Midwest_Ortho_Volume3_Issue5 by linxiaoqin


									                                                                                                               Volume 3 • Issue 5
     Cover Story
      Beyond Bumps and Bruises
      MOR enhances pediatric orthopaedic offerings ..............................................................6

     Sports Medicine
      Twisting and Turning
      Ankle sprains are the most common sports injury ......................................................10
6     Staying in the Game
      Winter sports leave knees vulnerable ...........................................................................12
      Reality Check for Young Athletes
      Long-term effects of overuse injuries are a serious concern ........................................16

     Diagnostics and Treatment
      Making Strides
      Controversy surrounds the treatment of idiopathic toe walking ..................................20
      ITW Defined
      Distinctive characteristics help pinpoint tiptoe gait .....................................................24

     Technology Insights
      Dictation Goes Digital
      Online platform makes cassette tapes obsolete ...........................................................26
      Smart Tools in Practice
12    Technology allows physicians to focus on the patient..................................................30

     In Every Issue
      President’s Letter ....................................................................................................4
      Chairman’s Letter .....................................................................................................5
      Physician Listing .......................................................................................................5

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20                                                                                                   Orthopaedic Excellence              
    President’s Letter

              hope 2006 was as good a year for all of you as it was for Midwest Ortho-
              paedics at Rush (MOR). We were proud to see the Rush University Medical
              Center (Rush) Orthopaedic Program continue its move up in the ranks in
          U.S.News & World Report’s “America’s Best Hospitals.” In three years we have                        A publication from
          moved from 10th to sixth in the nation, and we expect to keep this positive                    Midwest Orthopaedics at Rush
momentum going.                                                                                              www.rushortho.com

We also continued to grow and expand our organization and service lines during 2006 by                Central DuPage Hospital
adding a number of new physicians and subspecialties. First, we filled the pediatric ortho-           25 North Winfield Rd.
paedic surgeon void by signing Monica Kogan, MD, who comes to MOR from Children’s                     Winfield, IL 60190
Hospital in Oakland, California. Dr. Kogan started with MOR in October and has been a                 Toll free: (877) MD-BONES
fantastic addition to our organization. We feel very fortunate to have Dr. Kogan as a part            Phone: (630) 682-5653
of our team and are pleased to be able to provide these much-needed services.                         Fax: (630) 682-8946

Our Pediatric Program was further strengthened with the addition of Jeffrey Mjaanes, MD,              Chicago — South Loop/River City
a primary care sports medicine physician. In August, Dr. Mjaanes joined us part-time after            800 South Wells, Ste. M30
completing his primary care sports medicine fellowship at Advocate Lutheran General.                  Chicago, IL 60607
Dr. Mjaanes primarily practices at the Winfield office and supports our Athletic Training             Toll free: (877) MD-BONES
Outreach Program. Two days a week he also continues as a practicing pediatrician with                 Phone: (312) 431-3400
Rush’s pediatric department.                                                                          Fax: (312) 427-6116

Another new addition in 2006 was Johnny Lin, MD, a foot and ankle specialist. Dr. Lin is              Prairie Medical Center of Westchester
stationed primarily at our Winfield office, but he also sees patients at Rush and Oak Park            2450 South Wolf Rd., Ste. F
Hospitals. MOR was well-acquainted with Dr. Lin because he completed his orthopaedic                  Westchester, IL 60154
residency at Rush before his fellowship training at the renowned Campbell Clinic in Nashville.        Toll free: (877) MD-BONES
We believe that Dr. Lin, as the third physician member of the foot and ankle team, will provide       Phone: (708) 236-2750
                                                                                                      Fax: (708) 562-6875
the critical mass the program needs to take off, both clinically and academically.

In January, longtime, highly regarded spinal deformity surgeons Christopher DeWald, MD, and           Oak Park Hospital
K.W. Hammerberg, MD, joined our team. The addition of Drs. DeWald and Hammerberg con-                 Medical Office Building
solidates most of the Rush Orthopaedic Program under the MOR banner. It also immediately              610 South Maple Ave., Ste. 1400
established MOR as one of the leading spinal deformity practices in the nation.                       Oak Park, IL 60304
                                                                                                      Toll free: (877) MD-BONES
                                                                                                      Phone: (312) 243-4244
Adding world-renowned physicians and surgeons was not the only thing MOR was up to in
                                                                                                      Fax: (312) 942-1517
2006. We also added a new location. The Westchester patient office opened in November and
is providing a wide range of orthopaedic services in a convenient location. In addition, the state-
of-the-art orthopaedic ambulatory building on Rush’s campus is expected to open in 2009.              RUSH University Medical Center
                                                                                                      1725 West Harrison St., Ste. 1063
                                                                                                      Chicago, IL 60612
Lastly, we are proud and excited to continue our team relationships with the Bulls, White Sox,
                                                                                                      Toll free: (877) MD-BONES
World Champion Chicago Rush, Chicago Bandits, and other sports teams and cultural arts
                                                                                                      Phone: (312) 243-4244
programs. If there is anything we can do to improve your experience with our organization,
                                                                                                      Fax: (312) 942-1517
please contact me or MOR’s CEO, Dennis Viellieu, at (708) 236-2611.

Here’s to good health and a great year for all!

Charles A. Bush-Joseph, MD
Managing Member, Midwest Orthopaedics at Rush, LLC

    Orthopaedic Excellence
                                                                                                                                   Chairman’s Letter

Physician Listing
                                                                                                      he Rush University Medical Center (Rush)
                                                                                                      Orthopaedic Program continues to climb in the
                                                                                                      U.S.News & World Report’s rankings, moving up
Howard An, MD                            Monica Kogan, MD                                     to sixth in the nation in 2006. This continued improve-
Spine, Back, and Neck                    Pediatric Orthopaedics                               ment in the annual rankings validates the commitment
Gunnar Andersson, MD                     Simon Lee, MD                          and excellence of our physicians, researchers, and staff, as well as
Spine, Back, and Neck                    Foot and Ankle                         what we already knew: We are one of the best orthopaedic depart-
                                                                                ments in the country.
Bernard Bach Jr., MD                     Johnny Lin, MD
Sports Medicine                          Foot and Ankle                         I’m pleased to announce further consolidation on the part of the
                                         Jeffrey Mjaanes, MD                    practicing physicians at Rush. Drs. DeWald and Hammerberg have
Richard Berger, MD
Joint Reconstruction                     Sports Medicine and                    decided to merge with Midwest Orthopaedics at Rush (MOR),
                                          Pediatric Sports Medicine             adding two nationally renowned deformity surgeons to our already
Charles Bush-Joseph, MD                                                         highly successful spine practice. Consolidation is key as we move
Sports Medicine, Knee, Shoulder,         Gregory Nicholson, MD                  forward into new and better space.
 and Hip                                 Shoulder and Elbow, Sports Medicine,
                                          and Knee                              Regarding the orthopaedic ambulatory building project, we continue
Mark Cohen, MD
Hand, Wrist, and Elbow                   Trish Palmer, MD                       to make great progress. Eventually, this project will allow us to con-
                                         Sports Medicine and                    solidate all of our Rush and downtown practice facilities and provide
Brian Cole, MD                            Women’s Sports Medicine               complete diagnostic and outpatient treatment for patients with all
Sports Medicine, Cartilage Restoration                                          types of musculoskeletal injuries and diseases.
                                         Wayne Paprosky, MD
Craig Della Valle, MD                    Hip and Knee Joint Reconstruction
Joint Reconstruction
                                                                                In addition to the ambulatory building project, we are expanding
                                         Frank Phillips, MD                     our diagnostic facilities to include the latest technology and develop-
Christopher DeWald, MD                   Spine, Back, and Neck                  ing a large physical therapy facility capable of accommodating our
Spine, Back, and Neck                                                           everyday patients as well as world-class professional athletes. I’d also
                                         Anthony Romeo, MD                      like to mention the learning center we are planning, where we will
John Fernandez, MD                       Sports Medicine, Elbow,
                                                                                disseminate our knowledge and inventions to other physicians and
Hand, Wrist, and Elbow                    and Shoulder
                                                                                the latest products will be brought in for the benefit of our residents
April Fetzer, DO                         Aaron Rosenberg, MD                    and fellows.
Physical Medicine/                       Joint Reconstruction
 Pain Management                                                                All in all, 2006 was a tremendous year for MOR. We experienced
                                         Mitchell Sheinkop, MD
                                                                                continued clinical growth and were awarded large research grants from
Jorge Galante, MD                        Joint Reconstruction
Joint Reconstruction
                                                                                federal and industry sources. As we continue to grow, I am confident
                                         Kern Singh, MD                         we will continue to provide efficient, high-quality, and compassionate
Steven Gitelis, MD                       Spine, Back, and Neck                  services to our patients.
Orthopaedic Oncology/
 Joint Reconstruction                    Scott Sporer, MD
                                                                                Best regards,
                                         Hip and Knee Joint Reconstruction
Edward Goldberg, MD
Spine, Back, and Neck                    Nikhil Verma, MD                       Gunnar Andersson, MD, PhD
                                         Sports Medicine, Knee, Elbow,          Chairman, Department of Orthopaedic Surgery
K.W. Hammerberg, MD                       and Shoulder                          Rush University Medical Center
Spinal Surgery
                                         Walter Virkus, MD
George Holmes Jr., MD                    Orthopaedic Oncology/Trauma
Foot and Ankle
                                         Kathleen Weber, MD
Joshua Jacobs, MD                        Sports Medicine and
Joint Reconstruction                      Women’s Sports Medicine

