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Orthopaedic Experts, Close to Home. OAD’s new mantra is a fitting introduction to this seventh issue of OAD Orthopaedics Review as we showcase another distinctive OAD Center of Excellence: The Orthopaedic Foot and Ankle Center. OAD’s Centers and specialization ensure patients receive prompt, expert care, diagnosis and treatment with the added benefits of saving time and unnecessary medical appointments and expense. The Orthopaedic Foot and Ankle Center is directed by Jeffrey A. Senall, MD, a Mayo Clinic fellowship-trained foot and ankle surgical specialist. Dr. Senall’s unique specialization and comprehensive experience in conservative and surgical treatment of all foot and ankle disorders has helped establish OAD as the western suburbs’ premier foot and ankle practice. With few orthopaedic surgeons specifically trained in foot and ankle treatment, particularly total ankle joint replacement, advanced arthroscopic and/or minimally invasive procedures; patients are fortunate to have specialty foot and ankle expertise close to home. OAD’s podiatric physician and surgeon, Rachel A. Cisko, DPM, is our other specialist integral to The Orthopaedic Foot and Ankle Center. Dr. Cisko provides complete family-oriented medical and 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 complete range of nonoperative and operative treatment, including customized orthotic fittings and physical therapy 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 vast orthopaedic rehabilitation services staffed by extensively trained therapists at multiple OAD locations, our patients receive personalized attention and therapy programs beyond compare. We sincerely appreciate the support of our advertisers in making this issue possible and providing OAD the opportunity to share its expertise. As OAD continues to grow and reach more communities (our new Naperville full service facility at 101 East 75th Street is now open!), this educational publication becomes even more important to patients, referral sources and OAD.

Jerome L. Kolavo, MD Spine and Neck Specialist

Aaron A. Bare, MD Shoulder, Hip, Knee and Sports Medicine Specialist

Lenard W. LaBelle, MD Shoulder, Knee and Sports Medicine Specialist

Anup A. Bendre, MD Hand/Upper Extremity Specialist

Mary Ling, MD Hand/Upper Extremity Specialist

David K. Chang, MD Hip and Knee Specialist Rachel A. Cisko, DPM Podiatric Physician and Surgeon Beth B. Froese, MD Physical Medicine and Rehabilitation Specialist Matthew D. Gimre, MD Nonsurgical Sports and Orthopaedic Medicine Specialist Stephen E. Heim, MD Spine and Neck Specialist Thomas W. Kiesler, MD Hand/Upper Extremity Specialist

Vol. 4, No. 7

4 Achilles Tendon Disorders Causes and solutions for tendinopathy. 8 Physical Therapy in the Treatment of Lateral Ankle Sprains Proper management of injury can allow a return to sports. 10 Metatarsalgia Reducing and resolving chronic pain at the ball of the foot. 11 FYI from OAD

A publication from

Warrenville ■ Wheaton ■ Naperville Carol Stream ■ Bartlett ■ Winfield

The Physicians of OAD Orthopaedics John L. Andreshak, MD Spine and Neck Specialist

In this issue

(630) 225-BONE (2663) ■ (630) 225-2399 Fax

Richard L. Makowiec, MD Hand/Upper Extremity Specialist

Jeffrey A. Senall, MD Foot, Ankle and Sports Medicine Specialist

Vinita Mathew, MD Physical Medicine and Rehabilitation Specialist

William R. Sterba, MD Shoulder, Hip, Knee and Sports Medicine Specialist

Steven E. Mayer, MD Physical Medicine and Rehabilitation Specialist

Richard K. Thomas, MD Hand/Upper Extremity Specialist

David M. Mochel, MD Hip and Knee Specialist

David H. Watt, MD Shoulder, Knee and Sports Medicine Specialist

Mary T. Norek, MD Physical Medicine and Rehabilitation Specialist

Emeritus Physicians Douglas B. Mains, MD John F. Showalter, MD

Main OAD Office Medical Offices at Cantera 27650 Ferry Road, Suite 100 Warrenville, IL 60555-3845 Medical Offices at Danada 7 Blanchard Circle, Suite 101 Wheaton, IL 60189-2038 Medical Offices at Naperville 101 East 75th Street, Suite 100 Naperville, IL 60565-1469 Mona Kea Medical Park 515 Thornhill Drive, Suite A Carol Stream, IL 60188-2703

OAD Orthopaedics Review is an educational and informative resource for physicians, health care professionals, employer groups, and the general public. 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’s professional consultation and assessment. Please consult your physician on matters related to your personal health.

