Volume 3, Issue 5 - Midwest Orthopaedics at Rush

6 

12 

20 

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 

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 

Technology allows physicians to focus on the patient ..................................................30 

In Every Issue 

Volume 3 • Issue 5 

President’s Letter ....................................................................................................4 

Chairman’s Letter .....................................................................................................5 

Physician Listing .......................................................................................................5 

Directory.....................................................................................................................33 

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Orthopaedic Excellence

President’s Letter 

I 

hope 2006 was as good a year for all of you as it was for Midwest Orthopaedics 

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 

moved from 10th to sixth in the nation, and we expect to keep this positive 

momentum going. 

We also continued to grow and expand our organization and service lines during 2006 by 

adding a number of new physicians and subspecialties. First, we filled the pediatric ortho- 

paedic surgeon void by signing Monica Kogan, MD, who comes to MOR from Children’s 

Hospital in Oakland, California. Dr. Kogan started with MOR in October and has been a 

fantastic addition to our organization. We feel very fortunate to have Dr. Kogan as a part 

of our team and are pleased to be able to provide these much-needed services. 

Our Pediatric Program was further strengthened with the addition of Jeffrey Mjaanes, MD, 

a primary care sports medicine physician. In August, Dr. Mjaanes joined us part-time after 

completing his primary care sports medicine fellowship at Advocate Lutheran General. 

Dr. Mjaanes primarily practices at the Winfield office and supports our Athletic Training 

Outreach Program. Two days a week he also continues as a practicing pediatrician with 

Rush’s pediatric department. 

Another new addition in 2006 was Johnny Lin, MD, a foot and ankle specialist. Dr. Lin is 

stationed primarily at our Winfield office, but he also sees patients at Rush and Oak Park 

Hospitals. MOR was well-acquainted with Dr. Lin because he completed his orthopaedic 

residency at Rush before his fellowship training at the renowned Campbell Clinic in Nashville. 

We believe that Dr. Lin, as the third physician member of the foot and ankle team, will provide 

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 

K.W. Hammerberg, MD, joined our team. The addition of Drs. DeWald and Hammerberg consolidates 

most of the Rush Orthopaedic Program under the MOR banner. It also immediately 

established MOR as one of the leading spinal deformity practices in the nation. 

Adding world-renowned physicians and surgeons was not the only thing MOR was up to in 

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 stateof-the-art 

orthopaedic ambulatory building on Rush’s campus is expected to open in 2009. 

Lastly, we are proud and excited to continue our team relationships with the Bulls, White Sox, 

World Champion Chicago Rush, Chicago Bandits, and other sports teams and cultural arts 

programs. If there is anything we can do to improve your experience with our organization, 

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 

cbj@rushortho.com 

Orthopaedic Excellence 

A publication from 

Midwest Orthopaedics at Rush 

www.rushortho.com 

Central DuPage Hospital 

25 North Winfield Rd. 

Winfield, IL 60190 

Toll free: (877) MD-BONES 

Phone: (630) 682-5653 

Fax: (630) 682-8946 

Chicago — South Loop/River City 

800 South Wells, Ste. M30 

Chicago, IL 60607 


Phone: (312) 431-3400 

Fax: (312) 427-6116 

Prairie Medical Center of Westchester 

2450 South Wolf Rd., Ste. F 

Westchester, IL 60154 


Phone: (708) 236-2750 

Fax: (708) 562-6875 

Oak Park Hospital 

Medical Office Building 

610 South Maple Ave., Ste. 1400 

Oak Park, IL 60304 


Phone: (312) 243-4244 

Fax: (312) 942-1517 

RUSH University Medical Center 

1725 West Harrison St., Ste. 1063 



Phone: (312) 243-4244 

Fax: (312) 942-1517

Physician Listing 

Howard An, MD 

Spine, Back, and Neck 

Gunnar Andersson, MD 


Bernard Bach Jr., MD 


Richard Berger, MD 

Joint Reconstruction 

Charles Bush-Joseph, MD 

Sports Medicine, Knee, Shoulder, 

and Hip 

Mark Cohen, MD 

Hand, Wrist, and Elbow 

Brian Cole, MD 

Sports Medicine, Cartilage Restoration 

Craig Della Valle, MD 


Christopher DeWald, MD 


John Fernandez, MD 

Hand, Wrist, and Elbow 

April Fetzer, DO 

Physical Medicine/ 

Pain Management 

Jorge Galante, MD 


Steven Gitelis, MD 

Orthopaedic Oncology/ 


Edward Goldberg, MD 


K.W. Hammerberg, MD 

Spinal Surgery 

George Holmes Jr., MD 

Foot and Ankle 

Joshua Jacobs, MD 


Monica Kogan, MD 

Pediatric Orthopaedics 

Simon Lee, MD 


Johnny Lin, MD 


Jeffrey Mjaanes, MD 

Sports Medicine and 

Pediatric Sports Medicine 

Gregory Nicholson, MD 

Shoulder and Elbow, Sports Medicine, 

and Knee 

Trish Palmer, MD 


Women’s Sports Medicine 

Wayne Paprosky, MD 

Hip and Knee Joint Reconstruction 

Frank Phillips, MD 


Anthony Romeo, MD 

Sports Medicine, Elbow, 

and Shoulder 

Aaron Rosenberg, MD 


Mitchell Sheinkop, MD 


Kern Singh, MD 


Scott Sporer, MD 

Hip and Knee Joint Reconstruction 

Nikhil Verma, MD 

Sports Medicine, Knee, Elbow, 

and Shoulder 

Walter Virkus, MD 

Orthopaedic Oncology/Trauma 

Kathleen Weber, MD 


Women’s Sports Medicine 

The Rush University Medical Center (Rush) 

Orthopaedic Program continues to climb in the 

U.S.News & World Report’s rankings, moving up 

to sixth in the nation in 2006. This continued improvement 

in the annual rankings validates the commitment 

and excellence of our physicians, researchers, and staff, as well as 

what we already knew: We are one of the best orthopaedic departments 

in the country. 

I’m pleased to announce further consolidation on the part of the 

practicing physicians at Rush. Drs. DeWald and Hammerberg have 

decided to merge with Midwest Orthopaedics at Rush (MOR), 

adding two nationally renowned deformity surgeons to our already 

highly successful spine practice. Consolidation is key as we move 

forward into new and better space. 

Regarding the orthopaedic ambulatory building project, we continue 

to make great progress. Eventually, this project will allow us to consolidate 

all of our Rush and downtown practice facilities and provide 

complete diagnostic and outpatient treatment for patients with all 

types of musculoskeletal injuries and diseases. 

In addition to the ambulatory building project, we are expanding 

our diagnostic facilities to include the latest technology and developing 

a large physical therapy facility capable of accommodating our 

everyday patients as well as world-class professional athletes. I’d also 

like to mention the learning center we are planning, where we will 

disseminate our knowledge and inventions to other physicians and 

the latest products will be brought in for the benefit of our residents 

and fellows. 