                                                                                                                                Orthopaedic Excellence     
    Need Kicker

                              Bumps and
                              MOR enhances pediatric
                              orthopaedic offerings
                              By Paul Strandquist

    Orthopaedic Excellence
                                                                                                                                  Cover Story

          idwest Orthopaedics at Rush            Lake City, Utah, that serves five states in the   pickup hockey games in the alley, and tag in
          (MOR) has long had a gap in its        intermountain region.                             the neighborhood until the street lights came
          service line, but it has not been                                                        on. Now there are youth sports programs,
alone. During the last five years, the hardest   Before joining MOR, Dr. Kogan spent the           clubs, and elite training facilities open year-
subspecialty to fill by far has been pediatric   previous five years at Children’s Hospital        round. Youth soccer, gymnastics, baseball,
orthopaedics. With some recent additions         and Research Center in Oakland, California.       and wrestling schedules dominate parents’
to the team, MOR has filled that hole and        Dr. Kogan is proud to bring her education         calendars and travel schedules. This is where
then some.                                       and experience to MOR in the treatment of         Dr. Mjaanes comes in.
                                                 children’s broken bones and other orthopae-
In August, MOR added Jeffrey Mjaanes, MD,        dic problems unique to pediatric patients.        Dr. Mjaanes has a unique background in
a primary care sports medicine specialist and    Dr. Kogan will treat trauma, birth defects,       pediatric medicine and offers a wide range of
pediatrician. In October, the group added        developmental dysplasia, clubfoot, genetic        services to MOR patients. “I am trained in
Monica Kogan, MD, a pediatric orthopaedic        anomalies, neurologic dysfunction, scoliosis,     primary care sports medicine and therefore
surgeon. Further strengthening the team,         and walking disorders.                            can treat all sports injuries and problems
longtime, highly regarded, nationally rec-                                                         experienced by all ages. But I am also a pe-
ognized Rush University Medical Center           “I am excited to be a part of a multispecialty    diatrician and have an interest and specialize
(Rush) spinal deformity surgeons Christo-        practice like MOR. We now have a complete         in preventing and treating pediatric sports
pher DeWald, MD, and K.W. Hammerberg,            team of fellowship-trained subspecialty           injuries,” says Dr. Mjaanes.
MD, came on board in January.
                                                                                                   He is a graduate of the University of Wis-
These additions help satisfy the demands              “The addition of these                       consin School of Medicine in Madison,
of referral sources and patients clamoring           physicians and pediatric                      and he completed a residency in pediatrics
for pediatric orthopaedic services. Parents,
referring physicians, therapists, athletic
                                                       services will help us                       at Rush University Medical Center in
                                                                                                   Chicago. He then completed a fellowship
trainers, and coaches can turn to MOR for             in providing the best,                       in primary care sports medicine at Advo-
complete, comprehensive pediatric ortho-               broadest, and most                          cate Lutheran General Hospital in Park
paedic care for all injuries and pediatric
orthopaedic conditions.
                                                       convenient menu of                          Ridge, Illinois.

                                                       orthopaedic services                        With his training in sports medicine,
“The addition of these physicians and pe-           possible for our patients.”                    Dr. Mjaanes’ goal is to get child athletes
diatric services will help us in providing the                                                     on the road to recovery as soon as pos-
best, broadest, and most convenient menu                           – Charles A. Bush-Joseph, MD    sible. His training also gives him the skills
of orthopaedic services possible for our                                                           to treat nonorthopaedic sports injuries
patients,” says Charles A. Bush-Joseph, MD,      physicians that can diagnose and treat any        and problems, including heat illness, heat
Managing Member at MOR.                          type of orthopaedic injury or disorder,” she      stroke, concussion, and wrestling rashes.
                                                 says. And the feeling is mutual. Everyone at      He also performs pre-participation physicals
About Monica Kogan, MD                           MOR is pleased to have a pediatric orthopae-      for school athletic programs and sports
                                                 dic surgeon on the team — especially one as       teams. Both Dr. Mjaanes and Dr. Kogan are
Dr. Kogan is a medical graduate from the         skilled as Dr. Kogan.                             fluent in Spanish.
University of Illinois College of Medicine
in Chicago. She completed a residency at         About Jeffrey Mjaanes, MD                         About Christopher DeWald, MD
Northwestern Memorial Hospital and a
fellowship at Primary Children’s Medical         Children’s sports have certainly changed          Dr. DeWald attended Rush Medical College
Center, a renowned pediatric center in Salt      since the days of baseball on the prairie,        in Chicago. He completed a residency at the

                                                                                                                         Orthopaedic Excellence   
    Cover Story

University of Illinois Hospital and Clinics           School of Medicine in Chicago in 1977. He            Drs. DeWald and Hammerberg have an ex-
and at Shriners Hospital for Crippled                 completed a residency and an internship              cellent clinical staff that is part of the MOR
Children, both in Chicago. He then                    at Rush University Medical Center and a              team, including Mary Faut Rodts, MS, MSA,
completed his training with a fellowship              spine fellowship at Rush — the Univer-               CNP, ONC, FAAN, and Dorothy Pietrowski,
at Rush University Medical Center, also               sity of Illinois and at Shriners Hospital for        RN, BSN, ONC. The physicians and their
                                                                                                           clinical team play a vital role in the pediatric
                                                                                                           orthopaedic subspecialty and for MOR in
                                                                                                           the treatment of spinal deformities, using
                                                                                                           the latest techniques in nonoperative and
                                                                                                           advanced surgical approaches. For example,
                                                                                                           they use bracing and nonfusion scoliosis
                                                                                                           surgery as a conservative treatment for both
                                                                                                           pediatric and adolescent spinal deformity.

                                                                                                           The addition of these highly trained, talented
                                                                                                           subspecialty physicians and their services
                                                                                                           to MOR’s Pediatric Program helps further
                                                                                                           MOR’s mission to provide the best, most
                                                                                                           comprehensive, and convenient list of
                                                                                                           orthopaedic services to its patients.

                                                                                                           Paul Strandquist, Director of Marketing
                                                                                                           at Midwest Orthopaedics at Rush (MOR),
(left to right) K.W. Hammerberg, MD, Jeffrey Mjaanes, MD, Monica Kogan, MD, and Christopher DeWald, MD     has been in customer service and mar-
                                                                                                           keting with MOR for 20 years. He enjoys
in Chicago, and at Shriners Hospital for              Crippled Children. MOR is fortunate to               coaching baseball and is currently the
Crippled Children.                                    have a physician with his experience and             President of the St. Laurence High School
                                                      expertise on its medical team.                       Father’s Club in Burbank, Illinois.
Since joining MOR, Dr. DeWald and his
staff continue their focus on research and
corrective surgery of spinal deformities,
including scoliosis, kyphosis, and spondy-
lolisthesis. Dr. DeWald says he is very inter-
ested in research on disorders of the spine,
particularly adult and pediatric scoliosis.

About K.W. Hammerberg, MD

For the past 22 years, Dr. Hammerberg has
devoted his time and expertise to Shriners
Hospital for Crippled Children as the Chief
Spine Surgeon. Dr. Hammerberg and his
medical team specialize in a nonfusion surgi-
cal technique for pediatric spinal deformities.

