- Elbow Bursitis Exercises
- What do I need to know about elbow bursitis exercises?
- Which exercises increase range of motion?
- Which exercises increase strength?
- When should I contact my healthcare provider?
- Further information
- Muscle Soreness
- Proximal Biceps Tendonitis
- The Pull-Up Workout That Nearly Killed Me
- Swelling of both arms and chest after push-ups
- Exercise-Induced Acute Bilateral Upper-Arm Compartment Syndrome
Elbow Bursitis Exercises
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Medically reviewed by Drugs.com. Last updated on Sep 24, 2019.
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What do I need to know about elbow bursitis exercises?
Elbow bursitis exercises help decrease pain and swelling. They also help increase the movement and strength of your elbow. You will need to start with range-of-motion exercises. When you can do these exercises without pain, you will move to strength exercises. Your healthcare provider will show you how to do movement and strength exercises. The provider will tell you how often to do the exercises.
Which exercises increase range of motion?
- Finger extensions: Hold the fingertips of your injured arm close together with your fingers and thumb straight. Put a rubber band around the outside of your fingertips and thumb. Spread your fingers apart and then slowly bring them together without letting the rubber band fall off. Repeat 40 times.
- Grip: Hold a soft rubber ball or tennis ball in your hand. Squeeze the ball as hard as you can and hold this position. Ask your healthcare provider how long to hold this position. Repeat this exercise as directed by your healthcare provider.
- Wrist flexor stretch: Hold your arm straight out in front of you with your palm facing down. Use your other hand to grasp your fingers. Keep your elbow straight and slowly bend your hand back. Your fingertips should point up and your palm should face away from you. Do this until you feel a stretch in the top of your wrist. Hold for 10 seconds. Repeat 5 times.
- Wrist extensor stretch: This stretch is the opposite of the wrist flexor stretch. Hold your arm straight out in front of you with your palm facing down. Use your other hand to grasp your fingers. Keep your elbow straight and slowly bend your hand down. Your fingertips should point down and your palm should face you. Do this until you feel a stretch in your wrist. Hold for 10 seconds. Repeat 5 times.
- Elbow flexor stretch: Bend your elbow, and keep your palm facing toward you. Use your other hand to press gently on the back of your forearm so your arm moves toward you. Do this until you feel a stretch in the back of your upper arm. Hold for 15 to 30 seconds. Repeat 5 times.
- Elbow extension stretch: This exercise is the opposite of the elbow flexor stretch. Sit in a chair with your arm resting on your thigh. Hold your wrist with the other hand. Slowly straighten your arm so it is extended as far as possible. Keep holding your wrist as you move your arm slowly back to the starting position. Repeat 5 times.
Which exercises increase strength?
- Wrist curls: Sit in a chair with your forearm resting on your thigh or on a table. Hold a 3 pound dumbbell with your palm facing up. Bend your wrist up and then slowly lower it down. Repeat 20 times.
- Forearm rotation: Sit in a chair with your forearm resting on your thigh or on a table. Hold a 2 pound dumbbell with your palm facing up. Slowly turn your forearm until your palm faces down. Then slowly return to the starting position. Repeat 20 times.
- Bicep curls: Place your hand under your injured elbow for support. Turn your palm so that it faces up and hold a weight in your hand. Ask your healthcare provider how much weight you should use. Slowly bend and straighten your elbow. Repeat 30 times.
When should I contact my healthcare provider?
- You have a fever or chills.
- The skin around your elbow is red or warm.
- Your pain and swelling increase.
- Your symptoms do not improve after 10 days of treatment.
- You have questions or concerns about elbow bursitis exercises.
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
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A 24-year-old man with a history of moderate hypertension, treated with ramipril for two years, presented to the emergency department with progressive swelling of the arms and tingling in his hands. Five days earlier, he had done a short-duration (9 min) high-intensity exercise session that included 84 pull-ups and 84 overhead shoulder presses with 30-lb dumbbells. He regularly lifted weights and ran as part of his exercise routine, although short-duration high-intensity weight training was something new to him. No traumatic events had occurred between the workout and his visit to the emergency department. Immediately after the high-intensity exercise, his arms felt “tired and sore,” but this was not out of keeping with his normal postworkout fatigue. On the day of his visit, bilateral swelling progressed rapidly over three hours, and by the fourth hour, paresthesia had developed. He denied using any supplementation, stimulants, creatine or anabolic steroids. He had no family history of malignant hyperthermia, and he had previously had an uneventful general anesthetic for a minor procedure.
