Today on the Doc On The Run podcast I’m really excited have Dr. Vinh Ngo from Smart Medicine San Francisco. Doctor Ngo is going to explain hormone replacement as a way to make sure your training at full capacity and at lowest risk of injury. Dr. Ngo is a UCSF trained physician and he is an expert in men’s health and hormone optimization. So today I’m really excited that he’s here to share his integrative approach which can help athletes train harder by looking at hormonal limiters to identify changes that can be managed to improve the overall health and resilience of an athlete’s body.
For almost 20 years, Dr. Vinh Ngo, an integrative health specialist, has been dedicated to improving the overall health and well-being of his patients throughout San Francisco and beyond.
Dr. Segler: Dr. Ngo, welcome to the show.
Dr. Ngo: Thank you for having me on the show. We have been in contact for several years, almost ten years now and I have been treating low Testoterone and also optimal Testoterone for almost fifteen years.
Dr. Segler: I know this is an area you really specialize in, so maybe before we get started with some questions. Maybe you could just give us a little bit of background, about your education and why you really focus on more of a holistic approach for athletes.
Dr. Ngo: Okay so again my name is Dr. Vinh Ngo. I graduated from New York Medical College and I did my residency at UCSF in Family Medicine. But along the way I integrated hormonal therapy into my practice through looking at different complimentary way to prove and optimize health and looking at hormones particularly. So I have been in San Francisco since the end of my residency in 2004 and practicing here and expanding my approach and adding other things like hormonal therapy or fairly known as “bioidentical hormone replacement”.
Dr. Segler: These things, the bioidentical hormones and all these different, functional medicines, sort of that approach really is important for athletes. Because obviously the whole goal of athletes is to function better. For many of us of course, that changes as we age and we all know our hormone profile changes as we age, the function of hormones change as we age and we know that also their ability to train hard, recover fast and heal from injuries also seems to slow down as we get older. But of course these days, there are lots of athletes particularly cyclists, Ironman triathletes, even some marathon runners who are not only still training but they’re actually reaching their athletic peaks in their 40’s and even their 50’s. So for those of us who are interested in this idea, how do male hormones start to change in their 40’s and 50’s? More specifically how do those changes interfere with training capacity and risk for injury?
Dr. Ngo: That’s a great question! In particular, in your audience, 40’s and 50’s, that’s kind of the peak for endurance or at least there some studies that they peak later in age let’s say it usually happens. So that’s really important to your demographic, so let’s talk about first, Andropause. Just the word Andropause and what it means. It basically sounds like menopause for men, that’s exactly what it is. For women, menopause come pretty abruptly at around age 50, 52. For men, as we look at how testosterone levels develop in men, it’s the highest when you’re in your late teens, let’s say between mid-teens to late-teens and it maintains fairly consistently for the next ten to twenty years. Let’s say age 15 to age 35, it’s fairly consistent at between 800 and 1200 level.
Then at around age 35 or 30’s, every year the testosterone decreases by amount of 1.2%. Now that doesn’t sound that great. But if you think about it, every ten years you’re losing about 12% of your testosterone. Then you start to really start to do the math and by the time you’re 40 or 50, you’re testosterone levels are declining rapidly and you will not notice that in the first ten years or second ten years but you will notice that later down the road when it compounds. So that’s kind of how things develop. That’s basically the timeline on how things develop with testosterone, particularly andropause.
Dr. Segler: We know that these hormones, particularly testosterone, are important not only for energy levels but also for capacity for healing, right? Training really is just a period of not only building aerobic fitness but it’s also a period of sustaining minor repetitive injuries. Overtraining injuries, the things that happened when people call me because they have achilles tendinitis issue or peroneal tendonitis or plantar fasciitis or some sort of overuse injuries, stress fracture, whatever, those all happen because they have stacked all of these little repetitive injuries more than they’ve been able to recover from them. How does low testosterone play into that?
Dr. Ngo: Well, yes. Let’s look at the general properties of testosterone and what it does. It basically makes men male right? When you’re in about two weeks of life, you either start making testosterone or estrogen, you start basically for the first two weeks unisex. We don’t have a sex yet and we’re basically female. Then at the second week of life, if you have the male Y chromosome in the sperm, the Y chromosome starts making testosterone. That’s when you start to develop male characteristics and so starting from that point on you basically are defined by your testosterone, your gender.
