oad orthopeadics review v4i7

2 OAD ORTHOPÆDICS Review

OAD ORTHOPÆDICS Review 3

Orthopaedic Experts, Close to Home.

The Physicians of OAD Orthopaedics

John L. Andreshak, MDSpine and Neck Specialist

Aaron A. Bare, MDShoulder, Hip, Knee and

Sports Medicine Specialist

Anup A. Bendre, MDHand/Upper Extremity Specialist

David K. Chang, MDHip and Knee Specialist

Rachel A. Cisko, DPMPodiatric Physician and Surgeon

Beth B. Froese, MDPhysical Medicine and

Rehabilitation Specialist

Matthew D. Gimre, MDNonsurgical Sports and

Orthopaedic Medicine Specialist

Stephen E. Heim, MDSpine and Neck Specialist

Thomas W. Kiesler, MDHand/Upper Extremity Specialist

Jerome L. Kolavo, MDSpine and Neck Specialist

Lenard W. LaBelle, MDShoulder, Knee and


Mary Ling, MDHand/Upper

Extremity Specialist

Richard L. Makowiec, MDHand/Upper

Extremity Specialist

Vinita Mathew, MDPhysical Medicine and


Steven E. Mayer, MDPhysical Medicine and


David M. Mochel, MDHip and Knee Specialist

Mary T. Norek, MDPhysical Medicine and


Jeffrey A. Senall, MDFoot, Ankle and


William R. Sterba, MDShoulder, Hip, Knee and


Richard K. Thomas, MDHand/Upper Extremity Specialist

David H. Watt, MDShoulder, Knee and


Emeritus PhysiciansDouglas B. Mains, MDJohn F. Showalter, MD

OAD Orthopaedics Review is an educational and informative resource for physicians, health care professionals, employer groups, and the generalpublic. This publication provides a forum for communicating news and trends involving orthopaedic-related diseases, injuries, and treatments,as well as other health-related topics of interest. The information contained in this publication is not intended to replace a physician’sprofessional consultation and assessment. Please consult your physician on matters related to your personal health.

OAD Orthopaedics Review is published by Oser-Bentley Custom Publishers, LLC, a division of Oser Communications Group, Inc., 1877 N. KolbRoad, Tucson, AZ 85715. Phone (972) 687-9035 or (520) 721-1300, fax (520) 721-6300, www.oser.com. Oser-Bentley Custom Publishers, LLCspecializes in creating and publishing custom magazines. Inquiries: Tina Bentley, [email protected]. Editorial comments: Karrie Welborn,[email protected]. Please call or fax for a new subscription, change of address, or single copy. This publication may not be reproduced inpart or in whole without the express written permission of Oser-Bentley Custom Publishers, LLC. To advertise in an upcoming issue of thispublication, please contact us at (972) 687-9035 or (520) 721-1300 or visit us on the Web at www.oser-bentley.com. February 2009

OAD’s new mantra is a fitting introduction to this seventh issue of OAD Orthopaedics Reviewas we showcase another distinctive OAD Center of Excellence: The Orthopaedic Foot andAnkle Center. OAD’s Centers and specialization ensure patients receive prompt, expert care,diagnosis and treatment with the added benefits of saving time and unnecessary medicalappointments and expense.

The Orthopaedic Foot and Ankle Center is directed by Jeffrey A. Senall, MD, a Mayo Clinicfellowship-trained foot and ankle surgical specialist. Dr. Senall’s unique specialization andcomprehensive experience in conservative and surgical treatment of all foot and ankle disordershas helped establish OAD as the western suburbs’ premier foot and ankle practice. With feworthopaedic surgeons specifically trained in foot and ankle treatment, particularly total ankle jointreplacement, advanced arthroscopic and/or minimally invasive procedures; patients are fortunateto have specialty foot and ankle expertise close to home.

OAD’s podiatric physician and surgeon, Rachel A. Cisko, DPM, is our other specialist integralto The Orthopaedic Foot and Ankle Center. Dr. Cisko provides complete family-oriented medicaland surgical treatment of foot disorders including diabetic foot care, wound care, arthritis,fractures, and sprains/strains. She collaborates with Dr. Senall in providing the most completerange of nonoperative and operative treatment, including customized orthotic fittings and physicaltherapy protocols for optimal recovery.