On examination, our patient was alert and afebrile. Both arms were markedly swollen, firm and painful to palpation (Figure 1). His brachial, radial and ulnar pulses were palpable. Laboratory analysis showed a serum creatine kinase level of 84 318 (normal 10–234) U/L and myoglobinuria. His calcium, electrolyte, urea and creatinine levels were normal. We diagnosed rhabdomyolysis and started aggressive intravenous fluids. He was discharged after two days, with instructions to continue to take oral fluids and refrain from strenuous activity. He had substantial clinical improvement by day 8, at which time his creatine kinase level was down to 808 U/L. His renal function remained normal.
Photos of a 24-year-old man showing swelling of the arms and reduced elbow extension bilaterally, five days after a high-intensity workout.
Exercise-induced rhabdomyolysis is associated with problems ranging from an asymptomatic elevation of creatine kinase levels to severe electrolyte abnormalities, myoglobinuria and renal failure.1–3 A minimal workup includes testing for serum creatine kinase, calcium and electrolye levels, renal function, quantitative measurement of myoglobin in urine and an electrocardiogram.1 It has been suggested that the workup should include testing for malignant hyperthermia.2 The most widely accepted treatment for rhabdomyolysis is intravascular volume expansion.4,5
Rhabdomyolysis induced by exercise is typically seen in high-endurance athletes involved in marathons, triathlons and super marathons.3
Author: Richard Weil, MEd, CDE
For some individuals, sore muscles are a reward after a hard workout. In fact, some people aren’t happy unless they’re sore after their workout, while others could live without it. Either way, all of us have probably experienced muscle soreness at one time or another. In this article, I’ll review the causes, treatment, and prevention of muscle soreness.
What Causes Muscle Soreness? One of the consequences of vigorous exerciseheavy weight lifting, a tough day of speed work on the track, or the stairclimber at the gymis an accumulation of lactic acid in the muscles. Lactic acid is a normal byproduct of muscle metabolism, but it can irritate muscles and cause discomfort and soreness. Muscle soreness associated with exercise is known as delayed onset muscle soreness or DOMS. DOMS can make it difficult to walk, reduce your strength, or make your life uncomfortable for a couple of days.
But lactic acid isn’t the only culprit in DOMS. In fact, lactic acid is removed from muscle anywhere from just a few hours to less than a day after a workout, and so it doesn’t explain the soreness experienced days after a workout. What is it then that causes DOMS for days after exercise? The answer is swelling in the muscle compartment that results from an influx of white blood cells, prostaglandins (which are anti-inflammatory), and other nutrients and fluids that flow to the muscles to repair the “damage” after a tough workout. The type of muscle damage I am referring to is microscopic (it occurs in small protein contractile units of the muscle called myofibrils) and is part of the normal process of growth in the body called anabolism. It is not the type of damage or injury that you see your doctor about. The swelling and inflammation can build up for days after a workout, and that’s why muscle soreness may be worse two, three, or even four days after a workout (it can take up to five days for muscles to heal completely depending on the intensity of the workout).
In 1983, in one of the first studies of the causes of DOMS, subjects ran level or downhill on a treadmill (downhill running causes more muscle damage than level running due to eccentric muscle contractions), and then afterward, subjects’ perception of soreness, lactic acid levels, and muscle swelling was measured. Results showed approximately equal levels of lactic acid in both groups, but greater swelling in the downhill runners, and only downhill runners reported soreness. Since only the downhill runners were sore and the only difference between the level- and downhill-runners was the swelling, the investigators concluded that it was the swelling that caused the delayed onset muscle soreness and not the lactic acid, a finding consistent with the idea that lactic acid clears the muscle soon after exercise and is not responsible for DOMS.
Is Soreness a Prerequisite for Growth? I’m occasionally asked if soreness after a workout is necessary to get results. Although there’s no evidence to support this idea and individuals certainly get stronger even if they don’t get sore, some people just aren’t satisfied with their workout unless they’re sore, and there may be some rationale for this logic. Remember, there must be microscopic damage to muscle fibers before there can be growth, so if you’re sore, it means there was damage and thus growth must not be far behind. But again, there’s no evidence that soreness is necessary for growth, and until we understand more about the process, it’s probably enough to say that soreness could be a potential marker or predictor of how much growth there will be. In the meantime, I’ve included three tips for increasing muscle growth, and increasing the likelihood of soreness for those of you who crave it.
