View Article PDF

The illicit and unregulated nature of sourcing and using performance and image enhancing drugs (PIEDs) or steroids presents a risk to users because they are often unaware of correct dosage, contraindications, polypharmancy and side effects. Although the conversation can be challenging due to the perceived risks of offending or stigmatising the patient, it is important that clinicians broach the subject. The aim should be to understand why the patient uses PIEDs or steroids, educate them on the risks, screen for potential side effects and consider referral to substance abuse services if appropriate. Here we present the unusual case of a rotator cuff injury with incidental deltoid intramuscular oil cysts from apricot oil used as a delivery agent for anabolic steroids. Side effects of PIEDs and steroids are discussed along with simple screening tests, which can be undertaken to monitor patient health.

Case report

AB, a 46-year-old male body builder presented with a history of sudden pain in his right shoulder, which occurred during a heavy-weight bench press. Following the injury, AB was unable to actively abduct his arm greater than 30 degrees. Following a short period of self-enforced rest, the patient sought treatment from a physiotherapist due to his inability to perform his job as a landscape gardener. After three months of physiotherapy treatment, he was continuing to have problems and was referred to a sports surgery clinic.

Clinical examination revealed generalised muscle hypertrophy in keeping with prolonged resistance training. AB demonstrated a painful arc with abnormal muscle patterning during active forward flexion and active abduction arcs. Abnormal muscle patterning on movement is suggestive of asynchronous muscle activation and contraction, which is in keeping with a possible rotator cuff injury. There was significant weakness on examination of the supraspinatus; but the infraspinatus, teres minor and subscapularis showed no weakness on examination. An MRI was requested and showed a tear within the supraspinatus tendon.

Magnetic resonance imaging of the right shoulder demonstrated a supraspinatus tendon tear and, incidentally, multiple ovoid foci within a hypertrophied posterior deltoid muscle. These ovoid foci were of internal fat signal on T1 sequences, matching the signal intensity of adjacent subcutaneous fat (Figure 1). The ovoid foci demonstrated uniform fat suppression on both fat saturated T1 and T2 sequences (Figures 2 and 3) and fine peripheral enhancement on post-contrast T1 sequences (Figures 4 and 5). Appearances were compatible with intramuscular oil cysts related to repetitive, intramuscular anabolic steroid and oil suspension injectate. No intramuscular calcification was demonstrated on radiographs. During a discussion, the patient revealed that he was injecting Masteron (masteron enanthaate), Delatestryl (testosterone enanthate), Epistane (methylepitiostanol) and apricot oil. The patient was injecting apricot oil based on advice from a fellow bodybuilder regarding its effects of “enhancing the steroids” he was using.

Figure 1: Axial T1.

Figure 2: Axial T1 fat sat.

Figure 3: Axial T2 fat sat.

Figure 4: Axial T1 fat sat post contrast.

Figure 5: Coronal T1 fat sat post contrast.

Discussion

The prevalence of steroid use among recreational athletes is reported to be increasing, although exact numbers are always difficult to determine. In the UK in 2018, an estimated 411,000 people had used anabolic steroid recreationally, representing around 0.7% of the population.1 A literature review undertaken in New Zealand in 2015 highlighted the diversity of people using PIEDs, but that it is difficult to determine the true incidence and prevalence.2 A study of anabolic steroid use among gay and bisexual men in New Zealand and Australia found a prevalence of 5.2%, with the main reason for use being body-image dissatisfaction and eating disorders, rather than physical performance.3 There are no official figures for prevalence of use in New Zealand overall, but media coverage surrounding the criminal case of an individual distributing PIEDs or steroids suggests cases are not isolated.4,5 The New Zealand Ministry of Health and Medsafe have released figures on the seizures of PIEDs between 2013 and 2018.6 These figures demonstrated a peak in the number of packages seized during 2016, but the overall volume of tablets/capsules and active pharmaceutical ingredient (API) seized remains fairly steady over time. In 2018 more than 11kg of anabolic steroid API were seized, with the majority coming from China and Hong Kong. Greater than 40kg of tablets/capsules were seized, with the majority coming from the US.

