Australian Family Physician
Australian Family Physician


Volume 42, Issue 4, April 2013

Clinical challenge

Melissa Tan
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Case 1

Fred Stone

Fred, 45 years of age, is a bricklayer. He presents with a painful right elbow after injuring himself at work. You decide he has an acute tendon injury.  

Question 1

The initial management of acute tendon injuries should involve all of the following EXCEPT:

  1. avoiding aggravating activities
  2. bracing
  3. ice packing
  4. simple analgesia
  5. stretching exercises.

Question 2

Fred commences exercise rehabilitation and is concerned that the exercises are causing pain. Which one of the following statements is CORRECT regarding exercises for acute tendon injuries:

  1. exercises should be pain-free to avoid further tendon injury
  2. exercises may cause pain but severity should be milder than the initial pain experienced
  3. exercises may cause pain but should not cause progressively worsening pain
  4. exercises are expected to cause increasing pain as rehabilitation increases in intensity 
  5. exercises should be prescribed at a level that causes pain to promote muscle strength.

Question 3

Fred returns 4 weeks after his injury. He mentions that a workmate with a similar injury was treated with a patch. Which of the following statements is CORRECT regarding topical GTN treatment for tendon injuries:

  1. the dose of topical GTN is a continuous
    5 mg/24 hour patch
  2. the timeframe for initiating topical GTN has now passed
  3. topical GTN has more evidence for use in chronic rather than acute tendon injuries
  4. topical GTN is useful as a substitute for exercise rehabilitation
  5. topical GTN is useful for functional improvement but does not affect pain management.

Question 4

Fred requests a referral to an orthopaedic surgeon, as he is concerned about his rate of recovery. The appropriate timeframe before surgical referral for tendon injuries is at least:

  1. 4–6 weeks
  2. 3–6 months
  3. 9–12 months
  4. 18–24 months
  5. varies depending on pre-morbid level of function.

Case 2

Suzie Bianco

Suzie, 38 years of age, is a paramedic. She presents with left knee pain after landing heavily from the back of an ambulance. You decide she has a patellar tendinopathy.  

Question 5

Which of the following is CORRECT regarding the GP’s role in the return to work process:

  1. the GP should specify which specific work tasks the patient is able to do
  2. the GP needs to prepare the return to work plan
  3. the GP needs to list restrictions to prevent aggravation of the injury
  4. the process only involves the patient and their employer
  5. the process should start once rehabilitation is complete.

Question 6

Suzie has significant pain from fat pad inflammation associated with her patellar tendinopathy. She asks about corticosteroid injections. Which one of the following statements is CORRECT:

  1. a course of three corticosteroid injections over 4 weeks is typically used
  2. corticosteroid injections can reduce pain for up to 6–8 weeks
  3. corticosteroid injections should not be used in conjunction with any exercise
  4. most patients have a steroid ‘flare’ 1–2 days after the corticosteroid injection
  5. it is important that the corticosteroid injection is into the affected tendon.

Question 7

Suzie has ongoing knee pain several weeks after her corticosteroid injection. Her colleague recommended extracorporeal shockwave therapy (ESWT). The following conditions are contraindications to ESWT EXCEPT:

  1. asthma
  2. impaired coagulation
  3. open growth plates
  4. peripheral vascular disease
  5. previous surgical fixation.

Question 8

You determine that Suzie is not suitable for ESWT. She recalls her sister had platelet injections for a similar injury. Which one of the following statements regarding autologous platelet rich plasma injections (PRP) for management of chronic tendinopathy is CORRECT:

  1. it is important that PRP injections are delivered during rest periods from exercise
  2. PRP injections are a relatively new treatment introduced over the past 20 years
  3. PRP injections are typically given as four injections over a 4 week period
  4. PRP injections result in more injection pain than injection of whole blood
  5. there is no evidence that PRP injections effectively treat tendon injuries.

