Apricot oil as a cause for multi-lobulated oil cysts in the deltoid muscle of a bodybuilder
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clinical correspondence
Apricot oil as a cause
for multi-lobulated oil
cysts in the deltoid muscle
of a bodybuilder
Dominic P O’Dowd, David Dow, Michael P Rosenfeldt
T
he illicit and unregulated nature of strated a painful arc with abnormal muscle
sourcing and using performance and patterning during active forward flexion
image enhancing drugs (PIEDs) or and active abduction arcs. Abnormal muscle
steroids presents a risk to users because they patterning on movement is suggestive
are often unaware of correct dosage, contra- of asynchronous muscle activation and
indications, polypharmancy and side effects. contraction, which is in keeping with a
Although the conversation can be challenging possible rotator cuff injury. There was
due to the perceived risks of offending or stig- significant weakness on examination of
matising the patient, it is important that clini- the supraspinatus; but the infraspinatus,
cians broach the subject. The aim should be teres minor and subscapularis showed no
to understand why the patient uses PIEDs or weakness on examination. An MRI was
steroids, educate them on the risks, screen for requested and showed a tear within the
potential side effects and consider referral to supraspinatus tendon.
substance abuse services if appropriate. Here Magnetic resonance imaging of the
we present the unusual case of a rotator cuff right shoulder demonstrated a supra-
injury with incidental deltoid intramuscular spinatus tendon tear and, incidentally,
oil cysts from apricot oil used as a delivery multiple ovoid foci within a hypertro-
agent for anabolic steroids. Side effects of phied posterior deltoid muscle. These
PIEDs and steroids are discussed along with ovoid foci were of internal fat signal on T1
simple screening tests, which can be under- sequences, matching the signal intensity
taken to monitor patient health. of adjacent subcutaneous fat (Figure 1).
The ovoid foci demonstrated uniform fat
Case report suppression on both fat saturated T1 and
AB, a 46-year-old male body builder T2 sequences (Figures 2 and 3) and fine
presented with a history of sudden pain in peripheral enhancement on post-contrast
his right shoulder, which occurred during T1 sequences (Figures 4 and 5). Appear-
a heavy-weight bench press. Following the ances were compatible with intramuscular
injury, AB was unable to actively abduct his oil cysts related to repetitive, intramus-
arm greater than 30 degrees. Following a cular anabolic steroid and oil suspension
short period of self-enforced rest, the patient injectate. No intramuscular calcification
sought treatment from a physiotherapist was demonstrated on radiographs. During a
due to his inability to perform his job as a discussion, the patient revealed that he was
landscape gardener. After three months of injecting Masteron (masteron enanthaate),
physiotherapy treatment, he was continuing Delatestryl (testosterone enanthate),
to have problems and was referred to a Epistane (methylepitiostanol) and apricot
sports surgery clinic. oil. The patient was injecting apricot oil
based on advice from a fellow bodybuilder
Clinical examination revealed gener-
regarding its effects of “enhancing the
alised muscle hypertrophy in keeping with
steroids” he was using.
prolonged resistance training. AB demon-
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www.nzma.org.nz/journalclinical correspondence
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.
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NZMJ 16 April 2021, Vol 134 No 1533
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Discussion and gynecomastia (androgen imbalance in
favour of oestrogen). The latter is sometimes
The prevalence of steroid use among avoided by users adding in an anti-oestrogen
recreational athletes is reported to be medication such as tamoxifen.
increasing, although exact numbers are
Muscle and tendon ruptures are also
always difficult to determine. In the UK in
reported, but the exact cause is not clear and
2018, an estimated 411,000 people had used
evidence is largely limited to case reports.