So let’s move forward now to how you’re aging and repair. Let’s say you’re in your 30’s, 40’s, 50’s and your body doesn’t bounce back like it did when you were in your 20’s. The reason why for that is mainly hormonal. When we talked about in your late teens having let’s say a thousand nanograms of testosterone per deciliter, you’re able to have this huge reserves for repair, for growth for any type of injury you have. You might remember when you were younger, you wouldn’t have the soreness, you wouldn’t have that if you did sprain your ankle or have a repetitive injury. As you age, that general property is mainly due to testosterone helps you bounce back from injuries quicker.
Mostly in my practice when men come to me and they have low testosterone, I get their level back to normal or high normal level, they’ll see that they’re recovering. They basically feel like they’re 18, 20, 30 years old again. They recover, they bounce back and they can workout many days in a row work or they can workout multiple days in a row whereas when they get older like I am in my 40’s now and I don’t quite bounce back like I used to. My recovery particularly is the big part of that bounce back because the recovery isn’t the same. For your clients and for your demographic, as far as the triathlete and the aging triathlete, distance, endurance runner, I can see that being a big major issues as far as recovering from a workouts and form injuries.
Dr. Segler: Right, now that totally makes sense to me. And it’s becoming a lot sort of more mainstream this whole discussion of low-T. My guess is that virtually every listener on the show has at least seen some television commercial about low-T and usually at that advertisement is a pharmaceutical company with some product and they’ll have an image of some healthy athletic guy but usually looks tired and exhausted and the narrator just says something in effect of ask your doctor about low T and I think you’ve explained that pretty well about what really is low testosterone and how does a creep into us athletes in their 40’s, 50’s or so. But for athletes listening to this, like what would they experience in terms of symptoms of low testosterone.
Dr. Ngo: Well, low-T or low testosterone and if you’re not looking for low T then you will never find low-T because a lot of the symptoms are pretty ubiquitous in our culture of medicine. A lot of things you find are symptoms like fatigue, weakness, muscle pain, constipation, sometimes weight loss or inability to maintain muscle mass. That’s the common ones. Other ones are like kind of psychological ones nervousness, irritability, depression, being anti-social and inability to concentrate. You find that a lot of people who are either or adderall or concentration drugs have low testosterone because as they age they have inability to concentrate and impairs their ability to think.
Those are some of the common ones. Obviously with sex hormones, low libido and decrease in either quality or the frequency of the erections. Other symptoms are increase pulse rate meaning your heart is not strong as it used to be, hot flashes, palpitations, headache and chilliness or low temperature. Those are the common side effects and symptoms of low-T.
Dr. Segler: Who is at risk for getting this? I mean is it basically just everybody as they age?
Dr. Ngo: Yes, in our modern society everyone is at risk. Every male is at risk even in their 20’s. I have treated men in their 20’s. It could be genetic, it could be from environmental forces but since our society has had kind of 24 hour cycle now with news, with our smartphones beeping and e-mailing us and triggering stress response, we don’t sleep as we used to. We have interrupted sleep. And when is testosterone reproduced? During our deep sleep. So we’re getting interrupted all the time in our sleep. Testosterone isn’t being produced, isn’t being secreted from our pituitary gland, hypothalamus and testis. Those are the three glands that govern our testosterone production.
Number one, sleep. Number two, stress. Again, we’re always on our phones, we’re always busy with our lives. Stress is a big part why historically men have lower testosterone now and then as well as our environment. If we look at not only our diet and our foods being less nutritious than it used to be. We’re also looking at disrupters like plastic has basically weak estrogen properties they actually lower testosterone. Also our phones, we have these phones, we put them on our pockets, that’s radiation right next to our testis, close to a microwave level of radiation, inches from our testis which are creating testosterone. All these toxins and radiation, genetics too, causing low testosterone in our bodies.
