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• 1 Lower limb

• 1.1.2 Quiz

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• Ella demonstrates a positive hop test on her left leg. Placing a vibrating tuning fork over the site of pain on her anterior left tibia also reproduces her symptoms. You recommend an x-ray of the area to assess the injury further.Which is a common x-ray finding in the investigation of a tibial stress fracture?A. A normal x-ray seriesB. Periosteal reaction involving the tibial plafondC. "Moth-eaten" appearance and lifting of the periosteumD. "Dreaded white line" sign

  A. X-rays are usually normal early in the disease process of a tibial stress fracture. Changes take several weeks to develop. It is important to realise that many athletes never have an abnormal x-ray.

• Ella’s x-rays demonstrate periosteal reaction of her anterior left tibia with a “dreaded black line” linear defect. You discuss this diagnosis of an anterior tibial stress fracture with Ella, and the possibilities for management from here.Which of the following treatments is appropriate for the initial management of an anterior tibial stress fracture?A. Above-knee castB. Pneumatic leg braceC. Intramedullary fixationD. Therapeutic x-ray stimulation

  B. A pneumatic leg brace can shift a portion of the weight-bearing load from the tibia to the surrounding soft tissues, which results in less impact load being placed through the fracture site. This allows earlier bone healing while maintaining modified activity. It also gives pain control and may stimulate healing through its compressive effect.

• Ella undergoes immediate fitting of a pneumatic air brace and after one week of rest and non-weight-bearing is pain-free when performing everyday tasks. She responds well to a relative rest programme and slowly starts to build up her impact exercise over three to four weeks. During this period, you also address precipitating factors for her stress fracture.Which of the following factors may have contributed to Ella having developed this injury?A. Being eumenorrhoeicB. A reduction in training intensityC. Training on the club’s grass pitches rather than synthetic turfD. Being female

  D. Amongst the general population, women are more likely to suffer stress fractures than men, and two to ten times more likely in the military. Higher rates of tibial stress fractures amongst female football players have been recorded compared to male players.

• Ella asks about other treatment options, as she is very motivated to return to football as soon as possible.Which of the following statements is correct regarding the use of pharmacological treatments in Ella’s situation?A. There are no pharmacological therapies that will clearly enhance healingB. The oral contraceptive pill can increase bone mineral densityC. Bisphosphonates are a good option in this situationD. Non-steroidal anti-inflammatories are useful and will allow Ella to continue training

  A, There is no convincing evidence for increased bone healing with pharmacological input. Analgesics can be useful when the patient is uncomfortable, but should not be used to permit the player to continue training.

• Ella has an x-ray and MRI scan. These demonstrate that there has been no significant healing of her anterior cortical stress fracture. A referral is made for review with an orthopaedic surgeon.Which of the following statements is true regarding surgical management of this injury?A. Surgery may speed up healing of the fracture and prevent fracture progressionB. A compartment pressure release is an effective treatmentC. Intramedullary fixation is the only treatment in this situationD. Surgery is not indicated for this condition

  A. Surgery may provide a more predictable outcome in some settings. It is also indicated when there has been a non- or delayed union. Surgery may also allow an earlier return to her sport and prevent re-fracture.

• Ella is now five months post-op. She has no pain in daily life and has progressed an appropriate rehabilitation programme. You discuss the timing of her return to competitive football.Which of the following statements is true regarding a return to competitive football?A. DEXA scan results need to be repeated prior to returning to footballB. The time of the season does not have a bearing on her return to footballC. Psychological factors are an underestimated factor with respect to a return to playD. All athletes will be able to return to football six months post-surgery

  C. Whether an athlete feels confident to return to competitive football is an important, and frequently underestimated, consideration.

• 1.4.2 Quiz

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• Pedro is a 27-year-old professional football player. He comes to see you with pain in the region of his right Achilles tendon.Which of the following symptoms is MOST CHARACTERISTIC of Achilles tendinopathy?A. Pain which is worse with forced ankle plantarflexionB. Pain with hopping and all weight-bearing activityC. Severe “lancinating” pain radiating from the buttock and hamstringD. Pain and stiffness lasting a few minutes when he first gets up in the morning

  D. Athletes with Achilles tendinopathy typically complain of short-lived morning pain and stiffness. In contrast to an inflammatory arthropathy, this pain warms up quickly over a few minutes.

• Based on his initial description of his symptoms, you think that it is likely that he has Achilles tendinopathy. You wonder why this might have developed and ask him some more questions.Which of the following findings is a risk factor for developing tendinopathy?A. A reduction in his training loadB. A recent history of 2kg weight lossC. A past history of tendinopathyD. Recently stopping smoking

  C. A past history of tendinopathy would likely increase the likelihood of further problems.

• Before you decide how best to treat Pedro’s injury, you decide that you would like some further information about the condition of the tendon. You decide to arrange some imaging.Which of the following statements is CORRECT regarding the imaging of a painful tendon?A. USS is ideal as it can demonstrate the condition of other articular structuresB. MRI imaging of tendinopathy is very operator dependantC. USS is the most widely used imaging modalityD. X-rays show the tendon in good detail

  C. USS images the condition of the collagen fibres, as well as the new vessels around the tendon. One of the main benefits of USS is that it is a dynamic exploration that can complement clinical examination.

• Pedro has not had any treatment so far. Which of the following options do you consider to represent the best initial treatment?A. Refer the athlete for a platelet rich plasma (PRP) injectionB. A corticosteroid injection to get the patient’s pain under controlC. An increased football-training load to promote tendon resilienceD. A strength programme incorporating eccentric and isometric exercises

  D. This is the most appropriate initial treatment plan. This should be combined with changes in the athlete’s training loads and other physical therapy modalities.