A cum laude graduate from Yale Univer-
sity in New Haven, Connecticut, Dr. Ham-
merberg completed his medical degree at
the University of Illinois, Abraham Lincoln           (left to right) Christopher DeWald, MD, Jeffrey Mjaanes, MD, Monica Kogan, MD, and K.W. Hammerberg, MD

    Orthopaedic Excellence
Orthopaedic Excellence   
 Sports Medicine

Twisting and Turning                                                                              broken bone may have similar symptoms as
                                                                                                  a grade three sprain.

                                                                                                  There are several risk factors for sprained
Ankle sprains are the most common                                                                 ankles. Participating in sports such as

sports injury                                                                                     basketball, soccer, and football increases
                                                                                                  the risk. Also, those who suffered a previous
                                                                                                  ankle sprain or who are overweight are at
By Johnny Lin, MD                                                                                 increased risk of a severe sprain. Perhaps the
                                                                                                  worst statistic is that approximately 40% of
                                                                                                  ankle sprains can lead to chronic problems

      nkle sprains are the most common          Diagnosis                                         if not treated correctly.
      athletic injury, with more than 27,000
      sprains reported every day. That          Symptoms of an ankle sprain include pain          Treatment
equates to approximately 6% to 10% of all       and swelling. The grade of a sprain is
emergency room visits, costing more than        determined by the force of the injury. Grade      Proper treatment should start with PRICE
$3.65 billion per year.                         one injuries cause minimal disability. Putting    (protection, rest, ice, compression, and
                                                weight on the ankle is possible, and swelling     elevation). Through this approach, a person
Ankle sprains are caused by injuring the        is localized and minimal. The fibers of the       with a grade one sprain should be able to
ligament that stabilizes the ankle. They can    ligament are stretched but not ruptured.          walk without a limp within a week and
happen during sports, but they also can oc-     Grade two sprains cause moderate disability.      return to normal activities in one to two
cur when people land wrong on an uneven         Putting weight on the ankle is more difficult,    weeks. Swelling should be minimal at this
surface, such as a curb. The fibers in the      and swelling is more severe over the area of      point, and in some cases, anti-inflamma-
ankle ligaments are able to stretch; however,   injury. Only one of the three ankle ligaments     tory medications are used to control pain
severe sprains can actually cause the liga-     is completely torn.                               and swelling. Conversely, if noticeable
ments to tear. Some people report hearing                                                         improvement is not seen by this time, it is
a pop when the injury occurs, and the pain      The most debilitating sprains are those clas-     important to see an orthopaedic foot and
can be delayed or immediate.                    sified as grade three. Many times it is not       ankle physician who can check for a more
                                                possible to put weight on the leg, and severe     serious injury.
                                                        swelling is present over the whole
                                                               ankle and foot. In these cases,    If no other serious injury is present, the phy-
                                                                    two or three ligaments        sician may recommend muscle-strengthen-
                                                                       are completely torn.       ing and range-of-motion exercises, followed
                                                                          Noticeable instabil-    by activity-specific rehabilitation training,
                                                                            ity is apparent       which allows for a faster and safer recovery
                                                                              when a physician    and has been shown to minimize chances
                                                                              pushes or rotates   for reinjury.
                                                                              the ankle.
                                                                                                  Rehabilitation may include electric stimu-
                                                                          Depending on the        lation to ease pain and swelling and/or
                                                                        severity of the sprain,   water exercises, which can be a less painful
                                                                      a physician may order       alternative. Rehabilitation typically involves
                                                                    an x-ray or magnetic          three phases:
                                                                  resonance imaging (MRI)
                                                                scan to determine the grade.      1. Rest and protection (to decrease
                                                              In severe cases, the surface of        swelling)
                                                            the ankle joint is also damaged.
                                                        It is important to get medical treat-     2. Strengthening and flexing the muscles
                                                      ment for proper diagnosis because a            and tendons

10 Orthopaedic Excellence
    The Physiology of the Ankle                                                                                                                             3. Gradually returning to normal activity
                                                                                                                                                               (This process varies significantly depend-
                                                                                                                                                               ing on the grade of the injury and can
                                                                                                                                                               range from weeks to months.)

                                                                                                                                                            Surgery for a sprain is rare, unless the liga-
                                                                                                                                                            ment fails to heal correctly or the patient has
                                                                                                                                                            recurrent sprains due to a “loose ankle.”

                                                           Dorsal view of the ankle joint bones showing the calcaneus,
                                                           cuneiforms, metatarsals, and phalanges                                                           Recurring sprains or chronic ankle pain can
                                                                                                                                                            be easily prevented with rehabilitation and
                                                                                                                                                            proper healing time. It is important that the
                                                                                                                                                            ligament heals completely before returning to
                                                                                                                                                            activities that may aggravate the injury.

                                                                                                                                                            Risk can be reduced with braces, but be
                                                                                                                                                            careful. Ankle braces can increase strain
                                                                                                                                                            on the knee joint. Once an ankle has been
      Lateral view of the ankle joint bones showing the calcaneus, cuneiforms, metatarsals, and phalanges
                                                                                                                                                            sprained, strengthening exercises should
                                                                                                                                                            never cease, even if a brace is worn. Quitting
                                                                                                                                                            exercises can lead to a recurrence of the
    Classification of Ankle Sprains                                                                                                                         injury, particularly if they are stopped too
                                                                                                                                                            early. Abnormal mechanics of the ankle-joint
 Severity               Physical Exam                         Impairment                    Pathophysiology                        Typical                  complex also can be a contributing factor to
                        Findings                                                                                                    Treatment*              ankle sprains, so the use of orthotics may
                                                                                                                                                            help prevent injury.
 Grade 1                 Minimal tenderness                    Minimal                      Microscopic tearing of                 Weight bearing
                         and swelling                                                       collagen fibers                        as tolerated; no
                                                                                                                                   splinting/casting;       Prevention is up to the individual. Wearing
                                                                                                                                   isometric exercises;     sensible, proper-fitting shoes is as important
                                                                                                                                   and full range-of-       as staying fit enough to keep muscles strong
                                                                                                                                   motion and stretch-      and supportive. Patients should watch for
                                                                                                                                   exercises as tolerated   uneven surfaces when exercising and heed
                                                                                                                                                            the body’s warning signs if pain or fatigue
 Grade 2                 Moderate tenderness                   Moderate                     Complete tears of                      Immobilization           occurs during physical activity.
                         and swelling                          Moderate                     some but not all                       with air splint and                               Source: orthoinfo.aaos.org
                                                                                            collagen fibers in the                 physical therapy with
                                                                                            ligament                               range-of-motion and
                                                                                                                                   stretching/strength-                     Johnny L. Lin, MD, is a foot
                                                                                                                                   ening exercises                          and ankle specialist at Midwest
                                                                                                                                                                            Orthopaedics at Rush. A medi-
 Grade                  Significant swelling ,                Severe                       Complete tear/                         Immobilization;                          cal graduate from the Universi-
                         tenderness, and                                                    rupture of the                         physical therapy
                                                                                                                                                                            ty of Illinois College of Medicine
                         instability                                                        ligament                               similar to that for
                                                                                                                                   Grade 2 sprains but                      at Rockford, Dr. Lin completed
                                                                                                                                   over a longer period;    a residency in orthopaedic surgery at Rush
                                                                                                                                   and possible surgical    University Medical Center. His fellowship was
                                                                                                                                   reconstruction           completed at the world-renowned University
* Patients must receive treatment that is tailored to their individual needs. This table outlines common treatment protocols.                               of Tennessee-Campbell Clinic Department of
RepROduCed WIth peRMISSIOn fROM BeRnSteIn J (ed): MusculoskeleTal Medicine. ROSeMOnt, IL, AMeRICAn ACAdeMy Of ORthOpAedIC SuRGeOnS, 200, p 22.            Orthopaedic Surgery.

                                                                                                                                                                                   Orthopaedic Excellence 11
 Need Kicker

                                              inter has arrived, and so have
                                              winter sports such as basketball,
                                              volleyball, and indoor soccer.
                                  The constant running and jumping associ-
                                  ated with these sports are ideal for improv-
                                  ing cardiovascular fitness. However, these
                                  activities can also increase pressure on
                                  structures in the anterior knee, especially

 Winter sports leave              in young athletes.

 knees vulnerable                 Chronic anterior knee pain is one of the
                                  most common problems encountered by

 Staying in
                                  primary care physicians. The most likely
                                  causes for anterior knee pain in young
                                  athletes are Osgood-Schlatter disease,

 the Game
                                  patellofemoral stress syndrome, and patel-
                                  lar tendinopathies. All three conditions
                                  represent overuse injuries to the extensor
                                  mechanism of the knee.