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

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Achilles Tendon Disorders By Jeffrey A. Senall, MD What do Misty May-Treanor, Liu Xiang (China’s most famous athlete), Dan Marino and Boris Becker have in common? They have all been affected by disorders involving the Achilles tendon. The Achilles tendon is named after the Greek warrior Achilles who was dipped into the river Styx by his mother, Thetis, in order to render him invulnerable. Unfortunately for Achilles, the nonsubmerged area of his heel (where Thetis held him) was vulnerable and he was 4 OAD ORTHOPÆDICS Review

mortally wounded during the siege of Troy. He was struck in the unprotected heel with an arrow shot by Trojan Prince Paris. In this article we will discuss various disorders involving the Achilles tendon. To begin with, the Achilles tendon is the strongest and largest tendon in the body. It is the conjoined tendon of the gastrocnemius and soleus muscles. This is known as the triceps surae. The Achilles is a strong plantarflexor of the ankle. It is subject to high loads of up to ten times

an individual’s body weight with running or jumping activities. In discussing tendinopathy, this process is described as acute when symptoms have lasted two weeks or less, subacute when the symptoms have lasted two to six weeks and chronic when the symptoms have continued for over six weeks. There are many terms associated with describing pain involving the Achilles tendon. Currently we are moving away from using tendinitis in describing these conditions, as studies have


shown that inflammatory cells and markers of inflammation are not seen in most of these conditions. The term tendinopathy describes a pathologic process of the Achilles and is more appropriate. Most abnormalities of the Achilles are due to overuse injuries such as running and jumping. Most patients are men. Chronic conditions are more common in older athletes. There is a 41 percent chance of bilateral involvement.

CAUSES Causes of Achilles tendinopathy involve both intrinsic factors that have to do with gender, age, obesity, individual body constitution, blood group, autoimmune disease processes and abnormalities of the blood supply to the tendon. Additionally, malalignment of the lower extremity comes into play. This includes foot hyperpronation or hypopronation, forefoot rotational abnormalities, high arch or low arch feet, leg length discrepancies, muscle weakness or imbalances and decreased flexibility. Other causes can include the use of corticosteroids, fluoroquinolone, antibiotics, anabolic steroids, marijuana, heroin and cocaine. Sports related causes have to do with excessive loads and training errors in 60-80 percent of patients. 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. Running factors which come into play include running too long a distance, running too high in intensity, increasing distance too rapidly, too much up hill or down hill work, as well as monotonous asymmetric or specialized training. Poor technique and fatigue can also come into play. Poor equipment, such as not changing running shoes when the shock absorption has worn out, can be a factor.

PERI-TENDINOPATHY Peri-tendinopathy is a condition that occurs in the tissues surrounding the Achilles tendon. Early on in the disease process there is an inflammatory cell reaction in the region of the paratenon. Fluid forms

around the Achilles tendon and due to the swelling that occurs, there can be some circulatory impairment around the small vessels that supply the Achilles. Sometimes individuals can feel crepitus or a crunching sensation as the tendon moves within the paratenon that is filled with this fluid. If normal healing fails to occur, scar formation may occur with adhesions between the tissue that surrounds the Achilles and the Achilles tendon. Patients tend to present with pain in the main area of the Achilles and swelling and tenderness in the middle third of the Achilles. The tender area does not generally move with dorsiflexion or plantarflexion of the ankle. In more chronic conditions, pain is primarily associated with exercise. A nodular swelling occurs in the Achilles tendon, which elicits pain with pressure. The tender spot does not move when the ankle is flexed with dorsiflexion and plantarflexion. Clinical evaluation, ultrasound or MRI can be used to help make an accurate diagnosis. Treatment for peritendinitis usually involves rest, immobilization, decreasing activity, icing, gentle stretching and the use of heel lifts. Anti-inflammatories are consistently given in the early disease process, although recent studies have shown that they have minimal effects in more chronic processes.