Whether a sports- or work-related injury or a chronic, ongoing condition such as arthritis,physical therapy is often necessary to restore function and well-being. Thanks to OAD’s vastorthopaedic rehabilitation services staffed by extensively trained therapists at multiple OADlocations, our patients receive personalized attention and therapy programs beyond compare.

We sincerely appreciate the support of our advertisers in making this issue possible and providingOAD the opportunity to share its expertise. As OAD continues to grow and reach morecommunities (our new Naperville full service facility at 101 East 75th Street is now open!), thiseducational publication becomes even more important to patients, referral sources and OAD.

4 Achilles Tendon DisordersCauses and solutions fortendinopathy.

8 Physical Therapy in the Treatmentof Lateral Ankle SprainsProper management of injury canallow a return to sports.

10 MetatarsalgiaReducing and resolving chronic painat the ball of the foot.

11 FYI from OAD

In this issue Vol. 4, No. 7

Warrenville ■ Wheaton ■ Naperville Carol Stream ■ Bartlett ■ Winfield

(630) 225-BONE (2663) ■ (630) 225-2399 Faxwww.OADortho.com

Main OAD OfficeMedical Offices at Cantera

27650 Ferry Road, Suite 100Warrenville, IL 60555-3845

Medical Offices at Danada7 Blanchard Circle, Suite 101

Wheaton, IL 60189-2038

Medical Offices at Naperville 101 East 75th Street, Suite 100

Naperville, IL 60565-1469

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Carol Stream, IL 60188-2703

Physician Offices & Convenient Care Center at Bartlett Commons

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ACHILLES TENDON

What do Misty May-Treanor, Liu Xiang(China’s most famous athlete), Dan Marinoand Boris Becker have in common? Theyhave all been affected by disorders involvingthe Achilles tendon.

The Achilles tendon is named after theGreek warrior Achilles who was dippedinto the river Styx by his mother, Thetis,in order to render him invulnerable.Unfortunately for Achilles, the non-submerged area of his heel (where Thetisheld him) was vulnerable and he was

mortally wounded during the siege of Troy.He was struck in the unprotected heelwith an arrow shot by Trojan Prince Paris.In this article we will discuss variousdisorders involving the Achilles tendon.

To begin with, the Achilles tendon isthe strongest and largest tendon in thebody. It is the conjoined tendon of thegastrocnemius and soleus muscles. This isknown as the triceps surae. The Achillesis a strong plantarflexor of the ankle. It issubject to high loads of up to ten times

an individual’s body weight with runningor jumping activities.

In discussing tendinopathy, this process isdescribed as acute when symptoms havelasted two weeks or less, subacute when thesymptoms have lasted two to six weeks andchronic when the symptoms have continuedfor over six weeks. There are many termsassociated with describing pain involvingthe Achilles tendon. Currently we aremoving away from using tendinitis indescribing these conditions, as studies have

Achilles Tendon DisordersBy Jeffrey A. Senall, MD


ACHILLES TENDON

shown that inflammatory cells and markersof inflammation are not seen in most ofthese conditions. The term tendinopathydescribes a pathologic process of theAchilles and is more appropriate. Mostabnormalities of the Achilles are due tooveruse injuries such as running andjumping. Most patients are men. Chronicconditions are more common in olderathletes. There is a 41 percent chance ofbilateral involvement.

CAUSESCauses of Achilles tendinopathy involveboth intrinsic factors that have to do withgender, age, obesity, individual bodyconstitution, blood group, autoimmunedisease processes and abnormalities of theblood supply to the tendon. Additionally,malalignment of the lower extremity comesinto play. This includes foot hyperpronationor hypopronation, forefoot rotationalabnormalities, high arch or low archfeet, leg length discrepancies, muscleweakness or imbalances and decreasedflexibility. Other causes can include theuse of corticosteroids, fluoroquinolone,antibiotics, anabolic steroids, marijuana,heroin and cocaine. Sports related causeshave to do with excessive loads and trainingerrors in 60-80 percent of patients.Environmental causes can include trainingin cold weather, running on a hard groundsurface, slippery or icy surfaces and factorsrelated to humidity and altitude. Runningfactors which come into play includerunning too long a distance, running toohigh in intensity, increasing distance toorapidly, too much up hill or down hill work,as well as monotonous asymmetric orspecialized training. Poor technique andfatigue can also come into play. Poorequipment, such as not changing runningshoes when the shock absorption has wornout, can be a factor.

