CONTENTS VOLUME 15, NO. 1
2
Index to Advertisers
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IN THIS ISSUE
JANUARY/FEBRUARY 2013
Head, shoulders, knees and toes...and elbows, ankles, hips and backs. By Richard R. Sturgeon, M.D.
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PRESIDENT’S MESSAGE By Edwin N. Bogonko, M.D.
Patient-Physician Relationship — Tops 2013 List
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TCMS IN ACTION By Sue Schettle, CEO
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LETTERS
What’s on the Agenda for the 2013 Legislature? By Nathan Mussell, JD
Page 33
SPORTS MEDICINE
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Colleague Interview: A Conversation With David Fischer, M.D.
12
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Pediatric Sports Injuries By Steven Greer, M.D.
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Concussion Management in Youth has Evolved By Angela Sinner, D.O., Mark Gormley, Jr., M.D., Leslie Larson, P.N.P., and David Everson, PT
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Evaluation and Treatment of Running-Related Foot and Ankle Injuries By Marie-Christine Leisz, DO
Page 33
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Treatment of Common Shoulder and Elbow Injuries By Michael Q. Freehill, M.D.
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Strength Training Reduces the Risk of Knee Injury By Timothy Panek, M.D.
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The State of Imaging in Sports Medicine By Nathan Block, M.D.
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Injury Prevention 101 By Amy Hamilton, MA, ATC
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Fluid Replacement for High School Sports Safety By William O. Roberts, M.D., M.S.
Page 33
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New Members and Member Profile
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EMMSF Annual Meeting, Honoring Choices, Caring Hearts for Homeless People Supply Drive
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In Memoriam and Career Opportunities
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LUMINARY OF TWIN CITIES MEDICINE
A. Stuart Hanson, M.D. Page 33
MetroDoctors
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TCMS Physicians Receive Awards
The Journal of the Twin Cities Medical Society
On the cover: Sports Medicine — evaluation and treatment of unintended injuries. Articles begin on page 9.
January/February 2013
1
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS.
January/February Index to Advertisers
TCMS OfďŹ cers
President: Edwin N. Bogonko, M.D. President-elect: Lisa R. Mattson, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Kenneth N. Kephart, M.D. Past President: Peter J. Dehnel, M.D. TCMS Executive Staff
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Executive Assistant (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com Kristine Stevens, Project Coordinator (612) 362-3706 kstevens@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
Advanced Dermatology Care.........................23 Billing Buddies MN .........................................16 CrutchďŹ eld Dermatology.................................. 2 DMG Financial Group ...................................18 Fairview Health Services .................................30 HCMC ................................................................... 8 Healthcare Billing Resources, Inc. ................. 6 Kathy Madore..................... Inside Front Cover Lockridge Grindal Nauen P.L.L.P. ...............15 Neighborhood Health Source .......................31 Newman Long Term Care ..............................25 Saint Therese......................................................... 6 South Country Health Alliance ....................31 University of Minnesota Physicians.................. Outside Back Cover Uptown Dermatology & SkinSpa................11 U.S. Navy ............................................................30 Winona Health ..................................................31
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The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Head, shoulders, knees and toes ‌and elbows, ankles, hips and backs. MetroDoctors publishes articles with information for our physicians to apply in their practice while caring for their patients. Sports medicine clinicians are at the ready to address dysfunction in all these areas and more. This issue also provides interesting and useful information we can apply to our own personal health and that of our families and friends. One does not need to play NFL football to end up with a sore back, knee or ankle. Or worse. Steven Greer, M.D. reminds us that the more frequent bruises and strains respond to RICE therapy; Rest, Ice, Compression, and Elevation. Nice to know some things don’t change. He also supplied another useful guide — the Ottawa Ankle Rules to differentiate a mild ankle sprain from a more serious injury. Dave Fischer, M.D., our colleague interview, and Nate Block, M.D. call out the great leap forward made when MRI became an available diagnostic option. MRI provides images beyond just the bones for both acute injury assessment and for post-procedure evaluation of soft tissue integrity and healing. Drs. Timothy Panek and Chris Leisz, and Amy Hamilton, certiďŹ ed athletic trainer, remind us how lower extremity traumatic injury and the more common over-use injury of knee and ankle can be mitigated to a degree by optimum core muscle strength to stabilize the pelvic girdle and low back. This keeps the mechanics of energy transfer and movement of joint components aligned. They describe a plyometric conditioning program that was new to me. Chris describes effective non-surgical approach to common but painful heel and ankle conditions. And new ideas‌ nitroglycerine patches! What next? Mike Freehill, M.D. updates us on upper extremity trauma in the athlete. He also addresses the weekend athletes and their more common de-conditioned or repeated use injuries. New treatment using platelet-rich-plasma in cases refractory to conservative therapy broadens the treatment landscape. We are reprinting (with permission) a timely and informative article by Dr. William Roberts published earlier by the Minnesota State High School League. Sport drinks OK‌..Energy drinks not OK.
Our concussion article is contributed by the multidisciplinary team at Gillette Children’s Neurotrauma Clinic. Parents, coaches and the athletes have good reason to be vigilant. Fortunately sportsrelated concussions usually resolve without complications. The authors indicate there is no need for referral when your patients’ symptoms are mild and improve within three to ďŹ ve days after their injury. Consider referring concussion patients to a specialist when initial symptoms are moderate or severe, or symptoms persist or worsen after three to ďŹ ve days. And, lastly, our featured Luminary of Twin Cities Medicine showed his leadership skills on the court as a basketball star, and continues today to be a star in the public health and policy arenas. Leading the initiative for Minnesota to become a smoke-free state is just one example of the great work accomplished by A. Stuart Hanson, M.D. We urge our patients to preserve good health by practicing a physically active lifestyle. We try to do the same for ourselves. These authors and their advice help prepare us for unintended consequences.
Head, shoulders, knees and toes Ɖ Ɖ Ɖ.
By Richard R. Sturgeon, M.D. Member, MetroDoctors Editorial Board
MetroDoctors
The Journal of the Twin Cities Medical Society
January/February 2013
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President’s Message
Patient-Physician Relationship—Tops 2013 List EDWIN N. BOGONKO, M.D.
W
elcome to this edition of MetroDoctors, your society’s membership journal that keeps you abreast of what is challenging our profession, the role we play and our effort to represent most of your interests. TCMS continues to lead the way in Obesity Prevention through the efforts of the Twin Cities Obesity Prevention Coalition as well as a community approach to advance care planning through the award winning Honoring Choices Minnesota program. In these extraordinary times, both for our country and our profession, a lot is being asked of us to hold our elected officials accountable on the one hand and yet serve our profession with diligence and purpose on the other. This, while preserving the most crucial of ties, the doctor-patient relationship. With a spirited election leaving the country in a crossroad of ideological divide, one thing is clear — the Accountable Care Act is here to stay — at least for now. Obamacare will demand from us time and often completion of sometimes mundane tasks as our roles are apportioned. In an effort to define the path of Obamacare, several interest groups have rushed to define that which doctors, and the institutions they work in, must do. We will increasingly see our role defined by someone else — unless of course we rise up to the challenge of our time to do all we can to preserve the doctor-patient relationship as well as stand up for our profession. Yet we must also ask — what is the patient really accountable for? One thing is certain — we will be expected to lead in the reduction of medical errors and the improvement of care quality against a backdrop of reducing overall health care expenditures. Certain truths remain — we all have a desire to see health care access improve and efficiency in service provision increase at a more affordable cost while eliminating rampant waste and fraud. So many times we are caught in the middle — providing “emergency” care to all. Yet for those who don’t have insurance, this is a not-sustainable way to provide care. It raises huge challenges to our enduring promise to heal. One could argue that this is the reason health care affordability is the central issue for better health for America. For others, it is a simple principle — where is individual responsibility? Or, what if employers drop health coverage altogether? Is this just the cycle of health care and it is another turn for some form of capitation? I will leave the judgment to history and posterity. In the end, we have to endure a new, unpredictable landscape in order to stay relevant, have a say, and make our collective opinion count. I remain hopeful that when the dust settles we can all draw not a red or blue line but the right line — one that preserves that which we have always held sacred — our patients and the relationships we hold dear. And, that we can focus on delivering the best possible care to our patients. Ultimately, we have to remain stewards of both our profession and the care we deliver. In the past two years, TCMS has engaged in trying to help create the conversation about the ACA and our place in it. We all see it differently — a healthy reality in having a sober discourse. However, in order to be relevant, we have to be visible and engaged. Physician revenues are threatened and the independent practices we all grew to value in our communities are disappearing faster than we can comprehend — victims of the cost of health reform and its requirements. To say “all I want to do is see patients” is no longer par for the course — unless we are OK with someone looking over our shoulder, and telling us what to do. More than ever before, a little introspection on our part is necessary — to embrace the challenge and together define and preserve our place. But, I digress. Well, this journal issue is really about something else — the emergence of sports medicine as a discipline requiring our collective focus and support. Sports injuries threaten potential careers of many young people and new evidence of concussions and their long-term effects, for instance, continue to emerge. As physicians, we need to continually renew our knowledge to better serve our community of all people engaged in every sport, every day — from treatment to rehab. I look forward to serving as your president in 2013. I encourage you to contact me with your ideas, questions and/ or concerns: edwinbogonko@gmail.com. 4
January/February 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
Peter Dehnel, M.D., TCMS president, was honored at the American Medical Association’s interim meeting on November 12, 2012 as the recipient of the Benjamin Rush Award for Citizenship and Community Service. AMA Board Chair Steven J. Stack, M.D. stated that the award was given “honoring his public health work to improve the health of Minnesota’s youth by reducing tobacco use and preventing childhood obesity.”
A sincere thank you to outgoing TCMS board members: Peter Bornstein, M.D., Eric Crockett, MMGMA president, Cole Greves, M.D., and Sanjiv Kumra, M.D. Their leadership and commitment to TCMS has helped to shape the organization into what it is today. And, a special thank you to Thomas Siefferman, M.D., past-president of TCMS, whose term ended on December 31, 2012. Welcome New Board Members
The TCMS board of directors approved the appointment of six new Directors with terms beginning in January. The new members are Mark Destache, M.D., Carol Grabowski, M.D., Ryan Greiner, M.D., Thomas Kottke, M.D., Chris Reif, M.D., and Terzia Stephan, M.D. In addition, three medical student representatives: Zachary Lauer, Maddy Lenhard and Matthew McPheeters and MMGMA President-elect Bill Evans have joined the Board.
Board Updates
Mark Destache, M.D.
MetroDoctors
Bill Evans
The TCMS Board recently re-appointed the following members to the West Metro Medical Foundation Board of Directors for two year terms: Paul Hamann, M.D. and Elisabeth Hurlimann, M.D., Ph.D. EMMSF and WMMF Present Awards
Four TCMS members were recently honored by their colleagues and acknowledged with deserving awards. See article and photos on page 33. Legislative and Policy Committee Gears up for 2013 Session
Jeremy Lazarus, M.D., AMA president, presents Benjamin Rush Award to Peter J. Dehnel, M.D.
The 2013 TCMS Officers and Executive Committee members are: Edwin Bogonko, M.D., president, Lisa Mattson, M.D., president-elect, Carolyn McClain, M.D., secretary, Ken Kephart, M.D., treasurer, and Peter Dehnel, M.D., past president. Matthew Hunt, M.D. and Nick Meyer, M.D. join the executive committee as members-at-large.
West Metro Medical Foundation
From left: medical students Zachary Lauer, Maddy Lenhard and Matthew McPheeters.
Carol Grabowski, M.D.
The Journal of the Twin Cities Medical Society
In late 2012, the TCMS Legislative and Policy Committee conducted a survey of the TCMS membership asking for their input to help prioritize the policy and legislative activities of TCMS moving into the 2013 legislative session. A summary of those results will be presented to the membership through our e-newsletter, but more importantly, will serve as a guide to the committee as they focus their workplan.
New Board Members
Ryan Greiner, M.D.
Thomas Kottke, M.D.
Chris Reif, M.D.
Terzia Stephan, M.D.
January/February 2013
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Dear Dr. Hanson: I read with interest your article entitled “Finding our Future Doctorsâ€? in the NovemberDecember issue of MetroDoctors. I was quite taken aback by your statement, in reference to the supplemental application, “We ask them to explain any institutional actions, misdemeanors or felonies they may have.â€? Under what circumstances would the medical school admissions committee consider admitting a convicted felon? When there are many qualiďŹ ed applicants, the idea that the committee would consider a felon is appalling to me! Sincerely yours, JoAnn R. Reed, M.D.