Dr. Segler: Interesting. So maybe you could just talk a little bit more about that in terms of the for example the BPA in bottle which I think for the most part that’s kind of been filtered out. Most people are aware of that now. But certainly for me, ten years ago, I’ll bet almost all of the bottles that I used when I was a doing Ironman training, when I first started doing Ironman training, I’ll bet all of them had BPA in it. I would fill them up with water and then go ride my bike in a hundred degree weather in the sun all day long, which cannot be good for you. I know there’s still BPA around. Could you just talk a little bit about that, about how the BPA affects us in terms of our hormones?
Dr. Ngo: Yes I mean BPA is in everything, not just bottles, but the plastic wrappings on top of the single serving food that we eat, cans, bottles, wrappers, even packets in ketchup.
Dr. Segler: It’s in the coating of virtually all canned goods right?
Dr. Ngo: Oh yeah it’s coating, it’s in receipts for example is a big disrupter. Don’t receipts take if you don’t need them. If you became a complete compulsive person and trying to get rid of plastics, it would be impossible to live in modern times because it’s in everything.
Dr. Segler: How does the BPA affect you? If you ingested, if you’re exposed to, if it gets in your system. What exactly does BPA do to you?
Dr. Ngo: The BPA again is like an estrogen. Plastic comes from petroleum, right and petroleum is an oil. Well, testosterone chemically and so is estrogen, they’re both oils. We’re talking about chemicals that are closely related to oil. Testosterone and estrogen are both oils, they’re both part of the cholesterol family and BPA are made from oil as well.
BPA has been found to be a disrupter, but there are probably ten other plastics that haven’t done studies on that they already know are probably disrupters as well. So there’s already things out there that we haven’t even found out yet that are disrupters. I just wanted to give you the general sense of it. BPA is one of them but there are other disrupters out there and they’re oil based, plastics are made of oil and so l they get in the way because they act like hormones, particularly estrogen. What happens biochemically is that estrogen causes this hormone, this protein called Sex hormone-binding globulin (SHBG), it is increased when estrogen is around. So what happens is SHBG helps carry testosterone around our bloodstream. When we have too much SHBG around, a lot of our testosterone is bound to this protein and not free to be inside ourselves and do the work it needs to do.
Our percent free testosterone can be anywhere from two to ten percent in a normal individual. When we have a lot more SHBG caused by this plastics and estrogen, you have too much of this binding protein around. Then testosterone gets sequestered and pumped up and so they’re not free because they’re bound to this protein.
Dr. Segler: I see.
Dr. Ngo: When we talk about your free testosterone, when we talk about your functional testosterone level, your total testosterone number can be misleading because you could have a high total testosterone number but your Sex hormone-binding globulin (SHBG) might be elevated so that’s sequestering all your testosterone.
Dr. Segler: Okay so that makes sense. So then if one of the first steps in really doing something to increase your functional level of testosterone is really making sure you have free testosterone and one of the ways to do that is to avoid BPA. I know you don’t necessarily have to become OCD about it. But in terms of taking steps just to reduce some of the biggest offenders, you’ve mentioned one which was not taking receipts or not handling receipts and obviously not drinking out of bottles that are made with BPA. Using BPA fee plastics is probably a good idea. What are some other big things that people can avoid?
Dr. Ngo: Well you know it’s really difficult but, making your own food right? Knowing where your food comes from, did they come from plastic containers, do they come Styrofoam containers, do they come from something that we’ve been sitting in for a long time. We were talking about single serving that we eat when we buy at a deli or any other supermarkets. We take it upon ourselves to go to the farmers’ market to buy the food directly from the farmer, to go home and cook the food and not expose it to plastic and sitting in a jar or a can. Even sitting on top of your own Tupperware. Some Tupperware especially the lower type of Tupperware has BPA.
Dr. Segler: A lot of people will heat their food in those plastic Tupperware containers which is even worse right?
Dr. Ngo: It’s horrible. It’s going to leach the plastic out into the food. I even try to use glass as much as possible. I think other ways to also reduce is to see your doctor about checking your levels basically. You can keep an eye on it by having someone objectively look at your levels. Get in the process of doing that because that is how you’re going to catch it before it becomes a problem.