In the case presented here, the patient was receiving advice on steroid use from a fellow bodybuilder who we assume had no formal medical training. A study from Australia in 2010 demonstrated that over 40% of athlete-support personnel in professional sport advise on anti-doping or nutritional advice without training.7 Although this is concerning in elite sport, it suggests poor/incorrect advice given by lay people to others in the setting of PIEDs may be even more prevalent than assumed and a possible cause for the complications associated with PIED or steroid use. Common side effects that patients report from anabolic steroid use are acne (androgen associated sebum production), cutaneous striae (particularly around the deltopectoral area), mood swings and agitation (fluctuating androgen levels) and gynecomastia (androgen imbalance in favour of oestrogen). The latter is sometimes avoided by users adding in an anti-oestrogen medication such as tamoxifen.

Muscle and tendon ruptures are also reported, but the exact cause is not clear and evidence is largely limited to case reports. A cross-sectional cohort study of body builders found that 22% of those taking anabolic steroids had suffered at least one tendon rupture, compared to 6% of those not taking anabolic steroids.8 However, a systematic review of the effect that anabolic steroids have on tendon structure found limited research, most of which relied on animal models and often had conflicting results.9 Prospective research is required to determine whether PIEDs and steroids are the cause of the apparent increased tendon rupture rate, or whether the cause is multifactorial, surrounding training, recovery, drug use and other lifestyle factors.

Side effects diagnosed by clinicians after testing include gonadotrophin suppression, decreased spermatogenesis, liver toxicity and cardiac disease.10  

If clinicians are concerned, they should discuss screening with the patient. Screening typically involves blood pressure measurement, ECG and blood tests to look at liver function, cholesterol levels (increased low-density lipoproteins and decreased high-density lipoproteins), glucose levels and hormone levels.

Acute complications from the injection of steroids may also appear relatively commonly and include local inflammation or infection (eg, abscess formation). This can have implications in the setting of wound complications and delaying tendon repair surgery.  Acute complications from oil injections are also recognised and are commonly inflammatory or infective—but rarely are they life threatening, like a pulmonary oil embolism from mistakenly injecting the oil into a vein.11

Injecting oil into muscle compartments is sometimes performed by individuals to enhance the appearance or size of their muscle. Use of paraffin, synthol and coconut oil are described within the literature as site enhancement oils (SEOs).12,13 In this case the patient injected only a small amount of oil on the advice it would prolong the effect of the steroids he was injecting, thereby conferring a pharmacological benefit rather than an image benefit. Steroids have limited water solubility. Research has shown that dissolving the steroids in a non-aqueous oil solution for delivery (eg, castor oil) is safe and can prolong the effect of intramuscular injected steroids.14,15 Following a search of the literature, we were unable to find any information in relation to apricot oil as a vehicle for intramuscular steroid delivery.  

This case demonstrates an unusual radiological finding that may assist clinicians in the diagnosis of PIEDs and steroid use. The discussion informs clinicians of the common side effects of PIED and steroid use, along with some routine screening tests that can be undertaken to monitor patient wellbeing. Clinicians may use the information here to open a discussion with patients suspected of PIED or steroid use.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Dominic P O’Dowd: Sports Orthopaedic Fellow – Unisports Sports Medicine, Auckland, New Zealand. David Dow: Consultant Radiologist, Auckland Radiology Group, Auckland, New Zealand. Michael P Rosenfeldt: Consultant Orthopaedic Surgeon - Unisports Sports Medicine, Auckland, New Zealand.

Acknowledgements

Correspondence

Dominic P O’Dowd, Unisports Sports Medicine, 71 Merton Road, St Johns, Auckland, New Zealand, 095219857

Correspondence Email

dominicodowd@doctors.org.uk

Competing Interests

Nil.