All in all, 2006 was a tremendous year for MOR. We experienced 

continued clinical growth and were awarded large research grants from 

federal and industry sources. As we continue to grow, I am confident 

we will continue to provide efficient, high-quality, and compassionate 

services to our patients. 

Best regards, 

Gunnar Andersson, MD, PhD 

Chairman, Department of Orthopaedic Surgery 

Rush University Medical Center 

Chairman’s Letter 


Need Kicker 


Beyond 

Bumps and 

Bruises 

MOR enhances pediatric 

orthopaedic offerings 

By Paul Strandquist

Midwest Orthopaedics at Rush 

(MOR) has long had a gap in its 

service line, but it has not been 

alone. During the last five years, the hardest 

subspecialty to fill by far has been pediatric 

orthopaedics. With some recent additions 

to the team, MOR has filled that hole and 

then some. 

In August, MOR added Jeffrey Mjaanes, MD, 

a primary care sports medicine specialist and 

pediatrician. In October, the group added 

Monica Kogan, MD, a pediatric orthopaedic 

surgeon. Further strengthening the team, 

longtime, highly regarded, nationally recognized 

Rush University Medical Center 

(Rush) spinal deformity surgeons Christopher 

DeWald, MD, and K.W. Hammerberg, 

MD, came on board in January. 

These additions help satisfy the demands 

of referral sources and patients clamoring 

for pediatric orthopaedic services. Parents, 

referring physicians, therapists, athletic 

trainers, and coaches can turn to MOR for 

complete, comprehensive pediatric orthopaedic 

care for all injuries and pediatric 

orthopaedic conditions. 

“The addition of these physicians and pediatric 

services will help us in providing the 

best, broadest, and most convenient menu 

of orthopaedic services possible for our 

patients,” says Charles A. Bush-Joseph, MD, 

Managing Member at MOR. 

About Monica Kogan, MD 

Dr. Kogan is a medical graduate from the 

University of Illinois College of Medicine 

in Chicago. She completed a residency at 

Northwestern Memorial Hospital and a 

fellowship at Primary Children’s Medical 

Center, a renowned pediatric center in Salt 

Lake City, Utah, that serves five states in the 

intermountain region. 

Before joining MOR, Dr. Kogan spent the 

previous five years at Children’s Hospital 

and Research Center in Oakland, California. 

Dr. Kogan is proud to bring her education 

and experience to MOR in the treatment of 

children’s broken bones and other orthopaedic 

problems unique to pediatric patients. 

Dr. Kogan will treat trauma, birth defects, 

developmental dysplasia, clubfoot, genetic 

anomalies, neurologic dysfunction, scoliosis, 

and walking disorders. 

“I am excited to be a part of a multispecialty 

practice like MOR. We now have a complete 

team of fellowship-trained subspecialty 

“The addition of these 

physicians and pediatric 

services will help us 

in providing the best, 

broadest, and most 

convenient menu of 

orthopaedic services 

possible for our patients.” 

physicians that can diagnose and treat any 

type of orthopaedic injury or disorder,” she 

says. And the feeling is mutual. Everyone at 

MOR is pleased to have a pediatric orthopaedic 

surgeon on the team — especially one as 

skilled as Dr. Kogan. 

About Jeffrey Mjaanes, MD 

– Charles A. Bush-Joseph, MD 

Children’s sports have certainly changed 

since the days of baseball on the prairie, 

pickup hockey games in the alley, and tag in 

the neighborhood until the street lights came 

on. Now there are youth sports programs, 

clubs, and elite training facilities open yearround. 

Youth soccer, gymnastics, baseball, 

and wrestling schedules dominate parents’ 

calendars and travel schedules. This is where 

Dr. Mjaanes comes in. 

Dr. Mjaanes has a unique background in 

pediatric medicine and offers a wide range of 

services to MOR patients. “I am trained in 

primary care sports medicine and therefore 

can treat all sports injuries and problems 

experienced by all ages. But I am also a pediatrician 

and have an interest and specialize 

in preventing and treating pediatric sports 

injuries,” says Dr. Mjaanes. 

He is a graduate of the University of Wisconsin 

School of Medicine in Madison, 

and he completed a residency in pediatrics 

at Rush University Medical Center in 

Chicago. He then completed a fellowship 

in primary care sports medicine at Advocate 

Lutheran General Hospital in Park 

Ridge, Illinois. 

With his training in sports medicine, 

Dr. Mjaanes’ goal is to get child athletes 

on the road to recovery as soon as possible. 

His training also gives him the skills 

to treat nonorthopaedic sports injuries 

and problems, including heat illness, heat 

stroke, concussion, and wrestling rashes. 

He also performs pre-participation physicals 

for school athletic programs and sports 

teams. Both Dr. Mjaanes and Dr. Kogan are 

fluent in Spanish. 

About Christopher DeWald, MD 

Cover Story 

Dr. DeWald attended Rush Medical College 

in Chicago. He completed a residency at the 


Cover Story 

University of Illinois Hospital and Clinics 

and at Shriners Hospital for Crippled 

Children, both in Chicago. He then 

completed his training with a fellowship 

at Rush University Medical Center, also 

in Chicago, and at Shriners Hospital for 

Crippled Children. 

Since joining MOR, Dr. DeWald and his 

staff continue their focus on research and 

corrective surgery of spinal deformities, 

including scoliosis, kyphosis, and spondylolisthesis. 

Dr. DeWald says he is very interested 

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 surgical 

technique for pediatric spinal deformities. 

A cum laude graduate from Yale University 

in New Haven, Connecticut, Dr. Hammerberg 

completed his medical degree at 

the University of Illinois, Abraham Lincoln 


School of Medicine in Chicago in 1977. He 

completed a residency and an internship 

at Rush University Medical Center and a 

spine fellowship at Rush — the University 

of Illinois and at Shriners Hospital for 

(left to right) K.W. Hammerberg, MD, Jeffrey Mjaanes, MD, Monica Kogan, MD, and Christopher DeWald, MD 

Crippled Children. MOR is fortunate to 

have a physician with his experience and 

expertise on its medical team. 

Drs. DeWald and Hammerberg have an excellent 

clinical staff that is part of the MOR 

team, including Mary Faut Rodts, MS, MSA, 

CNP, ONC, FAAN, and Dorothy Pietrowski, 

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), 

has been in customer service and marketing 

with MOR for 20 years. He enjoys 

coaching baseball and is currently the 

President of the St. Laurence High School 

Father’s Club in Burbank, Illinois. 

(left to right) Christopher DeWald, MD, Jeffrey Mjaanes, MD, Monica Kogan, MD, and K.W. Hammerberg, MD



Twisting and Turning 

Ankle sprains are the most common 

sports injury 

By Johnny Lin, MD 

Ankle sprains are the most common 

athletic injury, with more than 27,000 

sprains reported every day. That 

equates to approximately 6% to 10% of all 

emergency room visits, costing more than 

$3.65 billion per year. 