Dr. Segler: That makes sense. Like you said, I mean there’s BPA, this other potential hormone disrupters that we sort of are suspicious of it haven’t necessarily been studied, identified yet and all of them can have the potential by messing with your low-T and creating low testosterone by binding it, they can all diminish your athletic performance. They can all slow your recovery after workouts and because of your decreased resilience, they can increase your risk of developing of an over training injury. So like you said, the big thing it sounds like is to figure it out, get checked, get an evaluation, see whether or not you actually have low free testosterone levels or not. Right? If you are an athlete who might be worried about exposure to these hormone disrupters that really sounds like the first step. Is it not an evaluation?
Dr. Ngo: Right, just get checked. Also there’s other things in the environment as well. For example, alcohol. I know some of you like to drink after a run. It’s very popular, it’s everywhere obviously. Alcohol also impedes testosterone production. How do they do that? There are certainly number of things. Number one, zinc is important in testosterone production and zinc helps you basically is a co-factor in the production of testosterone in your testis. Alcohol decreases your zinc absorption. Alcohol also inhibits liver enzyme and also is involved in the testosterone production.
One other thing, smoking obviously lowers the vascular flow to your testis and your genitals. We talked about radiation. There’s other drugs as well. If people take opiates (and there’s huge opiate epidemic right now) but if we take any type of opiates, that also lowers the testosterone. So can anti-depressants. The list very long but those are the main big groups that can lower testosterone.
Dr. Segler: Many years ago when I was doing lots of Ironman races, I was doing multiple races a year, an Anaesthesiologist in the operating room actually told me that as a consequence of training that many hours, training that hard, that my sperm count and my testosterone levels would be lowered just because of the volume of endurance training. Is there any truth to that?
Dr. Ngo: Well, I’ve seen it in different ways. Testosterone gets actually produced when you exercise. But the main thing is that the testosterone gets produced when you exercise the largest muscle, that area of exercise produces testosterone. When we talk about distance running and endurance athletes, you’re talking about areas that would probably lower the testosterone because they’re probably siphoning a lot of that heavy muscle groups into more lean muscles.
The other thing is being with a bike. You’re on a bike, you’re heating up your testis and the temperature does affect the synthesis of testosterone and formulating cells inside your testicles. So that’s a huge point for endurance athletes.
Dr. Segler: Yeah and not only does cycling position on the bike matter and affect you in that way, but also one thing that’s really a chronic problem for many triathletes and runners now is this idea that because they’re doing so much long straight line endurance training that it’s really like an epidemic now people that have glutes that are not firing at all. They’re not using their glutes even though it would help them to do so. They basically train themselves into a pattern where they’re not firing their glutes which also guess can decrease the testosterone production.
Dr. Ngo: For sure, I mean I have seen it as well. I treat more injuries so when I see people not firing their glutes, I send them to a place to get some type of PRP or stem cell procedure to help them do the right type of physical therapy and to regenerate those tissues properly.
Dr. Segler: That is interesting because endurance athletes will often get tested for lots of different things. We do functional threshold testing. We want to know how much power we can put out on the bike. We want to know how much we can run. When I was really trying to qualify for Ironman Hawaii, I went and got lactate threshold testing. I would go and pedal at certain watts, they withdraw some blood, checked my lactate levels and then I would keep increasing my wattage to check it again and again and again so that I can actually chart out, measure and know for sure what was optimal for me on race day. It’s interesting that so many people will do that, that they will go and sign up for a session, pay hundreds of dollars to get lactate threshold testing for this one measure and then completely neglect something when they’re in that sort of age range where they’re really at risk for low testosterone. Not really just a risk for but it’s almost predictable that they would have it and not even getting it checked.
It seems like it’s something to really consider or something maybe worthwhile for athletes who are in their 30’s, 40’s and 50’s. But in terms of doing it like how does someone go about getting tested to determine whether or not they really do suffer from low testosterone or low free testosterone?
Dr. Ngo: It’s one thing to go to your doctor and go to your primary care doctor and they’re not versed on kind of the latest in this area so what happens a lot, they’ll get frustrated because they go to the doctor, the doctor is not versed on numbers on low T and they get testosterone level and the testosterone level is within range and the range of the testosterone according to most lab ranges is between 250 and 1,100. So there is this huge gap. That’s why there’s a lot of misconception over getting treatment from low-T. So you almost have to go to a low-T center or a doctor trained in low testosterone in order to get the right testing, to know where you are in that spectrum.