1. Home Office, 2018. Drug Misuse: Findings from the 2017/18 Crime Survey for England and Wales

2. Curtis A, Gerrard D, Burt P, Osborne H. Drug misuse in sport: a New Zealand perspective. N Z Med J. 2015;128(1426):62-68.

3. Griffiths S, Murray SB, Dunn M, Blashill AJ. Anabolic steroid use among gay and bisexual men living in Australia and New Zealand: Associations with demographics, body dissatisfaction, eating disorder psychopathology, and quality of life. Drug Alcohol Depend. 2017;181:170-176.

4. Ministry of Health. Available from:https://www.health.govt.nz/news-media/media-releases/sentence-handed-down-after-steroid-operation-uncovered

5. Stuff. Available from: https://www.stuff.co.nz/sport/other-sports/117626410/ringleader-of-new-zealand-sports-biggest-steroid-operation-sets-up-new-health-company

6. Ministry of Health. Available from: https://www.health.govt.nz/system/files/documents/information-release/h201902160.pdf

7. Mazanov J, Backhouse S, Connor J, Hemphill D, Quirk F. Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance. Scand J Med Sci Sports. 2014;24(5):846-856

8. Kanayama G, DeLuca J, Meehan WP 3rd, Hudson JI, Isaacs S, Baggish A, Weiner R, Micheli L, Pope HG Jr. Ruptured Tendons in Anabolic-Androgenic Steroid Users: A Cross-Sectional Cohort Study. Am J Sports Med. 2015 Nov;43(11):2638-44.

9. Jones IA, Togashi R, Hatch GFR 3rd, Weber AE, Vangsness CT Jr. Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects. J Orthop Res. 2018 Nov;36(11):2830-2841.

10. de Ronde W, Smit DL. Anabolic androgenic steroid abuse in young males. Endocr Connect. 2020;9(4):R102-R111

11. Russell M, Storck A, Ainslie M. Acute respiratory distress following intravenous injection of an oil-steroid solution. Can Respir J. 2011 Jul-Aug;18(4):e59-61. doi: 10.1155/2011/743151. PMID: 22059184; PMCID: PMC3205107.

12. Figueiredo VC, Silva PR. Cosmetic doping--when anabolic-androgenic steroids are not enough. Subst Use Misuse. 2014;49(9):1163-1167.

13. Santos HO, Howell S, Teixeira FJ. Coconut oil as a Vehicle for Lipophilic Drug Administration. J Diab Obes 2019:6(1):8-12

14. Riffkin C, Huber R, Keysser CH. Castor oil as a vehicle for parenteral administration of steroid hormones. J Pharm Sci. 1964;53:891-895.

15. Sartorius G, Fennell C, Spasevska S, Turner L, Conway AJ, Handelsman DJ. Factors influencing time course of pain after depot oil intramuscular injection of testosterone undecanoate. Asian J Androl. 2010;12(2):227-233.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The illicit and unregulated nature of sourcing and using performance and image enhancing drugs (PIEDs) or steroids presents a risk to users because they are often unaware of correct dosage, contraindications, polypharmancy and side effects. Although the conversation can be challenging due to the perceived risks of offending or stigmatising the patient, it is important that clinicians broach the subject. The aim should be to understand why the patient uses PIEDs or steroids, educate them on the risks, screen for potential side effects and consider referral to substance abuse services if appropriate. Here we present the unusual case of a rotator cuff injury with incidental deltoid intramuscular oil cysts from apricot oil used as a delivery agent for anabolic steroids. Side effects of PIEDs and steroids are discussed along with simple screening tests, which can be undertaken to monitor patient health.

Case report

AB, a 46-year-old male body builder presented with a history of sudden pain in his right shoulder, which occurred during a heavy-weight bench press. Following the injury, AB was unable to actively abduct his arm greater than 30 degrees. Following a short period of self-enforced rest, the patient sought treatment from a physiotherapist due to his inability to perform his job as a landscape gardener. After three months of physiotherapy treatment, he was continuing to have problems and was referred to a sports surgery clinic.