1. Increase the weight so that you lift reps in the six to 10 range to fatigue, and then once a week lift heavier, in the one to six range.2. Try slow, eccentric contractions. Eccentric contractions are the lowering portion of the lift (sometimes called the negative contraction), and as I mentioned above, these contractions make you sorer than the concentric contractions (the lifting, or positive, portion of the exercise). To emphasize eccentric contractions, complete your set to failure, then either “cheat up” the weight or have your spotter assist with extra reps (assisted negatives), and then lower each rep slowly on your own (five to 10 seconds). For example, if you’re doing a standing biceps curl, complete the set to fatigue, cheat the weight up or have your spotter assist, and then lower it slowly on your own to the starting position. 3. Try forced negatives. Forced negatives are where you complete a set to failure, and then your spotter helps you lift another rep and then pushes back down on the weight while you resist. This is an effective but very demanding technique!
Treating and Preventing DOMS
Do Anti-inflammatories Work? In a 1993 study of the effect of an over-the-counter anti-inflammatory (ibuprofen) on DOMS, researchers compared subjects given ibuprofen four hours before weight lifting (pre-lifting group) to subjects given ibuprofen 24 hours after lifting. Results showed that the pre-lifting ibuprofen group reported 40% to 50% less soreness than the after-lifting group, proving in this study that ibuprofen taken before exercise reduced soreness more than taking it after. A limitation of this study was the lack of a control group of subjects who did not take ibuprofen after working out to compare with subjects who did to see if ibuprofen helps at all after exercise. To answer this question, a study in 2003 investigated subjects who took ibuprofen or sham (placebo) every eight hours for 48 hours after they lifted weights. The ibuprofen group reported less soreness than the sham group, proving that ibuprofen worked when taken after exercise.
From these studies, it appears as if some people will respond to taking anti-inflammatories before working out, and others will respond when they take it afterward. How hard you lift, how long you rest, and your level of activity when not working out will factor in to the equation as well.
Does Pre-Stretching Help? In an interesting study conducted in 1999, subjects were asked to stretch only one of their legs and then perform leg exercises with both legs. Subjects reported afterward that both legs had equal amounts of soreness for at least 48 hours, proving in this study that pre-exercise stretching did not help prevent DOMS. These results, and findings from other similar studies, lead to the conclusion that stretching before exercise does not help prevent DOMS. An intriguing question is what effect stretching after a workout has on DOMS, but I am not aware of any studies that have investigated this. However, I do believe that stretching, and physical activity in general, can help alleviate soreness and offer some suggestions about it at the end of the article.
Does Massage Help? Massage does help reduce DOMS and a number of studies prove it. In two similarly designed studies where all subjects lifted weights but only half received massages two hours after working out, subjects who received massages reported less muscle soreness than the subjects who did not. In a longer-term study in 2005 in which soreness and swelling were measured, all subjects lifted weights, but only half of them received massages 30 minutes after exercise and then one, two, three, four, seven, 10, and 14 days post-exercise. The subjects who received massages reported 30% less soreness than subjects who were not massaged, and importantly, swelling in the muscle was reduced only in the subjects who received massage. It may be that the pressure of the massage strokes moved fluid out of the muscle and reduced the swelling that causes DOMS. Whatever the mechanism of action, massage after a workout (sometimes lots of it) was effective in reducing DOMS in these studies.
Should You Work Out When You’re Sore? Some studies show that neither aerobic nor resistance exercise helps alleviate soreness. My experience is different. I have observed an alleviation of symptoms in sore individuals if they start their workout with light aerobic (cardio) exercise for 10-15 minutes followed up with stretching. In many of these cases, individuals can go on to do their full cardio and/or resistance exercise workout without a problem. This effect may be similar to the massage effect in that the light cardio and stretching help reduce swelling, perhaps by increasing circulation to and from the muscle.
If you want to work out when you’re sore, then I suggest starting with 10-15 minutes of light cardio followed by stretching, then lifting, and/or more cardio. If the soreness resolves or doesn’t interfere with your performance, then continue with the workout. But if the soreness worsens or causes too much pain for the workout to be worthwhile (you can only 50% of what you normally do), then you’re probably better off either working another muscle group, or taking the day off, because muscles grow during downtime, not when you train, and if your muscles get sorer during your workout, then you need more time to rest, recover, and grow.
In summary, ibuprofen taken before or after a workout, and massage afterward (sometimes a lot of massage), can reduce DOMS, but stretching before a workout doesn’t seem to help. Although there is no evidence that stretching after exercise reduces DOMS, I have seen light cardio for eight to 10 minutes followed by stretching reduce DOMS. Everyone responds differently, and so I encourage you to experiment with different routines until you find one that works for you. I also recommend that you speak with your doctor before taking any medication, over-the-counter or prescription, and that includes ibuprofen.
Proximal Biceps Tendonitis
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What Is Tendonitis?