Ankle sprains are caused by injuring the 

ligament that stabilizes the ankle. They can 

happen during sports, but they also can occur 

when people land wrong on an uneven 

surface, such as a curb. The fibers in the 

ankle ligaments are able to stretch; however, 

severe sprains can actually cause the ligaments 

to tear. Some people report hearing 

a pop when the injury occurs, and the pain 

can be delayed or immediate. 

10 Orthopaedic Excellence 

Diagnosis 

Symptoms of an ankle sprain include pain 

and swelling. The grade of a sprain is 

determined by the force of the injury. Grade 

one injuries cause minimal disability. Putting 

weight on the ankle is possible, and swelling 

is localized and minimal. The fibers of the 

ligament are stretched but not ruptured. 

Grade two sprains cause moderate disability. 

Putting weight on the ankle is more difficult, 

and swelling is more severe over the area of 

injury. Only one of the three ankle ligaments 

is completely torn. 

The most debilitating sprains are those classified 

as grade three. Many times it is not 

possible to put weight on the leg, and severe 

swelling is present over the whole 

ankle and foot. In these cases, 

two or three ligaments 

are completely torn. 

Noticeable instability 

is apparent 

when a physician 

pushes or rotates 

the ankle. 

Depending on the 

severity of the sprain, 

a physician may order 

an x-ray or magnetic 

resonance imaging (MRI) 

scan to determine the grade. 

In severe cases, the surface of 

the ankle joint is also damaged. 

It is important to get medical treatment 

for proper diagnosis because a 

broken bone may have similar symptoms as 

a grade three sprain. 

There are several risk factors for sprained 

ankles. Participating in sports such as 

basketball, soccer, and football increases 

the risk. Also, those who suffered a previous 

ankle sprain or who are overweight are at 

increased risk of a severe sprain. Perhaps the 

worst statistic is that approximately 40% of 

ankle sprains can lead to chronic problems 

if not treated correctly. 

Treatment 

Proper treatment should start with PRICE 

(protection, rest, ice, compression, and 

elevation). Through this approach, a person 

with a grade one sprain should be able to 

walk without a limp within a week and 

return to normal activities in one to two 

weeks. Swelling should be minimal at this 

point, and in some cases, anti-inflammatory 

medications are used to control pain 

and swelling. Conversely, if noticeable 

improvement is not seen by this time, it is 

important to see an orthopaedic foot and 

ankle physician who can check for a more 

serious injury. 

If no other serious injury is present, the physician 

may recommend muscle-strengthening 

and range-of-motion exercises, followed 

by activity-specific rehabilitation training, 

which allows for a faster and safer recovery 

and has been shown to minimize chances 

for reinjury. 

Rehabilitation may include electric stimulation 

to ease pain and swelling and/or 

water exercises, which can be a less painful 

alternative. Rehabilitation typically involves 

three phases: 

1. Rest and protection (to decrease 

swelling) 

2. Strengthening and flexing the muscles 

and tendons

The Physiology of the Ankle 

Classification of Ankle Sprains 

Severity Physical Exam Impairment Pathophysiology Typical 

Findings 

Treatment* 

Grade 1 

Grade 2 

Grade 

Minimal tenderness 

and swelling 

Moderate tenderness 

and swelling 

Significant swelling , 

tenderness, and 

instability 

Dorsal view of the ankle joint bones showing the calcaneus, 

cuneiforms, metatarsals, and phalanges 

Lateral view of the ankle joint bones showing the calcaneus, cuneiforms, metatarsals, and phalanges 

Minimal 

Moderate 

Moderate 

Severe 

Microscopic tearing of 

collagen fibers 

Complete tears of 

some but not all 

collagen fibers in the 

ligament 

Complete tear/ 

rupture of the 

ligament 

Weight bearing 

as tolerated; no 

splinting/casting; 

isometric exercises; 

and full range-of- 

motion and stretching/strengthening 

exercises as tolerated 

Immobilization 

with air splint and 

physical therapy with 

range-of-motion and 

stretching/strengthening 

exercises 

Immobilization; 

physical therapy 

similar to that for 

Grade 2 sprains but 

over a longer period; 

and possible surgical 

reconstruction 

* Patients must receive treatment that is tailored to their individual needs. This table outlines common treatment protocols. 

RepROduCed WIth peRMISSIOn fROM BeRnSteIn J (ed): MusculoskeleTal Medicine. ROSeMOnt, IL, AMeRICAn ACAdeMy Of ORthOpAedIC SuRGeOnS, 200 , p 2 2. 

3. Gradually returning to normal activity 

(This process varies significantly depending 

on the grade of the injury and can 

range from weeks to months.) 

Surgery for a sprain is rare, unless the ligament 

fails to heal correctly or the patient has 

recurrent sprains due to a “loose ankle.” 

Prevention 

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 

sprained, strengthening exercises should 

never cease, even if a brace is worn. Quitting 

exercises can lead to a recurrence of the 

injury, particularly if they are stopped too 

early. Abnormal mechanics of the ankle-joint 

complex also can be a contributing factor to 

ankle sprains, so the use of orthotics may 

help prevent injury. 

Prevention is up to the individual. Wearing 

sensible, proper-fitting shoes is as important 

as staying fit enough to keep muscles strong 

and supportive. Patients should watch for 

uneven surfaces when exercising and heed 

the body’s warning signs if pain or fatigue 

occurs during physical activity. 

Source: orthoinfo.aaos.org 

Johnny L. Lin, MD, is a foot 

and ankle specialist at Midwest 

Orthopaedics at Rush. A medical 

graduate from the University 

of Illinois College of Medicine 

at Rockford, Dr. Lin completed 

a residency in orthopaedic surgery at Rush 

University Medical Center. His fellowship was 

completed at the world-renowned University 

of Tennessee-Campbell Clinic Department of 

Orthopaedic Surgery. 


11

Need Kicker 

Winter sports leave 

knees vulnerable 

Staying in 

the Game 

12 

By Jeff Mjaanes, MD, FAAP 


Winter has arrived, and so have 

winter sports such as basketball, 

volleyball, and indoor soccer. 

The constant running and jumping associated 

with these sports are ideal for improving 

cardiovascular fitness. However, these 

activities can also increase pressure on 

structures in the anterior knee, especially 

in young athletes. 

Chronic anterior knee pain is one of the 

most common problems encountered by 

primary care physicians. The most likely 

causes for anterior knee pain in young 

athletes are Osgood-Schlatter disease, 

patellofemoral stress syndrome, and patellar 

tendinopathies. All three conditions 

represent overuse injuries to the extensor 

mechanism of the knee. 

Osgood-Schlatter Disease 

Accessory growth plates, or apophyses, 

are sites where tendons attach to bones 

in growing children. There are two apophyses 

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

with mild swelling in the overlying soft 

tissue is typical. Lateral imaging is imperative 

to rule out an avulsion fracture if the 

patient has sudden, severe pain at the 

apophysis and gait disturbance. 

Patellofemoral Stress Syndrome 

Anterior knee pain originating from increased 

pressure between the patella and the femoral 

condyles is known as patellofemoral stress 

(pain) syndrome (PFSS). Patients present 

with insidious onset of dull, achy peripatellar 

or retropatellar pain that increases when 

negotiating stairs or sitting for prolonged 

periods (“theater sign”). Patellar tracking 

problems and quadriceps weakness are major 

risk factors for PFSS, which affects more 

females than males. 

