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Monday, April 23, 2018

Chronic Pain: Try a Change in Habits over Opiods

This is another good article helping us try to avoid opiods and get healthy. There recommendations include:
  1. physical and occupational therapy
  2. massage and nutritional counseling
  3. cognitive behavioral therapy (see Dr. Rosemann's link in my blog)

Saturday, April 21, 2018

To Increase Training or Not: Email Advice

HI Dr. Blake, 

It sounds like my insurance company still hasn't confirmed approval for the MRI, which is holding up my treatment. I'm looking into this on my end. In the meantime, the time has crept forward and I'm staring down my race goals for the year. 
Dr. Blake's comment: We are trying to see if it is tendinitis or a partial tear in the achilles tendon which should be treated differently. 

The Broken Arrow 52K sky race has over 10,500 feet vertical gain/loss. It is on Saturday, June 16th. This race is one of two prerequisites in 2018 to qualify for a larger race in 2019. The second prerequisite is a 50K on November 17. And I am registered for the October 4 New York City marathon. 

You cleared me to run a maximum of 5 miles at a time. My current condition is that the Achilles is bearable for these short runs but sore at the beginning and after (it is also sore after resting like sitting). The achilles seems happiest when it is warm, but I have not tested it at longer distances and elevation gain, because I have not yet be cleared for this.  

I am writing to ask if I can be cleared to start training? And to ask if you have advice about the minimum distance and elevation gain I should be able to handle in order to clear the Broken Arrow race challenge. In other words, should I be able to run 13 mi, 20mi, 25 mi at this date without pain in order to run in June within healthy limits? 

I would like to test it and see what it will bear, but I also want to do this in a wise & healthy way. It is still sensitive to touch. I passed up at half marathon race two weeks ago, in order to be conservative in my recovery. Your advice is much appreciated. 

Dr. Blake's Response:
Hey, without the MRI we have to go on your running. The pain at the beginning of your run is fine, but the pain that comes on during a run is not. That is when you that reached the tissue fatigue and more injury can occur. If you finish the 5 miles runs without soreness, and by the time you start running again (typically 2 days later) you have fully recovered, then you can up to 7 miles, after 3 times at 7 you can go up to 9, etc. etc. Hope that makes sense. You first work on distance, then hills, and finally speed. You try to go into a hard, then easy pattern with your running as you challenge yourself. Therefore, every other workout is pushing you somewhat, and every other workout is more relaxed. Rich

PS. Attached is the link to my posting on Good vs Bad Pain to review

Tuesday, April 17, 2018

Heel Bursitis: Plantar

Hello Dr. Blake,

Kara's (name changed) stress fracture seems to have healed, unfortunately, she has a new problem.  She has pain in her right heel. Her physical therapist has told us that it is bursitis. She is now wearing Birkenstocks.  Is there anything you can do for bursitis?


Dr. Blake's response: 
Here is the section of my book. Rich
Say hello to Kara!!

5. Plantar Heel Bursitis
    A bursa is a sac between the skin and bone that, if the area is traumatized, can fill up with fluid (called bursitis) to protect the underlying bone. Bursitis is common in the feet, knees, hips, elbows, and shoulders. I once had 7 months of shoulder bursitis from incorrect biomechanics while painting a cathedral ceiling in my house. Plantar heel bursitis is often confused from plantar fasciitis. Acute plantar heel bursitis can develop suddenly from impact, but bursitis can also develop slowly from chronic inflammation (typically secondary to plantar fasciitis or calcaneal bone injuries. If you have plantar heel bursitis, you typically can not walk on your heels without pain. Having my patients first walk down the hall barefoot normally, then on their toes, and then on their heels only, can make the diagnosis of bursitis (although a small stress fracture on the heel bone may still be present. One of the treatments for heel bursitis (not initially) is a cortisone shot. Because bursitis can be secondary to something else that the shot may hurt, I try not to do a shot unless I have an MRI if possible. And, sometimes, you just have to take your chances if it does not make sense that anything but bursitis exists. Always consider that you may have bursitis, with plantar fasciitis, if treatment of the plantar fascia alone is not helping.

