Over
the last decades bodybuilding competitors, male models, and
even action toys (eg, “G.I. Joe”) have become increasingly muscular (1). Muscular
images are nowadays prevalent in social media, television, movies, and
magazines. This may influence young men (and some women) to be overly obsessed
with their muscular appearance and may in some extreme cases lead to a form of body image disorder called “muscle dysmorphia” (1,2,3).
In the US
it has been estimated that 2.2% of the population have body dysmorphic
disorder, and 9% to 25% of those have muscle dysmorphia (1,3). muscle
dysmorphia is characterized by dissatisfaction
with body size, body shape and insufficiently muscularity. Other features are mood
and anxiety disorders, obsessive and compulsive behaviors, substance abuse, and
impairment of social and occupational functioning (1,2,3).
Substances of abuse in these
populations include several performance enhancing substances such as growth hormone, insulin, thyroid hormones
and most commonly supraphysiologic doses of androgenic-anabolic steroids (AASs), all with potential toxic effects (4). It has been
estimated that 15–30% of bodybuilders use anabolic steroids (5,6). Other
high-risking behaviors are also observed such as unsafe injection practices (1,7,8).
Self-administered intramuscular injection of site enhancement
oil (SEO) is a cosmetic and performance-enhancing procedure used to reshape muscles in the bodybuilder
subculture (9). In the bodybuilder subculture, delusive theories exist
regarding the SEOs’ effect on muscle growth (9,10). Some claim SEOs and scar tissue may
add permanently to muscular volume or generate a beneficial inflammatory
process, triggering muscle fiber hypertrophy and the formation of new muscle
fibers (9).
Another
key effect of intramuscular oil injections to increase the musculature is thought
to rely on the stretching of the
respective muscle fascia due to the encapsulated slowly degrading
intramuscular oil implants (15). The fascia itself is thought to be a major
restrictive factor in muscle growth. This is meant to enable a muscle to break
past a plateau (sticking point) for further gain of muscle volume. SEOs contain
predominantly medium-chain triglycerides
(mct), local anaesthetics and alcohol. Additionally, silica to extend the duration of the volume gain, anabolic
steroids, prohormones or collagen are infrequently added to
these preparations (15).
SEOs are recommended to
be injected in the desired muscle in cycles of several weeks with incremental
volumes (11). The
typical application protocols involve frequent
injections of 1–3 ml daily in repeated locations within the target muscles
for durations of several weeks to 6 months or more (15). The potential long-term
side-effects associated with intramuscular oil injections are often ignored.
SEOs are usually used to
increase the volume of prominent muscles including the biceps, triceps, deltoid,
pectoral, rectus abdominis, quadriceps and gastrocnemius muscles (9).
Composites
most frequently associated with ‘site enhancement’ are Synthol, PumpnPose,
Syntherol™, EsikClean, Nuclear Nutrition Site Oil, Cosmostan and Liquid Muscle
(15). Since natural oils are often less costly than other synthetic
compounds they are more attractive in particularly to amateur bodybuilders. Examples
of this are injections of coconut oil
(12), sesame oil (13,14,15,20), walnut oil (16) and paraffin (17,18,19,21).
Purified oils (soy oil,
safflower oil, sesame oil and purified long-and medium-chain emulsions) are
employed by the pharmaceutical industry as solvents for lipophilic drugs like anabolic
steroids, and bodybuilders discovered that some of these preparations had the
side-effect of triggering muscle
swelling due to their irritant effect (9).
In particular, Esiclene
(Formebolone) was used to correct non-favorable muscle groups before competitions
(9). In a survey of 100 bodybuilders, 5 out of 33 bodybuilders who were
competing admitted to the pre-competition use of Esiclene (22). When this drug
was withdrawn, Christopher T. Clark, after experimenting with his own body,
developed and marketed his first formula in 1996 under the name of Synthol, later renamed Syntherol (23).
Xylocaine or procaine is
added to alleviate pain immediately after injection and preservatives like
benzyl alcohol. Some formulations are reported to contain anabolic steroids, collagen, and silicone. Most of the products are
marketed in glass bottles typically containing 100 ml ranging from 75 to 400
U.S. dollars each (9).