                                  Osgood-Schlatter Disease
      By Jeff Mjaanes, MD, FAAP
                                  Accessory growth plates, or apophyses,
                                  are sites where tendons attach to bones
                                  in growing children. There are two apoph-
                                  yses located at each end of the patellar
                                  tendon in the knee. Repeated quadriceps
                                  contraction, such as that associated with
                                  running and jumping, leads to significant
                                  traction at these apophyses.

                                  Pain at the proximal tendon insertion
                                  on the inferior pole of the patella occurs
                                  mainly in pre-adolescents and is termed
                                  Sinding-Larsen-Johansson disease. In
                                  Osgood-Schlatter disease, adolescent
                                  athletes present with pain and swelling
                                  at the tibial tuberosity.

                                  In both conditions, physical exam findings
                                  of point tenderness and/or swelling at the
                                  respective apophysis are usually sufficient
                                  to make the diagnosis. If lateral x-rays are
                                  obtained, fragmentation of the apophysis

12 Orthopaedic Excellence
                                                                                                                            Sports Medicine

with mild swelling in the overlying soft        Disease Management                                 a formal physical therapy consultation is
tissue is typical. Lateral imaging is impera-                                                      often helpful to reinforce strengthening
tive to rule out an avulsion fracture if the    Management of Osgood-Schlatter disease,            and stretching exercises, to use modali-
patient has sudden, severe pain at the          PFSS, and patellar tendonitis involves con-        ties such as electrical stimulation, and to
apophysis and gait disturbance.                 trolling pain and correcting biomechani-           perform a gait analysis for detecting and
                                                cal defects in knee extension. Activity            correcting other predisposing biomechani-
Patellofemoral Stress Syndrome                  modification along with rest, ice, compres-        cal factors.
                                                sion (such as an ACE® bandage wrap or
Anterior knee pain originating from increased   open-patella neoprene knee sleeve), and            There are key points to ensuring that
pressure between the patella and the femoral    elevation (“RICE”) are useful for control-         patients receive proper care. Keep in mind
condyles is known as patellofemoral stress      ling symptoms, as are nonsteroidal anti-           that any young patient with knee pain but
(pain) syndrome (PFSS). Patients present        inflammatory medications.                          a normal knee exam requires a detailed
with insidious onset of dull, achy peripatel-                                                      evaluation of the hip joint, including inter-
lar or retropatellar pain that increases when   Therapeutic exercises to strengthen the            nal rotation, to rule out a referred source
negotiating stairs or sitting for prolonged     quadriceps muscle, particularly the medial         of pain. Also, any athlete with more than
periods (“theater sign”). Patellar tracking     component (the vastus medialis oblique),           four weeks of knee pain or recurrent joint
problems and quadriceps weakness are ma-        and to stretch the hamstring and calf mus-         swelling should have x-rays performed
jor risk factors for PFSS, which affects more   cles work to improve patellar tracking and         (five views, including lateral, sunrise,
females than males.                             decrease pain over time. In elite athletes,        bilateral anteroposterior, bilateral skier’s,

During physical examination, quadriceps
atrophy or asymmetry and patellar hypermo-
                                                    The Physiology of the Knee
bility can be observed. Compression of the                                                    Quadriceps
patella often produces pain (“positive grind                                                  (thigh muscle)
test”), as does isometric quadriceps contrac-
tion. Tilting the patella and palpating the       Quadriceps
facets (articular surfaces) under the medial      (thigh muscle)
and lateral edges commonly elicit pain in
PFSS sufferers.                                                                               Patella
                                                  Patella                                     (kneecap)
Patellar Tendinosis
                                                  Patellar                                    Tendon
Adolescent athletes in jumping sports,            Tendon
such as basketball or volleyball, who pres-
ent with chronic pain below the kneecap,                                                       Tibial
often have patellar tendinosis, or “jump-         Tuberosity

er’s knee.” Examination elicits point ten-                                                    Tibia
derness on the body of the tendon itself                                                      (shinbone)
or, more commonly, at the inferior pole           (shinbone)
of the patella (similar to Sinding-Larsen-
Johansson disease). Occasionally, patients
experience tenderness at the superior
pole of the patella, indicative of quadri-                             Anterior View                                      Medial View
ceps tendonitis.

                                                                                                                        Orthopaedic Excellence 1
 Sports Medicine

and tunnel) to rule out growth plate
disturbances, osteochondral lesions, or
patellar abnormalities.

Lastly, physicians should be aware that other
entities, such as patellar subluxation/disloca-
tion and synovial impingement, commonly
lead to chronic anterior knee pain. Therefore,

  Any athlete with more
    than four weeks of
  knee pain or recurrent
   joint swelling should
  have x-rays performed
    to rule out growth
    plate disturbances,
 osteochondral lesions, or
  patellar abnormalities.
any patient who is not improving with con-
servative treatment should be referred to a
primary care or orthopaedic sports medicine
specialist for further management.

                Jeffrey M. Mjaanes, MD, is
                a medical graduate from the
                University of Wisconsin School
                of Medicine in Madison. Dr.
                Mjaanes completed a residency
                in pediatrics at Rush Univer-
sity Medical Center. During the residency, he
was awarded the Aesculapius Award for his
work in resident teaching and patient care. Dr.
Mjaanes is Assistant Professor of Pediatrics at
Rush University Medical Center. Through his
affiliation with Midwest Orthopaedics at Rush,
he looks to advance his research in pediatric
sports medicine, including studies on anterior
knee pain in children and throwing injuries in
young athletes.

   LaBella, C. patellofemoral pain syndrome: evaluation and
   treatment. Primary care clinics in office Practice. 200;Vol 1.
   Shea, K, et al. Idiopathic anterior knee pain in adolescents.
   orthop clin north am. 200; Vol .
   Smith, A, tao, S. Knee Injuries in young Athletes. clin sports
    Med. 1;Vol 1, no .

1 Orthopaedic Excellence
Orthopaedic Excellence 1
  Sports Medicine

Reality Check for                                                                                           The Truth Hurts
Young Athletes
                                                                                                            According to SAfe KIdS uSA:
                                                                                                            · More than . million children ages 1 and
                                                                                                              under receive medical treatment for sports

Long-term effects of overuse injuries                                                                         injuries each year.

                                                                                                            · Injuries associated with participation in
are a serious concern                                                                                         sports and recreational activities account for
                                                                                                              21% of all traumatic brain injuries among
By Dennis Viellieu                                                                                            children in the united States.

O                                                                                                           · Overuse injuries, which occur over time from
         ver a year ago, Midwest Orthopae-                information, clinical coverage for tourna-
         dics at Rush (MOR) decided to                    ments and games, and medical advice                 repeated motion, are responsible for nearly
         experiment with promoting sports                 or treatment.                                       half of all sports injuries to middle- and
safety in a vulnerable population — children.                                                                 high-school students. Immature bones,
This decision was precipitated by the con-                                  To lead the effort, MOR           insufficient rest after an injury, and poor
tinuing trend for athletes to select a sport of                             turned to Tammy Sciortino,        training or conditioning contribute to over-
choice at younger and younger ages. They                                    an experienced athletic           use injuries among children.
compete, train, and participate in these sports                             trainer familiar with young
year-round, increasing the probability of over-                             athletes in year-round          · Most organized sports-related injuries (2%)
use injuries and the chance for sustaining an                               programs. Before coming to        occur during practices rather than games.
injury that will affect them for a lifetime.              MOR, Sciortino was the president and CEO            despite this fact, a third of parents often
                                                          of her own sports performance company,              do not take the same safety precautions
MOR started a program to provide chil-                    Sports Sciorts. In addition, she had athletic       during their child’s practices as they would
dren and their coaches with sports safety                 training, strength training, and massage ex-        for a game.
                                                                  perience working with organizations
                                                                  like the Chicago Fire Soccer Team,        · A recent survey found that among athletes
                                                                  AVP Pro Beach Volleyball Tour, and          ages  to 1, 1% of basketball players, 2%
                                                                  Illinois Gymnastics Institute.              of football players, 22% of soccer players,
                                                                                                              2% of baseball players, and 12% percent
                                                                 Working with physical and athletic           of softball players have been injured while
                                                                 training company partners of MOR,            playing their respective sports.
                                                                 Sciortino had the program up and
                                                                 running quickly. In one year, there                                      source: sportssafety.org
                                                                 are more than 7,000 athletes par-
                                                                 ticipating in clubs affiliated with the   In 2007, Sciortino and MOR plan to roll
                                                                 MOR outreach program.                     out a sports safety program that is being
                                                                                                           developed in-house with the various sports
                                                                 Sciortino and MOR offer sports safety     medicine physicians. Anyone interested
                                                                 classes and seminars to help make         in either of these programs should call
                                                                 coaches and trainers aware of overuse     Sciortino directly at (708) 236-2624 (office)
                                                                 injuries as well as other safety con-     or (630) 272-2501 (cell).
                                                                 cerns. MOR also plans to offer first
                                                                 aid and CPR programs to the clubs         Dennis Viellieu is Chief Executive Officer of
                                                                 to ensure that coaches and trainers       Midwest Orthopaedics at Rush and has served
Tammy Sciortino (far right) teaches sports safety to athletes
and their coaches with the goal of reducing overuse injuries
                                                                 are prepared for medical issues that      in this position for five years. He enjoys golf,
through MOR’s athletic training outreach program.                might arise.                              basketball, and mountain biking.