be initiated. Modification of the training plan is evaluated when the patient returns to the sport. It will take three to six weeks for a patient to recover from an acute flare up and up to six months to recover from chronic 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. Surgery involves excision of the scar tissue from around the Achilles and debridement or clearing away of any paratenon as necessary. Long-term prognosis is generally positive—with 80 percent return to preinjury activity levels. Thirty percent of those with peritendinitis may require some type of surgical intervention.

TENDINOPATHY OF THE MAIN BODY Tendinopathy of the main body of the Achilles tendon primarily presents as pain 2-6 cm above the attachment point of the Achilles. It will occur most often after exercise in the early phases. As the disease process progresses, many patients experience pain during exercise. In severe cases, some patients experience pain with all activities. Many describe morning stiffness when dealing with this affliction. For runners, most describe pain at the beginning and at the end of their workout

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. When biomechanical abnormalities are present, occasionally orthotics will be used for correcting overpronation of the foot. As a rule, we recommend no athletic activity for at least seven to ten days. Occasionally an individual may have such an inflammation that they may require a fracture boot or cast immobilization for a brief period of time. Normally one abstains from the activities that caused the discomfort until the pain resolves. Once this resolves, a slow return to prior activity can

with a pain free period during the middle of their run. As the disease process progresses, most patients will present with a thickened nodular area in the midportion of the Achilles tendon. There are normally no signs of acute inflammation or excessive swelling present when they present at the office. However, the Achilles will be tender during palpation by the examining doctor. Patients may experience discomfort with footwear such as boots that press on the back of the Achilles. Nonoperative OAD ORTHOPÆDICS Review 5


Fig. 1 Radiograph, large posterior heel spur.

treatment is similar to that previously described for para-tendinopathy; that is, abstaining from activities that cause discomfort, use of a heel lift or a fracture boot, some gentle stretching and range of motion and avoidance of excessive stretching and overuse of the Achilles. Steroid injections are usually avoided as some studies show a weakening effect on the Achilles. Physical therapy has also been utilized in treatment of Achilles tendinosis. The focus in physical therapy has been on eccentric stretching and strengthening protocols. Eccentric training involves strengthening the Achilles while it is being

Fig. 2 Enlarged heel from heel spur and Achilles tendinopathy.

100 percent in different studies. Surgery has traditionally included open exploration and debridement of any abnormal-appearing scar tissue from within the midsubstance of the Achilles tendon. Depending on the extent of debridement, patients may occasionally require reconstruction of the Achilles if more than 50 percent of the tendon has been debrided. This currently involves transferring the flexor hallucis longus tendon from the back of the ankle joint into the heel bone just in front of the repair of the Achilles tendon. This increases the power of the Achilles, but it is also thought to bring a better blood supply into

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. stretched. An example would be stretching the Achilles using one’s body weight—as on the edge of a stair. Eccentric training has been shown to be superior to concentric training (pushing off or plantarflexion strengthening) in decreasing pain. Surgical treatment for Achilles tendinosis is reserved for those who fail conservative treatment for more than three to six months. Surgery carries a success rate of 756 OAD ORTHOPÆDICS Review

the diseased tendon to aid in healing. For smaller lesions measuring less than 2.5 cm, percutaneous techniques can be utilized with good results. This involves making small stab incisions over the diseased portion of the Achilles and small slits within the Achilles tendon. These tenotomies are thought to initiate a new healing response by bringing in a better blood supply to the diseased tendon. More recently, a new

technology known as TOPAZ has been utilized in a similar fashion. This is a more minimally invasive type of treatment for Achilles tendinosis. It involves a technology that uses a special wand to create small channels within the Achilles. It is theorized that causing microtrauma to the tendon will aid in a new reparative process.