PERI-TENDINOPATHYPeri-tendinopathy is a condition that occursin the tissues surrounding the Achillestendon. Early on in the disease process thereis an inflammatory cell reaction in theregion of the paratenon. Fluid forms

around the Achilles tendon and due to theswelling that occurs, there can be somecirculatory impairment around the smallvessels that supply the Achilles. Sometimesindividuals can feel crepitus or a crunchingsensation as the tendon moves within theparatenon that is filled with this fluid. Ifnormal healing fails to occur, scarformation may occur with adhesionsbetween the tissue that surrounds theAchilles and the Achilles tendon. Patientstend to present with pain in the main areaof the Achilles and swelling and tendernessin the middle third of the Achilles. Thetender area does not generally move withdorsiflexion or plantarflexion of the ankle.In more chronic conditions, pain isprimarily associated with exercise. Anodular swelling occurs in the Achillestendon, which elicits pain with pressure.The tender spot does not move whenthe ankle is flexed with dorsiflexionand plantarflexion. Clinical evaluation,ultrasound or MRI can be used to helpmake an accurate diagnosis. Treatmentfor peritendinitis usually involves rest,immobilization, decreasing activity, icing,gentle stretching and the use of heellifts. Anti-inflammatories are consistentlygiven in the early disease process, althoughrecent studies have shown that they haveminimal effects in more chronic processes.

When biomechanical abnormalities arepresent, occasionally orthotics will be usedfor correcting overpronation of the foot. Asa rule, we recommend no athletic activityfor at least seven to ten days. Occasionallyan individual may have such aninflammation that they may require afracture boot or cast immobilization for abrief period of time. Normally one abstainsfrom the activities that caused thediscomfort until the pain resolves. Once thisresolves, a slow return to prior activity can

be initiated. Modification of the trainingplan is evaluated when the patient returnsto the sport. It will take three to sixweeks for a patient to recover from anacute flare up and up to six months torecover from chronic tendinopathy.Surgical treatment for peri-tendinopathyis indicated for those who fail to improvewith nonoperative treatment in a timeperiod greater than three to six months.Surgery involves excision of the scar tissuefrom around the Achilles and debridementor clearing away of any paratenon asnecessary. Long-term prognosis is generallypositive—with 80 percent return topreinjury activity levels. Thirty percentof those with peritendinitis may requiresome type of surgical intervention.

TENDINOPATHY OF THE MAIN BODY Tendinopathy of the main body of theAchilles tendon primarily presents as pain2-6 cm above the attachment point of theAchilles. It will occur most often afterexercise in the early phases. As the diseaseprocess progresses, many patientsexperience pain during exercise. In severecases, some patients experience pain withall activities. Many describe morningstiffness when dealing with this affliction.For runners, most describe pain at thebeginning and at the end of their workout

with a pain free period during the middleof their run. As the disease processprogresses, most patients will present witha thickened nodular area in the midportionof the Achilles tendon. There are normallyno signs of acute inflammation or excessiveswelling present when they present at theoffice. However, the Achilles will be tenderduring palpation by the examining doctor.Patients may experience discomfort withfootwear such as boots that press onthe back of the Achilles. Nonoperative

Environmental causes can include training in cold weather,

running on a hard ground surface, slippery or icy surfaces and

factors related to humidity and altitude.


ACHILLES TENDON

treatment is similar to that previouslydescribed for para-tendinopathy; that is,abstaining from activities that causediscomfort, use of a heel lift or a fractureboot, some gentle stretching and range ofmotion and avoidance of excessivestretching and overuse of the Achilles.Steroid injections are usually avoided assome studies show a weakening effect onthe Achilles. Physical therapy has also beenutilized in treatment of Achilles tendinosis.The focus in physical therapy has been oneccentric stretching and strengtheningprotocols. Eccentric training involvesstrengthening the Achilles while it is being

stretched. An example would be stretchingthe Achilles using one’s body weight—as onthe edge of a stair. Eccentric training hasbeen shown to be superior to concentrictraining (pushing off or plantarflexionstrengthening) in decreasing pain.