Case 3

Angela Boehm

Angela, 43 years of age, is a shop assistant. She has chronic fatigue syndrome (CFS).    

Question 9

Which of the following statements regarding CFS is FALSE:

  1. CFS may be treated with antidepressants
  2. cognitive behavioural therapy is a therapeutic option for CFS
  3. short term management goals should be guided by the treating doctor
  4. social support helps patients cope with the stigma attached to CFS
  5. traumatic life experiences may lead to CFS.

Question 10

Angela reduced her working hours due to her symptoms. She now wishes to increase her hours. You decide to make a pragmatic rehabilitation plan. Which of the following is TRUE regarding pragmatic rehabilitation:

  1. evidence suggests that supportive listening is not an effective intervention
  2. it is important that the rehabilitation goals are determined by healthcare professionals
  3. liaising with employers is not recommended in the vast majority of cases
  4. referral of mild cases is recommended after 12 months of insufficient progress
  5. research does not support the use of graded return to work programs.

Question 11

Angela increases her working hours and sees you 12 months later. She is teary and reports workplace difficulties. The following behaviours constitute workplace bullying EXCEPT:

  1. last minute roster changes that repeatedly exceeds other workers
  2. negative feedback from senior staff to junior staff regarding poor teamwork abilities
  3. negative repeated comments about a worker’s socioeconomic background
  4. repeatedly withholding information preventing competent work performance
  5. withholding of access to resources that impact upon staff competency.

Question 12

Angela describes behaviour that constitutes workplace bullying. The following actions are recommended to address workplace bullying EXCEPT:

  1. discussing concerns with senior staff members
  2. documenting the workplace behaviour that constitutes bullying
  3. establishing informal and formal processes for punitive resolution of bullying
  4. seeking advice from the Australian Human Rights Commission
  5. taking legal action against the employer.

Case 4

Carly Silva

Carly, 45 years of age, is an emergency department nurse. She presents with a knee sprain after rushing up the stairs at work. 

Question 13

Which of the following statements is TRUE regarding WorkCover processes:

  1. MRI investigations are not covered by WorkCover for workplace injuries
  2. patients may be able to work at host companies that are able to comply with work restrictions
  3. return to work restrictions are not applicable to home duties outside of working hours
  4. standard consultation billing applies to appointments involving patients and their employers
  5. WorkCover protocols require notification of workplace injuries within 7 days of occurrence.

Question 14

Carly returns to usual work duties after 2 months of rehabilitation. Her knee is pain free. What is the most appropriate next course of action:

  1. a review appointment should be scheduled at 4 weeks to satisfy WorkCover requirements
  2. further treatment is not indicated given the full return of normal function
  3. referral to an occupational physician is important given the physical nature of Carly’s work
  4. rehabilitation should continue at this stage in order to reduce the risk of recurrence
  5. rehabilitation should not include stretching in order to reduce the risk of recurrence.

Question 15

Several weeks later, Carly presents with flu-like symptoms. You recommend a period of rest but she declines a sick certificate. Which of the following statements is FALSE regarding the practice of presenteeism:

  1. depression has a lower risk of presenteeism as compared to other conditions
  2. healthcare professionals tend to be at higher risk of presenteeism
  3. it is important to recognise that presenteeism is a risk factor for adverse health events
  4. patients with job insecurity are more likely to exhibit presenteeism
  5. presenteeism is a risk factor for cardiovascular disease.

Question 16

Carly returns with worsening symptoms. She again declines a sick certificate. You decide to raise the option of writing a ‘fit note’ for her. Which one of the following statements is FALSE regarding fit notes and sickness certificates:

  1. fit notes focus on what employees can do rather than what they can’t do
  2. fit notes tend to make GPs more likely to recommend a return to work
  3. patients who are returning to work from extended sick leave often benefit from fit notes
  4. patients with depression may benefit from fit notes to help maintain daily structure
  5. sickness certificates automatically provide employees with the entitlement to access sick leave benefits.

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