Yusuke Hirota, MD

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Swelling of both arms and chest after push-ups

Author(s)

Kiyoshi Shikino, MD, PhD

Yusuke Hirota, MD

Masatomi Ikusaka, MD, PhD

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.

EXERCISE-INDUCED RHABDOMYOLYSIS

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

References

Nance JR, Mammen AL. Diagnostic evaluation of rhabdomyolysis. Muscle Nerve 2015; 51:793–810.
Sayers SP, Clarkson PM. Exercise-induced rhabdomyolysis. Curr Sports Med Rep 2002; 1:59–60.
Have L, Drouet A. Isolated exercise-induced rhabdomyolysis of brachialis and brachioradialis muscles: an atypical clinical case. Ann Phys Rehabil Med 2011; 54:525–529.
Keah SH, Chng K. Exercise-induced rhabdomyolysis with acute renal failure after strenuous push-ups. Malays Fam Physician 2009; 4:37–39.
Nosaka K, Clarkson PM. Changes in indicators of inflammation after eccentric exercise of the elbow flexors. Med Sci Sports Exerc 1996; 28:953–961.
Peake J, Nosaka K, Suzuki K. Characterization of inflammatory responses to eccentric exercise in humans. Exerc Immunol Rev 2005; 11:64–85.
Lee G. Exercise-induced rhabdomyolysis. R I Med J (2013) 2014; 97:22–24.

Article PDF

shikino_rhabdomyolysis.pdf

Author and Disclosure Information

Kiyoshi Shikino, MD, PhD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Yusuke Hirota, MD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Masatomi Ikusaka, MD, PhD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Address: Kiyoshi Shikino, MD, PhD, Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba, 2608670 Japan; [email protected]

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Cleveland Clinic Journal of Medicine - 84(7)

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Cleveland Clinic Journal of Medicine

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508-509

Legacy Keywords

Rhabdomyolysis, swelling, push-ups, creatine kinase, exercise, Kiyoshi Shikino, Yusuke Hirota, Masatomi Ikusaka

Read more about Swelling of both arms and chest after push-ups

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The Clinical Picture

Author(s)

Kiyoshi Shikino, MD, PhD

Yusuke Hirota, MD

Masatomi Ikusaka, MD, PhD

Author(s)

Kiyoshi Shikino, MD, PhD

Yusuke Hirota, MD

Masatomi Ikusaka, MD, PhD

Author and Disclosure Information

Kiyoshi Shikino, MD, PhD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Yusuke Hirota, MD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Masatomi Ikusaka, MD, PhD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Address: Kiyoshi Shikino, MD, PhD, Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba, 2608670 Japan; [email protected]

Author and Disclosure Information

Kiyoshi Shikino, MD, PhD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Yusuke Hirota, MD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Masatomi Ikusaka, MD, PhD
Department of General Medicine, Chiba University Hospital, Chiba, Japan

Address: Kiyoshi Shikino, MD, PhD, Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba, 2608670 Japan; [email protected]

Article PDF

shikino_rhabdomyolysis.pdf

Article PDF

shikino_rhabdomyolysis.pdf

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.

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.

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.

EXERCISE-INDUCED RHABDOMYOLYSIS

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

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.

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.

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.

EXERCISE-INDUCED RHABDOMYOLYSIS

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

References

Nance JR, Mammen AL. Diagnostic evaluation of rhabdomyolysis. Muscle Nerve 2015; 51:793–810.
Sayers SP, Clarkson PM. Exercise-induced rhabdomyolysis. Curr Sports Med Rep 2002; 1:59–60.
Have L, Drouet A. Isolated exercise-induced rhabdomyolysis of brachialis and brachioradialis muscles: an atypical clinical case. Ann Phys Rehabil Med 2011; 54:525–529.
Keah SH, Chng K. Exercise-induced rhabdomyolysis with acute renal failure after strenuous push-ups. Malays Fam Physician 2009; 4:37–39.
Nosaka K, Clarkson PM. Changes in indicators of inflammation after eccentric exercise of the elbow flexors. Med Sci Sports Exerc 1996; 28:953–961.
Peake J, Nosaka K, Suzuki K. Characterization of inflammatory responses to eccentric exercise in humans. Exerc Immunol Rev 2005; 11:64–85.
Lee G. Exercise-induced rhabdomyolysis. R I Med J (2013) 2014; 97:22–24.

References

Nance JR, Mammen AL. Diagnostic evaluation of rhabdomyolysis. Muscle Nerve 2015; 51:793–810.
Sayers SP, Clarkson PM. Exercise-induced rhabdomyolysis. Curr Sports Med Rep 2002; 1:59–60.
Have L, Drouet A. Isolated exercise-induced rhabdomyolysis of brachialis and brachioradialis muscles: an atypical clinical case. Ann Phys Rehabil Med 2011; 54:525–529.
Keah SH, Chng K. Exercise-induced rhabdomyolysis with acute renal failure after strenuous push-ups. Malays Fam Physician 2009; 4:37–39.
Nosaka K, Clarkson PM. Changes in indicators of inflammation after eccentric exercise of the elbow flexors. Med Sci Sports Exerc 1996; 28:953–961.
Peake J, Nosaka K, Suzuki K. Characterization of inflammatory responses to eccentric exercise in humans. Exerc Immunol Rev 2005; 11:64–85.
Lee G. Exercise-induced rhabdomyolysis. R I Med J (2013) 2014; 97:22–24.

Issue

Cleveland Clinic Journal of Medicine - 84(7)

Issue

Cleveland Clinic Journal of Medicine - 84(7)

Page Number

508-509

Page Number

508-509

Publications

Cleveland Clinic Journal of Medicine

Publications

Cleveland Clinic Journal of Medicine