1 Orthopaedic Excellence
Orthopaedic Excellence 1
1 Orthopaedic Excellence
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                                                                                                                                 Orthopaedic Excellence 1
 Need Kicker

Making Strides
Controversy surrounds
the treatment of
idiopathic toe walking
By Monica Kogan, MD

            hen children begin walking, a         have congenitally short tendo Achilles6. Oth-    Brower et. al.1 showed that children with
            toe-to-toe gait pattern is consid-    ers have divided patients into habitual toe      ITW along with cerebral palsy who toe walk
            ered part of normal gait develop-     walkers or those with short tendo Achilles4.     and were treated with serial casting showed
ment. However, a toe-walking gait pattern         If left untreated, the natural progression of    improvement in dorsiflexion and toe walk-
that persists past the age of 2 is considered     persistent toe walking places children at risk   ing. Griffin et. al.5 performed a gait analysis
abnormal, depending on gait velocity11.           for falling2, developing limitations in ankle    comparing ITW with heel-toe walkers before
There are many causes for persistent toe          mobility, and structural abnormalities, such     and after serial casting; the analysis showed
walking in children, including cerebral pal-      as persistent outward tibial torsion3.           that serial casting increased the range of
sy, congenital contractures of the Achilles                                                        dorsiflexion and also changed the muscle
tendon, muscular dystrophy, and idiopathic        Treatment                                        synergy pattern from abnormal to normal.
toe walking (ITW).
                                                  Much controversy exists around the treat-        Tachdian13 suggested passive stretching of
Diagnosis                                         ment of ITW. The goal of any treatment is to     the heel cords, gait training, and below-knee
                                                  provide normal function, but also important      walking casts as the initial treatment of ITW,
The diagnosis of ITW is one of exclu-             is limiting the impact on the child and fam-     with surgery being reserved for patients more
sion and can be challenging. For example,         ily. Heel cord lengthening (either open or       than 8 years of age who have failed to re-
children with ITW typically walk on their         closed), serial casting, and stretching and      spond to nonoperative treatment. Stretching
toes but are able to flatten their foot on        physical therapy are treatment options.          without casting is an option where the child
request or when concentrating on their                                                             undergoes weekly stretching by a physical
gait. It may be especially difficult to distin-   Nonsurgical Solutions                            therapist, followed by gait training.
guish ITW from children with mild spastic
diplegia7-10. Children with cerebral palsy        Nonoperative management, such as serial          Surgical Solutions
begin walking at a later age, and children        casting to stretch the plantar flexors, is
with ITW begin to walk at the appropriate         believed by some to be the optimal initial       The reported failure rate of nonoperative
time, 18 months.                                  treatment13. Each week, the child goes to the    treatment is significant, leading to the
                                                  physical therapist to have the ankle stretched   recommendation by others that surgical
The etiology of ITW is not known. Some            and a new cast applied. This process goes        intervention be the primary treatment. Pro-
authors have suggested that ITW patients          on six weeks or longer.                          ponents argue that operative management

20 Orthopaedic Excellence
                                                                                                                                                                  Diagnostics and Treatment

of either an open or percutaneous Achilles                              younger children go to a center that has                              for at least six weeks, followed by physi-
lengthening produces more consistent                                    pediatric physical therapists.                                        cal therapy after cast removal. This can be
outcomes, with improved ankle dorsiflex-                                                                                                      time consuming for both the patient and
ion and greater parental satisfaction11.                                Conclusion                                                            the parent or caregiver.

Stricker and Angulo12 showed that children                              ITW is a problem that is seen quite often.                            Surgery as the initial treatment may be
treated initially with surgical intervention                            Both operative and nonoperative methods                               seen by some as aggressive, but the results
had better results with respect to restora-                             of treatment have been recommended,                                   have been more consistent. Often, parents
tion of ankle dorsiflexion and parental                                 and each has its pros and cons. Serial                                or caregivers will try nonoperative mea-
satisfaction, and that cast and brace treat-                            casting is a lengthy process with the child                           sures first and opt for surgical intervention
ment offered little long-term improvement                               attending physical therapy once a week                                if no improvement is seen. Studies show
compared with untreated ITW. Hall et. al.6                                                                                                    that most often children end up requir-
performed tendo Achilles lengthenings on                                                                                                      ing surgery. However, no damage is done
a group of patients who showed no im-                                                                                                         by trying physical therapy first. If noth-
provement after six months to two years                                                                                                       ing else, parents or caregivers feel secure
of observation. They showed that, when                                                                                                        knowing that all options were exhausted
treated surgically, the children exhibited                                                                                                    before opting for surgery.
normal passive and active dorsiflexion
with a heel-toe gait pattern, except for                                                                                                                      Monica Kogan, MD, special-
occasional toe walking in older children.                                                                                                                     izes in pediatric orthopaedics
                                                                                                                                                              at Midwest Orthopaedics at
Both percutaneous and open techniques                                                                                                                         Rush. A medical graduate from
have been used for tendo Achilles lengthen-                                                                                                                   the University of Illinois College
ing. Patients are placed in below-the-knee                                                                                                                    of Medicine in Chicago, Dr.
weightbearing casts for four weeks and are                                                                                                    Kogan completed a residency in orthopaedic
allowed to bear weight immediately. During                                                                                                    surgery at Northwestern Memorial Hospital.
the four-week period, they participate in                               If left untreated, persistent toe walking can lead
                                                                                                                                              A fellowship in pediatric orthopaedic surgery
physical therapy for gait training. Since they                          to structural limitations and abnormalities in the                    was completed at the Primary Children’s Medi-
                                                                        hips, knees, ankles, and feet. To achieve similar
have likely toe walked since ambulation                                 force and movement levels as those required
                                                                                                                                              cal Center in Salt Lake City, Utah, a renowned
began, patients need to be retrained to walk.                           during heel-toe walking, toe walkers require                          pediatric center serving five states in the
                                                                        greater activation of less commonly used muscles,
Physical therapy should continue after the                              weakening the quadriceps and other muscles and
                                                                                                                                              intermountain region.
casts are removed, and it is beneficial that                            threatening joint stability.

      1. Brouwer B, davidson LK, Olney SJ. Serial casting in idio-           toe walkers: a clinical and electromyographic gait analysis. J     gastrocnemius. J Pediatr orthop 1;1:-2.
         pathic toe-walkers and children with spastic cerebral palsy.        Bone Joint surg [Am] 1;:-101.
                                                                                                                                              10. Sala dA, Shulman Lh, Kennedy Rf, et al. Idiopathic toe
         J Pediatr orthop 2000;20:221-.
                                                                           . hall Je, Salter RB, Bhalla SK. Congenital short tendo               walking: a review. dev Med child neuro 1;1:-.
      2. Caselli MA, Rzonca eC, Lue By. habitual toe walking: evalu-          calcaneus. J Bone Joint surg [Br] 1;:-.
         ation and approach to treatment. clin Podiatr Med surg                                                                               11. Statham L, Murray Mp. early walking patterns of normal
                                                                           . hicks R, durinick n, Gage JR. differentiation of
         1;:-.                                                                                                                           children. clin orthop 11;:-2.
                                                                              idiopathic toe walking and cerebral palsy. J Pediatr orthop
      . deLuca pA. the musculoskeletal management of children                1;:10-.                                                   12. Stricker SJ, Angulo JC. Idiopathic toe walking:
         with cerebral palsy. Pediatr clin north am 1;:11-0.                                                                              a comparison of treatment methods.
                                                                           . Katz MM, Mubarak SJ. hereditary tendo Achilles contrac-
      . furrer f, deonna t. persistent toe walking in children:              tures. J Pediatr orthop 1;:11-.                               J Pediatr orthop 1;1:2-.
         a comprehensive clinical study of 2 cases. Helv Paediatr                                                                            1. tachdjian MO. the foot and leg. In: tachdjian MO,
                                                                           . Rose J, Martin J, torburn L, et al. electromyographic dif-
         acta 12;:01-1.                                                                                                                     ed. Pediatric orthopaedics, vol. 2. philadelphia: Saunders:
                                                                              ferentiation of diplegic cerebral palsy from idiopathic toe
      . Griffin p, Wheelhouse W, Shiavi R, Bass W. habitual                  walking: involuntary coactivation of the quadriceps and             12:1-0.