Clinical examination revealed generalised muscle hypertrophy in keeping with prolonged resistance training. AB demonstrated a painful arc with abnormal muscle patterning during active forward flexion and active abduction arcs. Abnormal muscle patterning on movement is suggestive of asynchronous muscle activation and contraction, which is in keeping with a possible rotator cuff injury. There was significant weakness on examination of the supraspinatus; but the infraspinatus, teres minor and subscapularis showed no weakness on examination. An MRI was requested and showed a tear within the supraspinatus tendon.

Magnetic resonance imaging of the right shoulder demonstrated a supraspinatus tendon tear and, incidentally, multiple ovoid foci within a hypertrophied posterior deltoid muscle. These ovoid foci were of internal fat signal on T1 sequences, matching the signal intensity of adjacent subcutaneous fat (Figure 1). The ovoid foci demonstrated uniform fat suppression on both fat saturated T1 and T2 sequences (Figures 2 and 3) and fine peripheral enhancement on post-contrast T1 sequences (Figures 4 and 5). Appearances were compatible with intramuscular oil cysts related to repetitive, intramuscular anabolic steroid and oil suspension injectate. No intramuscular calcification was demonstrated on radiographs. During a discussion, the patient revealed that he was injecting Masteron (masteron enanthaate), Delatestryl (testosterone enanthate), Epistane (methylepitiostanol) and apricot oil. The patient was injecting apricot oil based on advice from a fellow bodybuilder regarding its effects of “enhancing the steroids” he was using.

Figure 1: Axial T1.

Figure 2: Axial T1 fat sat.

Figure 3: Axial T2 fat sat.

Figure 4: Axial T1 fat sat post contrast.

Figure 5: Coronal T1 fat sat post contrast.

Discussion

The prevalence of steroid use among recreational athletes is reported to be increasing, although exact numbers are always difficult to determine. In the UK in 2018, an estimated 411,000 people had used anabolic steroid recreationally, representing around 0.7% of the population.1 A literature review undertaken in New Zealand in 2015 highlighted the diversity of people using PIEDs, but that it is difficult to determine the true incidence and prevalence.2 A study of anabolic steroid use among gay and bisexual men in New Zealand and Australia found a prevalence of 5.2%, with the main reason for use being body-image dissatisfaction and eating disorders, rather than physical performance.3 There are no official figures for prevalence of use in New Zealand overall, but media coverage surrounding the criminal case of an individual distributing PIEDs or steroids suggests cases are not isolated.4,5 The New Zealand Ministry of Health and Medsafe have released figures on the seizures of PIEDs between 2013 and 2018.6 These figures demonstrated a peak in the number of packages seized during 2016, but the overall volume of tablets/capsules and active pharmaceutical ingredient (API) seized remains fairly steady over time. In 2018 more than 11kg of anabolic steroid API were seized, with the majority coming from China and Hong Kong. Greater than 40kg of tablets/capsules were seized, with the majority coming from the US.

In the case presented here, the patient was receiving advice on steroid use from a fellow bodybuilder who we assume had no formal medical training. A study from Australia in 2010 demonstrated that over 40% of athlete-support personnel in professional sport advise on anti-doping or nutritional advice without training.7 Although this is concerning in elite sport, it suggests poor/incorrect advice given by lay people to others in the setting of PIEDs may be even more prevalent than assumed and a possible cause for the complications associated with PIED or steroid use. Common side effects that patients report from anabolic steroid use are acne (androgen associated sebum production), cutaneous striae (particularly around the deltopectoral area), mood swings and agitation (fluctuating androgen levels) and gynecomastia (androgen imbalance in favour of oestrogen). The latter is sometimes avoided by users adding in an anti-oestrogen medication such as tamoxifen.

Muscle and tendon ruptures are also reported, but the exact cause is not clear and evidence is largely limited to case reports. A cross-sectional cohort study of body builders found that 22% of those taking anabolic steroids had suffered at least one tendon rupture, compared to 6% of those not taking anabolic steroids.8 However, a systematic review of the effect that anabolic steroids have on tendon structure found limited research, most of which relied on animal models and often had conflicting results.9 Prospective research is required to determine whether PIEDs and steroids are the cause of the apparent increased tendon rupture rate, or whether the cause is multifactorial, surrounding training, recovery, drug use and other lifestyle factors.