During physical examination, quadriceps 

atrophy or asymmetry and patellar hypermobility 

can be observed. Compression of the 

patella often produces pain (“positive grind 

test”), as does isometric quadriceps contraction. 

Tilting the patella and palpating the 

facets (articular surfaces) under the medial 

and lateral edges commonly elicit pain in 

PFSS sufferers. 

Patellar Tendinosis 

Adolescent athletes in jumping sports, 

such as basketball or volleyball, who present 

with chronic pain below the kneecap, 

often have patellar tendinosis, or “jumper’s 

knee.” Examination elicits point tenderness 

on the body of the tendon itself 

or, more commonly, at the inferior pole 

of the patella (similar to Sinding-Larsen- 

Johansson disease). Occasionally, patients 

experience tenderness at the superior 

pole of the patella, indicative of quadriceps 

tendonitis. 

Disease Management 

Management of Osgood-Schlatter disease, 

PFSS, and patellar tendonitis involves controlling 

pain and correcting biomechanical 

defects in knee extension. Activity 

modification along with rest, ice, compression 

(such as an ACE ® bandage wrap or 

open-patella neoprene knee sleeve), and 

elevation (“RICE”) are useful for controlling 

symptoms, as are nonsteroidal antiinflammatory 

medications. 

Therapeutic exercises to strengthen the 

quadriceps muscle, particularly the medial 

component (the vastus medialis oblique), 

and to stretch the hamstring and calf muscles 

work to improve patellar tracking and 

decrease pain over time. In elite athletes, 

The Physiology of the Knee 

Quadriceps 

(thigh muscle) 

Patella 

(kneecap) 

Patellar 

Tendon 

Tibial 

Tuberosity 

Tibia 

(shinbone) 

a formal physical therapy consultation is 

often helpful to reinforce strengthening 

and stretching exercises, to use modalities 

such as electrical stimulation, and to 

perform a gait analysis for detecting and 

correcting other predisposing biomechanical 

factors. 

There are key points to ensuring that 

patients receive proper care. Keep in mind 

that any young patient with knee pain but 

a normal knee exam requires a detailed 

evaluation of the hip joint, including internal 

rotation, to rule out a referred source 

of pain. Also, any athlete with more than 

four weeks of knee pain or recurrent joint 

swelling should have x-rays performed 

(five views, including lateral, sunrise, 

bilateral anteroposterior, bilateral skier’s, 

Quadriceps 

(thigh muscle) 

Patella 

(kneecap) 

Patellar 

Tendon 

Tibial 

Tuberosity 

Tibia 

(shinbone) 

Anterior View Medial View 



1


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/dislocation 

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 conservative 

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 University 

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. 

Bibliography 

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


1


Reality Check for 

Young Athletes 

Long-term effects of overuse injuries 

are a serious concern 

By Dennis Viellieu 

Over a year ago, Midwest Orthopaedics 

at Rush (MOR) decided to 

experiment with promoting sports 

safety in a vulnerable population — children. 

This decision was precipitated by the continuing 

trend for athletes to select a sport of 

choice at younger and younger ages. They 

compete, train, and participate in these sports 

year-round, increasing the probability of overuse 

injuries and the chance for sustaining an 

injury that will affect them for a lifetime. 

MOR started a program to provide children 

and their coaches with sports safety 

Tammy Sciortino (far right) teaches sports safety to athletes 

and their coaches with the goal of reducing overuse injuries 

through MOR’s athletic training outreach program. 


information, clinical coverage for tournaments 

and games, and medical advice 

or treatment. 

To lead the effort, MOR 

turned to Tammy Sciortino, 

an experienced athletic 

trainer familiar with young 

athletes in year-round 

programs. Before coming to 

MOR, Sciortino was the president and CEO 

of her own sports performance company, 

Sports Sciorts. In addition, she had athletic 

training, strength training, and massage experience 

working with organizations 

like the Chicago Fire Soccer Team, 

AVP Pro Beach Volleyball Tour, and 

Illinois Gymnastics Institute. 

Working with physical and athletic 

training company partners of MOR, 

Sciortino had the program up and 

running quickly. In one year, there 

are more than 7,000 athletes participating 

in clubs affiliated with the 

MOR outreach program. 

Sciortino and MOR offer sports safety 

classes and seminars to help make 

coaches and trainers aware of overuse 

injuries as well as other safety concerns. 

MOR also plans to offer first 

aid and CPR programs to the clubs 

to ensure that coaches and trainers 

are prepared for medical issues that 

might arise. 

The Truth Hurts 

According to SAfe KIdS uSA: 

· More than . million children ages 1 and 

under receive medical treatment for sports 

injuries each year. 

· Injuries associated with participation in 

sports and recreational activities account for 

21% of all traumatic brain injuries among 

children in the united States. 

· Overuse injuries, which occur over time from 

repeated motion, are responsible for nearly 

half of all sports injuries to middle- and 

high-school students. Immature bones, 

insufficient rest after an injury, and poor 

training or conditioning contribute to overuse 

injuries among children. 

· Most organized sports-related injuries ( 2%) 

occur during practices rather than games. 

despite this fact, a third of parents often 

do not take the same safety precautions 

during their child’s practices as they would 

for a game. 

· A recent survey found that among athletes 

ages to 1 , 1 % of basketball players, 2 % 

of football players, 22% of soccer players, 

2 % of baseball players, and 12% percent 

of softball players have been injured while 

playing their respective sports. 

source: sportssafety.org 

In 2007, Sciortino and MOR plan to roll 

out a sports safety program that is being 

developed in-house with the various sports 

medicine physicians. Anyone interested 

in either of these programs should call 

Sciortino directly at (708) 236-2624 (office) 

or (630) 272-2501 (cell). 

Dennis Viellieu is Chief Executive Officer of 

Midwest Orthopaedics at Rush and has served 

in this position for five years. He enjoys golf, 

basketball, and mountain biking.


1


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1

Need Kicker 

Making Strides 

Controversy surrounds 

the treatment of 

idiopathic toe walking 

By Monica Kogan, MD 

When children begin walking, a 

toe-to-toe gait pattern is considered 

part of normal gait develop- 

ment. However, a toe-walking gait pattern 

that persists past the age of 2 is considered 

abnormal, depending on gait velocity 11 . 

There are many causes for persistent toe 

walking in children, including cerebral palsy, 

congenital contractures of the Achilles 

tendon, muscular dystrophy, and idiopathic 

toe walking (ITW). 

Diagnosis 

The diagnosis of ITW is one of exclusion 

and can be challenging. For example, 

children with ITW typically walk on their 

toes but are able to flatten their foot on 

request or when concentrating on their 

gait. It may be especially difficult to distinguish 

ITW from children with mild spastic 

diplegia 7-10 . Children with cerebral palsy 

begin walking at a later age, and children 

with ITW begin to walk at the appropriate 

time, 18 months. 

