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Topical NSAIDs are increasingly being used due to their minimisation of systemic effects. It has been found that plasma concentrations after topical administration are as low as 5 % of the plasma levels of oral NSAIDs, resulting in a greatly reduced side-effect profile, and should therefore be recommended. 25

Oral opioids should rarely be used, unless for severe pain, due to their potential gastrointestinal and neurological side effects, and addictive properties. 23

A recent meta-analysis found a lack of difference in analgesic efficacy between NSAIDs and paracetamol or NSAIDs and opioids for acute soft tissue injuries. 23

However, NSAIDs were associated with increased gastrointestinal side effects relative to paracetamol, but with fewer adverse events and better functioning than opioid-containing medications

23, 24

.

Return to exercise Due to the wide range of muscular injuries, no‘ one size fits all’ approach exists. Once a musculoskeletal injury has occurred, the main goals should be to return to exercise in a timely fashion, and minimise the risks of re-injury by completing rehabilitation in a step-wise fashion. 11

Returning to exercise should be guided by the severity of the injury, the healing process, patient and activity factors, and ideally, by a practitioner experienced in rehabilitation.

Universally, each patient must be allowed adequate time for the inflammatory and reparative phases to occur. Therefore it is important that practitioners deliver sound advice and education during this time to reduce injury, and maximise functional outcome. During the maturation / remodelling phase, the patient should be progressed through a stepwise rehabilitation program that incorporates multiple stages, as shown in figure 2.

Initially, the patient should build up to pre-injury range of motion with exercises to maintain muscular power and proprioception.

Once this has been achieved without pain, it is often tempting for the patient to return to pre-injury exercise, but this is not recommended. At this stage, the patient should resume controlled activity including whole-body exercise, building up to specific return-toactivity requirements such as increased speed, agility, and sports-specific fitness and skills.

Once the patient has reached sustained activityspecific exercise in a practice or training environment, their return to exercise should then be considered.

Sports clinicians( for example, sports physicians, exercise physiologists, and physiotherapists) are welltrained to deliver personalised advice on appropriate interventions, exercises, and guided return-to-exercise. ● Dr Wheeler is a medical officer at SA Health. Dr Tomkinson( PhD) is an associate professor in kinesiology and public health education at the University of North Dakota, US, and an adjunct professor at the University of SA.

References on request.

Figure 2. A stepped approach to returning to exercise.

NEW ACZONE ® dapsone 7.5 % w / w topical gel

· Once-daily dosing 1

· 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

2. Restoration of range of motion

1. Inflammatory and reparative phase

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. ACZONE ® Gel 7.5 % Approved Product Information. 2. 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.

™ ® 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.

6. Sport-specific activities

4. Restoration of general fitness 3. Restoration of muscle power

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