Tendonitis is when a tendon becomes inflamed, irritated, and swollen. Tendons are tough bands of soft tissue that connect muscle to bone. They are pulled when muscles contract to allow body parts to move.
What Is Proximal Biceps Tendonitis?
The biceps is the muscle on the front of the upper arm. The upper part of the biceps is called the proximal biceps. Proximal biceps tendonitis is tendonitis of the tendon that connects the upper part of the biceps to the shoulder.
Biceps tendonitis can happen on its own, or with or after a shoulder injury.
What Are the Signs & Symptoms of Proximal Biceps Tendonitis?
People with proximal biceps tendonitis usually have pain in the front of the shoulder. Most of the time, the pain starts slowly and gets worse the more a person uses that arm. The pain may be worse at night or with lifting, pulling, or reaching overhead. The shoulder may get stiff or weak.
What Causes Proximal Biceps Tendonitis?
Proximal biceps tendonitis usually is an overuse injury. This means it happens from doing the same movement over and over again.
Proximal biceps tendonitis usually affects adults and older teens whose growth plates have closed (which means they’ve stopped growing). Teens who play sports with a lot of arm movement, especially overhead movements — such as in baseball, swimming, volleyball, and tennis — are more likely to get it.
How Is Proximal Biceps Tendonitis Diagnosed?
To diagnose proximal biceps tendonitis, health care providers:
- ask about symptoms
- do an exam, paying special attention to the upper arm and shoulder
Occasionally, doctors order imaging tests such as an X-ray or MRI to check for or rule out other problems.
How Is Proximal Biceps Tendonitis Treated?
Someone with proximal biceps tendonitis needs to rest the arm and shoulder.
- Gentle stretching of the arm overhead, to the side, and behind the body. “Spider walking” fingertips up the wall to the front and side can assist with a gentle stretch. Slow, controlled arm circles also can stretch the biceps and shoulder.
- Changes to some activities, such as throwing underhand and doing an underhand serve in tennis, which can make it more comfortable to play.
- Shoulder rehabilitation and looking closely at techniques for pitching, spiking, serving, swimming strokes, etc.
Your health care provider also may recommend some or all of these:
- Putting ice or a cold pack on the shoulder a few times a day for 15 minutes at a time. (Put a towel over the skin to protect it from the cold.)
- Taking medicine for pain and swelling, such as ibuprofen (Advil, Motrin, or store brand) OR naproxen (Aleve or store brand) for 5–7 days. Follow the directions that come with the medicine for how much to take and how often.
- Physical therapy (PT) or a home exercise program for stretching and strengthening.
If these treatments don’t help, doctors may consider steroid injections in the area of the biceps tendon and shoulder.
When Can I Go Back to Sports?
Teen with biceps tendonitis can return to sports when the pain is better and they:
- have regained their full range of motion
- don’t have any numbness or tingling
- are back to their full strength
Going back to sports too soon puts someone at risk for another injury that could possibly be more serious. Your health care provider will let you know when it’s safe for you to go back to sports.
What Else Should I Know?
Proximal biceps tendonitis usually heals well in 6 weeks to a few months and doesn’t cause any long-term problems. It’s important to rest, stretch, and rehabilitate the arm and shoulder long enough to let it heal fully. A slow return to activities and sports can help prevent the tendonitis from coming back.
Reviewed by: Cassidy Foley Davelaar, DO Date reviewed: May 2019
The Pull-Up Workout That Nearly Killed Me
I work out, I’d say, four or five days a week at least. I’m usually running 20 to 30 miles weekly, but I do barre, I do yoga, and I try to take a restorative day. So it’s not all super hardcore.
I ran the 2016 NYC Half Marathon in March, and afterwards, I was going to the gym every day. I was in good shape, but I told a new trainer I was about to start working with that I felt like I’d plateaued a bit, and that my goal was to get to that next level and maybe to trim up a little bit too.
In April, we had our first session, a full-body workout, which my gym offered for free as a promotion. I don’t always work out with a trainer. I did before my wedding, though, and sometimes I felt like that trainer wasn’t pushing me hard enough; it was a lot of core work, and a lot of holding—just very controlled movements.
The thing that was different about this workout was I felt like I was kind of losing control. I’ve worked out before on my own, in classes, and with trainers, and I know something about proper form. But in some of these exercises, especially the negative pull-ups she had me doing (where you jump off a box or up from the floor to the top of a pull-up and slowly lower down), I felt like I was either dropping too hard or just losing the slow controlled movement I was used to. I was jumping up, grabbing the bar, and instead of lowering myself back down, I was just dropping back down, over and over. And I felt like it was shocking me, shocking my body.