The etiology of ITW is not known. Some 

authors have suggested that ITW patients 


have congenitally short tendo Achilles 6 . Others 

have divided patients into habitual toe 

walkers or those with short tendo Achilles 4 . 

If left untreated, the natural progression of 

persistent toe walking places children at risk 

for falling 2 , developing limitations in ankle 

mobility, and structural abnormalities, such 

as persistent outward tibial torsion 3 . 


Much controversy exists around the treatment 

of ITW. The goal of any treatment is to 

provide normal function, but also important 

is limiting the impact on the child and family. 

Heel cord lengthening (either open or 

closed), serial casting, and stretching and 

physical therapy are treatment options. 

Nonsurgical Solutions 

Nonoperative management, such as serial 

casting to stretch the plantar flexors, is 

believed by some to be the optimal initial 

treatment 13 . Each week, the child goes to the 

physical therapist to have the ankle stretched 

and a new cast applied. This process goes 

on six weeks or longer. 

Brower et. al. 1 showed that children with 

ITW along with cerebral palsy who toe walk 

and were treated with serial casting showed 

improvement in dorsiflexion and toe walking. 

Griffin et. al. 5 performed a gait analysis 

comparing ITW with heel-toe walkers before 

and after serial casting; the analysis showed 

that serial casting increased the range of 

dorsiflexion and also changed the muscle 

synergy pattern from abnormal to normal. 

Tachdian 13 suggested passive stretching of 

the heel cords, gait training, and below-knee 

walking casts as the initial treatment of ITW, 

with surgery being reserved for patients more 

than 8 years of age who have failed to respond 

to nonoperative treatment. Stretching 

without casting is an option where the child 

undergoes weekly stretching by a physical 

therapist, followed by gait training. 

Surgical Solutions 

The reported failure rate of nonoperative 

treatment is significant, leading to the 

recommendation by others that surgical 

intervention be the primary treatment. Proponents 

argue that operative management

of either an open or percutaneous Achilles 

lengthening produces more consistent 

outcomes, with improved ankle dorsiflexion 

and greater parental satisfaction 11 . 

Stricker and Angulo 12 showed that children 

treated initially with surgical intervention 

had better results with respect to restoration 

of ankle dorsiflexion and parental 

satisfaction, and that cast and brace treatment 

offered little long-term improvement 

compared with untreated ITW. Hall et. al. 6 

performed tendo Achilles lengthenings on 

a group of patients who showed no improvement 

after six months to two years 

of observation. They showed that, when 

treated surgically, the children exhibited 

normal passive and active dorsiflexion 

with a heel-toe gait pattern, except for 

occasional toe walking in older children. 

Both percutaneous and open techniques 

have been used for tendo Achilles lengthening. 

Patients are placed in below-the-knee 

weightbearing casts for four weeks and are 

allowed to bear weight immediately. During 

the four-week period, they participate in 

physical therapy for gait training. Since they 

have likely toe walked since ambulation 

began, patients need to be retrained to walk. 

Physical therapy should continue after the 

casts are removed, and it is beneficial that 

Bibliography 

1. Brouwer B, davidson LK, Olney SJ. Serial casting in idiopathic 

toe-walkers and children with spastic cerebral palsy. 

J Pediatr orthop 2000;20:221- . 

2. Caselli MA, Rzonca eC, Lue By. habitual toe walking: evaluation 

and approach to treatment. clin Podiatr Med surg 

1 ; : - . 

. deLuca pA. the musculoskeletal management of children 

with cerebral palsy. Pediatr clin north am 1 ; :11 - 0. 

. furrer f, deonna t. persistent toe walking in children: 

a comprehensive clinical study of 2 cases. Helv Paediatr 

acta 1 2; : 01-1 . 

. Griffin p, Wheelhouse W, Shiavi R, Bass W. habitual 

younger children go to a center that has 

pediatric physical therapists. 

Conclusion 

ITW is a problem that is seen quite often. 

Both operative and nonoperative methods 

of treatment have been recommended, 

and each has its pros and cons. Serial 

casting is a lengthy process with the child 

attending physical therapy once a week 

If left untreated, persistent toe walking can lead 

to structural limitations and abnormalities in the 

hips, knees, ankles, and feet. To achieve similar 

force and movement levels as those required 

during heel-toe walking, toe walkers require 

greater activation of less commonly used muscles, 

weakening the quadriceps and other muscles and 

threatening joint stability. 

toe walkers: a clinical and electromyographic gait analysis. J 

Bone Joint surg [Am] 1 ; : -101. 

. hall Je, Salter RB, Bhalla SK. Congenital short tendo 

calcaneus. J Bone Joint surg [Br] 1 ; : - . 

. hicks R, durinick n, Gage JR. differentiation of 

idiopathic toe walking and cerebral palsy. J Pediatr orthop 

1 ; :1 0- . 

. Katz MM, Mubarak SJ. hereditary tendo Achilles contractures. 

J Pediatr orthop 1 ; : 11- . 

. Rose J, Martin J, torburn L, et al. electromyographic differentiation 

of diplegic cerebral palsy from idiopathic toe 

walking: involuntary coactivation of the quadriceps and 


for at least six weeks, followed by physical 

therapy after cast removal. This can be 

time consuming for both the patient and 

the parent or caregiver. 

Surgery as the initial treatment may be 

seen by some as aggressive, but the results 

have been more consistent. Often, parents 

or caregivers will try nonoperative measures 

first and opt for surgical intervention 

if no improvement is seen. Studies show 

that most often children end up requiring 

surgery. However, no damage is done 

by trying physical therapy first. If nothing 

else, parents or caregivers feel secure 

knowing that all options were exhausted 

before opting for surgery. 

Monica Kogan, MD, specializes 

in pediatric orthopaedics 

at Midwest Orthopaedics at 

Rush. A medical graduate from 

the University of Illinois College 

of Medicine in Chicago, Dr. 

Kogan completed a residency in orthopaedic 

surgery at Northwestern Memorial Hospital. 

A fellowship in pediatric orthopaedic surgery 

was completed at the Primary Children’s Medical 

Center in Salt Lake City, Utah, a renowned 

pediatric center serving five states in the 

intermountain region. 

gastrocnemius. J Pediatr orthop 1 ;1 : - 2. 

10. Sala dA, Shulman Lh, Kennedy Rf, et al. Idiopathic toe 

walking: a review. dev Med child neuro 1 ; 1: - . 

11. Statham L, Murray Mp. early walking patterns of normal 

children. clin orthop 1 1; : -2 . 

12. Stricker SJ, Angulo JC. Idiopathic toe walking: 

a comparison of treatment methods. 

J Pediatr orthop 1 ;1 :2 - . 

1 . tachdjian MO. the foot and leg. In: tachdjian MO, 

ed. Pediatric orthopaedics, vol. 2. philadelphia: Saunders: 

1 2:1 - 0. 