                                                                                                                                                                               Orthopaedic Excellence 21
22 Orthopaedic Excellence
Orthopaedic Excellence 2
 Diagnostics and Treatment

ITW Defined                                                                                         of dorsiflexion. Because most ITW patients
                                                                                                    have at least 0 degrees of dorsiflexion, they
                                                                                                    may stand and walk normally on command.

distinctive characteristics help pinpoint                                                           In deciding the course and effectiveness of

tiptoe gait                                                                                         treatment, the degree of active and passive
                                                                                                    dorsiflexion ROM should be considered. If
                                                                                                    a child has at least 10 degrees of active dorsi-
By Tina Chase, MPT, PCS                                                                             flexion with the knee extended, then focus
                                                                                                    can be placed on strengthening the dorsiflex-

    diopathic toe walking (ITW) is char-         plantarflexed throughout most of the swing         ors and the timing of their activation during
    acterized by a bilateral tiptoe gait that    phase. In CP, the knees flex at initial contact,   gait. If there is significant dynamic tone in
    originates within several months of          have no loading response, and extend               the gastrocnemius and/or soleus muscles,
independent ambulation. In normal develop-       through mid or late stance. The feet dorsiflex     the Tardieu Scale measures of resistance 1
ment, a mature heel-toe gait pattern emerges     during the swing phase.                            (R1) and resistance 2 (R2) can be used.
and is consistent by 2 years of age. Before
that, intermittent toe walking can occur and     Late-onset toe walking implies a well-             R1 refers to the initial end range or dynamic
progress to a mature gait pattern.               established period of heel-toe gait followed       range of the muscle. It is the first resis-
                                                 by the emergence of toe walking. This pro-         tance, or “first catch,” appreciated when
For some of these children, however, toe         gression is not characteristic of ITW, and         the ankle is quickly, passively dorsiflexed.
walking persists without history of prema-                                                          R2, or “second catch,” refers to the maxi-
turity, difficult delivery, evidence of hyper-                                                      mal end-range length of the muscle, which
tonicity, or abnormal reflexes. Standing                                                            is obtained when the muscle is maximally
and walking on tiptoes throughout toddler                                                           stretched with continued pressure into the
and school-aged years continues despite                                                             elongated position.
relatively normal development and attain-
ment of advanced gross motor skills, such                                                           For an ITW patient, R1 is functionally more
as running and skipping.                                                                            relevant than R2 since most will only use the
                                                                                                    ROM up to R1 during gait. This is especially
Distinguishing Features and Diagnoses                                                               true when the “thickness” of resistance
                                                                                                    between R1 and R2 is great. When this is
When diagnosing ITW, mild spastic dip-                                                              the case, a fixed muscle contracture may be
legia cerebral palsy (CP) is considered in                                                          developing, and ROM gains are expected
the differential diagnosis. In addition to the                                                      to be minimal with stretching alone. Better
                                                 Serial casting can be an effective technique for
neurological exam, family history, range of      gaining stretch in the Achilles tendon. A below-
                                                                                                    ROM gains may be obtained with bracing,
motion (ROM), and gait pattern assist in         the-knee plaster or fiberglass cast is applied/    casting, or surgery.
                                                 changed weekly to progressively increase the
confirming ITW.                                  range of dorsiflexion.
Unlike CP, ITW is an autosomal dominant          neuromuscular abnormality — including
trait. Approximately 40% of those affected       spinal cord anomalies, peripheral neuropa-         Once ITW is diagnosed, a course of treat-
by ITW have a family history of tiptoe gait.     thies, and muscular dystrophies — should           ment can be determined. Conservative
Also differing is passive ankle dorsiflexion     be considered.                                     approaches to treating ITW include physical
ROM with the knee extended, which typi-                                                             therapy by a pediatric physical therapist for
cally averages more than 5 degrees in ITW        The Importance of Range of Motion                  stretching, strengthening, and gait training.
versus less than 5 degrees with mild CP.                                                            Night and/or daytime bracing in ankle foot
                                                 Kinematic studies show that approximately          orthoses (AFOs) or serial casting over several
The gait pattern of the two is also slightly     10 degrees of ankle dorsiflexion occurs dur-       weeks may be prescribed for children whose
different. In ITW, the knees typically remain    ing normal gait. A heel-toe gait pattern is        ankles do not easily dorsiflex beyond neutral.
flexed throughout the gait cycle and the feet    achievable, however, with as little as 0 degrees   Botox injections to weaken the overactive

2 Orthopaedic Excellence
gastrocnemius or surgical lengthening of the                                                                 three and eight times. With each cast, the
Achilles tendons by an orthopaedic surgeon                                                                   ankles are repositioned into a greater degree
also are successful treatment interventions                                                                  of ankle dorsiflexion until the desired ROM
and may appeal to families when conserva-                                                                    is obtained. Serial casting can result in large
tive measures fail.                                                                                          gains in ROM and improvements in walking
                                                                                                             in a short period of time.
Choosing the appropriate course of treat-
ment depends on many factors, including:                                                                     Conclusion

• Age, attention, and cognitive abilities of                                                                 Early detection of ITW is important because
  the child                                                                                                  prolonged tiptoe gait can lead to adaptive
                                                      Walking on challenging surfaces such as an
                                                      inclined treadmill can help reinforce heel contact     shortening of the heel cords, weakness and
                                                      and teach appropriate timing and coactivation of
• Ankle dorsiflexion, ROM, and degree of              the foot musculature.
                                                                                                             poor coordination in the knee and ankle
  toe walking                                                                                                musculature, and postural changes in the
                                                      outcomes in children who do not gain ROM               trunk. Timely referral to an orthopaedic
• Importance of speedy and full recovery              with stretching or who consistently toe walk           surgeon and a pediatric physical therapist
                                                      despite exercises. Although many children              increases the likelihood of successful treat-
Physical Therapy                                      return to toe walking once the AFOs are                ment and, in the long run, may be less
                                                      removed, the braces allow the heels to be              costly and time consuming.
Physical therapy for ITW can be most effec-           loaded correctly and the postural muscles to
tive when performed by a pediatric physical           be used in correct alignment.                                          Tina Chase, MPT, PCS,
therapist. Walking on challenging surfaces                                                                                   Clinic Director of The Pediatric
such as sand, ramps, or a mattress on the             Casting                                                                Place in Naperville, Illinois,
floor can reinforce heel contact and teach                                                                                   is available to speak with
appropriate timing and coactivation of the            Serial casting involves applying short leg                             physicians and/or groups who
foot musculature. These strategies can be             casts to the lower legs and feet to stretch the                        would like to learn more about
taught to caregivers for practicing at home.          gastrocsoleus muscles. It can be indicated             idiopathic toe walking (ITW). She received her
                                                      if conservative stretching fails, if bracing is        master’s degree in physical therapy from Gan-
Bracing                                               not well tolerated by the child, or if tightness       non University, where she was honored with
                                                      prevents bracing. With casting, the ankle              the “Outstanding Service in Physical Therapy
AFOs can be worn at night to apply a                  joint is held in an elongated position for             Award.” Chase’s professional certifications
long-duration, low-intensity stretch to the           several weeks vs. several minutes or hours             include pediatric clinical specialist and neuro-
heel cords or during the day to promote               as with stretching and bracing. Casts are              developmental treatment for the pediatric
a heel-toe gait. They have shown better               changed every one to two weeks between                 population. She also specializes in lower
                                                                                                             extremity biomechanics/serial casting and
                                                                                                             has a particular interest in cerebral palsy and
  Idiopathic Toe Walking                              Mild Diplegia
                                                                                                             developmental coordination disorder (DCD).
  Hip: normal kinematics                              Hip: normal kinematics
                                                                                                             The Pediatric Place is a Stryker Physiother-
  Knee: Remains flexed throughout gait cycle          Knee: flexes at ground contact, has no loading
                                                                                                             apy Associates company. Stryker currently
  Maximum extension is at ground contact with         response, and extends through mid and late stance
                                                                                                             has 18 adult and 12 pediatric facilities in
  the knee averaging 11 degrees of flexion            Maximum extension is at mid to late stance
                                                                                                             the Chicago area. Call (312) 944-7595 to
  Ankle: Average passive dorsiflexion is more than    Ankle: Average passive dorsiflexion is less than      be connected to Tina in Naperville or any
   degrees (range is less than 10 degrees to more    degrees (range is less than 20 degrees to 0 degrees)   Illinois facility.
  than 1 degrees)                                    Ground contact is in plantar flexion
  Ground contact is in plantar flexion                Swing phase: Ankle dorsiflexes throughout the          Editor’s Note: Tina Chase is not affiliated
  Swing phase: Ankle initially dorsiflexes but then   entire phase                                           with Midwest Orthopaedics at Rush. Treatment
  plantarflexes mid to late swing                                                                            recommendations presented in this article are
                                                                                                             solely the professional opinion of the author.