INSERTIONAL TENDINOPATHY Insertional tendinopathy is another condition involving the Achilles that is a major cause of posterior heel pain. This condition is seen not only in older athletes, but in older, less athletic and overweight individuals as well. Most patients complain of pain over the posterior aspect of the heel where the Achilles attaches. This condition can often overlap with a condition known as Haglund’s syndrome. This is a syndrome that involves enlargement of the posterior aspect of the heel bone and often includes retrocalcaneal bursitis. Other terms for an enlargement of the back of the heel are termed pump bumps and include pain over the bony prominence but do not involve the Achilles tendon. This condition involves bone spurs, which arise from ossification of the fibrocartilage where the tendon attaches to the bone. These bone spurs are thought to be due to repetitive traction forces on the back of the heel. The spurs associated with this condition


are often seen clinically as well as on the x-rays seen in the office. (Fig. 1) Symptoms include early morning stiffness and pain at the insertion point, which worsens after exercise, after climbing stairs, and after running. Examination reveals tenderness at the Achilles insertion, a thickening of the tendon and a palpable bony ridge or heel prominence. (Fig. 2) The diagnosis is usually made on physical examination. When the patient presents at the office, standing radiographs often show signs of this disease process. An MRI scan is frequently used, for diagnosis and to stage the extent of involvement. Ultrasound can be utilized for this purpose as well. Treatment includes rest, ice, modification of training, heel lifts, orthoses for biomechanical abnormalities and may include the use of nonsteroidal anti-inflammatory medications. Non-operative treatment can yield an 85 percent improvement. Eccentric training for this condition only shows a 32 percent improvement compared to an 89 percent improvement with non-insertional Achilles tendinopathy. Recently, low energy shockwave treatment has been shown to be better than eccentric loading in a recent study at four months. A 64 percent improvement was seen using low energy shockwave treatment versus 28 percent improvement with eccentric stretching techniques. Surgery for this condition is also indicated for those who have failed conservative treatment. It consists of debridement of the calcific and diseased tendon from the insertion point, excision of the retrocalcaneal bursa and resection of the posterior superior calcaneal bony prominence of the heel. This involves some detachment of the Achilles tendon and may require repair of the Achilles tendon using suture anchors, augmentation, or a tendon transfer often using the flexor hallucis longus (FHL) tendon based on the extent of the disease. If the tendon is not extensively involved and the main complaint involves prominence of the posterior heel bone, a lateral incision is commonly made with minimal elevation of the Achilles. Occasionally arthroscopic

surgery has been utilized for this purpose, with good results. For more extensive involvement where the Achilles shows disease throughout its substance and extension towards the inside of the heel bone as well as the outside, a straight incision is made over the center portion of the heel in order to access all of the tendon. The tendon is detached, cleaned of its degenerative areas and reattached with bioabsorbable suture anchors. (Fig. 3) If more than 50 percent of the tendon is involved or the tendinosis extends into the main body of the tendon, the repair may be reinforced with an FHL tendon transfer. This tendon is placed into a small bone tunnel created just anterior to the normal tendon attachment point and held in place with a bioabsorbable interference screw. Most patients who have surgery for insertional tendinopathy have an 80 percent or more improvement. The postoperative immobilization is dependent on the extent of surgery. Patients are placed in a cast from two to four weeks and then placed in a cast boot with or without a small foam heel wedge in order to begin some range of motion and gentle stretching. Weight bearing is usually incorporated at this time. Physical therapy

customarily begins six weeks after the surgical procedure and continues with gradual training. Patients are instructed not to expect a return to competitive sports for at least six months. Additionally, patients are informed that it may take nine to 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.