Response to Letter to the Editor: The American Medical College Admission System (AMCAS) asks questions about any institutional actions (usually a college action), misdemeanors or felonies that might be on a candidate’s college or public record and asks them to be explained. Any entrees to these questions are reviewed as part of the holistic review by the admissions committee. Not infrequently institutional actions and misdemeanors are reported and explained, including what the candidate learned from the process. Most of these reports are for not following policies or laws related to alcohol. Occasionally, it is an issue related to misrepresentation of ones own work (such as accusations of plagiarism). In my nine years on the committee, I cannot recall any candidate listing a felony. But, if a felony was reported, it would be a red ag and that applicant would receive comprehensive scrutiny. I cannot say such a candidate would never be allowed to start a medical career, but it would be a steep hill to climb. The question needs to be asked. I am glad the issue has not come up to date. But, if it does come up in the future, the committee has the procedures and is prepared to respond. A. Stuart Hanson, M.D. UMN Medical School Admissions Committee member
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January/February 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
What’s on the Agenda for the 2013 Legislature?
F
or the third time in three election cycles Minnesota has a new legislative majority. After two years of Republican controlled majorities in both the House and Senate, the pendulum swung back in November as the DFL regained control in both the House, with 73 members, and the Senate, with 39 members. Minnesota now has the Governor’s Office and both bodies of the Legislature controlled by one party, a feat that has not occurred since the early 1990s. The new committee chairs in Health and Human Services were named shortly after leadership was announced. The Senate is going back to a two committee structure, with the Health and Human Services Finance Division being chaired by Sen. Tony Lourey (D – Kerrick) and the Health, Housing and Family Security Committee being chaired by Sen. Kathy Sheran (D – Mankato). In the House, as expected, Rep. Tom Huntley (D – Duluth) will return as chair of the HHS Finance committee, while Rep. Tina Liebling (R – Rochester) takes over as chair of the Health and Human Services Policy Committee. Interestingly, this is one of the first times in recent history there is not a metro member chairing one of the health committees. The new legislative leadership and HHS committee chairs will have their hands full over the upcoming five months of the 2013 session as they tackle a budget deficit, an insurance exchange and Medicaid expansion, as well as other difficult and contentious health care policy questions. By Nathan Mussell, JD
MetroDoctors
The state once again faces an expected budget deficit for the upcoming biennium somewhere around $1.1 billion, not including the additional money needed to pay back the school shift. Unlike in the past couple budget cycles, this year there will likely be new revenue on the table to help balance the budget. Governor Dayton campaigned on and proposed significant income tax increases in the 2011-2012 budget. Whether or not there are enough votes to pass an income tax increase is yet to be determined, but this, along with other significant tax reforms, are sure to be the centerpieces of Governor Dayton’s budget recommendations in early February. From a health care perspective, one of the revenue raisers likely to get considerable discussion is an increase in the price of tobacco. There is some hope among those in the medical community that new revenue from a tobacco tax increase could help to prevent some of the cuts to reimbursement and other programs that plagued the health care budget over the past couple sessions. At the very least there is a desire that the revenues generated from a tobacco tax increase be reinvested into the state’s health care system. The one certainty to come out of the election at the federal level is that the Accountable Care Act is here to stay. Minnesota now faces a myriad of decisions over the next two years, including an expansion of Medicaid and implementation of a health insurance exchange. Although Minnesota does not face the same political
The Journal of the Twin Cities Medical Society
questions that other states face on whether to even do a state-based exchange or expand Medicaid, there are still significant questions that the legislature needs to address early in the 2013 session. Over the last 12 months, the Governor’s appointed Health Insurance Exchange Advisory Task Force has been slowly tackling the issues of governance, financing and risk adjustment. The financing questions are of interest to those in the physician community as one of the proposals being considered uses some of the provider tax dollars to help fund the ongoing maintenance of the exchange. Other options being vetted include taking a portion of each premium payment or a user fee paid by those utilizing the exchange. The end result will likely be some combination of financing mechanisms pending further guidance from the federal government. Physicians and other health care providers should continue to pay close attention to the insurance exchange discussions, as it is almost assuredly (Continued on page 8)
January/February 2013
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2013 Legislature (Continued from page 7)
going to become the platform through which a significant percentage of the state’s citizens receive health care coverage both in the public and private market. In addition to the insurance exchange discussion, Minnesota is almost certain to expand eligibility for the Medicaid program out to 133 percent of Federal Poverty Guidelines (FPG). Going back to 2011, on almost his first day in office, Governor Dayton elected then to expand Minnesota’s MA program to 75 percent of FPG for adults without children, a population that, up until 2010, had been served under the state only General Assistance Medical Care program. The expansion to 133 percent is projected to add almost 57,000 new individuals on to the state’s Medical Assistance program. As the Medical Assistance rolls continue to get larger in Minnesota, there will be increasing
pressure on reimbursement at the state level, particularly with the looming cuts to Medicare at the federal level. The more difficult question the state faces is not whether to expand Medical Assistance, but what to do about coverage for individuals from about 133 percent to 200 percent of FPG. Some of the options being considered include coverage on the exchange, coverage through a “basic” health plan, or another hybrid of sorts through MinnesotaCare. One of the concerns that has been raised with covering these individuals through the exchange is they are likely to move back and forth between income brackets as they change jobs or receive differing benefits. As a result there may be a gap in health care coverage on a month-to-month basis if they move in and out of the Medical Assistance program to the individual market or basic health plan. One of the potential advantages of the basic health plan option is that the
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January/February 2013
federal government picks up 90 percent of the cost of coverage through that plan. Although this would be a short-term boon to the state’s budget, there are a number of concerns about the long-term costs and the federal government’s share of the costs. There are likely to be a number of other policy issues on the table in 2013 including potential scope of practice changes, nurse staffing ratios and other public health issues. With the new majorities, the hospitals around the state have serious concerns about a push for mandated statewide nurse staffing ratios. Additionally, there could be a push for independent practice by advanced practice nurses. Going back to 2009 when the DFL was last in control of the legislature, there was an effort to remove the collaborative management and written prescribing agreement requirements in statute for advanced practice nurses. Although that effort eventually failed to advance, the new majorities likely provide a more receptive audience on licensure issues — a political reality that has to be concerning to many in the physician community. Finally, there could be a renewed interest in providing additional funding for the Statewide Health Improvement Program. SHIP was one of the foundations of the 2008 Health Reform package that Rep. Huntley helped advance, so don’t be surprised to see greater attention put toward SHIP and other public health initiatives again this session given the escalating rates of childhood obesity and obesity related illnesses around the state. Every legislative session brings a surprise or two. With new majorities, 60 new legislators, and a budget year, 2013 is sure not to be short on surprises, particularly in an ever-changing health care environment. It will be important for physicians to stay engaged in the legislative process throughout the 2013 session. Nathan C. Mussell, JD, Government Affairs, Lockridge Grindal Nauen. He can be reached at: ncmussell@locklaw.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
Sports Medicine
Colleague Interview: A Conversation With David Fischer, M.D.
D
avid A. Fischer, M.D. received his doctor of medicine from the University of Minnesota Medical School and completed his orthopedic surgery residency at the University of Minnesota. Prior to his residency he also received medical/ surgical training at Nuffield Orthopaedic Centre, Oxford, England, UK and Sir Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Wales, UK. Dr. Fischer served as director, Sports Medicine Fellowship Program at the Orthopaedic Center/TRIA Orthopaedic Center (1987-2011), and CEO and Chairman, TRIA Orthopaedic Center (2005-2006). He has served as the team orthopedic physician, Minnesota Timberwolves (1989-present), Minnesota Vikings (1981-2006), and U.S. Olympic Staff Physician (1986-1992). Dr. Fischer is board certified in orthopedic surgery. Dr. Fischer can be reached at: TRIA Orthopaedic Center: (952) 831-8742, or David.Fischer@tria.com.
Are athletic injuries different from non-athletic injuries? Or is it the patients who are different? Or is there no difference?
As a sports medicine doctor, do you just take care of true athletes? If not, what percentage of your patients would you consider “non-athletes”?
The injuries are similar to those sustained in the recreational population, regardless of their level of expertise or performance. Injuries occurring in sports are generally regarded as “low-level energy.” By that I mean that getting hit by a 250# linebacker is significant but not like getting hit by a car. As a result, most of the injuries seen in the elite and professional athlete are in common with those of the recreational and active person whether they occur in sport or daily life (miss-stepping on a curb, touch football, sliding into second base, etc.). The patients are different in that their lives, careers, income, visibility to others in their performance are under scrutiny and directly affected by injury. Also, the medical personnel (team athletic training staff and physicians) are under more scrutiny and the athlete’s care and progress more visible to all than in the general population with a similar injury or condition. All of this occurs under the umbrella of patient/physician confidentiality, team knowledge, player and agent involvement, etc. It is simply more complicated regardless of the injury or illness.
The majority of my patients are active youths to seniors. The elite and professional athlete has generally distinguished him or herself by their ability to stay out of the doctor’s office. I do not think any physician can stay busy and make a living taking care of just elite and professional athletes. There are not that many of them and they are where they are because they generally are well. Most of my patients I would regard as “non-athletes” and I think they would consider themselves the same. This does not mean they are inactive, etc. — most of my patients, regardless of age are very active with many recreational interests and activities and their condition generally is affecting their participation and enjoyment of these and that is why they come to the office. To me, perhaps, the title of an “athlete” carries a special level of performance and dedication by the patient on a daily basis to his or her activity and I think when this bar is raised most would consider themselves “athletic” rather than an “athlete.”
(Continued on page 10)
MetroDoctors
The Journal of the Twin Cities Medical Society
January/February 2013
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MedicalMedicine Sports Care Organizations Colleague Interview (Continued from page 9)
As the team physician for the Minnesota Timberwolves and former team physician for the Vikings, tell us about the special challenges you face as a physician when diagnosing and treating elite professional athletes of notoriety and economic value to the team. The issue here is mostly one of urgency. As best as possible, can a diagnosis be made with a reasonable estimate of disability in the shortest time? In the case of a team situation this is important as if the player will be expected to be unable to perform for a certain time, whether days, weeks, or months, this is important to the team. The game moves on and coaches and team need to know as quickly as possible regarding injuries to judge the impact on the team and make plans in terms of personnel, game planning, etc. Managing the medical information in regard to the media and public has always been a function of the team. The medical information is, of course, private and between the doctor and the patient — in this case the athlete. How this information is released to the media and public is done recognizing this element of privacy as well as a “need to know” issue given their visibility and this is between the patient (athlete) and the organization. Often this information seems a little misleading or confusing when read in the sports page. Nevertheless, I can assure all the best care is in process for the athlete and the sports page is not the New England Journal of Medicine!
How does the ability of the player or agent to ask for opinions and treatment from a national expert affect your relationship with a player and your ability to care for that player? Our concern is with the player, our patient. Dealing with agents is an important and necessary element of the player’s care. All our interests are the same, the best for the player/patient. I welcome second opinions and respect care of our athletes from other physicians who I respect, know and they have the same regard for us. An athlete seeking another opinion is not an ego concern for me and I aid them in this and have questions only if I have concerns on the opinion. If the player has an injury I feel would be better treated by another physician in another location, I will suggest and recommend this. If the condition is something I feel we can manage as well as anyone or any other facility in the world I will let the player know this. He or she is free to make a decision on their care and they do this. We will always work with other physicians in their care, rehabilitation, etc., as we all have the same goal in mind: get the athlete well and back to the highest level of performance possible.
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Caring for a major league sport team must be very time consuming. What adjustments do you make to your normal practice including time away from patients, compensation by your practice, on-call requirements and family life? Much of the time can be scheduled in terms of game coverage, travel with the teams when known. Much is simply our ability to respond to requests and circumstances. “Stuff ” comes up on nearly a daily basis and I and our TRIA personnel have to recognize this and accommodate on short notice. On occasion this does involve inconveniencing our “regular” patients as we may have to dedicate time and facility to these emergent needs. However, I have always been impressed and grateful to our patients who have understood this and accepted the delay in their care. Family is essential in being able to make these time commitments and I cannot undervalue this. You will miss some birthdays and anniversaries and everyone has to recognize the importance of both the events as well as the commitment to your work. I think individuals in these jobs have either enjoyed long lasting and rewarding relationships with spouses and families or short and numerable ones! In this role I have been most fortunate in enjoying a long partnership with my wife, Andrea. My partners at TRIA over the years who serve in similar roles with the other professional teams in the area understand the jobs and we all step forward for each other when needed!