The top 8 treatments for plantar heel bursitis:
1. 5-minute frozen sports bottle roll just under the heel 3 times daily
2.  Heel cushions to protect the heel (sometimes used alone, and sometimes an arch support to transfer weight off the heel is vital)
3.  Physical therapy to break down the bursa sac with a combination of ultrasound to superheat, deep tissue massage to break down or move fluid, and electrical stim to push fluid out.
4. Cortisone shot, if the above is not eliminating the problem, and an MRI has ruled out any other problem. These shots are given from the side of the heel, not from directly under, which makes them less painful. A series of cortisone shots may be necessary (see the section on cortisone shots). This is the only heel pain diagnosis that a cortisone shot is used for.
5. Avoid barefoot for continual irritation
6. Use some heeled shoe, like a Dansko clog, around the house.
7. Use wedges instead of straight heels to distribute the weight better.
8. Also, consider wearing Crocs for their shock absorption

Heel Bursitis (Plantar/Bottom of Heel): Typical Physical Therapy Regimen

Hi Dr. Blake!
I hope you have a fun-filled long weekend planned! I'm checking in at the two-week mark as we discussed. My stubborn little calcaneal bursitis is still causing me grief. I did try the contrast bath - but it seemed to irritate it, so I've stuck with icing. I have not been jumping in dance class or standing in spin. In fact, releve (going up on the ball of the foot) seems to bug it as well, so I've eliminated turning. Since I wasn't making the progress I'd hope to on my own, I thought I'd finally book the PT. I work in SF so I would consider coming over to St. Francis, but if you know of another good place in the East Bay, it might be more convenient.Thanks so much! It really is wonderful having someone I've known for 24 years (!!) I can come with these bothers. And even though it's an injury that brings me in to see you, it is always great to see you! ;-)
Have a fabulous weekend and talk soon,
Dr. Blake’s response:
    Physical Therapy for calcaneal bursitis (under the heel) should be done twice weekly for 4 weeks and should include in this order: Ultrasound as a way of producing deep heat to the bursitis tissue making it vulnerable to the next two treatments. The ultrasound is following by deep friction massage to break down the bursae. The deep tissue work is following by 5 minutes of vigorous ice massage to calm down any aggravation of the inflammation and further the breakdown process. Since plantar fasciitis is normally part of the problem, the PT may address part of the treatment for that also. If calcaneal bursitis is a major part of the pain, make sure that the 3 components in the order of ultrasound, deep friction massage, and icing are the central part of the treatment. I will see you following the first 4 visits to make sure we are all on the same page. Good luck, and great to see you again as always. Rich
PS. During the time you are in physical therapy, you must continue to ice massage 3 times a day (since the contrast bathing did not help), and do as much physical activity as you can without flaring up the symptoms. It is normally a mistake to go to physical therapy at the same time you are resting an injury completely. The physical therapist never gets a good feel for your improvement or lack of improvement. Use the information on Good Pain vs Bad Pain to base your Activity Modification Program.
Also, the next step with calcaneal bursitis is cortisone shots, but that requires 2 weeks off activity/shot and could require up to 3 shots (the response to the shot is evaluated in 2 weeks), so most athletes try to avoid with a passion. Good luck Tracy, email me after 4 physical therapy visits.

Add from Dr. Blake,
     MRIs are crucial before any thought of cortisone since it can weaken the tissue, especially the plantar fascia. I have given a cortisone shot and had the plantar fascia tear afterward. I have given 100's of these shots though without problems, but I think this possibility should be in the discussion before a shot is done. 