Surgical treatment for Achilles tendinosisis reserved for those who fail conservativetreatment for more than three to sixmonths. Surgery carries a success rate of 75-

100 percent in different studies. Surgery hastraditionally included open exploration anddebridement of any abnormal-appearingscar tissue from within the midsubstance ofthe Achilles tendon. Depending on theextent of debridement, patients mayoccasionally require reconstruction of theAchilles if more than 50 percent of thetendon has been debrided. This currentlyinvolves transferring the flexor hallucislongus tendon from the back of the anklejoint into the heel bone just in front of therepair of the Achilles tendon. This increasesthe power of the Achilles, but it is alsothought to bring a better blood supply into

the diseased tendon to aid in healing. Forsmaller lesions measuring less than 2.5 cm,percutaneous techniques can be utilizedwith good results. This involves makingsmall stab incisions over the diseasedportion of the Achilles and small slits withinthe Achilles tendon. These tenotomies arethought to initiate a new healing responseby bringing in a better blood supply to thediseased tendon. More recently, a new

technology known as TOPAZ has beenutilized in a similar fashion. This is a moreminimally invasive type of treatment forAchilles tendinosis. It involves a technologythat uses a special wand to create smallchannels within the Achilles. It is theorizedthat causing microtrauma to the tendon willaid in a new reparative process.

INSERTIONAL TENDINOPATHYInsertional tendinopathy is anothercondition involving the Achilles that is amajor cause of posterior heel pain. Thiscondition is seen not only in older athletes,but in older, less athletic and overweightindividuals as well. Most patients complainof pain over the posterior aspect of the heelwhere the Achilles attaches. This conditioncan often overlap with a condition knownas Haglund’s syndrome. This is a syndromethat involves enlargement of the posterioraspect of the heel bone and often includesretrocalcaneal bursitis. Other terms for anenlargement of the back of the heel aretermed pump bumps and include pain overthe bony prominence but do not involvethe Achilles tendon. This conditioninvolves bone spurs, which arise fromossification of the fibrocartilage where thetendon attaches to the bone. These bonespurs are thought to be due to repetitivetraction forces on the back of the heel.The spurs associated with this condition

Fig. 1 Radiograph, large posterior heel spur. Fig. 2 Enlarged heel from heel spur and Achilles tendinopathy.

Surgical treatment for peri-tendinopathy is indicated for those

who fail to improve with nonoperative treatment in a time period

greater than three to six months.


ACHILLES TENDON

are often seen clinically as well as on thex-rays seen in the office. (Fig. 1) Symptomsinclude early morning stiffness and painat the insertion point, which worsensafter exercise, after climbing stairs,and after running. Examination revealstenderness at the Achilles insertion, athickening of the tendon and a palpablebony ridge or heel prominence. (Fig. 2)

The diagnosis is usually made onphysical examination. When the patientpresents at the office, standing radiographsoften show signs of this disease process.An MRI scan is frequently used, fordiagnosis and to stage the extent ofinvolvement. Ultrasound can be utilizedfor this purpose as well.

Treatment includes rest, ice, modificationof training, heel lifts, orthoses for bio-mechanical abnormalities and may includethe use of nonsteroidal anti-inflammatorymedications. Non-operative treatment canyield an 85 percent improvement. Eccentrictraining for this condition only shows a 32percent improvement compared to an 89percent improvement with non-insertionalAchilles tendinopathy. Recently, low energyshockwave treatment has been shown to bebetter than eccentric loading in a recent studyat four months. A 64 percent improvementwas seen using low energy shockwavetreatment versus 28 percent improvementwith eccentric stretching techniques.

