Mastectomy, shin splints and ADHD

Our clinical experts tackle queries on BP readings after mastectomy and managing patients with shin splints.

Q: Does a mastectomy affect the accuracy of BP readings? Should you take readings on the other side?

A: Problems only arise where there is significant lymphoedema of the arm on the side of the mastectomy.

This could be overcome by using a larger cuff size, but it would be better to use the unaffected arm.

If the arm is normal, the mastectomy should not make a difference.

Dr Andrew Clark, reader and honorary consultant cardiologist at Castle Hill Hospital, Hull.

Q: What is the best management of someone with shin splints?

A: It is important to distinguish shin splints - or medial tibial stress syndrome (MTSS) - from other causes of tibial pain such as a stress fracture or compartment syndrome.

MTSS is associated with crescendo pain, at the junction of the anterior lower third and upper two thirds of the tibia.

The pain is worse on hill-running, and lasts for days after exercise.

The medial edge of the tibia is painful, and there is often pain on resisted tibialis posterior activity, and poor posture, often with hyper-pronated feet.

The pain of a tibial stress fracture is often precipitated by a change in training regime. Night pain is common, so bone cancers need to be excluded.

On examination, the fracture site is tender. An isotope bone scan will confirm the diagnosis.

MTSS is associated with overuse of the plantar flexor and supinator muscles of the foot in the front of the shin.

Causes include increasing running distance too quickly, changing running terrain too quickly, a change in footwear, muscle imbalance in the lower leg (the hamstring, calves and quadriceps), and abnormal posture and biomechanics.

Treatment involves identifying the precipitating cause and removing it. Advice from a podiatrist may be needed. In the acute phase, apply PRICE (protection, rest, ice, compression, elevation).

Physiotherapy is helpful to reduce inflammation, stretch and strengthen the muscles involved and help the patient's posture.

Anti-inflammatory drugs may be needed or, in severe cases, surgery.

Dr Mike Bundy, GP and sports physician, Cranleigh, Surrey

Q: A woman who recently moved to our area claims she has had attention deficit hyperactivity disorder (ADHD) for a year. She is asking for methylphenidate (Ritalin), and is applying for incapacity benefit. She saw a psychiatrist where she lived before and does not want to see another. What should I do?

A: It is important to confirm the diagnosis of adult ADHD before prescribing methylphenidate. Generally the diagnosis in adults requires a continuity of the disorder from childhood. An onset of a year ago would be most unlikely.

You should contact her previous GP and the psychiatrist to confirm her story, and ask them to forward you any letters documenting the diagnosis, and the treatment plan.

The application for incapacity benefit should be delayed until more information is available.

Methylphenidate should not be used as the sole treatment for ADHD. It should be one part of a treatment plan that addresses her psychosocial needs. Encourage her at least to agree to a review of her case.

Dr Paul Walters, section of primary care mental health, Institute of Psychiatry, London, physician, Cranleigh, Surrey

Q: What are the insurance implications for patients of having partial immunity to hepatitis B? By this I mean people who are positive for hepatitis B surface antigen, negative for e-antigen, and core antibody is present, or people described as non-responders.

A: I am not aware that there is a blanket policy for insuring people with hepatitis B. If there is no evidence of active liver disease or viral replication, some companies are willing to classify patients as standard risk.

It is vital to know patients' levels of hepatitis B virus DNA and whether they have liver disease. The prognosis is better for patients with normal LFTs and undetectable hepatitis B virus DNA (low or non-replicative phase), than for those with established liver damage or high levels of virus.

Professor David Adams, consultant hepatologist at Queen Elizabeth Hospital, and professor of hepatology at the Liver Research Laboratories, Birmingham University.

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