21



2


ITW Defined 

distinctive characteristics help pinpoint 

tiptoe gait 

By Tina Chase, MPT, PCS 

Idiopathic toe walking (ITW) is characterized 

by a bilateral tiptoe gait that 

originates within several months of 

independent ambulation. In normal development, 

a mature heel-toe gait pattern emerges 

and is consistent by 2 years of age. Before 

that, intermittent toe walking can occur and 

progress to a mature gait pattern. 

For some of these children, however, toe 

walking persists without history of prematurity, 

difficult delivery, evidence of hypertonicity, 

or abnormal reflexes. Standing 

and walking on tiptoes throughout toddler 

and school-aged years continues despite 

relatively normal development and attainment 

of advanced gross motor skills, such 

as running and skipping. 

Distinguishing Features and Diagnoses 

When diagnosing ITW, mild spastic diplegia 

cerebral palsy (CP) is considered in 

the differential diagnosis. In addition to the 

neurological exam, family history, range of 

motion (ROM), and gait pattern assist in 

confirming ITW. 

Unlike CP, ITW is an autosomal dominant 

trait. Approximately 40% of those affected 

by ITW have a family history of tiptoe gait. 

Also differing is passive ankle dorsiflexion 

ROM with the knee extended, which typically 

averages more than 5 degrees in ITW 

versus less than 5 degrees with mild CP. 

The gait pattern of the two is also slightly 

different. In ITW, the knees typically remain 

flexed throughout the gait cycle and the feet 


plantarflexed throughout most of the swing 

phase. In CP, the knees flex at initial contact, 

have no loading response, and extend 

through mid or late stance. The feet dorsiflex 

during the swing phase. 

Late-onset toe walking implies a well- 

established period of heel-toe gait followed 

by the emergence of toe walking. This progression 

is not characteristic of ITW, and 

Serial casting can be an effective technique for 

gaining stretch in the Achilles tendon. A belowthe-knee 

plaster or fiberglass cast is applied/ 

changed weekly to progressively increase the 

range of dorsiflexion. 

neuromuscular abnormality — including 

spinal cord anomalies, peripheral neuropathies, 

and muscular dystrophies — should 

be considered. 

The Importance of Range of Motion 

Kinematic studies show that approximately 

10 degrees of ankle dorsiflexion occurs during 

normal gait. A heel-toe gait pattern is 

achievable, however, with as little as 0 degrees 

of dorsiflexion. Because most ITW patients 

have at least 0 degrees of dorsiflexion, they 

may stand and walk normally on command. 

In deciding the course and effectiveness of 

treatment, the degree of active and passive 

dorsiflexion ROM should be considered. If 

a child has at least 10 degrees of active dorsiflexion 

with the knee extended, then focus 

can be placed on strengthening the dorsiflexors 

and the timing of their activation during 

gait. If there is significant dynamic tone in 

the gastrocnemius and/or soleus muscles, 

the Tardieu Scale measures of resistance 1 

(R1) and resistance 2 (R2) can be used. 

R1 refers to the initial end range or dynamic 

range of the muscle. It is the first resistance, 

or “first catch,” appreciated when 

the ankle is quickly, passively dorsiflexed. 

R2, or “second catch,” refers to the maximal 

end-range length of the muscle, which 

is obtained when the muscle is maximally 

stretched with continued pressure into the 

elongated position. 

For an ITW patient, R1 is functionally more 

relevant than R2 since most will only use the 

ROM up to R1 during gait. This is especially 

true when the “thickness” of resistance 

between R1 and R2 is great. When this is 

the case, a fixed muscle contracture may be 

developing, and ROM gains are expected 

to be minimal with stretching alone. Better 

ROM gains may be obtained with bracing, 

casting, or surgery. 


Once ITW is diagnosed, a course of treatment 

can be determined. Conservative 

approaches to treating ITW include physical 

therapy by a pediatric physical therapist for 

stretching, strengthening, and gait training. 

Night and/or daytime bracing in ankle foot 

orthoses (AFOs) or serial casting over several 

weeks may be prescribed for children whose 

ankles do not easily dorsiflex beyond neutral. 

Botox injections to weaken the overactive

gastrocnemius or surgical lengthening of the 

Achilles tendons by an orthopaedic surgeon 

also are successful treatment interventions 

and may appeal to families when conservative 

measures fail. 

Choosing the appropriate course of treatment 

depends on many factors, including: 

• Age, attention, and cognitive abilities of 

the child 

• Ankle dorsiflexion, ROM, and degree of 

toe walking 

• Importance of speedy and full recovery 

Physical Therapy 

Physical therapy for ITW can be most effective 

when performed by a pediatric physical 

therapist. Walking on challenging surfaces 

such as sand, ramps, or a mattress on the 

floor can reinforce heel contact and teach 

appropriate timing and coactivation of the 

foot musculature. These strategies can be 

taught to caregivers for practicing at home. 

Bracing 

AFOs can be worn at night to apply a 

long-duration, low-intensity stretch to the 

heel cords or during the day to promote 

a heel-toe gait. They have shown better 

Idiopathic Toe Walking 

Hip: normal kinematics 

Knee: Remains flexed throughout gait cycle 

Maximum extension is at ground contact with 

the knee averaging 11 degrees of flexion 

Ankle: Average passive dorsiflexion is more than 

degrees (range is less than 10 degrees to more 

than 1 degrees) 

Ground contact is in plantar flexion 

Swing phase: Ankle initially dorsiflexes but then 

plantarflexes mid to late swing 

Walking on challenging surfaces such as an 

inclined treadmill can help reinforce heel contact 

and teach appropriate timing and coactivation of 

the foot musculature. 

outcomes in children who do not gain ROM 

with stretching or who consistently toe walk 

despite exercises. Although many children 

return to toe walking once the AFOs are 

removed, the braces allow the heels to be 

loaded correctly and the postural muscles to 

be used in correct alignment. 

Casting 

Serial casting involves applying short leg 

casts to the lower legs and feet to stretch the 

gastrocsoleus muscles. It can be indicated 

if conservative stretching fails, if bracing is 

not well tolerated by the child, or if tightness 

prevents bracing. With casting, the ankle 

joint is held in an elongated position for 

several weeks vs. several minutes or hours 

as with stretching and bracing. Casts are 

changed every one to two weeks between 

Mild Diplegia 

Hip: normal kinematics 

Knee: flexes at ground contact, has no loading 

response, and extends through mid and late stance 

Maximum extension is at mid to late stance 

Ankle: Average passive dorsiflexion is less than 

degrees (range is less than 20 degrees to 0 degrees) 

Ground contact is in plantar flexion 

Swing phase: Ankle dorsiflexes throughout the 

entire phase 

three and eight times. With each cast, the 

ankles are repositioned into a greater degree 

of ankle dorsiflexion until the desired ROM 

is obtained. Serial casting can result in large 

gains in ROM and improvements in walking 

in a short period of time. 

Conclusion 

Early detection of ITW is important because 

prolonged tiptoe gait can lead to adaptive 

shortening of the heel cords, weakness and 

poor coordination in the knee and ankle 

musculature, and postural changes in the 

trunk. Timely referral to an orthopaedic 

surgeon and a pediatric physical therapist 

increases the likelihood of successful treatment 

and, in the long run, may be less 

costly and time consuming. 