Fig. 3 Suture anchors inserted for reattachment of Achilles after debridement. OAD ORTHOPÆDICS Review 7


Fig. 1 Lateral Ligaments of the Ankle Joint.

Physical Therapy in the Treatment of Lateral Ankle Sprains By Joseph Agostinelli, PT, DPT Sprains of the ligaments supporting the ankle are the most common ankle injury sustained during athletic activities. Of these, 85 percent occur to the lateral ankle complex. If not properly treated, chronic instability and pain often remain during future activities. The importance of proper management of these injuries, then, is crucial to allow a pain free and fully functional return to sports. Physical therapy has been shown to be very influential in reaching this level of function versus simple immobilization or RICE (rest, ice, compression, and elevation) alone.

ANATOMY AND PATHOPHYSIOLOGY There are three ligaments located on the outside, or lateral, aspect of the ankle: The anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL). 8 OAD ORTHOPÆDICS Review

These three ligaments form a “T,” originating from the lateral malleolus, the bony prominence on the outside of the lower leg, to parts of the talus or calcaneus. Their purpose, collectively, is to prevent inversion of the foot, that is, the motion of the toes moving medially towards the midline of the body. Also important in lateral ankle stability and foot control are the peroneal muscles, the peroneus longus and brevis. The contractile tissue for these muscles is located posteriorly on the fibula, and their tendons swing down underneath the lateral malleolus and attach on the fifth metatarsal. When engaged, these muscles evert the foot, moving the toes laterally away from the body’s midline. Functionally, these help to resist inversion during normal everyday tasks such as walking, and especially in athletics. (Fig. 1) Because the talus, the bone on which

weight-bearing occurs, has no muscular attachments itself, it is up to these ligaments to supply the stability this joint needs to support high forces that can occur with athletics. However, due to the natural anatomy of the ankle joint, the foot is more prone to move medially or invert, placing greater stress on these tissues for support. There are many common mechanisms for injury, including an aggressive cut on a planted foot such as in soccer or landing on another player’s foot during basketball.

TREATMENT A physician is responsible for diagnosing an ankle sprain from other possible pathologies. Lateral ankle sprains are graded from one (I) to three (III) based on severity. Lower grade ankle sprains are commonly addressed by conservative


Fig. 2 Patient performing a basic isotonic exercise with a theraband.

care, including physical therapy. Grade III sprains have been treated via surgical intervention, but research has shown conservative approach with a functional emphasis to be effective in most cases of acute ligamentous rupture. Often, surgical intervention is employed in the event an individual does not improve with conservative care, a decision reached between a patient and the physician. During the evaluation with the physical therapist, a number of objective measures will be taken. Some of these include range of motion (ROM), strength, and limb circumference for swelling. In the case of more chronic instability, a biomechanical evaluation will often be performed in which the therapist will determine arch height, rearfoot/forefoot varus or valgus, and other similar measures that help to identify what can contribute to these chronic issues. With this information, a therapist can better determine if a patient would benefit from taping techniques or braces to be worn during athletic activities. Initially, treatment in the acute stage of

Fig. 3 Patient performing high-end agility drills.

injury has an emphasis on pain control, swelling reduction and ROM. As these acute symptoms subside, more challenging activities are added gradually, focusing on muscle strength or restoring balance. These include single leg balance and isotonic muscle strengthening, all while working towards and/or maintaining full ROM. Towards the end of the rehabilitation protocol, a functional emphasis has been shown in research to improve lateral ankle stability and has higher scores for decreased pain and return to athletics, and overall patient satisfaction. Such activities include high-level balance activities, agility drills, and plyometrics. (Fig. 2 & Fig. 3)

treatment as well as diagnostic, in the sense that it allows determination of the necessity for bracing or orthotics. A tailored home exercise program focusing on balance and muscle strengthening can also help reduce the onset of recurrent lateral ankle sprains.


Joseph Agostinelli, PT, DPT, received his Masters degree in physical therapy from St. Louis University and completed 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.

