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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