Tina Chase, MPT, PCS, 

Clinic Director of The Pediatric 

Place in Naperville, Illinois, 

is available to speak with 

physicians and/or groups who 

would like to learn more about 

idiopathic toe walking (ITW). She received her 

master’s degree in physical therapy from Gannon 

University, where she was honored with 

the “Outstanding Service in Physical Therapy 

Award.” Chase’s professional certifications 

include pediatric clinical specialist and neurodevelopmental 

treatment for the pediatric 

population. She also specializes in lower 

extremity biomechanics/serial casting and 

has a particular interest in cerebral palsy and 

developmental coordination disorder (DCD). 

The Pediatric Place is a Stryker Physiotherapy 

Associates company. Stryker currently 

has 18 adult and 12 pediatric facilities in 

the Chicago area. Call (312) 944-7595 to 

be connected to Tina in Naperville or any 

Illinois facility. 

Editor’s Note: Tina Chase is not affiliated 

with Midwest Orthopaedics at Rush. Treatment 

recommendations presented in this article are 

solely the professional opinion of the author. 


2


Dictation 

Goes Digital 

Online platform makes 

cassette tapes obsolete By Victoria Chavez 

Midwest Orthopaedics at Rush (MOR) 

has a long history of working with 

various medical transcription (MT) 

services, including five independent MTs or 

MT services. Physicians have developed very 

close working relationships with their MTs. 

These MTs allow for great productivity and 

efficiency because of their familiarity with 

the physician’s dictation style and use of 

medical and technical jargon. 

MOR needed a system that would help improve 

the workflow of its support staff and 

turnaround time from its MT services, but 

converting all of the physicians to one new 

service where a number of different MTs 

are used was not an option. MOR decided 

to let all of its physicians keep their current 

MTs but to transition to one centralized 


technology platform to maximize efficiency 

while still preserving the quality of service. 

MOR found what it was looking for in Scribe 

Healthcare Technologies, Inc., Lake Forest, 

Illinois, a company that came highly recommended. 

Scribe offered a centralized system 

for all areas of transcription that would 

consolidate processes, limit paperwork, and 

eventually save time and money. In effect, 

MOR went from cassette tapes and daily 

courier services in December 2003 to using 

digital recording devices for digital transmission 

of data in January 2004. 

The flexibility of the Scribe system played 

a very important role in transitioning the 

physicians to a new system quickly, because 

the physicians were able to keep the 

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 relationships 

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 

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 provided 

training sessions with each of the MT 

services and assisted with setting up their 

new computers. Once each MT service was 

comfortable on the system, they proceeded 

to implementation. 

Second, the support staff, management 

team, and physicians were trained on 

Scribe’s online MD platform, reworking their 

processes to handle dictation efficiently 

on the new platform. Again, Scribe was 

there every step of the way, training MOR’s 

practice groups. This step also involved 

purchasing digital voice recorders for 

all clinicians and physicians, installing 

software on all computers 

for downloading audio files 

from the digital recorders, and 

training the staff how 

to download. 

With technology comes the need for 

support. Scribe was very familiar with 

typical troubleshooting issues and helped 

MOR’s IT staff through the transition.

The last step was training the physicians and 

clinicians to use the digital voice recorders. 

Although using them was not extremely 

different from using old devices that stored 

information on tapes, the look and feel of the 

new devices was slightly different and information 

was stored digitally. The MTs, physicians, 

and support staff were now working 

on one system divided into two platforms, 

one for the MTs and one for the physicians. 

Later, Scribe introduced the administrative 

platform. This platform allowed for MOR to 

support staff internally, and only on rare occasions 

do they need to reach out to Scribe 

for technical support. Now that the technical 

kinks have been worked out from the implementation 

process and the administrative 

platform has been introduced, MOR only 

needs one IT staff member to support its 

Scribe system. 

Improved Efficiencies 

For many reasons, the decision to use 

Scribe’s services has surpassed all expectations. 

MOR no longer has to store or 

purchase tapes or rely on a courier service 

to deliver dictations to the proper sources. 

Now, MOR has a constant flow of files 

going out and completed files coming in. 

By eliminating the middleman, MOR avoids 

costly intercepts that can result in the 

complete loss of audio 

files. With its 

new system, MOR rarely loses a file, in 

which case it is usually attributed to user 

error. In addition, the audio files are stored 

on the computer and are tracked on the 

Scribe system, substantially increasing the 

chances of finding missing information. 

MOR staff has quickly become accustomed 

to transferring audio files to its MT services 

in a matter of minutes. The audio files 

can be transmitted electronically from the 

physician to the MT service almost instantaneously. 

With courier service and tapes, the 

standard turnaround time was two weeks; 

now it is anywhere from four to 48 hours. 

With a practice that is constantly growing, 

space is a priority. Now that its files are 

stored electronically, it is not necessary for 

MOR to physically store everything in charts 

in its medical records department. Scribe’s 

platform is completely Web-based, so critical 

patient information is available at all times. 

Planning Ahead 

Since the transition, Scribe has been flexible 

in accommodating MOR’s needs as a 

company. For instance, MOR is taking large 

strides toward an electronic medical records 

system. 

A digital voice recorder stores information on an 

online platform rather than on tapes. 

MOR Thanks Its MTs 

Without our talented Mts, the transition to 

Scribe’s platform would have been a daunting 

challenge. We thank you for all you do and for 

your dedicated service to our company. 

– Anne Luginbill, independently contracted 

for 1 years 

– Ct transcription, 1 years 

– Accuscript, years 

– Keystrokes transcription Service, Inc., years 

– Joyce Garst, independently contracted for 

over a year 

MOR recently launched a Health Level Seven, 

Inc. (HL7) interface that exports patient identification 

information from its system application 

into the Scribe platform and imports 

patient clinical notes from Scribe into MOR’s 

system. The interface attaches all notes back 

into the patient’s chart in MOR’s system. 

Scribe has always taken into consideration 

any suggestions or needs of MOR to ensure 

the system is working at its full potential. 

So far, MOR has reduced costs and enhanced 

work processes on all fronts, and 

the company can report with simplicity 

for billing purposes and quality assurance. 

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 degree 

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 

Systems and Marketing Manager. She enjoys 

scrapbooking and traveling. 


2



2

Need Kicker 

Smart 

Tools in 

Practice 

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. 

Physicians should spend the majority 

of their day delivering quality patient 

care. This is why they have completed 

years of study and specialization. Most 

would probably prefer to focus their time 

on improving the quality of life for patients 

rather than dealing with administrative 

issues. The last thing a physician needs 

to be inconvenienced by is note dictation, 

including dictating his or her own notes, 

finding transcribed documents, or locating 

notes from referring physicians. 