There are a few measures that can be taken to help prevent the onset of an ankle sprain. Though the trauma of an acute sprain often makes prevention difficult, chronic instability can often be addressed by a number of changes, many of which can be addressed by a physical therapist. Taping techniques can be for

RESULTS Research demonstrates high patient satisfaction on pain scores and return to function with physical therapy. With a coordinated effort between the patient and the physical therapist, a return to pain-free athletics or physical activity can be achieved without residual complaint.



Fig. 1

Heads of Metatarsals

Metatarsalgia By Rachel A. Cisko, DPM

Does rising to your toes to reach for an item on a top shelf create foot pain? When you wear high heels do you find yourself wishing for your tennis shoes because there is pain in the ball of your foot? Did your jump shot lose all its air? During the push off phase, when walking, jumping or running, your body weight is transferred to the ball of your foot or the heads of the metatarsal bones. These are the five bones that connect your arch to your toes. This force may be up to 275 percent of your body weight. The stress may cause inflammation of the structures in the ball of the foot (bones, soft tissue, or nerves) referred to as METATARSALGIA. The main symptom of metatarsalgia is pain in the ball of your foot. The pain may be sharp, aching, or burning. It may radiate or stay stationary. It may cause numbness or tingling in the toes. Most of the time the pain is felt centrally, near the second, third or fourth toes. (Fig. 1) Metatarsalgia pain gets worse when standing, walking or with activity. It improves with rest. The pain worsens when walking on hard surfaces such as hardwood or ceramic floors. Some individuals feel as if they are walking on pebbles or stones. There is no one specific cause for metatarsalgia. It can be narrowed down to a 10 OAD ORTHOPÆDICS Review

few factors that create a change in the dynamics of the foot; thus producing increased pressure on the metatarsal heads. This will cause acute, recurrent, or chronic inflammation. 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 particular age group or gender, although women who wear high heeled or improperly fitting shoes are much more susceptible. High heels transfer weight to the ball of the foot. Athletes in high impact sports are even more susceptible. Those who practice pilates or yoga (without shoes) may suffer from metatarsalgia due to lack of cushioning. Conservative measures can potentially relieve pain of metatarsalgia. Initially, rest is recommended which may mean avoiding a favorite activity for a period of time. Low impact cardiovascular options include swimming and cycling. Keeping weight in a healthy range will help decrease potential

for pain. Ice may also be applied to the affected area, 15-20 minutes, several times daily. Over-the-counter nonsteroidal antiinflammatories (NSAIDs) can help reduce pain and inflammation. Proper shoes are recommended especially for certain foot types. Shoes may have extra support, motion control, increased rigidity, roller bar/rocker soles, or sock absorbing insoles. Remember that shoes should be activity specific; for example, running shoes for running only. Obviously, limiting high heeled shoes could reduce pain. Beyond some of these basic treatments, options may include specialized pads, orthotics, injections or surgery. Whether over-the-counter or physician dispensed, “metatarsal pads” placed correctly can help redistribute and relieve pressure under the metatarsal heads. These may also assist in “replacing” a fat pad that has displaced under the toes. Metatarsal pads increase the space between the bones that may be compressing a nerve. They also assist in the straightening of flexible hammertoes. Metatarsal pads may be added or imbedded into a customized arch support or orthotic. Custom arch supports, made by your physician, may be recommended to minimize stress on the metatarsal bones and improve foot function. Your doctor will evaluate with a physical exam, may take radiographic x-rays or possibly MRI tests to rule out other causes. If conservative treatments fail, surgery may be recommended, depending on the origin of the problem, to realign and change the mechanics of the foot. This may include bunion correction, hammertoe repair, loosening or tightening of tendons, excision of inflamed nerves, or shortening of bones. Talk to your doctor regarding risks and benefits if applicable. Although generally not a serious condition, when left untreated metatarsalgia may lead to other injuries such as toe problems, chronic stiffness, opposite foot pain, or possibly death to parts of the bone. If persistent foot pain has been stopping or limiting your activity level and not relieved by footwear changes, rest, and ice, it’s time to seek professional attention.