anabolic steroid recreationally, representing
A cross-sectional cohort study of body
around 0.7% of the population.1 A literature
builders found that 22% of those taking
review undertaken in New Zealand in 2015
anabolic steroids had suffered at least one
highlighted the diversity of people using
tendon rupture, compared to 6% of those
PIEDs, but that it is difficult to determine
not taking anabolic steroids.8 However, a
the true incidence and prevalence.2 A study
systematic review of the effect that anabolic
of anabolic steroid use among gay and
steroids have on tendon structure found
bisexual men in New Zealand and Australia
limited research, most of which relied on
found a prevalence of 5.2%, with the main
animal models and often had conflicting
reason for use being body-image dissatis-
results.9 Prospective research is required to
faction and eating disorders, rather than
determine whether PIEDs and steroids are
physical performance.3 There are no official
the cause of the apparent increased tendon
figures for prevalence of use in New Zealand
rupture rate, or whether the cause is multi-
overall, but media coverage surrounding
factorial, surrounding training, recovery,
the criminal case of an individual distrib-
drug use and other lifestyle factors.
uting PIEDs or steroids suggests cases are
not isolated.4,5 The New Zealand Ministry of Side effects diagnosed by clinicians after
Health and Medsafe have released figures testing include gonadotrophin suppression,
on the seizures of PIEDs between 2013 and decreased spermatogenesis, liver toxicity
2018.6 These figures demonstrated a peak in and cardiac disease.10
the number of packages seized during 2016, If clinicians are concerned, they should
but the overall volume of tablets/capsules discuss screening with the patient.
and active pharmaceutical ingredient (API) Screening typically involves blood pressure
seized remains fairly steady over time. In measurement, ECG and blood tests to look at
2018 more than 11kg of anabolic steroid API liver function, cholesterol levels (increased
were seized, with the majority coming from low-density lipoproteins and decreased
China and Hong Kong. Greater than 40kg high-density lipoproteins), glucose levels
of tablets/capsules were seized, with the and hormone levels.
majority coming from the US. Acute complications from the injection
In the case presented here, the patient was of steroids may also appear relatively
receiving advice on steroid use from a fellow commonly and include local inflammation
bodybuilder who we assume had no formal or infection (eg, abscess formation). This can
medical training. A study from Australia have implications in the setting of wound
in 2010 demonstrated that over 40% of complications and delaying tendon repair
athlete-support personnel in professional surgery. Acute complications from oil injec-
sport advise on anti-doping or nutritional tions are also recognised and are commonly
advice without training.7 Although this is inflammatory or infective—but rarely are
concerning in elite sport, it suggests poor/ they life threatening, like a pulmonary oil
incorrect advice given by lay people to embolism from mistakenly injecting the oil
others in the setting of PIEDs may be even into a vein.11
more prevalent than assumed and a possible Injecting oil into muscle compartments
cause for the complications associated with is sometimes performed by individuals to
PIED or steroid use. Common side effects enhance the appearance or size of their
that patients report from anabolic steroid muscle. Use of paraffin, synthol and coconut
use are acne (androgen associated sebum oil are described within the literature as
production), cutaneous striae (particularly site enhancement oils (SEOs).12,13 In this case
around the deltopectoral area), mood swings the patient injected only a small amount of
and agitation (fluctuating androgen levels) oil on the advice it would prolong the effect
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of the steroids he was injecting, thereby This case demonstrates an unusual radio-
conferring a pharmacological benefit rather logical finding that may assist clinicians in
than an image benefit. Steroids have limited the diagnosis of PIEDs and steroid use. The
water solubility. Research has shown that discussion informs clinicians of the common
dissolving the steroids in a non-aqueous oil side effects of PIED and steroid use, along
solution for delivery (eg, castor oil) is safe with some routine screening tests that can
and can prolong the effect of intramuscular be undertaken to monitor patient wellbeing.
injected steroids.14,15 Following a search of Clinicians may use the information here to
the literature, we were unable to find any open a discussion with patients suspected of
information in relation to apricot oil as a PIED or steroid use.
vehicle for intramuscular steroid delivery.
Competing interests:
Nil.
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.
Corresponding author:
Dominic P O’Dowd, Unisports Sports Medicine, 71 Merton Road, St Johns,
Auckland, New Zealand, 095219857
dominicodowd@doctors.org.uk
URL:
www.nzma.org.nz/journal-articles/apricot-oil-as-a-cause-for-multi-lobulated-oil-cysts-in-the-
deltoid-muscle-of-a-bodybuilder
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