all. The excessive pronation is bad for my feet and ankles.

    If I understood that correctly, you asked if I

    1) Point my foot up when landing
    2) Point my toe up when landing

    The answer is no, at least not when running in shoes. Also, those actions actually tighten up things, though they introduce their own problems, so I avoid doing them.

    My right foot has less of a natural arch than my left foot. The result is that my right foot has a lower STJ angle and is a little off balance to start with. It is more "willing" to pronate than my left foot.

    However, my left foot has a normal arch and it overpronates just as far. I don't think that arch height was the driving force behind my overpronation, and that's why I didn't bring it up before.

    Well, I suspect that it was my more flexible MTJ that used to make it easy for me to run on uneven terrain. But now it's unstable to the point that I avoid uneven terrain. And I suspect that this increase in instability was what made the difference between being able to run without orthotics while wearing shoes (circa two years ago) and not being being able to run without orthotics while wearing shoes (just inside two years ago).

    The decresed tension in my plantar fascia was one many factors that allowed for severe overpronation to happen. But like the MTJ stability, it wasn't a driving force behind my overpronation. It happened as result of my foot wanting to pronate combined with years of overtraining. The PF became more flexible in order to let it happen.

    When I bring my foot out in front of me, it continues to remain pointed outward at a certain angle. I've had this since I was a kid.


    I know.
    Last edited: Aug 29, 2007
  36. Nope. You've misunderstood very nearly everything there.
    :D I meant as in you have decided that your stj etc etc. I know you're not happy with it!

    Nope. Inverted on the rearfoot as in rotated clockwise as seen from behind. Thats what supinatus is. And dorsiflexed 1st RAY as in everything from the peak of your arch forward. Which is what is happening when your forefoot is inverted which it is if you have ff supinatus.

    The STJ axis is not the same as the height of arch (although there is a relationship). The axis is actually a bundle of instantaneous axis's and is triplanar. So i'm not really sure what you mean by a "lower STJ angle and a little off balance". I'm also not sure what you mean by "overpronation". One of the reasons we stopped using it is because it tells us very little. Is your STJ pronating to far? To soon? Remaining there too long? Pronating to easily? without sufficient control? With too much residual force left in the movement? Beyond the ability of the anatomy to safely limit? What anatomy is preventing it pronating any further? Deltoid ligament? Sinus tarsi compression? Tibialis stretch? What standard are you useing to decide how far is too far?

    You see the problem.

    So we now have a forefoot which is not only in supinatus but also very unstable? Sounds like a short 1st met is the least of the problems! If you have an unstable inverted forefoot then even if your 1st met was standard you would still have problems.

    We are having a failiure to communicate here because you don't understand the fundamental terminology. Like i said as much as i applaud your enthusiasm you cannot treat some web research and a few sessions with specialists as a substitute for 3-7 years of full time study and your experiance of a single patient (ie you) cannot be extrapolated to apply to the thousands of patients we see every year.

    I really don't want to discourage but this is the wrong forum for you. In a lay forum where you can share you're valuable experiance with lay people you will be as a king, your knowledge supreme and your expertise unchallenged. In a professional forum discussing things which people have spent whole careers studying in minute detail you lack the training and background knowledge to participate helpfully.

  37. Matt22

    Matt22 Member

    That's almost exactly what my last doctor said. The question is, was it the short first metatarsal that eventually led to all of those problems.

    Anyway, you're right. It's one thing to make observations and say "this works, this doesn't", but as I've seen, making an underlying theory isn't so easy a task.

    I don't know if there's much more point in continuing the discussion on this forum, so I will leave. I'm always willing to communicate by email (sonnensc@umich.edu).

    So thanks again for your input. It's a relief to have this discussion with highly qualified specialists. I was never able to get into this much depth with doctors that I met in person.


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