Side effects diagnosed by clinicians after testing include gonadotrophin suppression, decreased spermatogenesis, liver toxicity and cardiac disease.10  

If clinicians are concerned, they should discuss screening with the patient. Screening typically involves blood pressure measurement, ECG and blood tests to look at liver function, cholesterol levels (increased low-density lipoproteins and decreased high-density lipoproteins), glucose levels and hormone levels.

Acute complications from the injection of steroids may also appear relatively commonly and include local inflammation or infection (eg, abscess formation). This can have implications in the setting of wound complications and delaying tendon repair surgery.  Acute complications from oil injections are also recognised and are commonly inflammatory or infective—but rarely are they life threatening, like a pulmonary oil embolism from mistakenly injecting the oil into a vein.11

Injecting oil into muscle compartments is sometimes performed by individuals to enhance the appearance or size of their muscle. Use of paraffin, synthol and coconut oil are described within the literature as site enhancement oils (SEOs).12,13 In this case the patient injected only a small amount of oil on the advice it would prolong the effect of the steroids he was injecting, thereby conferring a pharmacological benefit rather than an image benefit. Steroids have limited water solubility. Research has shown that dissolving the steroids in a non-aqueous oil solution for delivery (eg, castor oil) is safe and can prolong the effect of intramuscular injected steroids.14,15 Following a search of the literature, we were unable to find any information in relation to apricot oil as a vehicle for intramuscular steroid delivery.  

This case demonstrates an unusual radiological finding that may assist clinicians in the diagnosis of PIEDs and steroid use. The discussion informs clinicians of the common side effects of PIED and steroid use, along with some routine screening tests that can be undertaken to monitor patient wellbeing. Clinicians may use the information here to open a discussion with patients suspected of PIED or steroid use.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Dominic P O’Dowd: Sports Orthopaedic Fellow – Unisports Sports Medicine, Auckland, New Zealand. David Dow: Consultant Radiologist, Auckland Radiology Group, Auckland, New Zealand. Michael P Rosenfeldt: Consultant Orthopaedic Surgeon - Unisports Sports Medicine, Auckland, New Zealand.

Acknowledgements

Correspondence

Dominic P O’Dowd, Unisports Sports Medicine, 71 Merton Road, St Johns, Auckland, New Zealand, 095219857

Correspondence Email

dominicodowd@doctors.org.uk

Competing Interests

Nil.

1. Home Office, 2018. Drug Misuse: Findings from the 2017/18 Crime Survey for England and Wales

2. Curtis A, Gerrard D, Burt P, Osborne H. Drug misuse in sport: a New Zealand perspective. N Z Med J. 2015;128(1426):62-68.

3. Griffiths S, Murray SB, Dunn M, Blashill AJ. Anabolic steroid use among gay and bisexual men living in Australia and New Zealand: Associations with demographics, body dissatisfaction, eating disorder psychopathology, and quality of life. Drug Alcohol Depend. 2017;181:170-176.

4. Ministry of Health. Available from:https://www.health.govt.nz/news-media/media-releases/sentence-handed-down-after-steroid-operation-uncovered

5. Stuff. Available from: https://www.stuff.co.nz/sport/other-sports/117626410/ringleader-of-new-zealand-sports-biggest-steroid-operation-sets-up-new-health-company

6. Ministry of Health. Available from: https://www.health.govt.nz/system/files/documents/information-release/h201902160.pdf

7. Mazanov J, Backhouse S, Connor J, Hemphill D, Quirk F. Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance. Scand J Med Sci Sports. 2014;24(5):846-856

8. Kanayama G, DeLuca J, Meehan WP 3rd, Hudson JI, Isaacs S, Baggish A, Weiner R, Micheli L, Pope HG Jr. Ruptured Tendons in Anabolic-Androgenic Steroid Users: A Cross-Sectional Cohort Study. Am J Sports Med. 2015 Nov;43(11):2638-44.