Rehabilitation programs after repairs of ligament injuries are crucial to optimal outcomes. What do rehab programs for these elite athletes entail? Who develops them, and how is progress assessed? Can you share lessons learned from the rehabilitation programs of athletes such as Kevin Love, Ricky Rubio, or Adrian Peterson which apply generally to good outcomes for patients? I cannot comment specifically on the individual programs for the athletes you mentioned above. What I can say is that their basic rehabilitation programs and progression are not dissimilar from the recreational patient with an identical injury and surgery. The difference is that these athletes have access to rehabilitation personnel and facilities 24 hours a day, seven days a week, all year. The goals may be the same in the recreational athlete as in the professional athlete: for example, return to full pre-injury activity in 9-12 months. The difference is what that goal is. For the elite and professional athlete it is high. He or she starts from a higher level than the recreational athlete but the goal is very high. The professional athlete benefits from much greater personal attention in this regard and a clear focus on what he or she needs to accomplish in their recovery. The rehabilitation, after MetroDoctors
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the initial recovery phase, is much more focused on the specific activities they need and this is where the resources of the Clubs and their athletic training staffs comes into importance. Their recovery becomes much more focused on the specific activities they require to return to their pre-injury of performance in that particular sport. We follow the same general rehabilitation guidelines and progression with our “regular” patients. The expectations by the patients are considered but with few exceptions; the expectations by the patient, doctor and therapist are not quite the same and we have more time and I must say I enjoy the slightly more “relaxed” atmosphere of this situation with similar gratifying results!
Opioid use for pain is common among professional athletes — as is misuse of alcohol and other drugs. How are medications and drug use currently monitored by team physicians or others? What steps are taken to mitigate opioid, alcohol and illicit drug dependency and addiction? Your recommendations?
The elite and professional athlete has been the “laboratory” in sports medicine. What we have learned from this small group of people and the resources we have had in evaluating and treating them have filtered down to the general population and this has been the great benefit of the growth of the specialty of sports medicine. Sports medicine has basically come into its own right over the past 20 years as a special area of interest and expertise. This has come largely from a better understanding of soft tissue injury, healing and rehabilitation: muscle, ligaments, tendons, etc. Most injuries and conditions of concerns in the general population fall into this category. The more we can learn about these, the better we can diagnose and treat them, the better for all: our patients, their families, our work force, our economy, etc.
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All the professional organizations as well as the international Olympic federation have taken aggressive steps in the past decades to control this. I think the efforts have been excellent in recognizing the problems, both in terms of controlled medication abuse as well as performance enhancing drugs. This has been assumed by our leagues with regular monitoring of prescription medication to players, testing of players, etc., and I have no further comment on this as this concern has been recognized by our league organizations and the supervision and enforcement of it has been assumed by them to the approval and satisfaction of all of us working team physicians.
What do you feel is the greatest contribution to society or medicine in the last 10 years by the sports medicine community? WOW! This is a really tough question as I think we have to look to the past 20 or 25 years to appreciate what our contribution has been as this covers some of the most important advances in our field: the application of MRI to sports and general health care, the refinement of what the arthroscope has been able to accomplish in minimally invasive surgery as well as knowledge of how our body works.
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January/February 2013
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MedicalMedicine Sports Care Organizations
Pediatric Sports Injuries unilateral to bilateral fractures, which may lead to spondylolisthesis and spinal cord compromise. These athletes should be removed from their sport and all extension exercises for a minimum of three months.
Introduction:
An estimated 38 million children and adolescents in the U.S. are involved in organized sports, with over 30 million under the age of 15. Athletics confers many advantages to children, from improving physical and mental health and decreasing risk-taking behavior during adolescence to increasing physical activity and healthy habits as adults. Unfortunately, few benefits come without risk, and sport is no exception. Childhood sports injuries amount to 3.5 million visits to medical professionals and an estimated cost of over 49 billion dollars annually. Common Injuries:
The most common injuries associated with youth sports are cuts and bruises, sprains, strains, bone and growth plate injuries, repetitive use injuries and heat illness. Basic first aid, provided by coaches, parents or medical personnel, is certainly adequate for most minor cuts and bruises as well as most muscle strains. Athletes should not play with uncovered wounds. For bruises and strains, play should be determined by the severity of the injury and whether performance is affected. Initial treatment consists of Relative rest, Ice, Compression and Elevation (RICE) therapy, with Relative Rest being the most important component. The child then progresses from range of motion exercises to strengthening. Sprains are tears or partial tears of ligaments and are too often overlooked as minimal injuries that will resolve on their own, when in fact, chronic ankle pain is most commonly caused by inadequate rehabilitation after a sprain. Initial bracing or immobilization, if necessary, should be By Steven Greer, M.D.
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Preventing stress fractures and other overuse injuries: s )NCREASE TRAINING GRADUALLY s !LLOW ADEQUATE REST TIME s !T LEAST ONE DAY PER WEEK WITHOUT organized sport s %MPHASIZE PROPER TECHNIQUE s %NSURE ADEQUATE NUTRITION PARTICUlarly calcium and vitamin D interrupted three times a day by range of motion exercises. Strengthening can begin when the swelling and pain is resolved. Repetitive Use Injuries
Over 50 percent of pediatric injuries involve overuse. In addition to those already discussed, shin splints, stress fractures, and spondylolyses are common. Shin splints must be differentiated from stress fractures because shin splints are treated with icing after activity, conditioning and strengthening, whereas stress fractures require decreasing or ceasing weight-bearing activity. If history and exam do not differentiate between the two, it is reasonable to image the athlete. Stress fractures may not be seen on initial x-rays; therefore, bone scan, MRI or repeat x-rays two weeks later are options to consider. Spondylolysis, fracture of the pars interarticularis, is the number one cause of low back pain in adolescent athletes. It is more common in sports requiring repeated extension, such as football, tennis, dance, volleyball and throwing sports. SPECT scan remains the most sensitive test for confirmation. The greatest concern is progression from
Bone and Growth Plate
Children have many unique bony injuries, which can make imaging decisions and diagnoses challenging. Imaging should be obtained for significant trauma, when obvious bony deformities exist, when movement is impaired or refused by the athlete, or when there is tenderness over the growth plate. Radiographs should also be obtained on children with pain not improving over time — typically two weeks. The Ottawa Ankle Rules have been validated down to age six and are very useful for determining when to x-ray the ankle. Imaging the uninjured limb is helpful, particularly in plastic (bend) and torus (buckle) fractures and growth plate injuries. It is also reasonable to splint an injured limb and repeat x-rays in two weeks, as some may not be visualized initially. CT scan or MRI can be helpful in diagnosing bony injury not readily seen on radiograph. Most nondisplaced fractures may be effectively treated with immobilization until the athlete no longer has bony tenderness and there is callous formation on x-ray. Displaced fractures may need
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reduction or surgery. Open fractures and any associated with neurovascular compromise are considered orthopaedic surgical emergencies. Growth plate injuries typically heal without incident over several weeks of immobilization. Salter Harris Types I and II are usually treated non-operatively and often get radiographs six months after initial injury to assess for growth arrest, which is rare in these injuries. Almost all Salter Harris type IV and V, and about half type III fractures require surgical intervention and should be evaluated by an orthopaedic surgeon. Apophyseal injuries fall under the category of growth plate injury as well. The most common involves the patellar ligament’s attachment to the tibia (Osgood-Schlatter’s disease), followed by medial humeral apophysitis (Little League Elbow), and calcaneal apophysitis (Sever’s disease). Osgood-Schlatter and Sever’s typically do well with modifying activity alone. Little League Elbow requires removal from throwing sports followed by a throwing program once the child is pain-free. Little League Shoulder is the separation of the proximal humeral physis and requires three months of no throwing to prevent growth arrest.
and rule enforcement are vital. Adequate strength, conditioning, and adequate recovery time reduce the risk of injury. Children should take one day a week off from organized sports to allow adequate recovery time, decreasing the risk of overuse/ repetitive use injury. Parents should look for organizations with well-maintained facilities, trained coaches, safety guidelines, and emergency action plans. Conclusion:
Organized sports participation has huge benefits for our children. They are more likely to develop goal-oriented behavior and self-discipline. They are less likely to drop out of school. They are more likely to get good grades and have jobs in high school. They are less likely to have sex, get pregnant and do drugs in high school. They are more likely to attend college. They are more likely to maintain active lifestyles as adults. With common sense, parental involvement, trained coaches, proper safety equipment, and adherence to safety guidelines it is worthwhile to
encourage our youth to stay active, have fun, and reap the benefits of organized sports. Steven A. Greer, M.D. attended medical school at St. George’s University, West Indies and completed his residency in family medicine and fellowship in primary care sports medicine at Moses Cone Memorial Hospital in Greensboro, NC. While there he served as an assistant team physician for Elon University, a small, private Division I school. Most recently, Dr. Greer comes to us from the Medical College of Georgia in Augusta. There, he served as the director of primary care sports medicine. He was team physician for four high schools, two Division II colleges and the Augusta Greenjackets Minor League baseball team. He also developed their sports medicine fellowship and was medical director for the largest Ironman 70.3 in the world. Dr. Greer is board certified in family medicine and family medicine-sports medicine. Dr. Greer can be reached at: Steven.A.Greer@HealthPartners.com, or (651) 254-8300.
OTTAWA
ANKLE RULES
For Ankle Injury Radiography
Heat Illness
Preparation and Prevention:
While it is impossible to remove all risk, many pediatric sports injuries are preventable. Injuries occur more often during practice than games. Proper safety equipment and teaching proper technique
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Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa Ankle Rules. JAMA 1994; 271:827-832.
a) An ankle x-ray series is only required if there is any pain in malleolar zone and any of these findings: 1. bone tenderness at A OR 2. bone tenderness at B OR 3. inability to bear weight both immediately and in ED b) A foot x-ray series is only required if there is any pain in midfoot zone and any of these findings: 1. bone tenderness at C OR 2. bone tenderness at D OR 3. inability to bear weight both immediately and in ED
January/February 2013
© Ottawa Health Research Institute
Children produce greater heat and have less capacity to sweat than adults, which puts them at higher risk of heat injury. Children not acclimatized to the heat are also at higher risk. Heat index should be assessed prior to practice and activity should be modified based on it. Children should be well hydrated. Water breaks should be at least every 20 minutes, more often early in season and during hot weather. All heat victims should be removed from the heat, hydrated and cooled. If the athlete has mental status changes or unremitting full body cramping, the athlete should be evaluated in the Emergency Department.
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Concussion Management in Youth has Evolved
M
ost patients who sustain concussions (mild traumatic brain injuries) recover fully, but as many as 15 percent experience persistent disabling problems.1 Until recently, many school-age athletes, their families and their coaches did not recognize the risks of mild traumatic brain injuries (MTBIs) — particularly if the athlete did not lose consciousness — so athletes often resumed play immediately, to their detriment. A Minnesota law requires that young athletes be removed from play until they no longer exhibit concussion symptoms. In addition, athletes must be evaluated by “a provider trained and experienced in evaluating and managing concussions” who must give the athlete “written permission to again participate in the activity.”2 This article offers a practical guide for identifying, diagnosing and managing MTBIs, including a plan for returning to activities. Recommendations for when to refer patients to a neurotrauma specialist are also included. Identifying and Diagnosing MTBIs in Children and Adolescents
MTBIs occur when an impact to the head or body causes the brain to quickly move forward and backward, striking the skull and injuring cells, nerves and blood vessels. When the brain hits the skull, the axons stretch or tear and the neurons fire simultaneously.
By Angela Sinner, D.O., Mark Gormley, Jr., M.D., Leslie Larson, P.N.P., and David Everson, P.T.
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The injury is not only structural but also metabolic. The cells release potassium and take in calcium. The calcium makes it difficult for cells to produce adenosine triphosphate (ATP), and because the neurons consume glucose to absorb the potassium, the injury ultimately draws on the energy needed for cognition, healing and resisting the effects of another injury. The duration of symptoms varies widely: from minutes to days, weeks, months or — in extreme cases — even years. Children and adolescents may take longer than older patients to recover. In the past, loss of consciousness was often used as the hallmark of a concussion diagnosis. Today, however, providers recognize that patients who have MTBIs may or may not lose consciousness. In addition, the results of neuroimaging studies usually are within normal limits. Immediate Symptoms
Within 24 hours of an injury, patients may experience some or all of these symptoms: s $ISORIENTATION TEMPORARY CONFUSION or a “dazed” feeling s $IZZINESS s (EADACHE s -EMORY PROBLEMS INCLUDING AMNESIA around the time of injury
Angela Sinner, D.O.
