Intramuscular Abscess

Occasionally, bodybuilders develop intramuscular abscesses, septic and sterile. The main difference between them is that the former develops the clinical symptoms of inflammation and deals with infection, while the later deals with hard lumps of oily solutions. In the long term, they get calcified and turn into scar tissue. Common areas of abscess include the buttocks (gluteus maximus), shoulders (deltoid), chest (pectorals), and calves (gastrocnemius).

Septic abscess is a result of contaminated injectable steroid solutions or non-sterile injection techniques (needle sharing, reusing needles and syringes). An oily solution is a hostile environment for bacterial growth. Even so, undergroundprepared injectable solutions are rarely assembled under sterile conditions. These are often contaminated with bacteria. Waterbased suspension solutions, such as stanozolol, testosterone, and recently trenbolone base, can be even worse. Bacteria are very likely to get cultivated in such solutions, as water is an ideal environment. Water-based injectables are the highest risk AAS products for bacterial contamination.

Location of injectable may also play a role. Thigh abscesses, pectoral and deltoid abscess have been reported in bodybuilders using ‘spot shots’ or ‘site locations, which are local injections into a specific muscle. This practice is believed to increase isolated muscle growth. Gluteal abscesses have also occurred in contaminated products. Administration of large volumes of testosterone esters in one injection (up to 5 mL) is also common, and can expose an individual to sterile abscess formation, where a pathogenic organism cannot be found.

Reported infections associated with AAS injection include abscesses attributable to Staphylococcus, Streptococcus, Pseudomonas and atypical Mycobacteria. The basic signs of inflammation process include: 1) local swelling-edema 2) erythema 3) elevated temperature/ pyrexia and 4) pain. All of these symptoms take place due to the increased blood flow, since macrophages and neutrophils are among the white blood cells responsible for phagocytosis of microorganisms. An abscess is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body. Besides clinical and laboratory findings [leukocytosis with increased neutrophils, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)], a useful laboratory examination that reveals the existence of intramuscular abscess is the Magnetic Resonance Image (MRI), ideal for the soft tissues (muscles, joints, ligaments, tendons).

Abscesses should never be squeezed by the person concerned. If the abscess burst under the skin and the bacteria spread through the blood circulation into the body, it can result in a lifethreatening blood infection such as sepsis. Sepsis symptoms include general malaise, fever, chills, nausea, vomiting, diarrhea, tachypnea, and confusion. Sepsis always requires hospitalization. Initially the steroid user should avoid injecting into the inflamed area, while rotating the injection spots. Discontinuing injections at least for one week, will give some time for the immune system to suppress the intramuscular inflammation. The use of nonsteroidal anti-inflammatory drugs-NSAIDs (sodium diclophenac, nimesulide) could provide some aid in first place and fight discomfort. Furthermore, hypertonic solution based on aluminum, provides pain relief when applied locally with a wet towel for about 10 minutes 4 times daily. A pharmaceutical medication that has a significant role in order to prevent further edema is the rerapeptase drug. This drug is widely used in several cases that include septic, or non-septic inflammation, where excessive swelling is present. Finally, the danaparoid sodium cream is a helpful material, able to suppress edema, thus providing a relief feeling.

However, sometimes inflammation process is more severe and complicated and pus develops in the intramuscular abscess. Pus contains dead white blood cells, trying to control the inflammation. In the beginning, an intramuscular infection is reddish and sort of hard in touch. Later, as the inflammation proceeds and pus is gathered, it becomes softer. Usually surgeons find this a warning sign, where surgical incision and drainage is obligatory. The surgeon cuts the skin and fat beneath with a scalpel, entering the inflamed muscle. This will give the opportunity for the drug (oily) solution and pus to leave the contaminated area, which has to be excessively cleaned afterwards. As soon as the pus has drained, the surgeon will insert some packing into the remaining cavity to minimize any bleeding and keep it open for 24-48 hours. As the scar heals, the patient can expect to be out of the gym for weeks. If it is a deeper abscess, the surgeon may insert a drainage tube. Drainage is maintained for several days to help prevent the abscess from reforming.

Microbiological culture of biologic samples from the wound is performed by the biopathologist and according to the antibiogram, a proper medication shall be prescribed. In most cases, the physician supplies a combination of different antibiotics,

including treatment of aerobic and anaerobic bacteria. In those cases, an anti-staphylococcus antibiotic (flucloxacillin, dicloxacillin) or amoxicillin-clavulanic acid is given. Alternative antibiotics effective against community-acquired methicillinresistant Staphylococcus aureus (MRSA), often include clindamycin, doxycycline, minocycline and trimethoprimsulfamethoxazole, while combination therapy with antipseudomonal antibiotics (imipenem, meropenem, aztreonam) is used to ensure treatment of resistant strains. Of course, we should not neglect the possible side effects of antibiotics, especially to the gastrointestinal system (diarrhea). The diarrhea occurs due to eradication of the normal gut flora by the antibiotic and results in an overgrowth of infectious bacteria. Therefore, the patient has to follow a diet rich in lactobacillus, found in organic yogurt, or kefir. In case there is a lactose intolerance, lactobacillus is also available in pharmaceutical made capsules. Another side effect symptom involves inflammation of gingiva, giving an itching feeling in the oral cavity. Supplementation of B complex vitamins is also quite helpful.