                                                                                                                                   Orthopaedic Excellence 2
  Technology Insights

                                                                                                   quality of their transcription service while
                                                                                                   improving all other aspects of processing
                                                                                                   dictations. If this were not the case, MOR
                                                                                                   might not be where it is today in terms of
                                                                                                   transcription. The company values the rela-
                                                                                                   tionships it has with its transcription services
                                                                                                   and the quality of service they provide.

                                                                                                   Executing Change

                                                                                                   The implementation consisted of three
                                                                                                   steps to transition to 100% digital via the
                                                                                                   Scribe system. First, the MTs were trained
                                                                                                   on Scribe and brought up to speed with
                                                                                                   hands-on training. This undertaking was
                                                                                                   challenging for them because moving to
                                                                                                   the new Scribe platform changed so many

                                                                                                   of their processes.

                                                                                                   The computer systems of the MTs were

   Goes Digital
                                                                                                   updated so that they could support the
                                                                                                   Scribe online MT platform. Many, if not
                                                                                                   all, of their computers were outdated, with
                                                                                                   some systems as old as DOS. Scribe pro-
                                                                                                   vided training sessions with each of the MT

   Online platform makes                                                                           services and assisted with setting up their
                                                                                                   new computers. Once each MT service was

   cassette tapes obsolete                             By Victoria Chavez
                                                                                                   comfortable on the system, they proceeded
                                                                                                   to implementation.

          idwest Orthopaedics at Rush (MOR)       technology platform to maximize efficiency       Second, the support staff, management
          has a long history of working with      while still preserving the quality of service.   team, and physicians were trained on
          various medical transcription (MT)                                                       Scribe’s online MD platform, reworking their
services, including five independent MTs or       MOR found what it was looking for in Scribe      processes to handle dictation efficiently
MT services. Physicians have developed very       Healthcare Technologies, Inc., Lake Forest,      on the new platform. Again, Scribe was
close working relationships with their MTs.       Illinois, a company that came highly recom-      there every step of the way, training MOR’s
These MTs allow for great productivity and        mended. Scribe offered a centralized system      practice groups. This step also involved
efficiency because of their familiarity with      for all areas of transcription that would        purchasing digital voice recorders for
the physician’s dictation style and use of        consolidate processes, limit paperwork, and      all clinicians and physicians, in-
medical and technical jargon.                     eventually save time and money. In effect,       stalling software on all comput-
                                                  MOR went from cassette tapes and daily           ers for downloading audio files
MOR needed a system that would help im-           courier services in December 2003 to using       from the digital recorders, and
prove the workflow of its support staff and       digital recording devices for digital trans-     training the staff how
turnaround time from its MT services, but         mission of data in January 2004.                 to download.
converting all of the physicians to one new
service where a number of different MTs           The flexibility of the Scribe system played      With technology comes the need for
are used was not an option. MOR decided           a very important role in transitioning the       support. Scribe was very familiar with
to let all of its physicians keep their current   physicians to a new system quickly, be-          typical troubleshooting issues and helped
MTs but to transition to one centralized          cause the physicians were able to keep the       MOR’s IT staff through the transition.

2 Orthopaedic Excellence
The last step was training the physicians and     new system, MOR rarely loses a file, in
clinicians to use the digital voice recorders.
Although using them was not extremely
                                                  which case it is usually attributed to user
                                                  error. In addition, the audio files are stored       MOR Thanks Its MTs
different from using old devices that stored      on the computer and are tracked on the               Without our talented Mts, the transition to
information on tapes, the look and feel of the    Scribe system, substantially increasing the          Scribe’s platform would have been a daunting
new devices was slightly different and infor-     chances of finding missing information.              challenge. We thank you for all you do and for
mation was stored digitally. The MTs, physi-                                                           your dedicated service to our company.
cians, and support staff were now working         MOR staff has quickly become accustomed
on one system divided into two platforms,         to transferring audio files to its MT services       – Anne Luginbill, independently contracted
one for the MTs and one for the physicians.       in a matter of minutes. The audio files                for 1 years
                                                  can be transmitted electronically from the           – Ct transcription, 1 years
Later, Scribe introduced the administrative       physician to the MT service almost instanta-
                                                                                                       – Accuscript,  years
platform. This platform allowed for MOR to        neously. With courier service and tapes, the
support staff internally, and only on rare oc-    standard turnaround time was two weeks;              – Keystrokes transcription Service, Inc.,  years
casions do they need to reach out to Scribe       now it is anywhere from four to 48 hours.            – Joyce Garst, independently contracted for
for technical support. Now that the technical
                                                                                                         over a year
kinks have been worked out from the imple-        With a practice that is constantly growing,
mentation process and the administrative          space is a priority. Now that its files are
platform has been introduced, MOR only            stored electronically, it is not necessary for
needs one IT staff member to support its          MOR to physically store everything in charts       MOR recently launched a Health Level Seven,
Scribe system.                                    in its medical records department. Scribe’s        Inc. (HL7) interface that exports patient iden-
                                                  platform is completely Web-based, so critical      tification information from its system appli-
Improved Efficiencies                             patient information is available at all times.     cation into the Scribe platform and imports
                                                                                                     patient clinical notes from Scribe into MOR’s
For many reasons, the decision to use             Planning Ahead                                     system. The interface attaches all notes back
Scribe’s services has surpassed all expec-                                                           into the patient’s chart in MOR’s system.
tations. MOR no longer has to store or            Since the transition, Scribe has been flex-
purchase tapes or rely on a courier service       ible in accommodating MOR’s needs as a             Scribe has always taken into consideration
to deliver dictations to the proper sources.      company. For instance, MOR is taking large         any suggestions or needs of MOR to ensure
Now, MOR has a constant flow of files             strides toward an electronic medical records       the system is working at its full potential.
going out and completed files coming in.          system.                                            So far, MOR has reduced costs and en-
By eliminating the middleman, MOR avoids                                                             hanced work processes on all fronts, and
costly intercepts that can result in the                                                             the company can report with simplicity
complete loss of audio                                                                               for billing purposes and quality assurance.
files. With its                                                                                      This transition was a huge step in the right
                                                                                                     direction and has opened the door to endless
                                                                                                     possibilities. MOR feels that it is vital to move
                                                                                                     forward relentlessly in its pursuit of the latest
                                                                                                     technology. The 100% digital transcription
                                                                                                     system is a testament to that, and MOR’s
                                                                                                     staff looks forward to the changes ahead.

                                                                                                     Victoria Chavez received her bachelor’s de-
                                                                                                     gree in information and decision sciences from
                                                                                                     the University of Illinois at Chicago. She has
                                                                                                     been with Midwest Orthopaedics at Rush for
                                                                                                     five years and currently serves as Information
                                                 A digital voice recorder stores information on an
                                                                                                     Systems and Marketing Manager. She enjoys
                                                 online platform rather than on tapes.               scrapbooking and traveling.