Mark Gormley, Jr., M.D.
s s
5NCOORDINATED HAND EYE MOVEMENTS .AUSEA AND VOMITING OFTEN RELATED to blows to the back of the head)
Subsequent Symptoms
Warning signs that can appear hours or days after an injury include: s #HRONIC HEADACHES s &ATIGUE s 3LEEP DIFlCULTIES s 0ERSONALITY OR BEHAVIORAL CHANGES s 3ENSITIVITY TO LIGHT OR NOISE s $IZZINESS WHEN STANDING QUICKLY s ! POOR ATTENTION SPAN s $ElCITS IN SHORT TERM MEMORY PROBlem-solving and general academic functioning Getting a comprehensive history is vital to determining the severity of a patient’s concussion. Carefully question patients and their families about changes in cognitive abilities, emotional function and/or sleep patterns. Symptoms may appear days or weeks after the injury, and patients might not realize that cognitive and emotional symptoms are related to the brain injury, so they may not report them. The more specific your questions about symptoms are, the better. To learn
Leslie Larson, P.N.P.
MetroDoctors
David Everson, P.T.
The Journal of the Twin Cities Medical Society
more about cognitive function, ask questions such as: s h$O YOU HAVE MORE DIFlCULTY FOLLOWing directions?â€? s h!RE YOU ABLE TO TAKE NOTES IN CLASS v When asking about headaches or vision problems, ask if the symptoms worsen during various activities: s h$O YOU NOTICE ANY DIFlCULTY FOCUSING on computer screens or texting?â€? s h$O YOUR HEADACHES WORSEN WHILE reading?â€? To identify potential sleep difďŹ culties, ask questions such as: s h$O YOU HAVE PROBLEMS FALLING asleep?â€? s h$O YOU WAKE UP FROM A SOUND SLEEP and have trouble returning to sleep?â€? While patients are in the early postinjury phase, they may have more difďŹ culty answering your questions because their cognitive process is impaired — a signiďŹ cant ďŹ nding. For example, patients may have trouble ďŹ nding the proper words and may need extra time to understand and answer your questions. Speak slowly and allow patients ample time to express themselves.
Current Approach to MTBI Management
In the past decade, research has shown that even MTBIs may have lingering effects on cognitive and physical function. In addition, the risks associated with repeated concussions point out the importance of careful management. Management by monitoring is appropriate in the following circumstances: s )F THE PATIENT HAS FEW -"4) SYMPtoms and they are mild s )F THE PATIENT S MILD SYMPTOMS STEADILY improve or are completely gone within three to ďŹ ve days While symptoms are present, or if cognitive testing indicates deďŹ cits, providers should educate patients so they understand that: The recovery process must be gradual. Skipping sports and physical education for a few hours or days is insufďŹ cient. Children and adolescents should not return to their activities until they are symptom-free. When patients return to their activities,
Additional Risk Factors Affect Management
It is important to evaluate each episode of MBTI in the context of a patient’s history of concussions, headaches, and developmental or psychiatric issues (such as learning disabilities or depression). Patients with a history of those conditions may have a more complicated recovery, and that will affect your decisions about management. Because student athletes are eager to return to play, they may minimize the extent of their symptoms and be reluctant to allow enough recovery time. The likelihood of athletes experiencing an MBTI after an initial brain injury is three times that of experiencing the initial brain injury. Repeated injuries increase the risk of symptoms such as headaches, memory loss and difďŹ culty concentrating, and they heighten chances that the patient will experience a serious and permanent brain injury.
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they should do so slowly. Parents and health care providers should monitor the effects of resuming activity — if symptoms worsen, the patient needs to do less and rest more. Rest is necessary for recovery. Patients should get plenty of sleep and may need to take naps. If the patient’s attention span or reaction time is affected, driving is not safe. Symptoms may return or worsen when patients are fatigued. Patients should limit cognitive, social, work and physical activities. Teachers, coaches and employers should be informed that patients may require accommodations. Recommendations for Returning to Activity
At Gillette Children’s Specialty Healthcare, we carefully monitor patients’ post-injury progress. When patients are asymptomatic and their imaging studies, physical
(Continued on page 16)
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4HAT $OCTORS 4RUST ,OCKRIDGE 'RINDAL .AUEN HELPS OUR HEALTH CARE CLIENTS MEET THE CHALLENGES POSED BY TODAY S RAPIDLY CHANGING HEALTH CARE ENVIRONMENT 4HE FIRM S ATTORNEYS AND LOBBYISTS PROVIDE REPRESENTATION IN s'OVERNMENT RELATIONS s,ITIGATION AND ADMINISTRATIVE LAW s"USINESS STRUCTURING s#ONTRACTS SALES MERGERS JOINT VENTURES s%MPLOYMENT MATTERS s#OMPLIANCE AND REIMBURSEMENT ISSUES
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MedicalMedicine Sports Care Organizations Concussion Management (Continued from page 15)
exams and cognitive screening tests (e.g., ImPACT) are all within normal limits, they can begin a staged return to activity. Each stage of activity may last several days. After patients have been evaluated and a care plan developed, a physical therapist who is experienced with MBTI monitors patients’ progress. Patients can progress to the next level of activity, if they remain symptom-free. However, difďŹ culty with any stage leads to a plateau in stage advancement until improvement is seen. If patients develop increased symptoms while doing a speciďŹ c activity, that activity should be discontinued. Continuing an activity that increases symptoms can delay recovery from an MTBI — symptoms may last longer and become more intense, and new symptoms may occur. In addition, patients who continue an activity before the MTBI is fully healed risk repeated injury and second impact syndrome (a rare condition in which a second head
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trauma results in cerebral swelling, brain herniation and even death). We follow this protocol for a staged return to athletic activities: s 2EST AND NO ACTIVITY UNTIL ASYMPtomatic. Or, patient should be asymptomatic during an activity that a provider has approved. s 3TAGE ,IGHT AEROBIC EXERCISE such as walking, light stationary biking, light weightlifting (lighter weights, higher repetitions, no bench presses, no squats). Patients should be able to speak freely and not be out of breath during activities. They should limit head movements, quick position changes and activities requiring concentration. s 3TAGE 3PORT SPECIlC TRAINING including moderate jogging, stationary biking, brief running and weightlifting. The patient may be sweating mildly, but should be able to speak a sentence while performing exercises. Some positional changes, head movements, and a low level of activities requiring concentration are acceptable. s 3TAGE .ONCONTACT DRILLS such as outdoor sprinting/running, high intensity stationary biking, regular weightlifting routine and noncontact, sport-speciďŹ c drills. Patients should be able to speak a couple of words during these activities. s 3TAGE &ULL PRACTICE DRILLS EXCEPT contact. At this stage, patients should not be able to speak more than a couple of words at a time. Patients should continue to avoid contact sports, but they can resume aggressive training in all environments. Patients may return to noncontact practice activities, if they remain symptom-free. s 4AKE lNAL )M0!#4 TEST If patients are cleared after the test, they can return to full contact sports without limitations.
When to Refer a Patient to a Specialist
Often, sports-related concussions resolve without complications. If your patients’ symptoms are mild and improve within three to ďŹ ve days after the injury, there is no need to refer the patient to a specialist. Consider referring MBTI patients when: s )NITIAL SYMPTOMS ARE MODERATE OR severe s 3YMPTOMS PERSIST OR WORSEN AFTER three to ďŹ ve days Gillette’s Neurotrauma Clinic provides a multidisciplinary approach to caring for patients who have lingering head and neck injuries. For further information on concussion management, contact Gillette Children’s Specialty Healthcare at (651) 291-2848. Or for physician referrals, (651) 325-2200. Angela Sinner, D.O., is a pediatric rehabilitation medicine specialist at Gillette. She has a special interest in neurotrauma, spina biďŹ da and spasticity management. Mark Gormley Jr., M.D., is a pediatric rehabilitation medicine specialist at Gillette in St. Paul. He also serves as Gillette’s section chief for pediatric physical medicine and rehabilitation. Leslie Larson, R.N., P.N.P., is a certiďŹ ed brain-injury specialist and credentialed Immediate Post-concussion Assessment and Cognitive Testing consultant at Gillette. David Everson, P.T., rehabilitation supervisor at Gillette’s Minnetonka Clinic, is the minor neurotrauma lead for Rehabilitation Therapies. References 1) “Heads Up: Facts for Physicians About Mild Traumatic Brain Injury,â€? Centers for Disease Control and Prevention http://www.cdc.gov/concussion/index.html. 2) Minnesota state law (Section1. [121A.37] of Minnesota S.F. No. 612, at www.revisor.mn.gov/ laws/?id=90&year=2011&type=0).
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Evaluation and Treatment of Running-Related Foot and Ankle Injuries
T
here are 37 million runners in the United States and 75 percent of them will sustain an injury at some point. If you provide primary care, your office may be the first stop for these athletes. Injuries to the foot and ankle are becoming more common as runners are experimenting with barefoot running and minimalist footwear. If you don’t feel comfortable treating these injuries, YOU may want to run when you see these patients are on your schedule! In the article, I will discuss the etiology of foot and ankle injuries and offer simple strategies for management of the three most common problems you may see in your office. The Feet Take a Beating!
The foot and ankle are remarkable! Elegantly constructed of bones, muscles, tendons and ligaments, they convert from a rigid lever transferring power at heel strike and toe-off, to a flexible structure accommodating uneven surfaces and dissipating stress when the foot is flat on the ground. As the foot is the only part of the body contacting the ground during upright activity, stress translated through the ankle to the rest of the lower extremity is considerable. Walking generates impact 1½ times body weight through the foot and ankle with each step taken. Running is a higher stress activity generating impact 2½ times body weight. If running mileage or intensity of training is advanced slowly, the bones and soft tissues of the foot and ankle adapt to stress of this magnitude and strengthen. If training is not prudent, the system breaks down leading to an overuse injury. Injuries can also result By Marie-Christine Leisz, D.O.
MetroDoctors
from transitioning too quickly to running barefoot or in minimalist footwear as there is less shock dissipation between the heel and the ground. Stress fractures, tendinitis and muscle strains comprise the most common overuse injuries. The Top Three
The most common foot and ankle injuries are plantar fasciitis, Achilles tendinitis and metatarsal stress fractures. Plantar Fasciitis: This is the most common cause of heel pain in runners and non-runners and can be hard to resolve if not treated immediately. The plantar fascia is a strong ligament, originating at the calcaneus, flaring and attaching at the metatarsal heads. It helps maintain the long arch of the foot and dissipates stress like the spring of a car. The repetitive impact of running causes micro-tearing and inflammation at the fascial origin. Risk factors include high-arched, rigid feet with tight Achilles tendons, low-arched, flexible feet, obesity and older age. The classic symptom is heel pain that is worse with the first step in the morning. This
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happens because the ankles are plantarflexed at night in bed. The fascia begins to heal in a shortened position. The first step causes sudden traction of the irritated fascia at its origin. Clinically, patients have pinpoint pain and palpable edema over the middle of the plantar surface of the heel. X-rays are not needed. If obtained, a heel spur may be visualized. This is thought to develop in reaction to traction of the fascia at the calcaneal origin but is not the cause of the pain. Instead of running, I recommend lower impact activity like cycling, deep-water running or elliptical training while the pain is acute. Resolution is greatly hastened by wearing a garment called the Strassburg Sock. Runners wear this at night, if tolerated, or anytime when sitting for a prolonged period of time. The device passively stretches the Achilles tendon and plantar fascia, allowing it to heal “long.” Rolling the heel on a golf ball helps and I recommend off-the-shelf shoe inserts to redistribute pressure over the plantar surface of the foot. I prescribe one-two physical therapy visits to address any deficits in ankle strength or range of motion. It is important for the athlete to understand it will take weeks to months to resolve. There should be no pain with walking or the first step in the morning before return to training. Achilles Tendinopathy: The Achilles tendon attaches the gastrocs-soleus muscle complex to the posterior, inferior calcaneus. The tendon becomes irritated from sudden changes in intensity of training. Risk factors are older age, tight calves and decreased ankle range of motion. (Continued on page 18)
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Clinically, the tendon will be erythematous, edematous and exquisitely tender to touch. The major complication is rupture of the tendon. If rupture occurs, the athlete will probably need surgical repair with a long rehabilitation course so, running should stop! Low impact activity is indicated as long as it causes NO pain. Icing, a
short course of NSAIDs and the Strassburg sock can also help. New research shows nitric oxide enhances tendon healing. The latest treatment is application of half of a nitroglycerine 0.1mg transdermal patch to the affected area, replacing it every 12-24 hours. Headache can be a side effect but usually resolves by reducing the dose to ¼ patch or wearing it 12 hours on 12 hours off. Refer to physical therapy for a carefully monitored stretching program and
correction of any other strength/range of motion issues. This will also take weeks to months to resolve and running should be avoided until the pain and edema completely resolve. Metatarsal Stress Fractures: Bone remodels in reaction to stress according to Wolf ’s Law. Osteoclasts are constantly resorbing bone while osteoblasts replace the resorption cavities with stronger bone. The impact of running accelerates resorption. If there is sufficient recovery time between running bouts, bone remodels stronger. If not, the bone fails and a stress fracture occurs. Most common sites are the distal 2nd, 3rd and 4th metatarsals. Runners will complain of progressive mid-foot pain, worse with running and better with rest. Clinically, there may be mild edema over the dorsal foot and there will be pain with palpation over the shaft of fractured metatarsal. X-rays may not reveal the fracture until at least three weeks after the injury. Bone scan and MRI are sensitive much earlier. If radiologic imaging reveals a fracture of the proximal 2nd or anywhere along the 5th metatarsal, these patients should be casted non-weight-bear for six-eight weeks. Distal metatarsal stress fractures are treated with a stiff-soled shoe and cessation of running. Athletes may engage in low impact activities like cycling or swimming if non-painful. These fractures take foursix weeks to heal. Runners can advance training slowly. A good rule of thumb is to run at a slower pace and resume running half the weekly mileage before the injury occurred. Marie-Christine Leisz, D.O. is board-certified in both physical medicine and rehabilitation and sports medicine, with advanced training in the diagnosis and management of running and endurance sports injuries. She is medical director of the Running and Endurance Sports Injury Clinic at Sister Kenny Institute and collaborates with the Sister Kenny RunSmart Physical Therapy Program. Learn more at www.allina.com/ahs/ski.nsf/ page/running_endurance and http://www. allina.com/ahs/ski.nsf/page/Run_smart. Dr. Leisz can be reached at: (651) 2418295, or marie.leisz@allina.com.