Intramuscular abscess after it is surgically opened has to be cleaned up twice on a daily basis, as long as the patient follows an antibiotic medication. White blood cells (WBCs) count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory evaluations that should be considered on a weekly basis. This follow up will provide details concerning the progress of inflammation. Fever is also a good sign of inflammatory response. Creatinokinase enzyme (CPK) is a biochemical marker that is also elevated, as a result of the repeated intramuscular injections; named as rhabdomyolysis effect. Lactate dehydrogenase (LDH) is another biochemical evaluation, raised in tissue inflammation and cellular damage. When the abscess heals, scar tissue will form, therefore, no more injections in that area.

Sometimes, when the abscess is localized into the gluteal area, the athlete is unable to perform a hip flexion. This particular movement happens during the negative-eccentric phase of the leg press for example, or the squat. The reason is because of the extensive intramuscular abscess that forces press against the sciatic nerve. The hip flexion stretches the sciatic nerve, giving a painful sensation. As well know from human anatomy, the particular nerve is the largest in the peripheral nervous system. When sciatic nerve undergoes irritation, pain reflects on the head of the fibula; the bone located on the outer area of tibia. As the sciatic nerve proceeds down to the posterior femoral region, it splits into the posterior tibial nerve and the peroneal nerve.

Rarely, poor septic conditions (needle sharing, reusing needles and syringes) are responsible for the entrance of microbes into the muscle. Pure ethanol 95% must be used for sterilization of the skin (epidermis), both before after the injection. Of course, we have to change the needles and better to use another syringe, in case we shoot on different areas on the same day. Subcutaneous injections are rarely to develop any kind of infection, since the adipose tissue has lesser amount of vessels and contamination spreads slower. Peptides are usually injected into the fat, as somatropin (human growth hormone- hGH), insulin and human chorionic gonadotropin.

Personally, I have once experienced a localized inflammation, dealing with a subcutaneous injection of HGH. It was something inevitable, since I had not followed strictly the sterilization circumstances and wrongly used the same needle twice. According to my personal experience, as a former steroid abuser during my bodybuilding competitive career, I faced two intramuscular abscesses, that both had to be surgically opened, while I was following an effective combination of antibiotics. For the first time, I decided to switch from the pharmaceutical brand (Winstrol Depot-Desma) of stanozolol, manufactured in Spain. Instead, I wrongly chose to use an underground product.

After a couple of weeks, both my deltoid and gluteus were infected, giving a feeling of discomfort and nausea. At first, I tried to self-care at home, by applying the initial steps of abscess treatment; but there was no progress. I was lucky that it was during my residency practice at the hospital, so my colleagues treated me successfully. General surgeons cooperation, along with biopathologists, helped me to heal within four weeks. As I was told later, the steroid abuse cost me in terms of blood coagulation, so my bleeding time was prolonged (INR>1.3). In such cases, vitamin K and plasma factors are administrated IV. Two years later, during my final competition at the masters nationals, there was a visible scar on my buttocks, although i was pretty well tanned and colored by spray.

How to Avoid Abscess

Intramuscular abscess is something that can be avoided. Sadly, sometimes the repeated steroid abuse is inevitable and steroid solution is not able to get absorbed from system. Proper procedures should be followed and safety should be maintained. Rotation of injection sites and areas, along with extra cautious sterilization, will diminish possibilities. When injecting into the buttock muscle you must be particularly careful the needle does not touch the sciatic nerve. Injecting the nerve causes severe radiating pain to the lower limbs (similar to an electric shock) and can damage the nerve permanently.

In a worst case scenario, sciatic nerve damage can lead to lower limb paralysis. The proper spot is the upper outer gluteal area. Sciatic’s nerve origin is located towards the inner side of gluteus maximus. When injecting, ensure that no blood vessels are touched. If blood is visible in the syringe when pulling the syringe plunger back towards you, immediately remove the needle and press on the injection site to stop the bleeding. A broken blood vessel causes internal bleeding within the muscle. You may feel pain and stiffness in the muscle. When a blood vessel breaks, scar tissue or blood clots can form and if a blood clot starts to wander and reaches the heart or lungs, the consequences can be life-threatening, known as pulmonary embolism. Injections that hit an artery can be particularly dangerous.

Most bodybuilders do not have the means or education necessary to recognize counterfeits or have all of their drugs tested in a laboratory for purity. It is also doubtful whether counterfeit blackmarket products are subject to the appropriate sterilization processes. As a result, people are gambling with their health by using steroids they procure from black market sources. Sometimes the product is fairly pure and the user experiences the expected results. ROIDTESTTM is a brilliant new project by William Llewellyn, able to spot the fake underground, or counterfeit products. Injecting drugs carries a number of potential risks. Intramuscular abscesses are secondary complications and should therefore be preventable.

References: Intramuscular Abscess

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