Surgery for this condition is alsoindicated for those who have failedconservative treatment. It consists ofdebridement of the calcific and diseasedtendon from the insertion point, excisionof the retrocalcaneal bursa and resectionof the posterior superior calcaneal bonyprominence of the heel. This involves somedetachment of the Achilles tendon andmay require repair of the Achilles tendonusing suture anchors, augmentation, or atendon transfer often using the flexorhallucis longus (FHL) tendon based on theextent of the disease. If the tendon is notextensively involved and the maincomplaint involves prominence of theposterior heel bone, a lateral incision iscommonly made with minimal elevation ofthe Achilles. Occasionally arthroscopic Fig. 3 Suture anchors inserted for reattachment of Achilles after debridement.

surgery has been utilized for this purpose,with good results. For more extensiveinvolvement where the Achilles showsdisease throughout its substance andextension towards the inside of the heelbone as well as the outside, a straightincision is made over the center portion ofthe heel in order to access all of the tendon.The tendon is detached, cleaned of itsdegenerative areas and reattached withbioabsorbable suture anchors. (Fig. 3) Ifmore than 50 percent of the tendon isinvolved or the tendinosis extends into themain body of the tendon, the repair maybe reinforced with an FHL tendon transfer.This tendon is placed into a small bonetunnel created just anterior to the normaltendon attachment point and held in placewith a bioabsorbable interference screw.

Most patients who have surgery forinsertional tendinopathy have an 80percent or more improvement. Thepostoperative immobilization is dependenton the extent of surgery. Patients areplaced in a cast from two to four weeksand then placed in a cast boot with orwithout a small foam heel wedge in orderto begin some range of motion and gentlestretching. Weight bearing is usuallyincorporated at this time. Physical therapy

customarily begins six weeks after thesurgical procedure and continues withgradual training. Patients are instructednot to expect a return to competitive sportsfor at least six months. Additionally,patients are informed that it may take nineto 12 months for complete recovery.

Jeffrey A. Senall, MD, earned

his medical degree magna cum

laude from the State University

of New York at Buffalo.

He completed a five-year

orthopaedic surgery residency

at the Henry Ford Health System in Detroit

followed by a fellowship in foot and ankle

surgery at the Mayo Clinic in Scottsdale,

Arizona. Dr. Senall joined OAD in 1999 and

is Director of OAD’s Orthopaedic Foot and

Ankle Center. Specializing in all foot and

ankle disorders, Dr. Senall’s areas of surgical

expertise include total ankle joint

replacement, arthroscopic and minimally

invasive treatment of foot and ankle

conditions, and arthroscopic surgery of the

knee. Dr. Senall is board certified by the

American Board of Orthopaedic Surgery and

is a member of the American Academy of

Orthopaedic Surgeons and the American

Orthopaedic Foot and Ankle Society.


ANKLE SPRAINS

Sprains of the ligaments supporting theankle are the most common ankle injurysustained during athletic activities. Ofthese, 85 percent occur to the lateral anklecomplex. If not properly treated, chronicinstability and pain often remain during fu-ture activities. The importance of propermanagement of these injuries, then, is cru-cial to allow a pain free and fully functionalreturn to sports. Physical therapy has beenshown to be very influential in reachingthis level of function versus simple immo-bilization or RICE (rest, ice, compression,and elevation) alone.

ANATOMY AND PATHOPHYSIOLOGY There are three ligaments located on theoutside, or lateral, aspect of the ankle:The anterior talofibular ligament (ATFL),calcaneofibular ligament (CFL) and theposterior talofibular ligament (PTFL).

These three ligaments form a “T,” origi-nating from the lateral malleolus, thebony prominence on the outside of thelower leg, to parts of the talus or calca-neus. Their purpose, collectively, is to pre-vent inversion of the foot, that is, themotion of the toes moving medially to-wards the midline of the body.

Also important in lateral ankle stabilityand foot control are the peroneal muscles, theperoneus longus and brevis. The contractiletissue for these muscles is located posteriorlyon the fibula, and their tendons swing downunderneath the lateral malleolus and attachon the fifth metatarsal. When engaged, thesemuscles evert the foot, moving the toes later-ally away from the body’s midline. Function-ally, these help to resist inversion duringnormal everyday tasks such as walking, andespecially in athletics. (Fig. 1)

Because the talus, the bone on which

weight-bearing occurs, has no muscularattachments itself, it is up to these liga-ments to supply the stability this jointneeds to support high forces that canoccur with athletics. However, due to thenatural anatomy of the ankle joint, thefoot is more prone to move medially or in-vert, placing greater stress on these tissuesfor support. There are many commonmechanisms for injury, including an ag-gressive cut on a planted foot such as insoccer or landing on another player’s footduring basketball.