                                                                                                                               Orthopaedic Excellence 2
2 Orthopaedic Excellence
Orthopaedic Excellence 2
 Need Kicker

       Tools in
       technology allows
       physicians to focus on
       the patient
       By Lora Freeman, Midwest Region
       Account Manager, and John Weiss,
       Vice President of Sales and Marketing,
       Scribe Healthcare Technologies, Inc.

      hysicians should spend the majority       patient. Companies such as Scribe Health-         and electronic medical records (EMR) were
      of their day delivering quality patient   care Technologies, Inc., Lake Forest, Illinois,   once predicted to make transcriptionists
      care. This is why they have completed     and Vianeta Communications, Milpitas,             obsolete by the year 2000, the reality is that
years of study and specialization. Most         California, offer Web-native technologies that    physicians still dictate, and transcriptionists
would probably prefer to focus their time       are cost-effective to purchase and maintain       still transcribe.
on improving the quality of life for patients   compared to other software solutions. These
rather than dealing with administrative         integrated Internet technologies work with        A Personal Touch
issues. The last thing a physician needs        the existing hardware and widely used Micro-
to be inconvenienced by is note dictation,      soft technology that most offices use.            There is a bright side. After years of failed
including dictating his or her own notes,                                                         technological implementations, new
finding transcribed documents, or locating      In the short history of transcription tech-       technologies are adapting to the require-
notes from referring physicians.                nology, an easy, inexpensive, predictable,        ments of the physicians. Technology-based
                                                quality product has not always existed. Many      transcription had to take a close look at what
An Affordable, Convenient Solution              technologies implemented during the last 15       physicians needed, how they did their work,
                                                years involved purchasing exorbitantly priced     and what the end product needed to be.
Fortunately, a new breed of company is          hardware and/or software or the use of voice-     Both Scribe and Vianeta are companies that
making a difference and enabling physicians     recognition software that did not provide a       have responded to these needs and provided
to focus on their number-one priority, the      suitable product. While speech recognition        products that fit easily into a physician’s

0 Orthopaedic Excellence
                                                                                                                          Technology Insights

                                                 Back End Support                                    tion product in 2007 that will allow physi-
                                                                                                     cians to share information with other physi-
                                                 What does a physician need to run these             cians or their patients,” says John Weiss,
                                                 systems? While many dictation and tran-             Vice President of Sales and Marketing for
                                                 scription systems cost between tens and             Scribe. “As insurance companies begin to
                                                 hundreds of thousands of dollars in upfront         embrace phone and e-mail consultations,
                                                 expenses, Scribe’s system is Internet-based.        our new communication product will allow
                                                 All that is needed is an updated PC with            for tracking and reimbursement for these
                                                 Microsoft Windows and Office programs, a            types of services.”
                                                 high-speed Internet connection, and access
                                                 to a phone. For a low monthly licensing fee         The University of Chicago Hospitals have
                                                 and a per-line charge for the storage of docu-      found Scribe’s package to be tremendously
                                                 ments on Scribe’s platform, physicians can          supportive of their dictation and transcrip-
                                                 use MTs they already work with or choose            tion process. “The customer service is excel-
                                                 from offshore or domestic vendors who type          lent,” says Dennis Gray, Assistant Director
                                                 on the Scribe MT platform.                          of Medical Records at University of Chicago
                                                                                                     Hospitals. “The training and ownership are
                                                 Systems like these allow physicians to:             fabulous. They are right in there with the
                                                                                                     physicians, training them and helping them
                                                 • Perform an advanced search of all docu-           use the system correctly.”
                                                   ments on the platform, meaning they can
                                                   search all patient files by the name of a         The University of Chicago Hospitals are
                                                   drug, diagnosis, or treatment.                    implementing an electronic signature pro-
                                                                                                     cess, and Gray says he is looking forward to
                                                 • Listen to all of their audio files, which are     experiencing its full benefits soon.
                                                   stored electronically.
                                                                                                     In much the same way that physicians re-
                                                 • Keep an address book of all the referring         lieve patients’ pain and increase their ability
                                                   physicians with whom they communicate,            to function in life, technology has evolved
                                                   which is available online to the MTs.             during recent years to ease physicians’ work-
                                                                                                     loads and improve their ability to function
existing workflow. In the typical workflow of    An Evolving Industry                                more efficiently in providing patient care.
a Web-based transcription:
                                                 This new breed of healthcare technology             Lora Freeman is the Midwest Region Account
• The physician picks up the phone or hand-      company has been growing its value proposi-         Manager for Scribe Healthcare Technologies,
  held recorder and dictates his or her notes.   tion. Scribe has begun to make its move             Inc., where Midwest Orthopaedics at Rush is
                                                 from dictation and transcription technology         one of her customers. Freeman has been with
• The dictation is routed to voice-recogni-      to offering a complete online repository that       Scribe for more than two years. She uses the
  tion software or to the medical tran-          looks like an EMR database. In 2006, Scribe         dictation platform to support her writing when
  scriptionist (MT). The record is created       announced PatientChart as an “add-on”               she cannot access the computer directly.
  in Microsoft Word using the physician’s        module. PatientChart allows a practice to
  preferred formatting and letterhead.           centralize and store all patient information,       John Weiss is the Vice President of Sales and
                                                 including transcribed records, images, lab re-      Marketing for Scribe Healthcare Technologies,
• The document is sent to a physician-           sults, and more. It is flexible, allowing records   Inc. Prior to acquiring Scribe, John was an
  accessed inbox via the Internet. On this       to be created through “smart templates.”            early Internet entrepreneur, having founded
  Internet platform, the physician can edit,                                                         several successful dotcoms like Starting Point,
  print, fax, e-mail, and store documents        “Scribe focuses on documentation technolo-          WebPromote, and YesMail. In his free time
  securely. Authorized persons can access        gies that complement the way physicians             John enjoys spending time with family, sailboat
  the documents at home or in the office.        work. We plan to add a secure communica-            racing, and water skiing.

                                                                                                                           Orthopaedic Excellence 1
2 Orthopaedic Excellence
Midwest Orthopaedics at Rush thanks the following advertisers for helping
make this publication possible.

Accelerated Rehabilitation Centers ... see page 22                     Gallagher Healthcare
                                                                        Insurance Services, Inc. .....................see page 23
AMDC ................................................... see page 18
                                                                       Girling Health Care, Inc. ..................... see page 32
AthletiCo ................................see inside front cover
                                                                       Harris Private Bank .............................. see page 23
ATI Physical Therapy ............ see inside back cover
                                                                       H-Wave ................................................. see page 23
Benefitdecisions, Inc.
 125 S. Wacker Dr., Ste. 2075                                          Illinois Collection Service, Inc. ............ see page 32
  Chicago, IL 60606                                                                                                                           Rush SurgiCenter LP ............................ see page 22
                                                                       MB Financial Bank ............................... see page 22
  (312) 606-4800 • (312) 606-8101 Fax
  www.benefitdecisions.com                                                                                                                    Scheck & Siress ..................................... see page 14
                                                                       McGuireWoods LLP
                                                                        77 W. Wacker Dr., Ste. 4100
Central DuPage Hospital .................... see page 18                                                                                      Scribe Healthcare Technologies, Inc. . see page 18
                                                                        Chicago, IL 60601
                                                                        (312) 849-8100 • (312) 849-3690 Fax
Chicago Bulls ........................................ see page 32                                                                            Spada Law Offices, P.C. ....................... see page 15
Chicago Magazine .............................. see page 17            OccuSport Physical Therapy ............... see page 19                 The Center, Inc.
                                                                                                                                                1853 Bernice Rd.
Chicago Office Technology Group .... see page 33                       Omnia Marketing & Design ............... see page 32                     Lansing, IL 60438
Chicago Rehabilitation Services, Inc. .. see page 15                                                                                            (800) 237-8228 • (708) 730-3324 Fax
                                                                       Patient Care ......................................... see page 29

Chicago Rush Arena Football ............. see page 29                  Perkins + Will ....................................... see page 28     WCS Physical Work Re-Training ......... see page 29

Citigroup ..........................................see back cover     Physiotherapy Associates ...................... see page 9             William Blair & Company, L.L.C. ......... see page 19

DePuy Spine ......................................... see page 18      Rush Oak Park Hospital ……………… see page 23                              Wolf Financial Group .......................... see page 33

                                                                                                                                                                               Orthopaedic Excellence 
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Need Kicker
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