An Affordable, Convenient Solution 

Fortunately, a new breed of company is 

making a difference and enabling physicians 

to focus on their number-one priority, the 


patient. Companies such as Scribe Healthcare 

Technologies, Inc., Lake Forest, Illinois, 

and Vianeta Communications, Milpitas, 

California, offer Web-native technologies that 

are cost-effective to purchase and maintain 

compared to other software solutions. These 

integrated Internet technologies work with 

the existing hardware and widely used Microsoft 

technology that most offices use. 

In the short history of transcription technology, 

an easy, inexpensive, predictable, 

quality product has not always existed. Many 

technologies implemented during the last 15 

years involved purchasing exorbitantly priced 

hardware and/or software or the use of voice- 

recognition software that did not provide a 

suitable product. While speech recognition 

and electronic medical records (EMR) were 

once predicted to make transcriptionists 

obsolete by the year 2000, the reality is that 

physicians still dictate, and transcriptionists 

still transcribe. 

A Personal Touch 

There is a bright side. After years of failed 

technological implementations, new 

technologies are adapting to the requirements 

of the physicians. Technology-based 

transcription had to take a close look at what 

physicians needed, how they did their work, 

and what the end product needed to be. 

Both Scribe and Vianeta are companies that 

have responded to these needs and provided 

products that fit easily into a physician’s

existing workflow. In the typical workflow of 

a Web-based transcription: 

• The physician picks up the phone or handheld 

recorder and dictates his or her notes. 

• The dictation is routed to voice-recognition 

software or to the medical transcriptionist 

(MT). The record is created 

in Microsoft Word using the physician’s 

preferred formatting and letterhead. 

• The document is sent to a physician- 

accessed inbox via the Internet. On this 

Internet platform, the physician can edit, 

print, fax, e-mail, and store documents 

securely. Authorized persons can access 

the documents at home or in the office. 

Back End Support 

What does a physician need to run these 

systems? While many dictation and transcription 

systems cost between tens and 

hundreds of thousands of dollars in upfront 

expenses, Scribe’s system is Internet-based. 

All that is needed is an updated PC with 

Microsoft Windows and Office programs, a 

high-speed Internet connection, and access 

to a phone. For a low monthly licensing fee 

and a per-line charge for the storage of documents 

on Scribe’s platform, physicians can 

use MTs they already work with or choose 

from offshore or domestic vendors who type 

on the Scribe MT platform. 

Systems like these allow physicians to: 

• Perform an advanced search of all documents 

on the platform, meaning they can 

search all patient files by the name of a 

drug, diagnosis, or treatment. 

• Listen to all of their audio files, which are 

stored electronically. 

• Keep an address book of all the referring 

physicians with whom they communicate, 

which is available online to the MTs. 

An Evolving Industry 

This new breed of healthcare technology 

company has been growing its value proposition. 

Scribe has begun to make its move 

from dictation and transcription technology 

to offering a complete online repository that 

looks like an EMR database. In 2006, Scribe 

announced PatientChart as an “add-on” 

module. PatientChart allows a practice to 

centralize and store all patient information, 

including transcribed records, images, lab results, 

and more. It is flexible, allowing records 

to be created through “smart templates.” 

“Scribe focuses on documentation technologies 

that complement the way physicians 

work. We plan to add a secure communica- 


tion product in 2007 that will allow physicians 

to share information with other physicians 

or their patients,” says John Weiss, 

Vice President of Sales and Marketing for 

Scribe. “As insurance companies begin to 

embrace phone and e-mail consultations, 

our new communication product will allow 

for tracking and reimbursement for these 

types of services.” 

The University of Chicago Hospitals have 

found Scribe’s package to be tremendously 

supportive of their dictation and transcription 

process. “The customer service is excellent,” 

says Dennis Gray, Assistant Director 

of Medical Records at University of Chicago 

Hospitals. “The training and ownership are 

fabulous. They are right in there with the 

physicians, training them and helping them 

use the system correctly.” 

The University of Chicago Hospitals are 

implementing an electronic signature process, 

and Gray says he is looking forward to 

experiencing its full benefits soon. 

In much the same way that physicians relieve 

patients’ pain and increase their ability 

to function in life, technology has evolved 

during recent years to ease physicians’ workloads 

and improve their ability to function 

more efficiently in providing patient care. 

Lora Freeman is the Midwest Region Account 

Manager for Scribe Healthcare Technologies, 

Inc., where Midwest Orthopaedics at Rush is 

one of her customers. Freeman has been with 

Scribe for more than two years. She uses the 

dictation platform to support her writing when 

she cannot access the computer directly. 

John Weiss is the Vice President of Sales and 

Marketing for Scribe Healthcare Technologies, 

Inc. Prior to acquiring Scribe, John was an 

early Internet entrepreneur, having founded 

several successful dotcoms like Starting Point, 

WebPromote, and YesMail. In his free time 

John enjoys spending time with family, sailboat 

racing, and water skiing. 


1


Midwest Orthopaedics at Rush thanks the following advertisers for helping 

make this publication possible. 

Accelerated Rehabilitation Centers ... see page 22 

AMDC ................................................... see page 18 

AthletiCo ................................see inside front cover 

ATI Physical Therapy ............ see inside back cover 

Benefitdecisions, Inc. 

125 S. Wacker Dr., Ste. 2075 


(312) 606-4800 • (312) 606-8101 Fax 

www.benefitdecisions.com 

Central DuPage Hospital .................... see page 18 

Chicago Bulls ........................................ see page 32 

Chicago Magazine .............................. see page 17 

Chicago Office Technology Group .... see page 33 

Chicago Rehabilitation Services, Inc. .. see page 15 

Chicago Rush Arena Football ............. see page 29 

Citigroup ..........................................see back cover 

DePuy Spine ......................................... see page 18 

Gallagher Healthcare 

Insurance Services, Inc. .....................see page 23 

Girling Health Care, Inc. ..................... see page 32 

Harris Private Bank .............................. see page 23 

H-Wave ................................................. see page 23 

Illinois Collection Service, Inc. ............ see page 32 

MB Financial Bank ............................... see page 22 

McGuireWoods LLP 

77 W. Wacker Dr., Ste. 4100 


(312) 849-8100 • (312) 849-3690 Fax 

www.mcguirewoods.com 

OccuSport Physical Therapy ............... see page 19 

Omnia Marketing & Design ............... see page 32 

Patient Care ......................................... see page 29 

Perkins + Will ....................................... see page 28 

Physiotherapy Associates ...................... see page 9 

Rush Oak Park Hospital ……………… see page 23 

Rush SurgiCenter LP ............................ see page 22 

Scheck & Siress ..................................... see page 14 

Scribe Healthcare Technologies, Inc. . see page 18 

Spada Law Offices, P.C. ....................... see page 15 

The Center, Inc. 

1853 Bernice Rd. 

Lansing, IL 60438 

(800) 237-8228 • (708) 730-3324 Fax 

Directory 

WCS Physical Work Re-Training ......... see page 29 

William Blair & Company, L.L.C. ......... see page 19 

Wolf Financial Group .......................... see page 33 



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Westchester, IL 60154-5701

Volume 3, Issue 5 - Midwest Orthopaedics at Rush

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