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The Journal of the Twin Cities Medical Society
Treatment of Common Shoulder and Elbow Injuries
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he upper extremity is a frequent site of injury in the athlete, whether it be a professional or weekend warrior. Reliable treatment options for the most common injuries are well documented, and primarily consist of conservative approaches for both the shoulder and elbow. Specific diagnoses and the recommend treatment for the most common shoulder and elbow injuries will be discussed in this review. Impingement/Rotator Cuff Injury
Impingement syndrome is the most common shoulder diagnosis for all athletes, young and old. This includes the more commonly known entities, shoulder “bursitis” and rotator cuff “tendinitis.” Both terms are somewhat misnomers, as the condition is often degenerative in nature due to overuse. Although anti-inflammatories are frequently utilized for the treatment of impingement syndrome, there is no evidence that this is an effective approach. Studies have shown that activity modification (avoid overhead and outstretched reaching) combined with physical therapy and, if needed, a corticosteroid injection, is the most reliable means of treating this common shoulder injury. Nearly 70 percent of patients treated early with this approach will have a successful outcome, but the patient should be educated that complete resolution of symptoms may take several months. A rotator cuff tear, in contrast, can be a more significant issue than impingement syndrome. Tears can be partial (a portion of the tendon remains attached)
or full-thickness (tendon is completely detached) in nature. Moreover, the tears can be small or medium in size involving a single tendon or large to massive involving two or more tendons. Tears in young athletes are rare and typically traumatic in etiology. Overhead athletes, especially pitchers, tennis players, and swimmers, are particularly at risk for progressive rotator cuff injuries. As athletes age, rotator cuff tears can become more common and problematic, resulting in extended recovery (12 months or more) and in many cases, are career-ending. The recreational athlete may be able to return to their chosen sport after extensive rehabilitation. Surgery is frequently recommended in the younger athlete or those with full thickness tears that are acute in nature. Physical therapy is the approach utilized initially for those athletes with a partial tear or more chronic tears with associated muscle atrophy. Patients should be educated that recovery from a rotator cuff tear can be quite lengthy and that return to overhead sports may be more challenging. Shoulder Instability
A shoulder dislocation is one of the more common issues seen in the office during the fall and winter seasons when contact sports such as football and hockey are in full action. While initially disabling, return to sport is possible for the in-season athlete. Studies have demonstrated that initiation of a rehabilitation program can allow for return to sports, including contact sports, in as few as 10 days on average. Long-term sling immobilization has not demonstrated a decrease in the potential for recurrent dislocation, and therefore is not recommended.
By Michael Q. Freehill, M.D.
MetroDoctors
The Journal of the Twin Cities Medical Society
Although early surgical intervention has been advocated by some specialists, surgery can frequently be delayed until the season has been completed. Return to sports, especially for contact or overhead athletes, does not begin until six months postoperatively. Data from Major League Baseball indicates 12 to 16 months before returning to previous level of play, with roughly 70 percent of surgical patients reaching their prior level. Furthermore, recurrence of instability is more common in contact athletes, particularly those less than 16 years of age. Nevertheless, return to throwing sports with instability involving the dominant arm can be difficult without surgical intervention. Athletes over 40 years of age should be carefully evaluated for a rotator cuff tear or neurologic injury following a dislocation. Since this demographic group is at decreased risk for recurrent instability (Continued on page 20)
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MedicalMedicine Sports Care Organizations Shoulder and Elbow Injuries (Continued from page 19)
compared to patients less than 20 years of age, a rehabilitation program should be initiated once radiographs have ruled out the presence of a fracture. If continued weakness exists, the patient should be referred to a specialist to assess for the possibility of a rotator cuff tear or nerve injury. Frequently, patients are diagnosed with a labral tear identified on a MRI scan. In contrast to the patient who has instability, an isolated atraumatic labral tear is typically insignificant, particularly the commonly referenced “SLAP” tear. Labral pathology can be an expected, age-appropriate finding on MRI in active patients over the age of 40, and these tears are often degenerative in nature. Physical therapy, not surgery, should be the initial treatment recommended in these individuals. Acromioclavicular Separation
Acromioclavicular separations (a.k.a. shoulder separation) is a common traumatic injury that can occur in athletes of all ages. Contact athletes, in particular hockey players, are at risk for this injury, although the issue is frequently seen in cyclists (bike crashes), downhill skiers, snowboarders, and other high velocity athletes at risk for a direct blow to the shoulder or high energy fall. Radiographs can be helpful in grading the degree of separation, which in turn, dictates treatment options. Most separations are low grade (1 or 2) and typically respond to conservative care initiated with days of the injury. Patients with this degree of injury should be informed about the possibility of post-traumatic AC joint arthritis in the future. Patients with grade 3 separations are typically treated non-surgically initially, but manual laborers or overhead athletes may require surgical stabilization if symptoms and AC joint instability persists. Grade 4 separations and above require surgical intervention to stabilize the AC joint and should be referred to a specialist at the time of diagnosis. Conservative treatment consists of a structured rehabilitation program focusing on scapular stabilization, active range of 20
January/February 2013
motion, and rotator cuff strengthening. Therapy should be initiated after the acute phase of injury has passed (10-14 days) and can be expected to take 6-12 weeks for a functional recovery. Return to sport can occur once the athlete has near full return of motion and strength symmetric to the uninjured shoulder. Protective pads are available commercially for contact athletes. Lateral Epicondylitis
Lateral epicondylitis is the most common elbow diagnosis seen in the orthopaedic office. Weightlifters and tennis players appear to be athletes at greatest risk for this degenerative condition involving the main wrist extensor origin, the extensor carpi radialis brevis (ECRB). Athletes in the third to fifth decade are most likely to develop this problem — one that can be very debilitating. Initial treatment always begins with conservative options. Research has shown that an eccentric strengthening and stretching program, combined with activity modifications and counterforce bracing, are the most reliable non-surgical options. More recent evidence suggests the injection of platelet-rich plasma, or PRP, can be very effective in the treatment of refractory lateral epicondylitis. Indications for PRP are evolving, but recent studies seem to indicate the outcomes may be similar to surgical intervention. Patients should be aware that a short period of wrist immobilization will be required (two weeks or more) followed by activity modifications for several weeks to allow for healing. This treatment should be reserved for patients who have failed traditional conservative treatment. The injection, however, is frequently not covered by insurance, and when performed under ultrasound guidance, can be somewhat costly. The use of corticosteroid injections, while effective for short-term pain relief, does not usually resolve the issue, and may ultimately lead to further complications such as localized fatty atrophy and blanching of the skin. In racquet sports athletes suffering from the condition, equipment evaluation and modifications by appropriate personnel can be helpful. Surgical treatment is utilized only in cases that are truly refractory to conservative
treatment over many months. This typically involves an open or arthroscopic approach in which the degenerative tendon is debrided and repaired. After a short period of immobilization, therapy is initiated with full recovery expected at three-six months postoperatively. Imaging Considerations
Basic imaging, such as radiography, should be considered in all cases of acute bone trauma to rule out the possibility of fracture. However, some fractures can be nondisplaced and difficult to visualize on plain x-rays. If a fracture is still suspected, MRI can be helpful, especially in cases of overuse, stress fractures. For most acute soft tissue injuries, MRI can be considered in cases where surgery may be recommended (acute tendon tears, dislocations). Chronic injuries that fail to respond to appropriate conservative management may also require advanced imaging for further assessment. Most injuries, including sprains and strains, do not require advanced imaging in an acute setting. Summary
The preceding review is just a brief introduction with regard to the numerous sports injuries that can occur in the upper extremity. Researchers continue to evaluate techniques to encourage more rapid and reliable healing in the injured athlete. Time will tell if these advances truly enhance an athlete’s return to sport or recovery from surgery. Until then, continue with the R.I.C.E.! Michael Q. Freehill, M.D. is an orthopaedic surgeon who specializes in the treatment of shoulder and elbow injuries. He is a partner at Sports and Orthopaedic Specialists based in Edina, MN. Current memberships include the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and the American College of Sports Medicine. Leadership positions include past-president of the Minnesota Orthopaedic Society and former CEO of SAOS. Dr. Freehill can be reached at: michael. freehill@allina.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
Strength Training Reduces the Risk of Knee Injury
T
he risk of knee injury and loss of playing time is a major concern for athletes. There are multiple studies that show the most common form of knee injury is a “non-contact� injury. It may be a chronic pain that steadily worsens, or it may be an acute “pop� that occurs during a sudden stop or cut. Coaches, trainers and doctors are becoming more and more aware of how to train athletes in an attempt to prevent knee injuries.
plyometric program must be maintained threefour days per week over the course of six-eight weeks. At the conclusion of a plyometric program, athletes have been shown to lower their peek landing force, improve their maximal knee exion, and improve their hamstring power so it better balances with their quadriceps musculature. In some studies this has shown a lowered risk of knee injuries. Ligament and Cartilage Diagnosis and Treatment
Strength and Conditioning Programs
Many athletes are working to improve their strength, power and quickness with “sportspeciďŹ câ€? training methods. These excellent programs are designed to optimize the athlete within their sport. They often focus on sprint speed and quickness, explosive multidirectional movements, and power training for the sporting activities. These programs are an excellent resource for athletes to improve their abilities within a given sport, but they are rarely designed to be a “stand-aloneâ€? program for total body ďŹ tness. Sometimes, the “coreâ€? muscle stabilizers are not incorporated in the training regimen and imbalance between the core and the extremities can lead to nagging pains about the knee known as patellofemoral pain syndrome. The “coreâ€? muscle groups are any of the muscles that support the pelvis and spine. The goal of core strength is to create a solid foundation for the transfer of energy to the extremities. This is just like the foundation upon which a house must stand. “Coreâ€? muscles include the abdominal muscles, gluteus muscles, erector spinae, the hip exors, hip adductors, and the hamstrings. When assessing a training regimen, one always wants to assure a solid element of core strengthening is included. Common tools By Timothy Panek, M.D.