And I remember I said to this trainer, “I’m failing.” I was going into muscle failure, that point where my arms were shaking and I was literally collapsing over and over again. But she was saying, I guess to motivate me, “One more, two more, you can do it!” So I pushed through. You know, you’re motivated, someone’s standing with you, you don’t want to quit in the middle of an open gym in front of everyone.
Within the next two or three hours after, I was at work and I was like, I’m really sore. It was very intense soreness, the kind that ususally hits a day or two after working out, but this was within two or three hours after the session. I felt ridiculously sore and I couldn’t even open these heavy doors at work; I couldn’t fully extend or bend my arms. They were kind of stuck in the middle. I texted my trainer and said, “I’m really sore, my arms kind of feel like noodles.” She just said, “You did a great job, it’ll be better in a day or two!”
So I went about my day and just thought, Maybe I haven’t done a lot of upper-body work lately. But I think that was one of the first warning signs, that I was so sore so quickly and lost range of motion too. (Unlike immediate, intense pain, check out five post-workout aches it’s okay to ignore).
The next day was a Saturday, and I was still really sore. But I actually went running that day because sometimes that helps loosen me up a bit. I finished the run, but I definitely felt the stiffness and soreness in my arms, shoulders, and into my chest and upper back too.
That night I went out and as I was getting ready, I put on a cropped sweater. And it was inches shorter than it should have been, to the point where I thought the dry cleaner might have shrunk it—until I remembered I hadn’t brought it to the dry cleaner yet. So that was the second weird red flag moment. I was obviously at that point swelling, but I just thought my clothes were riding up.
That night I had some wine and a cocktail with dinner, maybe four or five drinks over the course of six or seven hours. Then the next day I had lunch with a friend, and I still couldn’t really straighten or bend my arms, now two days after the workout. Back at home I changed clothes, and that’s when I looked in the mirror and I was just like, “Oh my God.” I looked like the Michelin Man.
I Googled “really swollen arms after workout” and I started seeing results about this rhabdo thing—rhabdomyolosis, which is basically when you have so much muscle tissue breakdown that it dumps a damaging protein into your blood, and it can be really dangerous. It happens after intense workouts, but really any form of muscle damage that’s severe enough can cause it. My husband started Googling it too and he said, “Well, it’s so uncommon, and your urine isn’t Cola colored,” which is what he was reading was the main symptom. But I still decided to go to emergency care anyway because of the swelling.
So I went and I didn’t even bring up rhabdo, but I told them, “I worked out, I’m really sore, it hurts.” They did a urine sample and blood test immediately and while I was waiting they hooked me up to an IV because they figured I was dehydrated. And they came back with the blood test and said, “Yeah, it’s rhabdo, and we’re admitting you to the hospital.” That’s when I thought, okay, this is really serious.
They admitted me to the cardiac wing because my potassium levels were very high, which is super scary because it means you can have a heart attack. I’ve always been healthy; now here I was sitting in the cardiac wing with an IV with just continuous fluid—which is the only treatment for rhabdo—in my hand because my arms were so stiff and swollen they couldn’t find a vein in my arm. The doctors weighed me, and I was nine pounds heavier than my normal weight from the swelling. I thought they must be wrong. You don’t gain nine pounds in one day!
The doctors had to test my blood every four to six hours; they’d even wake me up during the night. They were testing levels of a muscle enzyme called CPK. The CPK level for a normal person should be between 10 to 120 IU/liter. I was admitted at 38,000 IU/liter.
Of course I said to my husband, “I told you!” He read that is was so rare, but I told him every single doctor I saw, and I saw five or six M.D.s at different points during all this, every one said they’d seen a case within the past week. And they kept saying, “Oh, yeah, you know, with CrossFit and SoulCycle, it’s more common. And after the marathon we saw a bunch…”
The good news was that I didn’t suffer any kidney damage. The big issue with rhabdo is that all the muscle enzyme that gets broken down into your blood has to exit your body, so it goes through your kidneys. And when it’s at such a high level, if you’re not diluting it with tons and tons of water—more than you can just drink, I was on a continuous IV for four full days until they were satisfied with my CPK levels—it can put you into kidney failure. (Another woman shares: “I Gave My Dad a Kidney to Save His Life.”)
Later, when I Googled rhabdo more, I noticed that some blogs and certain fitness communities like CrossFit tend to speak about the condition casually—I read about people talking about “meeting Uncle Rhabdo,” or whatever. They spoke about it like it was akin to getting a cramp or almost like a badge of honor. That’s dangerous; it’s serious, people die. It’s not something to push through or shake off.
