Therapy Update
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Investigations to rule out more serious bony pathology may be considered, but usually the diagnosis is made on clinical grounds. Plain X-rays will be normal. Bone scan and MRI typically show patchy areas of increased uptake and bone oedema respectively— both can be seen in asymptomatic individuals as well.
Management Management focuses on identifying risk factors, relative rest, ice and analgesics, if needed. Physical therapies directed at soft tissue dysfunction— especially in the soleus, gastrocnemius, tibialis posterior and flexor digitorum longus— may be useful. For more severe cases, a short period in a pneumatic leg splint can be helpful.
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ning. Low-impact activities, such as water running and cycling, can help keep fitness levels up while the patient returns to running, increasing mileage by about 10 % every week.
Stress fracture of the anterior cortex of the tibia needs special consideration due to its propensity for non-union. This area of the tibia has a relatively poor blood supply and is an area of high biomechanical load.
X-rays reveal an area of cortical lucency, the dreaded black line( see figure 1). These stress fractures may
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Figure 1. Black line indicates an area of cortical lucency.
require surgery and their recovery is prolonged. A pneumatic brace is usually recommended for a period of time dependent on the extent
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of involvement of the cortex / bone oedema on MRI.
If progress is not being made after four months, consider surgical intervention
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with intramedullary nailing.
Other causes Other causes for exertional lower leg pain include referred pain, nerve entrapment, peripheral vascular disease and tendinopathy. Pain may be referred from the lumbopelvic area, hip and thigh. Consider nerve entrapments of the saphenous, peroneal( common and superficial) and sural nerves, usually occurring after trauma. Tendinopathy is common in the Achilles region. DVT, infection and tumours should not be forgotten.
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Conclusions A structured approach to the history, examination and investigation of exertional lower limb pain in runners will usually lead to a clear diagnosis.
Returning patients to a satisfying and safe level of activity is the desired goal and is achievable in the majority of cases. ●
Dr Masters is a musculoskeletal physician and director of Caloundra Spinal and Sports Medicine Centre,
Queensland.
References on request.
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Stress fractures People who engage in regular activity are also at risk of stress fracture, particularly if they ignore the symptoms of MTSS and continue running. The tibia is the usual site of injury and the location depends on the type of activity.
Runners characteristically suffer stress fractures at the junction of middle and distal third of the posteromedial aspect, while jumping sports— such as netball, basketball and volleyball— are associated with injuries in the upper diaphyseal or proximal metaphyseal regions.
Stress fractures are usually associated with a change in training load or conditions, for example, running on concrete footpaths. In females, always consider the possibility of the female athlete triad( eating disorder, amenorrhoea and low bone density).
The pain normally starts insidiously, occurring only with activity, but then may occur with walking or at rest. Examination reveals focal tenderness on the tibia.
Bone scan and MRI have high sensitivity and specificity for the diagnosis. MRI has the additional advantage of prognostic value as the amount of bony oedema and cortical involvement is directly related to the time taken to return to sport.
Management Management of stress fractures entails relative rest, and reducing or eliminating identifiable risk factors. The athlete needs to have their shoe wear, training schedule, running style, and nutritional and endocrine status assessed.
There will need to be a period of rest until the athlete is pain-free and this may necessitate a period of nonweight bearing or pneumatic brace.
Recovery should be expected over 8-16 weeks, with a graded return to run-
START
STRONG1
· Once-daily dosing 2
· Proven efficacy and tolerability at week 12 1, 2
· Studied in large pivotal trials used for the approval of a topical acne drug 1, 2
PBS Information: ACZONE ® is not listed on the PBS.
BEFORE PRESCRIBING, PLEASE REVIEW APPROVED PRODUCT INFORMATION AVAILABLE ON REQUEST FROM ALLERGAN BY PHONING 1800 252 224 OR FROM www. allergan. com. au / products
Australian Minimum Product Information. ACZONE ® topical gel is a prescription medicine containing 75 mg / g( 7.5 % w / w) of dapsone. Indications: For the topical treatment of acne vulgaris in patients 12 years of age and older. Contraindications: Hypersensitivity to ingredients; individuals with congenital or idiopathic methaemoglobinaemia. Precautions: Only apply to affected areas and unbroken skin. For external use only. Avoid contact with eyes, eyelids and mouth. If contact with eyes occurs, rinse thoroughly with water. Use with caution in patients- with G6PD deficiency; on oral dapsone or antimalarial medications; on trimethoprim / sulfamethoxazole( TMP / SMX); lactating; below 12 years and over 65 years; on medications which may induce methaemoglobinaemia or on topical antibiotics or topical retinoids. Use in pregnancy is not recommended. Interactions: Trimethoprim / sulfamethoxazole( TMP / SMX) co-administration may cause increases levels of dapsone and its metabolites. Topical application of ACZONE ® 7.5 % w / w gel followed by benzoyl peroxide in patients with acne vulgaris may result in a temporary local yellow or orange discolouration of the skin and facial hair. Concomitant use of ACZONE ® 7.5 % w / w gel with drugs that induce methaemoglobinaemia may increase the risk for developing this condition. Adverse Reactions( AE): ≥1.0 %: dry skin, pruritus, pain. Dosage / Method of Use: For dermatological( topical) use only. After the skin is gently washed and patted dry, approximately a pea-sized amount of ACZONE ® 7.5 % w / w gel, should be applied in a thin layer to the entire face once daily. In addition, a thin layer may be applied to other affected areas once daily. ACZONE ® 7.5 % w / w gel should be rubbed in gently and completely. Patients should be instructed to wash their hands after application. Date of first inclusion in the ARTG: 10 January 2017
References: 1. Thiboutot DM et al. Efficacy, Safety, and Dermal Tolerability of Dapsone Gel, 7.5 % in Patients with Moderate Acne Vulgaris: A Pooled Analysis of Two Phase 3 Trials. J Clin Aesthet Dermatol 2016; 9( 10): 18 – 27. 2. ACZONE ® Gel 7.5 % Approved Product Information.
™ ® Trademark( s) and registered trademark( s) of Allergan, Inc. Allergan Australia Pty Ltd 810 Pacific Highway, Gordon NSW 2072. ABN 85 000 612 831. © 2017 Allergan. All rights reserved. AU / 0391 / 2016 Date of preparation: February 2017.
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