Dr. Segler: You mentioned this earlier, you said that when you’re talking about in beginning, when you’re treating someone you really aim for them kind of being at least the “high of the normal range”. You don’t want them just normal in that wide span of numbers, you want them at the high end of that range and in addition to the total testosterone, your course of evaluating free testosterone. So if somebody came to see you who is an athlete. They just want to get checked out or they’ve had any of this other symptoms like feeling more exhausted than they used to feel, difficulty concentrating. A lot of times we attribute that just a hard workout. Certainly when I go do a six-hour bike ride I really don’t think that well for the rest of the day and but a lot of these sort of symptoms could be attributable to low testosterone.
If an athlete has this issues or somebody’s training for ultra-marathons and they start having some of these issues and they just want to get it checked out and they came to you, what exactly would you do to check them?
Dr. Ngo: First I do a thorough history and physical. I Ask them about environmental toxins, ask them about their diet, ask them about their sleep, ask them about what drugs they’re taking, how their lifestyle is and then I go check them out, check their skin, their hair quality, I listen to the heart and lungs, I do the general exam too and had they had, ask them what their testis look like. I look at the general stuff that makes it easier to diagnose. Then you can go dig deeper.
A lot of times there’s not one source of low testosterone, not one defining cause. You don’t know the actual cause and that’s frustrating for some people but and on the functional level, we’re just here to restore their levels. On one side, I would love to know the cause but a lot of times i don’t get to it. If I can, great. If I can’t then we just try to get you to a functional level and that’s what we’re talking about the optimum level meaning high normal or within the normal range just that that you stay in deviations about that.
When someone comes in, I do a blood draw. I have them withdraw a baseline before treatment. I put them on another hormone that helps stimulate their testosterone production to see how they respond. The hormone is clonodine. I give them a pill that they take once a day for a week and then they come back and then give me another blood draw on the stimulating hormone and what happens is you get the baseline. Let’s say it’s 500 and it should jump up a 100 or 200 points after this new stimulator. So it tells me that your testicles are secreting properly.
Dr. Segler: And that’s within the number you’re talking about that like 250 to 1,100 range.
Dr. Ngo: Exactly, on their baseline. I give them this clonidine challenge, you take it for a week and you get blood test again and you see it should come to 700. If it doesn’t jump at all then you kind have to get, it gives us the measure to kind of treat you properly based on how your testis respond to stimulation. So we get really designed specifically you don’t just. We really follow-up closely as professionally as we can so that you get the best effect from your treatment.
Dr. Segler: Okay, that’s really helpful to understand the process. If you’ve gone through this, you’ve had this challenge test of the week of taking something to see how you respond and check levels again and then you actually get started on treatment for low T because you do have some low testosterone. How long does it take before most runners, triathletes, cyclists, whatever. How long would it take for them to actually notice a change in the way that they feel in terms of energy level capacity for training of ability to focus and concentrate? How long do you expect people to take before they actually report back to you they’ve noticed a change?
Dr. Ngo: Fortunately, testosterone is a very strong hormone. You change your levels even a couple of hundred points within the same week. Most of my people come back to me like I have never felt this good since when I was 20 or they keep thanking me like its drastic change if they have low levels. But most people find big change even if they’re at even middling levels.
Again, I don’t try to shoot over. Sometimes with treatment it goes over and they’re not dropping down a little bit to the normal range so I’m not trying to kind of out think the body like most bodybuilders, they triple the amount, triple the level of testosterone than a normal individual. We are not trying to get to the super optimum level. We are just getting to the high normal level and make them feel good and not just feel good but testosterone doesn’t just help you with your libido and your sex drive, erections, it helps you have great greatly other properties as well and as far as heart, testosterone with muscle gains and muscle metabolism and your heart is the most important muscle of your body. People with low testosterone die from heart attacks, heart disease at a higher rate than men with more high normal levels.
Dr. Segler: Okay so that’s an interesting point because you know one of my really good friends, one of my cycling friends, I remember one day he really trains a lot. He rides a whole lot and he’s at that time was in his late 50’s and I remember one day his wife actually said to me she said well you know I would really rather him spend that much time on his bike than end up dying of a heart attack and it’s interesting because so many of us will go train, ride a bike for hundreds of miles a week but then not do something as simple as let’s get checked for low T that could actually contribute to cardiac death at an early age.