But my doctors told me they saw no indication that I was ever in that kind of trouble. My urine never changed color, which is that scary sign. Usually, one doctor said, people only come when they’re at that scary point and it can be a lot worse.
Still, at first I thought I’d spend a night in the hospital and then they’d send me on my way. But I wasn’t released until four days later, and even then it was just because I caused such a commotion; I was desperate to be home. What was so frustrating was there’s no time period they can give you. Every day, I asked, “How much longer?” And they said, “We don’t know. It depends on the person.” I learned that the more muscular you are, the worse it can be, since you have that much more muscle to break down.
Even after four days, my CPK was only down to 17,000 IU/liter. They let me go home as long as I promised to follow their treatment plan: drink tons of water, no salty foods, no caffeine, no alcohol, no exercise or sweating at all—I could only walk 10 or 15 minutes at a time. You can’t risk getting dehydrated at all. They said to do that for at least three weeks. It was so frustrating to be so active and then to do nothing.
Two or three days after leaving the hospital, I was down to 13,000 IU/liter, which was reassuring. And a week after that, my levels were completely normal again. The crazy thing is that throughout all of this, I felt totally normal. Except for the swelling; I felt bloated from the IV, but that’s it. I didn’t have a temperature, nothing.
My doctors told me I have to wait a month to exercise again. The thing is, there’s not a lot of information on what to do fitness-wise after rhabdo. One doctor said, “don’t do any upper-body exercise,” because that’s what triggered mine. So now I’ve been running again, and I do yoga—yoga has never hurt me. (It’s one of the 30 Reasons We Love Yoga.) I do more lengthening classes and restorative classes, like barre. But I used to do boot camp or HIIT classes once a week, and I haven’t been back to those classes. To be honest, I’m afraid of pushing myself. I kind of don’t trust myself; I know that at least once, I pushed myself so hard that I ended up in the hospital. And doctors don’t know whether this is more likely to happen again now that’s it already happened.
I also refuse to go back to a trainer for now. I kind of think I have no one to blame but myself; I didn’t stop, and I’m sure it didn’t help that I ran and drank the next day, since I got dehydrated. But at the same time, every doctor I saw said, “You need to tell the gym, and tell your trainer what happened.” I didn’t want to get anyone in trouble, and I know it was my fault too, but the trainer does need to know the signs. Their actions contribute—how hard they push you and what they say after if you’re complaining about being sore.
So I did call my gym and it ended up being a complete cover-their-ass kind of call, even though I was clear that I knew I played a part and I wasn’t trying to get anyone fired. They told me my nutrition must have been not great to cause this, they asked whether I even told the trainer I needed to stop, they said that she’d done nothing wrong. They said they even looked into my correspondence with her, which got me—I looked back at our texts, and I saw that within two hours after the workout I’d told her I was very sore. During the workout, I used the words, “my muscles are failing.” The head trainer, who was on the call, said in her 15 years as a trainer she’d only seen one other case of rhabdo. But my doctors all said they’d just seen someone last week. It’s not some super rare thing that only happens to CrossFit addicts or body builders.
A few weeks ago I ran into an old trainer I used to see. I told him everything, almost like a funny story. And you know what? He’d never even heard of rhabdo. These are trainers at a designer, luxury gym that prides itself on its “science-fueled” approach. But obviously the gym isn’t telling its trainers about rhabdo. That’s frustrating, and it’s scary—because it can happen to anyone.
Swelling of both arms and chest after push-ups
A healthy 16-year-old boy presented with muscle pain and weakness in the chest and both arms after performing 50 push-ups daily for 3 days, and the symptoms did not seem to improve after 3 days.
Figure 1. Initial visit: The patient showed swelling in the triceps brachii, deltoid, and pectoralis major muscles.
He denied dark urine or drug abuse. Physical examination revealed swelling of both arms and the chest, with tenderness and weakness in the triceps brachii, deltoid, and pectoralis major muscles ( Figure 1 ). Laboratory testing showed a creatine kinase level of 59,380 U/L (reference range 30–220). T2-weighted magnetic resonance imaging (MRI) showed diffuse hyperintensity in all affected muscles ( Figure 2 ) with hyperintensity on T1-weighted images, findings consistent with rhabdomyolysis. The rhabdomyolysis was deemed to have been induced by exercise, in our patient’s case by push-ups.
Figure 2. T2-weighted magnetic resonance imaging showed diffuse hyperintensity in both triceps brachii muscles (arrows).