9. Jones IA, Togashi R, Hatch GFR 3rd, Weber AE, Vangsness CT Jr. Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects. J Orthop Res. 2018 Nov;36(11):2830-2841.

10. de Ronde W, Smit DL. Anabolic androgenic steroid abuse in young males. Endocr Connect. 2020;9(4):R102-R111

11. Russell M, Storck A, Ainslie M. Acute respiratory distress following intravenous injection of an oil-steroid solution. Can Respir J. 2011 Jul-Aug;18(4):e59-61. doi: 10.1155/2011/743151. PMID: 22059184; PMCID: PMC3205107.

12. Figueiredo VC, Silva PR. Cosmetic doping--when anabolic-androgenic steroids are not enough. Subst Use Misuse. 2014;49(9):1163-1167.

13. Santos HO, Howell S, Teixeira FJ. Coconut oil as a Vehicle for Lipophilic Drug Administration. J Diab Obes 2019:6(1):8-12

14. Riffkin C, Huber R, Keysser CH. Castor oil as a vehicle for parenteral administration of steroid hormones. J Pharm Sci. 1964;53:891-895.

15. Sartorius G, Fennell C, Spasevska S, Turner L, Conway AJ, Handelsman DJ. Factors influencing time course of pain after depot oil intramuscular injection of testosterone undecanoate. Asian J Androl. 2010;12(2):227-233.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The illicit and unregulated nature of sourcing and using performance and image enhancing drugs (PIEDs) or steroids presents a risk to users because they are often unaware of correct dosage, contraindications, polypharmancy and side effects. Although the conversation can be challenging due to the perceived risks of offending or stigmatising the patient, it is important that clinicians broach the subject. The aim should be to understand why the patient uses PIEDs or steroids, educate them on the risks, screen for potential side effects and consider referral to substance abuse services if appropriate. Here we present the unusual case of a rotator cuff injury with incidental deltoid intramuscular oil cysts from apricot oil used as a delivery agent for anabolic steroids. Side effects of PIEDs and steroids are discussed along with simple screening tests, which can be undertaken to monitor patient health.

Case report

AB, a 46-year-old male body builder presented with a history of sudden pain in his right shoulder, which occurred during a heavy-weight bench press. Following the injury, AB was unable to actively abduct his arm greater than 30 degrees. Following a short period of self-enforced rest, the patient sought treatment from a physiotherapist due to his inability to perform his job as a landscape gardener. After three months of physiotherapy treatment, he was continuing to have problems and was referred to a sports surgery clinic.

Clinical examination revealed generalised muscle hypertrophy in keeping with prolonged resistance training. AB demonstrated a painful arc with abnormal muscle patterning during active forward flexion and active abduction arcs. Abnormal muscle patterning on movement is suggestive of asynchronous muscle activation and contraction, which is in keeping with a possible rotator cuff injury. There was significant weakness on examination of the supraspinatus; but the infraspinatus, teres minor and subscapularis showed no weakness on examination. An MRI was requested and showed a tear within the supraspinatus tendon.

Magnetic resonance imaging of the right shoulder demonstrated a supraspinatus tendon tear and, incidentally, multiple ovoid foci within a hypertrophied posterior deltoid muscle. These ovoid foci were of internal fat signal on T1 sequences, matching the signal intensity of adjacent subcutaneous fat (Figure 1). The ovoid foci demonstrated uniform fat suppression on both fat saturated T1 and T2 sequences (Figures 2 and 3) and fine peripheral enhancement on post-contrast T1 sequences (Figures 4 and 5). Appearances were compatible with intramuscular oil cysts related to repetitive, intramuscular anabolic steroid and oil suspension injectate. No intramuscular calcification was demonstrated on radiographs. During a discussion, the patient revealed that he was injecting Masteron (masteron enanthaate), Delatestryl (testosterone enanthate), Epistane (methylepitiostanol) and apricot oil. The patient was injecting apricot oil based on advice from a fellow bodybuilder regarding its effects of “enhancing the steroids” he was using.