Saturday, April 14, 2018

Alcohol Injections for Morton's Neuroma

     I just got an email from a patient undergoing alcohol shots for Morton's neuroma. She had unsuccessful surgery several years ago for Morton's neuroma, having the same pain after surgery as before. Her insurance company denied my request for another post-MRI since I was not going to do more surgery. I just wanted to know what I was dealing with.  
     When I first started using these injections 4% alcohol to de-sensitize the nerves was common. 50% of the time the relief was good enough that the patients could avoid surgery. But, 50% of those patients required surgery. So, I started upping the dose. Now, I start patients at 10% titrate them to 20% (my max). I definitely have more flare-ups that last 4 days to 2 weeks, but my % percentage of patients needing surgery seems less. I just want to get the most out of these shots. Anyone who thinks injecting nerves with alcohol is simple, it is not. It takes great effort and much patient counsel. You are trying to avoid surgery and it's issues, a noble cause? 
     There are so many other treatments for Morton's neuroma that should be tried first that only 2% of my Morton's neuroma patients need even to consider these shots. Since I am trying to perfect how I use the alcohol, I am trying to prevent the 1% of my Morton Neuroma patients that still need surgery. 99% of these patients never need these shots in their treatment. My patient wanted to know if I had some knowledge of possible side effects from 20% shots so I sent her the link to the article below.

Dr. Blake's response to her email: 
     Thanks for the email. I had to try to find the article on 20% that made me go above 4% years ago. I think it is well written. I have also read various patient blogs. Some get poor results from these shots. With a percentage of patients going to surgery, no surgeon has ever told me that there is damage. Wish I could be 100% confident, but I believe it is rare. I think if you get the shots, and something goes wrong, you should be ready for the surgery you are trying to avoid with the shots. A true quandry!!. But, it does make me soul search, as I never want anyone hurt. That is why I try to read and go to seminars, etc. Here is the article, and we can talk some more before I give you any more shots. Rich

    The only issue I have with alcohol injections in my practice is that I do not use ultrasound. I have been giving these shots forever into the nerve, and know where to inject. Yet, I do know there any variations of nerve alignments, so how close do you have to be? I feel secure that our surgeons, and MRI imaging, has never found damage post shots to my knowledge. And, for this topic, I always look or always ask. Rich

See several of my articles on Morton's neuromas attached:

Saturday, April 7, 2018

Is the Government Still Blocking Calmare Pain Therapy: Intriguing Article

And the appropriate billing code: 0278t
I spent 30 minutes trying to see if I could find out if Medicare covered it at all, and was unsuccessful. I send my patients for Calmare to either Dr. Gutierrez in San Ramon or Dr. Ellis in Emeryville, but they tend to have to self-pay for the treatments, not the evaluation.

Thursday, April 5, 2018

Complex Foot Injury: CRPS??

Dear Dr. Blake,

     The gentleman from Mountain Family Products referred me to you because my podiatrist recommended a bone stimulator.  I didn't want to wait for the insurance to pay some time next month because I am concerned about my work and getting healed in a timely manner. 
   On February 2, I stubbed my toe on the way to the airport for a business trip in Europe.  I was sort of healing the month of February when I re-injured it about 3 weeks ago and now the pain is through the roof.  Nothing seems to help.  I went to my osteopath first and he told me to get metal inserts for my tennis shoes.  That didn't help.  Then he did a cortisone shot on March 12 that lasted about 4 days and the pain came back. 
Dr. Blake's comment: This is the first clue about what will help. We know the pain can be eliminated by the shot, even if temporary. What did he inject? The MRI revealed bone edema at the 4th metatarsal. Did you stub the 4th toe? 

  Then he did a nerve block and it didn't help.  
Dr. Blake's comment: Was the nerve block in the same spot? 

     Finally, yesterday I saw a podiatrist who gave me an insert for my shoe, told me to take Calcium, Mag, D and some neuro vitamins like Metanx - which I happen to have.  I have a scooter I am using since last Friday to keep as much weight as possible off the foot.  I tried on a boot and it was too painful. The doctor also recommended a bone stimulator and using some ice packs no more than several times a day for 20 minutes or less.  He also gave me tramadol which didn't help.  I tried ketamine cream and that didn't help.  I started something called Dr. Christopher's tissue and bone ointment to see if that will help.