Treatment with aggressive fluid transfusion was started, with strict monitoring of fluid input and urine output. There was no evidence of acute renal failure or hyperkalemia. The creatine kinase level improved progressively: to 28,734 U/L on day 2, 15,386 U/L on day 3, and 11,472 U/L on day 4. By 2 weeks after symptom onset, the level had normalized (164 U/L), and all symptoms had resolved. The patient was able to resume exercising.
Approximately 50% of patients with rhabdomyolysis present with the characteristic triad of myalgia (84%), muscle weakness (73%), and dark urine (80%), and 8.1% to 52% present with muscle swelling. 1 Rhabdomyolysis may be caused by exercise, 2 and risk factors include physical deconditioning, high ambient temperature, high humidity, impaired sweating (due to anticholinergic drugs), sickle cell trait, and hypokalemia from sweating. 2 Pain and swelling of the affected focal muscles is the chief complaint. 3
Although acute renal failure in exercise-induced rhabdomyolysis is rare, failure to recognize rhabdomyolysis can cause diagnostic delay and inappropriate treatment. 4
In healthy people, exercise-induced muscle damage begins to resolve within 1 to 3 days. 5,6 Physicians should suspect exercise-induced rhabdomyolysis in patients with prolonged muscle swelling and tenderness in affected muscles that lasts longer than expected. 7
Exercise-Induced Acute Bilateral Upper-Arm Compartment Syndrome
We present a rare case of acute exercise-induced bilateral upper-arm compartment syndrome in a patient who, after a year-long hiatus from exercise, subjected his upper-extremities to the stress of over 100 pushups. The patient presented with severe pain of the bilateral biceps and triceps and complaints of dark urine. Decompressive fasciotomy was performed followed by an intensive care unit (ICU) stay for associated myoglobinuria secondary to rhabdomyolysis. The patient suffered no long-term sequelae as a result of his conditions and recovered full function of the bilateral upper-extremities. Albeit rare, acute exercise-induced compartment syndrome should be considered as a diagnosis following unaccustomed bouts of exercise.
Acute compartment syndrome is a condition defined by increased compartmental pressure which causes a decrease in perfusion pressure, ultimately leading to tissue ischemia. The condition is a clinical emergency, requiring prompt diagnosis and intervention. While most cases of acute compartment syndrome occur secondary to traumatic fracture, up to 30% occur without evidence of fracture . Other relatively common causes of acute compartment syndrome include complications of surgery, constricting circumferential casts, and thermal injuries . While acute compartment syndrome can occur in any compartment, it is rare in the upper-arm. Although few cases have been reported in the literature, making ascertainment of the true prevalence difficult, trauma remains the most commonly reported cause of acute compartment syndrome in the upper-arm . Reports of bilateral acute upper-arm compartment syndrome are even fewer, with most cases attributable to those aforementioned etiologies. We present a rare case of acute exercise-induced bilateral upper-arm compartment syndrome.
2. Case Report
A 24-year-old man presented to the emergency department complaining of left shoulder pain. The patient reported completing over 100 pushups 48 hours prior to presentation, but denied pain immediately after the workout. Prior to those pushups, he had taken a year-long hiatus from exercise. Plain radiographs of the left shoulder were negative and the patient was discharged and instructed to follow-up with orthopedics.
The patient returned to the emergency department after 24 hours, complaining of increased swelling in both arms and darkening of his urine. Blood testing returned a normal complete blood count, normal sedimentation rate, negative urine toxicology screen, myoglobin of 176 ng/mL, and a chemistry panel with a Na of 133 mmol/L, Cl of 97 mmol/L, Ca of 9.1 mg/dL, K of 4 mmol/L, and creatine kinase of 215,420 U/L. Urinalysis was significant for 3+ blood and 1+ protein with fewer than 1 RBC and 1 WBC per high power field. The patient was diagnosed with rhabdomyolysis and admitted.
After further evaluation, given a normal sedimentation rate, the admitting service had no concern for occult infection but they noted upper-extremity swelling, concerning for compartment syndrome. Orthopedics was immediately consulted. On examination, the patient appeared to be in moderate to severe pain with very tense bilateral upper-extremities, especially about the triceps but also involving the biceps. Passive range of motion at the elbow exacerbated his pain involving the upper-arm compartments. Muscle strength was graded at 3/5 in both the triceps and biceps bilaterally. Radial and ulna pulses were 2+ bilaterally. Compartment pressures were obtained by injecting saline into the affected compartments using a Stryker Intra-Compartmental Pressure Monitor (Kalamazoo, MI) which returned readings of 36 mmHg and 72 mmHg in the left forearm and right triceps, respectively. Additional compartments were not tested as the decision to go to the operating room was made upon recording the aforementioned pressures. In light of the clinical presentation, an absolute compartment pressure of >30 mmHg was used as the cutoff for operative management. Compartment pressures of 0–8 mmHg were considered normal .