TREATMENTA physician is responsible for diagnosingan ankle sprain from other possiblepathologies. Lateral ankle sprains aregraded from one (I) to three (III) based onseverity. Lower grade ankle sprains arecommonly addressed by conservative

Physical Therapy in the Treatment of Lateral Ankle SprainsBy Joseph Agostinelli, PT, DPT

Fig. 1 Lateral Ligaments of the Ankle Joint.


ANKLE SPRAINS

care, including physical therapy. Grade IIIsprains have been treated via surgical in-tervention, but research has shown con-servative approach with a functionalemphasis to be effective in most cases ofacute ligamentous rupture. Often, surgi-cal intervention is employed in the eventan individual does not improve with con-servative care, a decision reached betweena patient and the physician.

During the evaluation with the physicaltherapist, a number of objective measureswill be taken. Some of these include rangeof motion (ROM), strength, and limb cir-cumference for swelling. In the case ofmore chronic instability, a biomechanicalevaluation will often be performed inwhich the therapist will determine archheight, rearfoot/forefoot varus or valgus,and other similar measures that help toidentify what can contribute to thesechronic issues. With this information, atherapist can better determine if a patientwould benefit from taping techniques orbraces to be worn during athletic activities.

Initially, treatment in the acute stage of

injury has an emphasis on pain control,swelling reduction and ROM. As theseacute symptoms subside, more challengingactivities are added gradually, focusing onmuscle strength or restoring balance.These include single leg balance and iso-tonic muscle strengthening, all while work-ing towards and/or maintaining full ROM.Towards the end of the rehabilitation pro-tocol, a functional emphasis has beenshown in research to improve lateral anklestability and has higher scores for de-creased pain and return to athletics, andoverall patient satisfaction. Such activitiesinclude high-level balance activities, agilitydrills, and plyometrics. (Fig. 2 & Fig. 3)

PREVENTIONThere are a few measures that can betaken to help prevent the onset of anankle sprain. Though the trauma of anacute sprain often makes prevention dif-ficult, chronic instability can often be ad-dressed by a number of changes, many ofwhich can be addressed by a physicaltherapist. Taping techniques can be for

treatment as well as diagnostic, in thesense that it allows determination of thenecessity for bracing or orthotics. A tai-lored home exercise program focusing onbalance and muscle strengthening canalso help reduce the onset of recurrentlateral ankle sprains.

RESULTSResearch demonstrates high patient satis-faction on pain scores and return to func-tion with physical therapy. With acoordinated effort between the patient andthe physical therapist, a return to pain-freeathletics or physical activity can beachieved without residual complaint.

Joseph Agostinelli, PT, DPT,

received his Masters degree

in physical therapy from

St. Louis University and com-

pleted his clinical doctorate in

summer 2008. Joining OAD

Orthopaedics in 2007, Joe is a graduate of

Benet Academy and is a member of the

American Physical Therapy Association.

Fig. 2 Patient performing a basic isotonic exercise with a theraband. Fig. 3 Patient performing high-end agility drills.


METATARSALGIA

Does rising to your toes to reach for an itemon a top shelf create foot pain? When youwear high heels do you find yourself wishingfor your tennis shoes because there is pain inthe ball of your foot? Did your jump shotlose all its air?

During the push off phase, when walking,jumping or running, your body weight istransferred to the ball of your foot or theheads of the metatarsal bones. These are thefive bones that connect your arch to your toes.This force may be up to 275 percent ofyour body weight. The stress may causeinflammation of the structures in the ball ofthe foot (bones, soft tissue, or nerves) referredto as METATARSALGIA.