     I saw that Dr. Axe mentioned the following:  L-lysine, bromeliad, vitamin k as supplements for bone bruises.
Dr. Blake's comment: There are 3 types of pain: mechanical (just as a break), inflammatory due to the healing response, and neuropathic due to nerve injury or nerve protection (hypersensitivity). You are succeeding in mechanical means to lower the pain, some inflammatory should be helpful. It does not sound like neurological treatments like ketamine help topically, but you must have some neurological component to your injury. You may want to try oral pills like Gabapentin. 

     I have an autoimmune neuropathy from a toxic exposure last year.  My feet already burn and my nerves are hyper anyway.  The pain is very agitating for me because the burning isn't under control.  My neurologist is trying to get IVIG infusions for me.  The pain from the foot is radiating all over my foot and up my leg.  I think part of that is the way I have been walking - or limping around.  My feet have been burning since last October and sometimes I don't know if it is the SFN or the foot.
Dr. Blake's comment: So, have they worked you up for Complex Regional Pain Syndrome? You are set up for it with the nerve issue already. You create a 0-2 pain level with your scooter, you may need Sympathetic Blocks, IV Ketamine, or Calmare Pain Therapy. You may just need Lyrica or some cocktail that cools the nerves down. How does it feel to rub in creams like Ketamine? 

I guess I am just wondering if there is anything on your blog or on the internet that may help me in my healing process.
Dr. Blake's comment: Typically, while docs work on the nerves, PTs and acupuncturists help with the pain, and deciding what you can and can not do. See my blog on CRPS to see if that makes sense. See a neurologist if it does. Try to find a PT who understands CRPS because it is important to honor the pain at times and push through the pain at times. 

I am enclosing the notes from the MRI. Does not say much!!

Thank you in advance for any direction.

Kindest regards

And the patient's response:

Dear Dr. Blake,

I posted my responses to your questions on the blog.  Thank you very much for your responses and insight.    I am going to have a ketamine infusion on Monday.  My neurologist says one infusion each month is enough so I will see how I tolerate it.  My foot was healing ok until I decided to do a little dance to make myself happy - now I wish I had just stayed morose... Anyway, I am doing meditation, self-hypnosis, 2000 mg of C divided during the day, I have glia modulators - LDN and Nortriptilyne.  I am weaning my self off the lamotrigine.  I am hoping to get a trial of IVIG in the near future.   I went ahead and bought the bone stimulator and it will arrive tomorrow.  I couldn't wait until the middle of next month when the insurance will kick in.

I am going to try the nerve flossing and I have a mirror set up for the mirror therapy (I saw it on youtube)  I also called my PT who will call me back next week.

I am trying to cover all my bases because I have a very real possibility of losing my job since the autoimmune neuropathy has been going on for 8 months now.

Anyway, thank you again for all your help.  Greatly appreciated.

Dr. Blake's response: I am so happy and great faith you will get the nerves calmed down. Go to NOI group website and order their extremity cards. It will make sense when you see them. You can get sublingual Ketamine for flare-ups. Let me know 2 weeks after the Ketamine infusion, and for our readers, get as much information on exactly what the infusion center will do: dosage, mixture, time of drip, etc. Good luck Rich

Another Response from the patient:

Another question...

How often can I use the stimulator?  My doctor suggested 20 minutes once a day and any more than that would be a waste.  Ross - at mountain family - mentioned that he heard of some patients using it 20 minutes with a 12-hour window between treatments.

Thank you

Dr. Blake's comment: Yes, I would do the 20 minutes twice a day for the first 4 months, and then you can cut it down to once a day. 