Compartment pressures and clinical findings were consistent with compartment syndrome and the patient underwent emergent bilateral upper-extremity fasciotomies utilizing a posterior and medial approach to the upper-arm extending from the axilla to the level of the humeral epicondyles. Intraoperative inspection of the biceps and triceps musculature revealed a dusky grayish color beneath the fascia. Once the fascia was incised and the muscle was released, a majority of the involved muscle regained a pink color and was responsive to electrosurgical stimulus. Postoperatively, the patient reported immediate pain reduction. He was placed in the ICU for 3 days of continued fluid resuscitation with kidney function monitoring before transfer to the general medical/surgical floor. He was discharged 3 days later, upon normalization of his kidney function.
Acute compartment syndrome, while less common in the upper-arm, is a surgical emergency with significant sequelae if not diagnosed and treated promptly. The case we reported is noteworthy because of its atypical nature. While most cases of acute compartment syndrome can be attributed to causes including trauma, surgery, or the placement of a circumferential cast or bandage, it can reasonably be inferred that our case is the result of exercise intolerance. This notion is supported when considering our patient’s clinical picture and history. After burdening his upper-extremity musculature with over 100 pushups, the patient presented with bilaterally tense upper-extremity compartments, most severe in the compartments of the triceps. This is consistent with our proposed etiology, as the triceps are most heavily involved in the work associated with performing pushups.
The development of acute compartment syndrome following strenuous exercise may be attributable to the development of rhabdomyolysis . Numerous cases of rhabdomyolysis following bouts of exercise have been reported. Tran et al. published a case report of a 23-year-old woman who developed rhabdomyolysis after exercise . Similar to our patient, the woman had no significant medical history and developed symptoms after low-intensity and high-repetition exercise. The pathological manifestations of rhabdomyolysis are secondary to increased intracellular calcium levels, initiating a cascade of intracellular processes that culminates in outcomes including mitochondrial dysfunction and the production of reactive oxygen species . Dysfunction of muscle cells, induced by rhabdomyolysis, promotes the accumulation of extracellular fluid within the cells, causing local edema formation with a subsequent increase in intramuscular pressure. The elevated pressure impedes muscle perfusion and venous return, resulting in muscle ischemia. The ischemic muscle leads to increased capillary permeability, thereby promoting a cycle of worsening local edema. This process has been hypothesized as a possible cause of acute compartment syndrome in rhabdomyolysis .
Other cases have been reported that support the association between intense exercise and the development of rhabdomyolysis with progression to acute compartment syndrome. DeFilippis et al. reported a case of exercise-induced rhabdomyolysis complicated by acute kidney injury and bilateral acute compartment syndrome of the thighs following a spinning-class . Aynardi and Jones described a case similar to that of our patient in which bilateral upper-arm compartment syndrome was diagnosed after a vigorous cross-training workout .
Regardless of the etiology or site of compartment syndrome development, the same principles of diagnosis and treatment can be applied. To prevent irreversible tissue necrosis, prompt diagnosis with subsequent emergent surgical decompression with fasciotomy is mandated . Appropriate interpretation of compartment measurements remains controversial, as some experts utilize the difference between diastolic blood pressure and the compartment pressure to guide decision-making, as opposed to absolute compartment pressures alone . Ultimately, all compartment measurements should be interpreted in light of the clinical setting. In our case, the diagnosis was delayed and our patient experienced myonecrosis with resulting myoglobinuria that required intensive care monitoring and resuscitation but did not progress to acute tubular necrosis. While the patient discussed in this case returned for a six-month follow-up with no resultant long-term deficits in muscle function, the potential for irreversible tissue damage increases with increased duration and severity of the elevated compartment pressures. Retrospectively, an orthopedic consultation during the patient’s initial visit to the emergency department may have been warranted but the subtle signs and symptoms that were present at that time may not have been alarming to the emergency department staff. With only subtle signs and symptoms available to the emergency department staff on the patient’s initial presentation, a high level of suspicion would have been required for inclusion of compartment syndrome in the differential diagnosis. The conventional thinking remains that compartment syndrome occurs secondary to prolonged pressure on an extremity or following trauma or surgery. We therefore conclude that acute compartment syndrome should be considered in patients presenting with any signs or symptoms consistent with the diagnosis in the setting of a recent bout of intensive exercise.
Conflicts of Interest
There exist no proprietary interests in the materials described in the article for any of the authors.