The main symptom of metatarsalgia ispain in the ball of your foot. The pain maybe sharp, aching, or burning. It may radiateor stay stationary. It may cause numbness ortingling in the toes. Most of the time thepain is felt centrally, near the second, thirdor fourth toes. (Fig. 1) Metatarsalgia paingets worse when standing, walking or withactivity. It improves with rest. The painworsens when walking on hard surfacessuch as hardwood or ceramic floors. Someindividuals feel as if they are walking onpebbles or stones.

There is no one specific cause formetatarsalgia. It can be narrowed down to a

few factors that create a change in thedynamics of the foot; thus producing increasedpressure on the metatarsal heads. Thiswill cause acute, recurrent, or chronicinflammation. Some of these factors include:

• Excess weight• Intense training or activity• Poorly fitting shoes• Bunions• Hammertoes• Certain foot types or shapes• Neuroma• Stress fractures• Aging

Metatarsalgia is not confined to a particularage group or gender, although women whowear high heeled or improperly fittingshoes are much more susceptible. Highheels transfer weight to the ball of the foot.Athletes in high impact sports are even moresusceptible. Those who practice pilates oryoga (without shoes) may suffer frommetatarsalgia due to lack of cushioning.

Conservative measures can potentiallyrelieve pain of metatarsalgia. Initially, restis recommended which may mean avoidinga favorite activity for a period of time. Lowimpact cardiovascular options includeswimming and cycling. Keeping weight in ahealthy range will help decrease potential

for pain. Ice may also be applied to theaffected area, 15-20 minutes, several timesdaily. Over-the-counter nonsteroidal anti-inflammatories (NSAIDs) can help reducepain and inflammation. Proper shoes arerecommended especially for certain foottypes. Shoes may have extra support,motion control, increased rigidity, rollerbar/rocker soles, or sock absorbing insoles.Remember that shoes should be activityspecific; for example, running shoes forrunning only. Obviously, limiting highheeled shoes could reduce pain.

Beyond some of these basic treatments,options may include specialized pads,orthotics, injections or surgery. Whetherover-the-counter or physician dispensed,“metatarsal pads” placed correctly can helpredistribute and relieve pressure under themetatarsal heads. These may also assist in“replacing” a fat pad that has displacedunder the toes. Metatarsal pads increase thespace between the bones that may becompressing a nerve. They also assist in thestraightening of flexible hammertoes.Metatarsal pads may be added or imbeddedinto a customized arch support or orthotic.Custom arch supports, made by yourphysician, may be recommended tominimize stress on the metatarsal bones andimprove foot function.

Your doctor will evaluate with a physicalexam, may take radiographic x-rays orpossibly MRI tests to rule out other causes.If conservative treatments fail, surgery maybe recommended, depending on the originof the problem, to realign and change themechanics of the foot. This may includebunion correction, hammertoe repair,loosening or tightening of tendons, excisionof inflamed nerves, or shortening of bones.Talk to your doctor regarding risks andbenefits if applicable.

Although generally not a seriouscondition, when left untreated metatarsalgiamay lead to other injuries such as toeproblems, chronic stiffness, opposite footpain, or possibly death to parts of the bone.If persistent foot pain has been stopping orlimiting your activity level and not relievedby footwear changes, rest, and ice, it’s timeto seek professional attention.

MetatarsalgiaBy Rachel A. Cisko, DPM

Heads of Metatarsals

Fig. 1


NEWS

FYI from OADAll On BoardAaron Bare, MD and William Sterba, MD,became board certified in orthopaedic surgery

by the American Board ofOrthopaedic Surgery (ABOS) inSeptember 2008. The multistageprocess for board certification re-quired fulfilling ABOS-specifiededucational and practice evalua-tion requirements and passingPart I (written) and Part II(oral) examinations. Successfullymeeting the ABOS’ stringentstandards for board certificationdistinguishes Doctors Bare andSterba as orthopaedic expertsand demonstrates to patients

and the public their commitment to providingthe highest quality orthopaedic care. Werecognize Dr. Bare and Dr. Sterba for theseachievements and further establishing OAD asThe Center of Orthopaedic Excellence.