Dr. Ngo: Yes, I mean if you ride so much that it would lower your testosterone, you’re not firing your large muscle groups and aging of course and other factors then yeah, you could be doing detriment to yourself. Some of the inflammation can lead to heart disease. I’m not saying there’s a direct correlation but there’s definitely an indirect correlation with inflammation and heart disease.
Dr. Segler: It’s interesting because you would think that anyone who does Ironman triathlons or Ultra marathons or any sort of long distance endurance events like that they’re so we’ll trained, their aerobic fitness is so good and all that sort of stuff, you think that they would outlive everybody else. But some of the studies actually show that endurance athletes especially those who do Ironman triathletes (like me, I like doing long races just because I’m not fast but I can go for a long time) and ultra-marathoners that they actually don’t live longer than the average population. So maybe that they may be because all of the benefits of so much cardiovascular exercise is actually contributing to the reduction of longevity because some of these hormones disruptions. It is possible although I haven’t seen the documented, it is possible theoretically. Right?
Dr. Ngo: I have seen some study saying that endurance athletes especially marathoners, that type of high endurance can lead to lowering their life. But just theoretically the inflammation caused by these long races can affect your health. We talk about inflammation now in a more general sense, even having cavities, the inflammation in your mouth, the inflammation in your vessels and other areas in your body.
We now look at inflammation as a specialty in this and where decreasing inflammation is a huge portion of what we do now and we want to kind of control that and manage it as much as possible. Obviously, if we live long enough we will encounter inflammation and we want to manage that as much as we possibly can and keeping to the things we really love doing.
Dr. Segler: Yeah, now that’s all very helpful I most of the people listening to this, the whole goal of the Doc On The Run podcast is to help runners continue to run and help athletes continue to train as long as possible without getting injured and to figure out how to avoid those overtraining injuries and then when they do get an overtraining injury, get back to recovery and get back to running as quickly as possible. Clearly based on everything you have shared with this, it really does seem like for male athletes who are in their 30’s, 40’s, 50’s, even 60’s who are continuing to train and are getting injured. This may be another thing to consider because, as I talk about all the time, there’s not one thing that fixes an athlete. It’s not one new pair of shoes, it’s not avoiding one workout or adding one stretch. It’s all additive. It’s all the little things that you do that will compound themselves and actually continue to improve the way that you recover from injuries so that you don’t wind up with stacked levels of inflammation that lead to overtraining injuries.
It really does seem like this is one of those things that people can really consider. It is something that athletes should consider having get checked out. So for athletes here in the San Francisco Bay Area, where can they find you? How can they find you? How can they see you in person?
Dr. Ngo: One more piece about the injury level, the testosterone actually helps any new tissue regeneration. Any tissue that gets made in your body is made a little faster on testosterone. Your skin, your hair, your nails, they all grow a little faster on testosterone with the right amount. Any tissue that gets recovery level, the joints and the muscles that get broken down and built back up constantly day after day when you train. Those also can regenerate quicker when you have the right levels of testosterone.
Yes my office as far as finding me is called Smart Medicine SF and if you look at my website that’s http://www.smartmedsf.com/. You can also call my office at (415) 598-7633 and my office is located in the south of market area on 468 Tehama Street. So look online, find me on Facebook, it’s also smartmedsf, I’m also on Twitter as well. Just find me and I would be happy to help you with this process.
Dr. Segler: That’s great so to find Dr. Ngo you can just go straight to the show notes, we will have links to his website as well as links to his Twitter feed and Facebook page so the you can get some more information and see him and get your testosterone levels checked out to figure out whether or not you need any help in that area and make sure that you can continue training and racing at your best capacity.
Dr. Ngo: Now that sounds fine, go to the blog and get the information there and again I’m happy to answer questions through visit or quick consultation on the phone.
Dr. Segler: That’s fantastic. Thank you very much for coming on the show. This has really been great. It’s been a ton a useful information and I really appreciate you taking time out of your schedule to talk about low testosterone and hormone disrupters today.
Dr. Ngo: Thanks Chris, my pleasure.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!
Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often initially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.
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