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.

FYI from OAD All On Board

Prestigious Membership

Aaron Bare, MD and William Sterba, MD, became board certified in orthopaedic surgery by the American Board of Orthopaedic Surgery (ABOS) in September 2008. The multistage process for board certification required fulfilling ABOS-specified educational and practice evaluaBare tion requirements and passing Part I (written) and Part II (oral) examinations. Successfully meeting the ABOS’ stringent standards for board certification distinguishes Doctors Bare and Sterba as orthopaedic experts Sterba and demonstrates to patients and the public their commitment to providing the highest quality orthopaedic care. We recognize Dr. Bare and Dr. Sterba for these achievements and further establishing OAD as The Center of Orthopaedic Excellence.

Jerome Kolavo, MD, an OAD Spinal Surgery Specialist, became an active member of the prestigious Scoliosis Research Society (SRS). Active membership was granted after a five year CandiKolavo date Fellowship period during which time Dr. Kolavo presented his research in spinal disorders to the SRS. We congratulate Dr. Kolavo on this professional milestone.

Specialization is OAD’s hallmark and many of our physicians have earned subspecialty certifications. OAD acknowledges Hand and Upper Extremity Specialist, Anup Bendre, MD, for earning a Certificate of Added Qualification (CAQ) in Surgery of the Hand. The ABOS Bendre awards a CAQ after numerous requirements are fulfilled including performing a minimum number of specific hand surgeries and passing a written exam. OAD has the largest team of orthopaedic board certified, fellowship-trained hand and upper extremity surgeons in Chicagoland with all five surgeons having CAQ’s in Surgery of the Hand. Congratulations, Dr. Bendre!


OAD’s newest Physical Medicine and Rehabilitation Specialist, Vinita Mathew, MD, passed Part I (written) of the American Board of Physical Medicine and Rehabilitation certification examination.

Expansion Team During 2008, OAD expanded its team of Certified Physician Assistants with the additions of Shannon Backes, Christi Bartz and Laurie Morgan. Working collaboratively with our physicians, Laurie can be found assisting OAD surgeons during procedures while office-based PAs, Shannon and Christi, maintain their own patient appointments. Physicians and patients alike value the PAs’ clinical assistance and orthopaedic care in hospital, surgery center and OAD office settings.




New Naperville Office Our new Naperville medical facility at 101 East 75th Street opened in December 2008, replacing OAD’s office at 120 Spalding Drive in Naperville. Another state-of-the-art OAD office, the new fullservice site offers comprehensive orthopaedic care, on-site physical and occupational therapy, diagnostic imaging and MRI services. OAD continues to respond to the orthopaedic needs of Naperville, Bolingbrook, Plainfield, Romeoville and surrounding communities by giving patients increased access to OAD’s specialty care and services.





ADVERTISER DIRECTORY OAD Orthopaedics would like to thank the following advertisers for making this publication possible: Altura Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 AthletiCo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Central DuPage Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 DePuy Mitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Doctors of Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Dr. James E. Wilson, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Forum Financial Management, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Gallagher Healthcare Insurance Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Girling Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Industrial Rehab Allies, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Jericho Cleaning Services 637 Cleveland D Bolingbrook, IL 60440-9027 630.327.6508 Medtronic Spinal & Biologics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Midwest Center for Advanced Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 MioMed Orthopaedics, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Newsome Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 NuVasive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Physician Sales and Service 300 Airport Road Elgin, IL 60123 630.730.7073 Premier Medical Products, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Tressler, Soderstrom, Maloney & Priess, LLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Wayne Xray Incorporated 245 W Roosevelt Rd Bldg 11 Ste 75 West Chicago, IL 60185-4804 630.562.1613 Wheaton Bank & Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15


OAD Orthopaedics 27650 Ferry Rd., Ste. 100 Warrenville, IL 60555-3845

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