Specialization is OAD’s hallmark and many ofour physicians have earned subspecialty cer-

tifications. OAD acknowledgesHand and Upper ExtremitySpecialist, Anup Bendre, MD,for earning a Certificate ofAdded Qualification (CAQ) inSurgery of the Hand. The ABOSawards a CAQ after numerous

requirements are fulfilled including perform-ing a minimum number of specific handsurgeries and passing a written exam. OADhas the largest team of orthopaedic boardcertified, fellowship-trained hand and upperextremity surgeons in Chicagoland with all fivesurgeons having CAQ’s in Surgery of the Hand.Congratulations, Dr. Bendre!

OAD’s newest Physical Medi-cine and Rehabilitation Spe-cialist, Vinita Mathew, MD,passed Part I (written) of theAmerican Board of PhysicalMedicine and Rehabilitationcertification examination.

Prestigious MembershipJerome Kolavo, MD, an OADSpinal Surgery Specialist, becamean active member of the presti-gious Scoliosis Research Society(SRS). Active membership wasgranted after a five year Candi-date Fellowship period during

which time Dr. Kolavo presented his research inspinal disorders to the SRS. We congratulate Dr.Kolavo on this professional milestone.

Expansion Team

During 2008, OAD expanded its team ofCertified Physician Assistants with the additionsof Shannon Backes, Christi Bartz and LaurieMorgan. Working collaboratively with ourphysicians, Laurie can be found assisting OADsurgeons during procedures while office-based PAs,Shannon and Christi, maintain their own patientappointments. Physicians and patients alike valuethe PAs’ clinical assistance and orthopaedic care inhospital, surgery center and OAD office settings.

New Naperville Office

Our new Naperville medical facility at 101 East75th Street opened in December 2008, replacingOAD’s office at 120 Spalding Drive in Naperville.Another state-of-the-art OAD office, the new full-service site offers comprehensive orthopaedic care,on-site physical and occupational therapy, diag-nostic imaging and MRI services. OAD continues torespond to the orthopaedic needs of Naperville,Bolingbrook, Plainfield, Romeoville and surround-ing communities by giving patients increasedaccess to OAD’s specialty care and services.

Bare

Kolavo

BendreMorgan

Mathew

Sterba

BartzBackes

Rachel A. Cisko, DPM, received

her Doctorate of Podiatric

Medicine degree from the Dr.

William M. Scholl College of

Podiatric Medicine in Chicago. She

completed her two-year postgraduate residency

in foot surgery from Loretto Hospital in

Chicago. Joining OAD Orthopaedics in 2004 as

OAD’s podiatric physician and surgeon, Dr.

Cisko provides medical and surgical treatment of

foot conditions and disorders to patients of all

ages. She specializes in wound care, diabetic feet,

arthritis, fractures, sprains and customized

orthotics. Other areas of expertise include heel

pain, bunions, corns, calluses, hammertoes and

ingrown toenails. Dr. Cisko is an Associate of the

American College of Foot and Ankle Surgeons

and a member of both the American Podiatric

Medical Association and Illinois Podiatric

Medical Association. She has had the distinction

of having served as an Assistant Professor and

Clinician at the Dr. William M. Scholl College of

Podiatric Medicine within Rosalind Franklin

University of Medicine and Science.


ADVERTISER DIRECTORY

Altura Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14AthletiCo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Central DuPage Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2DePuy Mitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Doctors of Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Dr. James E. Wilson, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Forum Financial Management, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Gallagher Healthcare Insurance Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Girling Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Industrial Rehab Allies, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Jericho Cleaning Services637 Cleveland DBolingbrook, IL 60440-9027630.327.6508

Medtronic Spinal & Biologics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Midwest Center for Advanced Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13MioMed Orthopaedics, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Newsome Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14NuVasive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Physician Sales and Service300 Airport RoadElgin, IL 60123630.730.7073

Premier Medical Products, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Tressler, Soderstrom, Maloney & Priess, LLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Wayne Xray Incorporated245 W Roosevelt Rd Bldg 11 Ste 75West Chicago, IL 60185-4804630.562.1613

Wheaton Bank & Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

OAD Orthopaedics would like to thank the following advertisers for makingthis publication possible:

OAD Orthopaedics27650 Ferry Rd., Ste. 100Warrenville, IL 60555-3845

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