The Response from the patient:


Thank you for your message and the information.   I had the ketamine infusion and it was one of the worst experiences of my life.  I will go back and find out the specifics.  I had horrible hallucinations and was very nauseous.  I could hear the nurses laughing and talking the whole time.  It didn't help at all and in fact, I felt worse probably because it traumatized me.   I think that it is best to go to a clinic that specializes in ketamine.  I haven't given up on it but I think that it's important to find the right place.

I am going back to the podiatrist tomorrow and I found a pain management physician who knows about CRPS and she actually had an opening on Thursday this week.  I am going to order the R-alpha lipoic acid and the NAC to get started on them.  Unfortunately, I will have to cancel a very important business trip and I am nervous that will cost me my job.

I will look into ordering the cards.

Thank you

Dr. Blake's comment: I am so sorry for your bad experience. Infusion Centers in general are peaceful, calm, no noise, so you were definitely not in the right place. Yes, you need one familiar with the nuisances of Ketamine. I have attached a reference for dosing for you. Please find out what the dose they gave you. You can see from the article that the range is from 1 to 4.5 mg ketamine/kg of your weight. It would be important to know if you got minimum or maximum dose as your loading dose based on your side-effects. Was there someone there with you to hold your hand? Important. Were the lights dim in the room? Important. Quiet!! Very Important.

The patient's later response:

Hi Dr Blake,

I wanted to give you and your blog readers an update...

I was worried after fracturing my toe (4th toe on left foot) I was developing CRPS because I have other nerve issues.  I fractured my toe on Feb 2 and the pain just got worse.  My foot turned ice cold blue and was like that for over a week plus my fracture wasn't healing and I was having shooting nerve pain/burning in my foot.  I am wearing a boot and have a scooter.  I did the following to try to heal my foot (which I found some of it on the blog from another reader):

  • Went to a new anesthesiologist who just moved here from Cleveland Clinic and specializes in CRPS.  I was lucky to get a next day appt with her.  She was very nice and felt that it wasn't CRPS.  She did give me Cymbalta - which I didn't take since I am sensitive to medication.
  • Bought a used bone stimulator and used it twice a day (based on recommendations from several doctors - including Dr Blake)
  • Light massaging to increase the blood flow
  • Putting leg up when sitting or lying down
  • Started taking (all of these without fillers) each day:
    • 1200 mg of R-Alpha lipoic acid
    • 1200 mg of NAC
    • 2000 mg of vitamin C (powder to mix in water with cranberry concentrate)
    • 600 mg of Calcium Citrate (powder to mix in water with cranberry concentrate)
    • 5000 mg of vitamin D
    • Magnesium citrate
  • I am taking some herbs as well
    • Stinging nettle tincture (without alcohol)
    • Horsetail (without alcohol)
    • Comfrey tincture rubbing on skin over fracture and applying DMSO on top for better absorption.  I purchased Heiltrophen on Amazon - the bottle and dropper are glass which is important because DMSO absorbs everything.  I applied with clean hands and washed them afterwards without soap.
    • I tried Dr Christopher's Syrup and Ointment for bone and tissue repair a friend recommended.  Tastes and smells awful.  Lots of stars on Amazon but I couldn't stand it to take it consistently.
  • Mirroring 
    • My friend let me borrow a mirror so I am doing some mirroring exercises I found on youtube.
  • Went to Orthopedic surgeon (I wanted a second opinion in addition to my very good podiatrist just because the foot wasn't healing).  I was lucky that the orthopedic doctor for the feet of the US ski team had an appt.  Really nice guy - he just confirmed what my podiatrist had recommended)  He said I needed to be off the foot for 6 weeks and gave me a clearance for work.
So I am happy to say after 6 weeks on my protocol,  that the pain is almost gone from my foot.  I don't have the shooting nerve pain in my big toe and the burning is less.  I am able to walk very short distances without the boot.  It isn't keeping me up at night.  It looks like I am on a positive trajectory.  I think it will still be a while before I really feel comfortable walking longer distances and doing my normal routine but at least, it is getting better.

Thank you so much Dr Blake for your support and help.  

