The Quest For The Perfect Body - Muscle Dysmorphia, Site Enhancement Oils, Adverse Effects and Treatment

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 anesthetics 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-Sachs 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
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”.



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


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