MetroDoctors
used for core strengthening include, but are not limited to: medicine balls, bosu balls, stability balls, wobble boards, and dumb bells. Risk vs. Safety Positions
Once the foundation is built, there are ways to train the neuromuscular centers of the athlete’s brain to avoid the positions of risk. The traumatic “non-contact� knee injury has some predictable positions of risk. The positions of risk include: s 'ROUND CONTACT IN THE hmAT FOOTv POSITION s 4HE EXTENDED KNEE AND STEP STOPS OR turns. s 4HE CENTER OF BODY MASS BEHIND THE FOOT s ,ANDING A JUMP WITH KNEES TOGETHER Coaches and trainers work on plyometric programs that train athletes to assume positions of safety during sports. A plyometric program is a focused technique based in the positions of safety. The positions of safety include: s )NCREASED KNEE mEXION WITH THREE STEP stops or turns. s 'ROUND CONTACT WITH WEIGHT TOWARD THE toes. s ,ANDING A JUMP WITH KNEES SEPARATED In order to elicit a fundamental change in the neuromuscular centers of the athlete, a
The Journal of the Twin Cities Medical Society
In the event of cartilage or ligament injury, methods of diagnosis are well established both by exam and diagnostic imaging. The techniques for surgical intervention and rehabilitation are evolving so as to optimize the outcome for athletes. More accurate techniques are now reproducing a more precise restoration of normal anatomy. Bracing has not been shown to reduce the risk of re-rupture in athletes who have undergone previous reconstruction and the risk of re-rupture doesn’t seem to be any higher in the reconstructed athlete than it might be otherwise. With athletes getting bigger, faster and stronger, there is a concern that we might see a higher propensity for joint injury. Through study and science-based methods, we may be able to lower that risk for our athletes. Dr. Timothy Panek joined St. Croix Orthopaedics in 2001. He graduated from the University of Minnesota Medical School and completed his orthopedic surgery residency at the University of Minnesota. Dr. Panek is board certiďŹ ed by the American Board of Orthopaedic Surgery and holds subspecialty certiďŹ cation in sports medicine. He has a special interest in arthroscopy, joint replacements and sports medicine and provides care to local sports teams, including Mahtomedi High School. Dr. Panek can be reached at: info@ stcroixortho.com. January/February 2013
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The State of Imaging in Sports Medicine
T
he benefits of athletics and fitness are myriad, but each sport or activity carries with it the risk of injury. Various methods of reporting yield varying estimates of injury, but Robert Wood Johnson University puts the total at five million sports related injuries in America per year, with 775,000 emergency room visits in children under 15. Apart from the emergency room setting, more than 3.5 million children ages 14 and under receive medical treatment for sports injuries each year. Athletics and fitness in the adult population presents additional challenges, as the phenomena of the “weekend warrior” can predispose to injury, and decreased elasticity of soft tissues and deconditioning are setups for injury. While we typically think of the fall, the collision, the traumatic incident, over half of these injuries are classified as repetitive motion trauma/over use type injuries. Increasingly, medical imaging is integral to sports medicine. “Imaging is essential in my practice not only for diagnosing acute injuries, but also for more chronic conditions such as arthritis or tendinopathy,” according to Dr. Angela Voight, Summit Orthopedics Sports Medicine. “It makes my practice more efficient because it narrows down the clinical situation to focus on.” In today’s medical marketplace, competent physicians and ancillary medical staff such as P.A.s and L.P.N.s need to know the appropriate indications and applications for efficient use of medical imaging. There is likely some overutilization By Nathan Block, M.D.
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January/February 2013
of medical imaging, but the risk of missing a real injury in the setting of generalized soreness or pain is real, and returning an athlete of any age to activity too soon, or missing a fracture or torn ligament, can lead to premature and permanent damage to a joint. Patients have widely different experiences of pain, and tolerance to pain, and a physical exam is only part of the process. Often imaging is the deciding factor in diagnosis and appropriate therapy. While it has always been used to diagnose injury, there has also been a rise in the usage of medical imaging to document response to treatment. If there has been operative intervention, imaging may be performed to assess the integrity of the repair, especially after repeat injury or new onset pain status post surgery. Also increasing is the use of imaging for inquiry into response to more conservative measures, such as checking the integrity of a joint after several weeks of physical therapy, or checking for resolution of bone edema after a stress reaction or bone contusion. Radiographs, the hallmark of sports medicine imaging for 100 years, retain an important role. X-ray analysis is quick, cheap, and always available. In 2010 in the United States, about two billion x-rays were performed, with between a quarter and one half of them performed for joint/ bone analysis.1 It remains an excellent diagnostic tool for fracture diagnosis, but the rise of specialized modalities has uncovered some intrinsic limitations. Several bones and joints with a high incidence of injury are notoriously hard to image with plain film, the wrist most notably, with one in
five frank fractures impossible to detect. As the standard of care changes, and patient expectation changes, it is less and less palatable to take a quick x-ray, and only revisit the issue with repeat plain films in one-two weeks, or immobilize a patient presumptively without an underlying diagnosis. It is also worth remembering that the majority of sports medicine injuries have no plain film abnormalities. Recently, CT has enjoyed a renaissance in sports medicine imaging, as it allows for excellent spatial resolution in bone imaging. Modern scanners are accurate to less than a millimeter, and fast speed multi-slice detectors have allowed for isometric imaging. This “isometric voxel” analysis allows for a bone or joint to be imaged in any plane and then reconstituted in any other plane, with no loss of data. This is a true advantage when pain, frank deformity, or decreased range of motion precludes optimal positioning of the patient in the scanner. Faster and better
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The Journal of the Twin Cities Medical Society
computing power has allowed for multiplanar analysis and 3D reconstruction to become commonplace. 3D reconstructions can convey complex comminuted fractures with more thorough understanding and speed than a two dimensional axial image can. Finally, a CT roadmap prior to internal fixation provides the orthopedic surgeon with a detailed and accurate plan of attack prior to surgery. However, frank fracture accounts for a minority of sports injuries, with soft tissue and connective structure damage resulting in the majority of sports injuries across all age groups. MRI has resulted in the most revolutionary transformation of sports medicine imaging. According to the CDC, the number of magnets has increased about 500 percent since 1990 and the number of MRI scans has increased five fold since 1996.2 What was once the province of academic medical centers and tertiary hospitals is now available in county hospitals. MRI has clear advantages in the realm of sports medical imaging by providing essentially a “one-stop shop.” It provides excellent diagnostic utility for virtually all sports medicine diagnoses, and what it may lack in sub millimeter spatial accuracy, it makes up for in soft tissue analysis and the presence or absence of bone edema and pre-fracture states such as bone contusion and stress reaction. There is no specter of ionizing radiation, so multiple MRIs can be performed without risk, making it especially attractive in pediatric or settings where multiple examinations can be expected. MRI is also useful as a follow-up tool; evaluating the integrity of a postoperative repair, such as a rotator cuff or an ACL, or evaluating response to nonoperative conservative management, such as resolution of bone edema in a stress fracture. Dr. Voight states “If a runner continues to have pain with activity and I see bone marrow edema on MRI it’s much easier to decide it’s too early to return to activity.” Higher strength magnets have increased signal to noise, and better software packages and innovative sequences have decreased exam times and lessened MetroDoctors
the artifact associated with metal from prior orthopedic repair. Ultrasound has not reached the level of usage in extremity and joint evaluation in the United States as it has in Europe. Some of this comes from economic considerations as well as greater oversight and regulation of ionizing radiation. Most radiologists in this country (and sonographers) leave training without a great deal of experience in musculoskeletal ultrasound for diagnosis, but economic factors could result in a resurgence. Ultrasound is excellent for dynamic evaluation of tendons and their attachments, and can readily diagnose full thickness tearing of extensor tendons about the knee and rotator cuff retraction, in the hands of qualified operators. In addition, ultrasound guidance is utilized commonly in radiologist delivered therapy, in terms of steroid or pain killer injection into joints or tendon sheaths. However, ultrasound is of very limited utility in evaluation of bone or cartilage damage and less sensitive in evaluating intrinsic inflammatory change in ligaments or tendons, often coming down to a “torn or not” binary diagnosis, and missing the continuum of injury leading up to complete disruption. It is hard to envision a radical change in the use of diagnostic imaging in sports medicine over the next decade. No new modalities are on the horizon, and we’ll likely see further refinement of the tools we have. Economic forces will only act to encourage greater synergy in the patientclinician/surgeon-radiologist axis with a goal of prompt and accurate diagnosis, appropriate therapeutic intervention, and the return of the athlete to the playing field in the shortest possible time, with the best possible outcome. Nathan Block, M.D., musculoskeletal imaging, St. Paul Radiology. Dr. Block can be reached at: nblock@stpaulrad.com. References: 1. Medical and Care Compunetics 5, Lodewijk Boss, prepared as an accompaniment for the 5th annual conference of the International Council on Medical and Care Compunetics. 2. Organization for Economic Cooperation and Development “Health at a Glance; 2011 Report.”
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MedicalMedicine Sports Care Organizations
Injury Prevention 101
W
orking in sports medicine as a certified athletic trainer (ATC), one of my jobs is injury prevention for my patients. It is widely accepted that for an individual to compete at a high level athletically they must be physically fit and that those who are not fit may be more likely to suffer an injury. Injuries can occur for a number of reasons and not all are preventable, but those that result from improper conditioning can be. When prescribing an exercise plan, the components that must be addressed to aid in the prevention of injury, lessen
By Amy Hamilton, M.A., A.T.C.
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January/February 2013
the severity of injury that might occur, and help to prevent re-injury include: range of motion and flexibility; muscular strength; endurance and power; balance and proprioception; and cardiorespiratory endurance. A well-designed program will address each of these areas and include a proper warm up and cool down. It may be important to work on each component individually at first to address biomechanical imbalance and weakness, and then build upon a good foundation into functional, sport- or activity-specific exercises as training progresses. Many individuals perform at a high level but use compensatory movement patterns which are less efficient. If they continue, the poor
movements continue to be reinforced and lead to improper biomechanics and potential injury. For any individual looking to start a fitness program or for an experienced athlete, the foundations of physical conditioning are the same. A systematic approach involving specific, repetitive and progressive exercise is important. Any biomechanical problems must be addressed and good fundamentals practiced. For any improvement to occur the body must be forced to work at a higher level than it is used to. The SAID principle (Specific Adaptation to Imposed Demands) states that when the body is subjected to stresses of varying intensities, it will gradually adapt over time to the demands placed on it. The critical component is to create enough stress for the body to adjust to the demands without creating too much stress too soon, resulting in injury. For any physical activity it is important to ensure that the involved joint can move a full range of motion working together in the kinetic chain to produce a functional movement. There is evidence to suggest that it is more beneficial for dynamic activities and that static stretching before activity does not necessarily help to prevent injury. Muscular strength, power and endurance are critical pieces of physical fitness and injury prevention. Each of these components will build upon the other. Strength of the muscle is determined by the size and number of the individual muscle fibers, and by neuromuscular efficiency. The individual fibers respond to
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The Journal of the Twin Cities Medical Society
weight training by increasing in size, but the number of individual muscle fibers one possesses has a genetic limitation. The neuromuscular system, if trained efficiently, results in initial increases in strength by recruiting more motor neurons within a muscle to fire increasing the contraction of the muscle. Progressive resistive exercises are the most common tool for strength training and use an isotonic contraction in which the muscle changes in length throughout the time the force is being generated. These contractions have two phases, the concentric and eccentric phase, both of which are important to address with regard to proper function and injury prevention. Plyometric exercise is commonly used to increase muscular power. These exercises involve a rapid eccentric contraction (lengthening of the muscle) followed immediately by a rapid concentric contraction (shortening of the muscle). This produces forceful, explosive movements. Muscles surrounding a joint can be conditioned to optimally stabilize that joint, and prevent unwanted movement from occurring. A popular concept heard frequently is that of core strength or core stability. This is extremely important and foundational. The “core” refers to the lumbo-pelvic-hip complex and is the center of gravity for the body and thus where all movement begins. Twenty-nine different muscles form this complex and must all work effectively together to stabilize and produce dynamic postural control through the rest of the joints of the body while it is in motion. A stable core and strong muscular balance improves functional strength and neuromuscular efficiency throughout the entire body. Balance and proprioception are critical to enhance motor control. Functional balance training that incorporates occupational or sport-specific exercises to produce movement patterns in multiple planes of motion can improve this proprioceptive sense and decrease the risk of injury. Cardiorespiratory endurance is critical for performance as well as preventing MetroDoctors
general fatigue that may predispose a person to injury when the nervous and muscular systems are unable to respond adequately to an injury-producing situation. The ability to react is the first reflex to suffer if fatigued and is important for avoiding collisions, staying on your feet and remaining in control of body movements. Start slowly when beginning a new exercise program and progress carefully when trying to achieve a higher level of performance. Remember, safe but challenging exercises that stress multiplanar motions will build functional strength and endurance. Some soreness is normal as muscle adapts, but pain that persists or joint pain can be an indication of training error or injury. Amy Hamilton, M.A., A.T.C., is the sports medicine program representative at TRIA
The Journal of the Twin Cities Medical Society
Orthopaedic Center. She holds a Bachelor of Science degree in Athletic Training from Minnesota State University, Mankato, and a Master of Arts in Sport Administration from the University of Northern Colorado. Ms. Hamilton was the certified athletic trainer for U of M Gopher Women’s Hockey and Gopher Tennis from 1999-2012. She can be reached at: amy.hamilton@tria.com, or (952) 806-5693. References: Fredericson, M., Moore, T. Muscular Balance, Core Stability, and Injury Prevention for Middle- and Long-Distance Runners. Physical Medicine and Rehabilitation Clinics of North America (2005) 16: 669-689. O’Connor, C. Proprioception and Balance – Part 1. Retrieved from: www.qswellness.ca. Peate, W.F., Bates, G., Lunda, K., Francis, S., Bellamy, K. Core Strength: A new model for injury prediction and prevention. Journal of Occupational Medicine and Toxicology 2007, 2:3. Prentice, W. E. Essentials of Athletic Injury Management (8th Edition). NY: McGraw Hill, 2010.