Figure 1: Axial T1.

Figure 2: Axial T1 fat sat.

Figure 3: Axial T2 fat sat.

Figure 4: Axial T1 fat sat post contrast.

Figure 5: Coronal T1 fat sat post contrast.

Discussion

The prevalence of steroid use among recreational athletes is reported to be increasing, although exact numbers are always difficult to determine. In the UK in 2018, an estimated 411,000 people had used anabolic steroid recreationally, representing around 0.7% of the population.1 A literature review undertaken in New Zealand in 2015 highlighted the diversity of people using PIEDs, but that it is difficult to determine the true incidence and prevalence.2 A study of anabolic steroid use among gay and bisexual men in New Zealand and Australia found a prevalence of 5.2%, with the main reason for use being body-image dissatisfaction and eating disorders, rather than physical performance.3 There are no official figures for prevalence of use in New Zealand overall, but media coverage surrounding the criminal case of an individual distributing PIEDs or steroids suggests cases are not isolated.4,5 The New Zealand Ministry of Health and Medsafe have released figures on the seizures of PIEDs between 2013 and 2018.6 These figures demonstrated a peak in the number of packages seized during 2016, but the overall volume of tablets/capsules and active pharmaceutical ingredient (API) seized remains fairly steady over time. In 2018 more than 11kg of anabolic steroid API were seized, with the majority coming from China and Hong Kong. Greater than 40kg of tablets/capsules were seized, with the majority coming from the US.

In the case presented here, the patient was receiving advice on steroid use from a fellow bodybuilder who we assume had no formal medical training. A study from Australia in 2010 demonstrated that over 40% of athlete-support personnel in professional sport advise on anti-doping or nutritional advice without training.7 Although this is concerning in elite sport, it suggests poor/incorrect advice given by lay people to others in the setting of PIEDs may be even more prevalent than assumed and a possible cause for the complications associated with PIED or steroid use. Common side effects that patients report from anabolic steroid use are acne (androgen associated sebum production), cutaneous striae (particularly around the deltopectoral area), mood swings and agitation (fluctuating androgen levels) and gynecomastia (androgen imbalance in favour of oestrogen). The latter is sometimes avoided by users adding in an anti-oestrogen medication such as tamoxifen.

Muscle and tendon ruptures are also reported, but the exact cause is not clear and evidence is largely limited to case reports. A cross-sectional cohort study of body builders found that 22% of those taking anabolic steroids had suffered at least one tendon rupture, compared to 6% of those not taking anabolic steroids.8 However, a systematic review of the effect that anabolic steroids have on tendon structure found limited research, most of which relied on animal models and often had conflicting results.9 Prospective research is required to determine whether PIEDs and steroids are the cause of the apparent increased tendon rupture rate, or whether the cause is multifactorial, surrounding training, recovery, drug use and other lifestyle factors.

Side effects diagnosed by clinicians after testing include gonadotrophin suppression, decreased spermatogenesis, liver toxicity and cardiac disease.10  

If clinicians are concerned, they should discuss screening with the patient. Screening typically involves blood pressure measurement, ECG and blood tests to look at liver function, cholesterol levels (increased low-density lipoproteins and decreased high-density lipoproteins), glucose levels and hormone levels.

Acute complications from the injection of steroids may also appear relatively commonly and include local inflammation or infection (eg, abscess formation). This can have implications in the setting of wound complications and delaying tendon repair surgery.  Acute complications from oil injections are also recognised and are commonly inflammatory or infective—but rarely are they life threatening, like a pulmonary oil embolism from mistakenly injecting the oil into a vein.11

Injecting oil into muscle compartments is sometimes performed by individuals to enhance the appearance or size of their muscle. Use of paraffin, synthol and coconut oil are described within the literature as site enhancement oils (SEOs).12,13 In this case the patient injected only a small amount of oil on the advice it would prolong the effect of the steroids he was injecting, thereby conferring a pharmacological benefit rather than an image benefit. Steroids have limited water solubility. Research has shown that dissolving the steroids in a non-aqueous oil solution for delivery (eg, castor oil) is safe and can prolong the effect of intramuscular injected steroids.14,15 Following a search of the literature, we were unable to find any information in relation to apricot oil as a vehicle for intramuscular steroid delivery.  