Tuesday, April 3, 2018

Hallux Limitus/Rigidus Restriction vs. Motion

Hello Dr. Blake

If I don't bother you I would like to ask you two questions related to your post from your blog "Hallux Limitus and Hallux Rigidus: When do we allow Motion and When do we Restrict":

-are you using an entire (supporting the entire forefoot) or Morton's type extension of the flat carbon graphite plate?
Dr. Blake's comment:   I have used either. It seems that 2 stores near me have the plates with the full foot stiffness. So it has been easy for patients to start with that. If it seems that is too much stiffness with irritation somewhere (metatarsals, ankles, knees in particular) from such radical restriction of motion, then I have them get the plate that is flat but has only a hallux extension for Morton's restriction. Again, I typically am going looking for a short-term restriction of motion when it is needed, with a return to motion when possible. 

-how do you choose the stiffness/flexibility or the thickness of the plate? 
Dr. Blake's comment: I am sure there is more sophistication in the process then what I know. I use the one from Otto Bock and have the patient simply buy their size. They are really stiff. Mine are stiff (firm) and flat (since used under the orthotic device). I guess I could go stiffer if it was not doing the job for a big guy. I love the spica taping at this time of restriction also.

I will write these questions on your blog also!
Many thanks for your kindness,

Tarsal Tunnel: Basic Thoughts for Treatment

Hi Dr. Blake,

It's been a while since I have been to see you. I hope you are well.

When I was in your office last I was dealing with tarsal tunnel syndrome, and I solved it with repeated acupuncture. However, the acupuncture does not seem to be doing the trick anymore, and it has become too painful for me to run. Shall I come back to visit you or do you know of a specialist that might be able to help me?

Thanks so much for your help.

Dr. Blake's response: 

 I will be happy to re-evaluate. I am including a blog post I wrote to see if anything can be addressed. 

The following is a short piece from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

1. Introduction to Nerve Pain Treatment

First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves you should be addressing 4 areas---mechanics (what stresses the nerve and what protects the nerve), anti-inflammatory (in general, contrast bathing or warm water soaking is better than ice, along with oral & topical anti-inflammatory meds), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc).

          Therefore, the standards of care I use for nerve pain in the foot and ankle involve the following:

1.      Mechanics
2.      Anti-Inflammatory
3.      Nerve Desensitization
4.      Diagnostics

          It is the 4 areas that form the basics of each visit decision making. The KISS (keep it simple stupid) principle does apply based on the level of pain and disability being produced.


          The 3 aspects of mechanics for nerve pain on the foot/ankle (and other parts of the lower extremity) are:

1.      Recognizing if motions or positions that the patient places themselves in can
        stress the sciatic nerve and its branches.
2.      Creating protected weight bearing environment so that every step does not create      
        pain. This is done with inserts, braces, pads, shoe gear, etc.
3.      Protecting a sore spot when shoe pressure causes pain with pads, sleeves,  
        skipping laces, etc.


         Nerve pain may be neuropathic (produced by the nerve itself), inflammatory (produced by inflammation around the nerve), or a combination. When treating nerves, various anti-inflammatory measures should be tried to see if there is a response. Ice, one of the mainstays of anti-inflammation can be very irritative to nerves and may have to be limited to 5 minutes. Massage can also have the same helpful or irritating effect. So, anti-inflammatory treatments of nerves can be a little more tricky than treating tendinitis. Contrast bathing, warm socks, oral meds, topical patches may be helpful.

Nerve Desensitization:

          Nerve pain can spiral out of control easily, so doing treatment to desensitize the nerve from the start can be very helpful. I typically start with an OTC medicine called Neuro-Eze (product online) and Neural Flossing or Gliding (both done 3 times daily). Oral medicines are started only in the evening, and started at low doses, like Lyrica, Neurontin etc. But, many of my patients get wonderful help with Acupuncture, skin rolling (common for fibromyalgia), or Compounding topical medications.