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Fluid Replacement for High School Sports Safety and Performance
F
luid replacement for sports activity can be divided into three phases: before, during and after. Maintaining body fluid balance is important to preserve intravascular volume for oxygen, nutrient, waste product, and heat transport around the body, and for thermal control through sweating. Fluid balance can be monitored by thirst, by measuring and recording before and after practice body weights, and by noting urine color. Fluid lost during practice or a game will be reflected by the drop in pre- to post-activity weight. This fluid loss should be replaced before the next activity. Urine color can give an indication of roundthe-clock hydration status as dark urine, like apple juice, indicates dehydration and light yellow urine, like lemonade, indicates good hydration. Thirst kicks in when the serum osmolality rises to a preset level. Osmolality rises as body water content drops. Thirst is a marker of dehydration and should not be ignored during practices or games. The biggest challenge to keeping fluid in balance occurs when there is more than one practice or game on the same day — especially if it is hot and sweat volumes are high. Replacing weight lost between sessions requires more than a pint per pound of weight loss and is difficult to accomplish if there are large fluid losses and less than three hours between events. As a general rule, 150 percent of weight loss replacement with fluid is necessary to be back to normal body water after an event. That translates to 24 ounces of
By William O. Roberts, M.D., M.S.
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January/February 2013
fluid for each pound of weight loss for post-activity fluid replacement. Ingesting that much fluid in a short time span can be difficult and requires an athlete to monitor urine color, weight, and thirst. One of the easiest fluids to use for post-event recovery and replacement is chocolate skim milk as it contains carbohydrate, protein and salt in addition to water. When the next event is the following day, the replacement schedule is a little more relaxed and the regular meals help with fluid replacement. In a normal diet, half of the food content is water and this helps with fluid intake. Replacing fluid during a practice or game helps maintain fluid balance for performance and heat safety, and replacement during the game decreases the need for aggressive post-game fluid intake. Water is fine for events lasting less than an hour and is adequate for longer events, too. For events that last an hour or more, there is some advantage to using a sports drink that contains carbohydrate for energy replacement, but the primary ingredient in a sports drink is water. There may be some advantage to using sports drinks when there is more than one game or practice on the same day. The volume of fluid replacement needed is highly variable from athlete to athlete. Sweat rates vary from 400 to 2400 or more ml per hour (12 to 80 ounces) so a single statement of “x” ounces every 20 minutes is nearly impossible to determine and safely recommend. The body cannot absorb more than 32 ounces an hour, so athletes who sweat heavily will always end a longer session with a fluid deficit. Likewise, an athlete with a very low sweat rate
who ingests more than needed over a longer period of time will run the risk of fluid overload, which can be fatal. Athletes can calculate their needs based on weight lost during practice and increase fluid intake during practice if the post-practice weight is greater than 2 to 3 percent lower than the pre-practice weight. Fluid ingested before the game or practice will help start the activity fully hydrated, but humans do not store excess water, so timing is important. Drinking 12 to 16 ounces of water about two hours before the activity should give time for absorption of the fluid ingested and excretion of any excess through the kidneys before the event. An additional 4 to 6 ounces about 20 minutes before taking the field may help start replacement during the game. Energy (stimulant) drinks are not sports drinks, and for athletes are best classified as supplements with the attached risks. Some common brands are Red Bull, Rock Star, Monster, Full Throttle, Jolt, and Go Girl. For athletes in training, nutritional supplements are purported to improve training adaptations, allow more intense training, promote recovery between training bouts, and enhance competitive performance. Like nutritional supplements, energy drinks are not regulated by the Food and Drug Administration (FDA) due to the 1994 U.S. Dietary Supplement Health and Education Act. This means manufacturers are not required to prove either effectiveness or safety of the product and there is no oversight group that regulates the products for purity. Energy drinks are advertised to give users an “edge.”
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The Journal of the Twin Cities Medical Society
However, recent work by Woolsey and associates using an assigned double-blind placebo controlled study found that while subjects felt they were performing better, they really were making signiďŹ cantly more errors probably due to being over-aroused or over-focused. Energy drinks seem to reduce performance for technical skills that rely on timing and coordination; not attributes that help most athletes. Energy drinks contain, beyond water, various combinations of sugar, caffeine,
psychoactive drug in the world. Recent ďŹ ndings suggest that low doses of caffeine provide some ergogenic effects by directly affecting the central nervous system during exercise. Caffeine can cross the blood-brain barrier and antagonize the effects of adenosine, resulting in higher concentrations of stimulatory neurotransmitters. It does improve performance and endurance during long duration, heavy exercise, and also improves, to a lesser extent short-term, high-intensity athletic performance. Caffeine improves concentration, reduces fatigue, and enhances alertness. Sports drinks may help performance Regular repeated use does not moderate cafin longer duration games and feine’s ergogenic propactivities, but water is ďŹ ne for most erties. Chronic use of caffeine leads to depenhigh school events. dence, tolerance, drug craving, and, upon abrupt cessation, unand “otherâ€? ingredients that are reported pleasant withdrawal symptoms. Its use to increase energy levels and improve alertis widespread by athletes as young as 11 ness. These other ingredients includes B years of age who are seeking a legal boost in vitamins (vit B6, vit B12, and niacin), performance and no longer on the WADA taurine, guarana, ginseng, Tibetan goji prohibited list. berry, green tea, yerba mate, ginkgo biThere are down sides to drinks taken loba, policosan’s, glucuronolactone, and during activity, the most frequent being vitamin C. None of these ingredients have gastrointestinal (GI) complaints. Using known performance enhancing properties. sports drinks as a model, it was found Ginseng and niacin both cause a vasodithat sport drink ingestion led to higher latation and ushing sensation that may incidences of GI complaints compared give a feeling of “energy.â€? Much of the to water. Adding caffeine to the sports stimulant properties of the drink come drink has no effect on GI complaints and from the caffeine or other stimulants in the carbohydrate component may be the the mixture. culprit for the GI distress that occurred in Amphetamines, ephedrine, Ma some of the athletes. Sugar or carbohydrate Huang, synephrine, bitter orange, citrus is one of the main components in the nonaurantium, zhi shi are all banned subdiet energy drinks. stances for athletic competition and may There are case reports and clinical be found in stimulant drinks, although observations that describe adverse cardioamphetamines are in the FDA-controlled vascular adverse events, including sudden substance category and ephedrine has been death, associated with the use of some taken off the market. Stimulants can cause performance-enhancing substances, but or have been associated with tachycardia, these episodes have not been tied to ennervousness, laxative effects, sleep disturergy drinks. The usual cardiovascular combance, anxiety, tremor, insomnia, aggresplaints involve racing heart or palpitations siveness, hallucinations, addiction, and and many of these complaints were due to an increased risk of stroke, heart attack, ephedrine and/or caffeine. cardiac arrhythmia, and sudden death. The ingredients in an energy drink Caffeine is the most frequently used that will help athletes are the water (but MetroDoctors
The Journal of the Twin Cities Medical Society
there is not much in each can), the sugar (although usually present it large quantities that cause GI upset in exercising athletes), and caffeine (as long as it does not cause heart palpitations or racing heart). The “otherâ€? ingredients may do more to upset an athlete’s concentration and focus than improve performance, so it is probably best for athletes to skip the energy drinks before practice and competition and concentrate their uids on proven replacements like water and sports drinks. Summary
Fluid replacement is critical for athlete safety and performance. Fluids and foods in the normal diet help maintain body water. An individual hydration plan to replace weight lost during practice will help ensure good hydration for the next day. Sports drinks may help performance in longer duration games and activities, but water is ďŹ ne for most high school events. Energy drinks, as opposed to sports drinks, should be avoided and their use prior to and during sports events is not recommended. Hydration Tips
s s s s
s s s s s
7ATER IS lNE 3PORTS DRINKS HELP WITH ACTIVITY GREATER than an hour. %NERGY DRINKS SHOULD NOT BE USED FOR sports. 4RY TO REPLACE SWEAT LOSSES DURING ACtivity to remain within 2- to 3 percent of baseline weight. 2EPLACE WEIGHT LOSSES WITH mUID BEFORE the next activity. 4HERE IS ADEQUATE SODIUM AND POTASsium in the normal diet. 7EIGH BEFORE AND AFTER ACTIVITIES +EEP URINE LIGHT YELLOW LIKE LEMONADE ,ISTEN TO YOUR BODY AND DO NOT IGNORE thirst.
William O. Roberts, M.D., M.S. is a professor of Family Medicine and Community Health, Division of Sports Medicine, University of Minnesota Medical School, and also is chair of the Minnesota State High School League’s Sports Medicine Advisory Committee. Reprinted with permission. Dr. Roberts can be contacted at: rober037@umn.edu.
January/February 2013
27
New Members
David S. Feldman, M.D. Cardiovascular Disease
Terrance F. Longe, M.D. Cardiovascular Disease
Elizabeth Z. Grey, M.D. Cardiovascular Disease
Daniel P. Melby, M.D. Cardiovascular Disease
Kevin M. Harris, M.D. Cardiovascular Disease
Michael R. Mooney, M.D. Cardiovascular Disease
Robert G. Hauser, M.D. Cardiovascular Disease
Richard R. Nelson, M.D. Cardiovascular Disease
Timothy D. Henry, M.D. Cardiovascular Disease
Quirino G. Orlandi, M.D. Cardiovascular Disease
Katarzyna M. Hryniewicz-Czeneszew, M.D. Cardiovascular Disease
Wesley R. Pedersen, M.D. Cardiovascular Disease
Desmond B. Jay, M.D. Cardiovascular Disease
Anil K. Poulose, M.D. Cardiovascular Disease
William T. Katsiyiannis, M.D. Cardiovascular Disease
Robert S. Schwartz, M.D. Cardiovascular Disease
M. Nicholas Burke, M.D. Cardiovascular Disease
Thomas Knickelbine, M.D. Cardiovascular Disease
Scott S. Sharkey, M.D. Cardiovascular Disease
Barry Cabuay, M.D. Cardiovascular Disease
John R. Lesser, M.D. Cardiovascular Disease
Norma L. Thiessen, M.D. Cardiovascular Surgery
Ivan J. Chavez, M.D. Cardiovascular Disease
David Lin, M.D. Cardiovascular Disease
Jay H. Traverse, III, M.D. Cardiovascular Disease
Butch M. Huston, M.D. Ramsey County Medical Examiners Forensic Pathology Frederick S. Mosch, M.D. Fairview Southdale Hospital Internal Medicine Katherine S. Park, M.D. Hennepin Health Care System Anatomic/Clinical Pathology Gary B. Wilhelm, M.D., Ph.D. Minneapolis V.A. Hospital Occupational Medicine Minneapolis Heart Institute Raed H. Abdelhadi, M.D. Cardiovascular Disease
Member Profile:
TCMS Serves as Resource for Community Advocacy
W
hile completing her dermatology residency at Columbia University in New York, a mole was discovered on the face of a teenage girl who frequented tanning booths in advance of special events. Pathology confirmed the suspected melanoma. The resulting scar on this young girl ignited the passion of Mohiba Tareen, M.D., to educate the public, especially teenagers, of the risks of cancer from tanning bed use. “Teenagers think they are invincible and live for the moment,” said Dr. Tareen. Through education and legislation it is her goal to prevent stories similar to the one above from occurring. According to an epidemiological study conducted by Reed, KB et al., Department of Dermatology at Mayo Clinic, there is an expediential growth in melanomas in Minnesota, with a higher rate in young girls. (Mayo Clinic Proceedings; Vol 87; Issue 4; pgs 328-334, April 2012). These results have been correlated to tanning bed use. Within days after Dr. Tareen made a new member visit to the Twin Cities Medical Society and met with Sue Schettle, CEO, Sue received a call from the American Cancer Society Cancer Action Network (ACS CAN) Midwest Division inquiring if she was aware of a physician who might be willing to partner with them on legislation banning the use of tanning beds by minors. As TCMS and ACS CAN have a history of working together on Smoke-Free Minnesota, this call for assistance in connecting physicians to community advocacy initiatives was not unprecedented. Of course, Dr. Tareen was immediately contacted and is now working in partnership with the ACS CAN to support the Teen
28
January/February 2013
Tan Ban, a public health policy campaign to prohibit children under 18 from using commercial tanning facilities. “TCMS serves as our ‘go-to’ resource when physician expertise and partnership is needed in a variety of policy areas. We would love to have dermatologists, plastic surgeons, pediatricians and any other physicians who are passionate about the issue join us,” said Rebecca Thoman, M.D., Government Relations Specialist for ACS CAN. Melanoma is a preventable cancer. California, Delaware, New York, Vermont and the City of Chicago have already successfully passed legislation which prohibits any person under the age of 18 from tanning bed use under any circumstance. Several other states have also implemented tanning bed usage restrictions for youth under the age of 16, and even as young as age 13. To discuss ways you can get involved in this campaign, or other advocacy issues, contact Sue Schettle at sschettle@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
EMMS Foundation Annual Meeting and Honoring Choices Documentary Screening
T
he EMMS Foundation and Honoring Choices Minnesota shared an inspiring event on November 7, 2012, at Twin Cities Public Television Studios celebrating the annual meeting of EMMSF and the final Honoring Choices Minnesota documentary, “Giving Thanks.” Speakers included Mary Brainerd, president and CEO of HealthPartners, Ed Ehlinger, M.D., MSPH, Minnesota Commissioner of Health, and Yvonne Prettner Solon, Lieutenant Governor. In addition to giving out two awards (see page 33), a video was shown, featuring the legacy of an early medical society member, Dr. Eduard
Boeckmann. Attendees also screened the “Giving Thanks” documentary. This final documentary is the culmination of a three-year partnership between Twin Cities
Medical Society and Twin Cities Public Television. The documentary and previous ones can be viewed at: www.honoringchoices.org.