This case demonstrates an unusual radiological finding that may assist clinicians in the diagnosis of PIEDs and steroid use. The discussion informs clinicians of the common side effects of PIED and steroid use, along with some routine screening tests that can be undertaken to monitor patient wellbeing. Clinicians may use the information here to open a discussion with patients suspected of PIED or steroid use.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Dominic P O’Dowd: Sports Orthopaedic Fellow – Unisports Sports Medicine, Auckland, New Zealand. David Dow: Consultant Radiologist, Auckland Radiology Group, Auckland, New Zealand. Michael P Rosenfeldt: Consultant Orthopaedic Surgeon - Unisports Sports Medicine, Auckland, New Zealand.

Acknowledgements

Correspondence

Dominic P O’Dowd, Unisports Sports Medicine, 71 Merton Road, St Johns, Auckland, New Zealand, 095219857

Correspondence Email

dominicodowd@doctors.org.uk

Competing Interests

Nil.

1. Home Office, 2018. Drug Misuse: Findings from the 2017/18 Crime Survey for England and Wales

2. Curtis A, Gerrard D, Burt P, Osborne H. Drug misuse in sport: a New Zealand perspective. N Z Med J. 2015;128(1426):62-68.

3. Griffiths S, Murray SB, Dunn M, Blashill AJ. Anabolic steroid use among gay and bisexual men living in Australia and New Zealand: Associations with demographics, body dissatisfaction, eating disorder psychopathology, and quality of life. Drug Alcohol Depend. 2017;181:170-176.

4. Ministry of Health. Available from:https://www.health.govt.nz/news-media/media-releases/sentence-handed-down-after-steroid-operation-uncovered

5. Stuff. Available from: https://www.stuff.co.nz/sport/other-sports/117626410/ringleader-of-new-zealand-sports-biggest-steroid-operation-sets-up-new-health-company

6. Ministry of Health. Available from: https://www.health.govt.nz/system/files/documents/information-release/h201902160.pdf

7. Mazanov J, Backhouse S, Connor J, Hemphill D, Quirk F. Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance. Scand J Med Sci Sports. 2014;24(5):846-856

8. Kanayama G, DeLuca J, Meehan WP 3rd, Hudson JI, Isaacs S, Baggish A, Weiner R, Micheli L, Pope HG Jr. Ruptured Tendons in Anabolic-Androgenic Steroid Users: A Cross-Sectional Cohort Study. Am J Sports Med. 2015 Nov;43(11):2638-44.

9. Jones IA, Togashi R, Hatch GFR 3rd, Weber AE, Vangsness CT Jr. Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects. J Orthop Res. 2018 Nov;36(11):2830-2841.

10. de Ronde W, Smit DL. Anabolic androgenic steroid abuse in young males. Endocr Connect. 2020;9(4):R102-R111

11. Russell M, Storck A, Ainslie M. Acute respiratory distress following intravenous injection of an oil-steroid solution. Can Respir J. 2011 Jul-Aug;18(4):e59-61. doi: 10.1155/2011/743151. PMID: 22059184; PMCID: PMC3205107.

12. Figueiredo VC, Silva PR. Cosmetic doping--when anabolic-androgenic steroids are not enough. Subst Use Misuse. 2014;49(9):1163-1167.

13. Santos HO, Howell S, Teixeira FJ. Coconut oil as a Vehicle for Lipophilic Drug Administration. J Diab Obes 2019:6(1):8-12

14. Riffkin C, Huber R, Keysser CH. Castor oil as a vehicle for parenteral administration of steroid hormones. J Pharm Sci. 1964;53:891-895.

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