Adverse effects
SEO ide effects and complications
Other
reported adverse side effects and
complications (9):
• Post-injection
muscle pain for a couple of days,
exacerbated by muscle activity, after the local anesthetic’s
effect has declined;
• Bulging
of the muscle if the SEO is not distributed thoroughly after injection or after
repeated injections at the same site;
• Infections, abscesses, skin perforation,
chronic wounds related to the injection site;
• Accidental
intravenous injection leading to pulmonary
and cerebral embolism;
• Accidental
intraneural injection leading to permanent
nerve injury (24);
• Long-term
muscle atrophy and decreased muscular volume;
• Local swelling and reactive changes of lymph nodes.
In one of the cases studies presented (table), a 25 year old bodybuilder with repeated hospital
presentations was observed with complete
triceps rupture, and multiple cystic
areas within the muscles of the arm (12). The patient was agitated and sweating profusely during the
examination. The lesions were suggested to represent either focal haematomas
or proteinaceous lesions. The patient was also observed with tricep tendon rupture at its distal
insertion, likely related to anabolic
steroid use with progressive stiffening of tendons and rupture with
repeated weight lifting (25).
The
patient then admitted to intramuscular
self-inoculation of coconut oil. However several other more concerning practices became apparent such as (12):
1.
Non-prescribed use of rapid-acting
insulin., which led to three tonic-clonic
seizures and recurrent left shoulder dislocation with resultant advanced
osteoarthritic change within the left glenohumeral joint and a significant
reverse Hill-Sach’s lesion;
2.
Non-prescribed use of liothyronine
causing fluctuating
thyroid function tests and suppression of
endogenous sex and thyroid hormone;
3.
Self-administered intramuscular vitamin
B12 injections resulting in
cellulitis and hospital admission for intravenous antibiotics;
4.
Anabolic steroid use, including cyclical
testosterone undecanoate depots, leading to surgery for gynaecomastia and liver haemangiomas.
5. Glomerulonephritis
5. Glomerulonephritis
In another case study (from
table), a 40 year old male semi-professional bodybuilder had systemic infection and painful reddened
swellings of the right upper arm that forced him to discontinue
weightlifting (15). Over the last 8
years he daily self-injected 2 ml of sterilized sesame seed oil at numerous
intramuscular locations, resulting in massive muscle building
with an upper arm circumference of up to 70 cm.
Whole body MRI showed more than “100 intramuscular rather than subcutaneous oil cysts” in the left upper arm, both shoulders, legs and breast with no obvious signs
of infection. Their location reflected the frequently used injection sites of
the last 10 years. However in the right upper arm a dramatic loss
of normal muscle anatomy was observed– a near-complete absence of normal muscle.
Even after further careful debridement of the fibrotic and edematous
tissue healthy muscle could not be reached in the depth.
After more than a year of “believable abstinence from
any artificial enhancement including substitutes, drugs or (oil) injections” there was no sign of relevant muscle regeneration, and
he still suffered
from persistent pain without signs of infection. 3 years after the operation the patient still suffered from moderate
pain and weakness.
Authors noted that:
“This alarming finding indicating irreversible
muscle mutilation may hopefully discourage people interested in
bodybuilding and fitness from oil-injections”.
(15)
Treatment
The nonsurgical treatment
consists of antibiotics and steroids
during inflammatory attacks (26), and compression
therapy for chronic ulcerations (19). More aggressive interventional
strategies might be beneficial to attempt removal of excessive oil deposits and
infected areas before they are dispersed in the tissue and generate more lipogranulomatous
lesions (9,27). However aggressive surgical
removal will lead to unnecessary loss
of muscular tissue and functional loss in the muscle.
Plastic surgery to remove the damaged areas followed by
skin, solid silicone implants, or
even muscle-flap transplantations may be required (9,28,29,30).
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Summary of 34 articles with
36.528 words and 1121 references on
Exercise and nutrition
References:
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