From left: Mary Brainerd, Paul Jarris, M.D., Ed Ehlinger, M.D., and Kent Wilson, M.D.
From left: Steve Mattson, Lisa Mattson, M.D., and Carolyn McClain, M.D.
Frank Indihar, M.D. (left) and Craig Svendsen, M.D.
From left: Craig Bowron, M.D. Joseph Amberg, M.D. and Dwight Townes, M.D.
Clinics & Hospitals Needed to Register for Homeless Supply Drive Caring Hearts for Homeless People, the annual supply drive for homeless adults and children in the Twin Cities area, will take place again this winter. Throughout February 2013, clinics and hospitals simply display a collection box and signage and encourage staff and/or patients to donate health and hygiene items. At the end of the month, all donations can be brought to either St. Joseph’s Hospital in St. Paul or the Twin Cities Medical Society office in Minneapolis. Have your site representative contact Katie or Kris at the EMMS Foundation (612-362-3704 / KSnow@metrodoctors.com) to express your interest
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The Journal of the Twin Cities Medical Society
and receive display materials and information electronically. All donated items are distributed directly to the homeless through the following three programs: Health Care for the Homeless, Listening House of St. Paul, and SafeZone Drop-In Center. Caring Hearts for Homeless People is sponsored by HealthEast Care System, Cerenity Senior Care and East Metro Medical Society Foundation.
January/February 2013
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CAREER OPPORTUNITIES
In Memoriam E. WILLIAM HAYWA, M.D., passed away at the age of 85 in September 2012. Dr. Haywa attended the University of Minnesota Medical School. He practiced as an OB/GYN at Fairview Southdale for several years. Dr. Haywa became a member in 1957. JOHN W. JAMES, M.D., passed away on October 5, 2012 at the age of 91. Dr. James attended the University of Minnesota Medical School. Dr. James became a member in 1951. JOSEPH R. KELLY, M.D., age 81, passed away October 11, 2012. Dr. Kelly graduated from the University of Vermont Medical School in 1956 going on to complete a fellowship in allergy and immunology at the University of Michigan. Dr. Kelly became a member in 1965. ROBERT R. MCCLELLAND, M.D., age 80, passed away on September 28, 2012. Dr. McClelland graduated from Columbia University College of Physicians and Surgeons in New York City specializing in interventional radiology. Dr. McClelland became a member in 1978.
See Additional Career Opportunities on page 31.
Fairview Health Services Leading the way in innovation Fairview is seeking compassionate and adventurous caregivers—full-time physicians and full-time nurse practitioners/physician assistants—to join us in developing a unique new outpatient care model. Highlights of this opportunity include: , $ !$ ' & " & &% ) & ! " * ( !$ %-& !% !& well-served in the traditional outpatient clinic—through development of a primarily ! % "$ & , $& $ ) & $( ) $!'" & ) ! % ! %&$ & & " &+ &! "$!( ! " %% ! & #' &+ . & $ !$ % $ + ! " * patient population , $!( !'&" & & $ ! + " & & $ "$!( + !'$ & ! !%" & %&% our community and academic medical centers
& % '%& ( + $% *" $ % "$ & " % % !%" & % $ "' ! $+ !$ ! $ "$ $$ Visit fairview.org/physicians to explore this and other opportunities and apply online, call 612-672-2277 or email recruit1@fairview.org. Sorry, no J1 opportunities.
fairview.org/physicians TTY 612-672-7300 EEO/AA Employer
WILLARD C. PETERSON, M.D., passed away at age 81 on October 21, 2012. Dr. Peterson attended the University of Minnesota Medical School. Dr. Peterson became a member in 1965.
Search for Twin Cities Medical Society on Facebook and follow us on Twitter 30
January/February 2013
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CAREER OPPORTUNITIES
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t Dermatology t Family Medicine t Hospital Medicine
t Internal Medicine t Oral Surgery t Orthopedics
t Pediatrics t Podiatry t Urgent Care
Winona, a sophisticated community nestled between beautiful bluffs and the mighty Mississippi— kayak the rivers, fish the streams, watch the eagles, take in world-class performances during the Beethoven and Shakespeare festivals and stand inches away from a Van Gogh at the MN Marine Art Museum. Learn more at visitwinona.com.
Contact Cathy Fangman t cfangman@winonahealth.org .BOLBUP "WF t Winona, MN 55987 t 800.944.3960, ext. 4301 t winonahealth.org January/February 2013
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
A. STUART HANSON, M.D. THE TALL, ANGULAR, CREW CUT ADORNED SENIOR
cut deftly, gathered the rebound and arched the ball toward the basket. The 18,000+ Williams Arena crowd cheered lustily as the ball fell through the net … the initial points of Washburn High School’s tournament games were scored. That lad was to go on to total 48 points in three games, gain All-Tournament honors and help lead his team to the 1955 State Basketball Championship. Dr. Stuart Hanson contributed mightily to that winning effort, but that was just a prelude to a lifetime of hard work and leadership successes. He was Minneapolis reared, received his undergraduate degree from Dartmouth College and graduated from our U of M Medical School. His General Hospital (HCMC) internship, internal medicine residency and pulmonary fellowship were via the U of M system — interspersed with a three year U.S. Navy stint at the height of the Vietnam war. Dr. Hanson’s faculty appointment at the U of M parallels his equally long practice tenure at the Park Nicollet Medical Center where he served in various leadership roles. He’s also been a long-standing member of his alma mater’s Medical School Admissions Committee. In conversation, Stuart stated that “the community nurtured and trained me for my first 13 years and they educated me for another 13 — by then it was my turn to ‘give back.’” And give back he did! In addition to the above noted full professional life, he somehow found time to become profoundly involved in tangential areas that included presidencies of the Hennepin Medical Society and the Minnesota Medical Association (MMA). When asked if his dedicated work for a smokefree society and violence prevention resulted in positive outcomes, he proudly — though modestly — cited Minnesota’s striking improvement in smoking statistics over the past three decades, and the now common performance of physicians asking their patients whether they feel safe from harm — a practice that openly first addresses and then often leads to the avoidance of domestic violence. Dr. Hanson’s involvement in these activities have far reaching implications and will continue to pay dividends for years to come. 32
January/February 2013
Stuart keeps himself physically and spiritually fit participating in cross country ski marathons and church leadership activities. He and his wife have two children who undoubtedly looked to him as a role model while they embarked on their own successful medically associated careers. His favorite professional pursuit continues to be “seeing patients,” and he remains available for specialty consultation on an “as needed” basis. Dr. Hanson’s work has been recognized by receiving honored awards from a variety of organizations including Park Nicollet, our medical society, the Minnesota Department of Health and the Public Health Association, the MMA and the U of M. He continues to be involved and contribute — exhibiting a strong interest in system change and the evolution of existing community norms and systems. His clinical and administrative experiences have led him to a vision and heartfelt wish relating to an as yet unachieved change in the health care delivery system which will result in an improved standard universal benefit coverage system associated with appropriate distribution of funding and a more efficient payment system. Not only is our Luminary an industrious, brilliant, caring and energetic visionary — he was also one heck of a good basketball player. Dr. Stuart Hanson is still scoring points for his patients, his profession, his community and future generations. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
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East Metro Medical Society Foundation Awards Peter J. Daly, M.D. received the Boeckmann Community Service and Leadership Award at the EMMS Foundation Annual Meeting in November. The award recognizes “unsung physician heros” who have made positive contributions to the community and is named after Eduard Boeckmann, M.D., a St. Paul physician who practiced at the turn of the 20th century and made several significant gifts to the medical society of both time and funds, the latter which still supports the medical society today. Dr. Daly is an orthopedic surgeon at Summit Orthopedics in St. Paul and has served as president of Ramsey Medical Society, chief of staff at St. Joseph’s Hospital and president of the Minnesota Ambulatory Health Care Consortium. Several years ago, Dr. Daly and his family took a volunteer trip to an orphanage in Honduras and got closely involved with the surgery and care of an eight-yearold patient, whom Peter J. Daly, M.D. (center) and family with the
they brought back to their home in Minnesota until after her extensive rehabilitation. He now travels often to Honduras as a volunteer surgeon and overseer of a permanent outpatient surgery facility which he helped to build. The Minnesota Medical Association Foundation’s Community Service Award honors a civic-minded individual who goes beyond personal altruism to volunteer in the community. Kent Wilson received this award for his great leadership, guidance and vision in the Honoring Choices Minnesota (HCM) initiative. In his role as medical director of HCM, he has raised significant funds, energized community partners, and enticed health care leaders to collaborate and coordinate for the betterment of Minnesotans. His leadership in creating a community-wide, collaborative advance care planning program has impacted many individuals and families who take ac- Kent S. Wilson, M.D. (center) and wife, tion to have conversations about Missy, receiving the Community Service award from Lyle Swenson, M.D. end-of-life care.
Boeckmann award.
West Metro Medical Foundation Awards The West Metro Medical Foundation of the Twin Cities Medical Society honored two outstanding physicians with the prestigious Charles Bolles Bolles-Rogers Award. Joseph J. Westermeyer, M.D., a clinician, teacher, researcher, author and international expert in cross-cultural psychiatry, was presented with his award on Thursday, September 27, 2012 at a meeting of his peers at the Minneapolis VA Health Care System. Dr. Westermeyer has been closely attuned to the needs of the veterans and worked especially hard in dealing with mental health issues in soldiers returning from deployment in Iraq and Afghanistan. In addition to his interest in substance abuse and addiction, he has studied the health adjustments of refugees and the consequences of trauma for both veterans and refugees. He has been an active researcher, written more than 232 peer reviewed publications Joseph J. Westermeyer, M.D. and has worked as a consultant to the World Health Organization. Anthony A. Spagnolo, M.D., a compassionate primary care physician, talented educator and gifted leader, received his award at the Saints MetroDoctors
The Journal of the Twin Cities Medical Society
Healthcare Foundation Gala 2012, on Saturday, November 10, 2012 at Hazeltine National Golf Club. Dr. Spagnolo followed his dream of becoming a physician in a small community by moving to Shakopee in 1964 — the fifth doctor in town. Making house calls, delivering babies, and performing tonsillectomies were all part of a day’s work. In 1973, he co-founded the Shakopee Medical Clinic, which merged with Park Nicollet Clinic in 1985. Dr. Spagnolo, who served the Shakopee community for 48 years, retired this past summer. The Charles Bolles Bolles-Rogers Award was established in 1951. Mr. Bolles-Rogers served on the St. Barnabus Hospital Board of Trustees and was president of that Board for many years. Originally called the St. Barnabas Bowl, this award is given to a physician in recognition of his/her professional contribution to medicine on the basis of medical research, achievement or leader- Drs. Richard Schmidt, WMMF Chair, (L) and incoming TCMS President, Edwin Bogonko, (R) ship. present award to Dr. Anthony Spagnolo. January/February 2013
33
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