From the first visit, I continue to ask do I need more information. Low Back Evaluations, MRIs, lab values, Nerve Conductions Tests & Diagnostic Injections can all play a vital role.   

Monday, April 2, 2018

0-2 Pain Levels: Guaranteeing the Potential of Healing

     I preach and preach about creating 0-2 pain levels for healing. As we all deal with injuries, some are out of our control, and others we do have some control over. No matter what is said to start this activity, or that activity, do this, or do that, so much hangs on the simple fact of pain. We must let pain be our guide at times. At times, we push through, but mostly we honor and keep the pain between 0-2. 
     Today, a young gal came in for a second opinion. She hurt her left heel. She was placed in the boot to create a healing environment. The first mistake, she never felt any relief day after day in the boot, it hurt just the same, but for 2 months the boot was going to heal something. The magical 8 weeks guaranteed to heal did not happen. When the boot came off, and the pain intense, the doctor said to go back and do everything because that 8 weeks had to have healed. The patient was mystified, explaining all along that the boot had not helped, so mistake number two, try another treatment. The patient then came in for 10 laser treatments. Each laser treatment first caused more pain for 2 hours, but then the original pain was back. No time in the 10 treatments was there any sign of improvement. 
Mistake number 3, and last for this doc, when you are not helping, and you forgot that referring for opinions is a good thing, you offer surgery to try to fix things. 
     The moral is simple: Spend the early days of treatment to create that 0-2 pain level. If the pain is not improving with standard treatment, you probably are not treating the right thing (which on looking at the original MRI I believe was the case). I am getting a new MRI now that 5 months have pasted to see what is going on. 

Toenail Fungus begins to get a Toehold!!

Dear Dr. Blake, 

I have noticed brownish skin above my toenail for a few weeks, do you know what it is caused by? I have included a picture. 

Dr. Blake's comment: Looks like fungus, so start vinegar soaks for 30 minutes 3 times a week. Try to time it right before you shower to get the salad dressing smell off. 

Toe Nail Fungus: 30 Minute Vinegar Soaking

Dr. Blake,
I just looked at my calendar and noticed I will be seeing you soon, this week!
I also realized that I hadn’t the sent the photographs of my soaking method that you requested.
I so sorry for the delay, though I did take the pictures soon after our conversation.
I am using my rubber like Adidas sandals to raise the back of my tub so I can soak my toes
comfortably as I relax. I found that I use a combination of about 3 to 4 oz of vinegar and warm water each.
I pull my legs in as if I wanted to put my feet beneath my chair that’s I need to do.
I do this every other day which is a schedule that enables me to remember.

Here is my original blog post:

And here is a link to other reasons to use Vinegar all the time!!

Exogen and Sesamoid Healing

Dr. Blake - I was a patient of yours back in 2016 when I broke my sesamoid bone in my left foot. You were AMAZING and helped me figure out that a) I didn't need to be wearing that large 1/2 leg boot and b) I could bike with my little boot. This was the inflection point in my healing process (and happiness).
The other part of my healing was the EXOGEN bone healing system that I purchased with the prescription you made for me.
My wife now has a fracture in one of her metatarsals. I suggested she use the EXOGEN machine that I still have, but unfortunately, the battery ran out. When we contacted the manufacturer, they said that we need to have an active prescription.

Do you think you could help us with this? She is happy to come see you and get a second diagnosis if that would help. Unfortunately, her doctor at Kaiser didn't think that the EXOGEN was important. I feel that it helped me a lot, so I wanted to see if I could help set Joanna up it as well.
I hope all is well on your end,

Dr. Blake's comment: 
     I am so happy you have done well. Yes, the Exogen will strengthen the bone well. Unfortunately, I would need to see her and have an active record. Sorry because this is an expense for Kaiser patients. Tell the doc at Kaiser what is the big deal for him to write an RX. Kaiser does not have to pay. Have they checked Vit D deficiency or Bone Density? Need to know the overall health of the bone to see if it will heal. Rich