Isolated Rhabdomyolysis of the Infraspinatus Muscle Following the CrossFit Sissy test

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T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Isolated Rhabdomyolysis of the Infraspinatus Muscle Following the CrossFit “Sissy Test” A Report of Two Cases Howard D. Routman, DO, Jacob J. Triplet, DO, Jennifer Kurowicki, MD, and Neil Singh, DO Investigation performed at Atlantis Orthopaedics, Palm Beach Gardens, Florida

Abstract Case: Following the completion of a CrossFit-style challenge (the “Sissy Test”), 2 patients presented with severe pain and swelling over the posterior aspect of the scapula. Magnetic resonance imaging demonstrated isolated edema of the infraspinatus muscle in both patients; the compartments were compressible. Neurovascular checks and observation of range of motion were performed. The patients were treated nonoperatively and were discharged with the diagnosis of overuse syndrome with rhabdomyolysis of the infraspinatus muscle. Conclusion: With marked increase in the popularity of extreme fitness, monitoring for rhabdomyolysis and potential renal dysfunction is essential.

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ostexercise rhabdomyolysis is becoming more frequent because extremely vigorous exercise programs are a growing trend in the United States1. Few reports of periscapular rhabdomyolysis or compartment syndrome have been published2-6. Understanding this condition and its deleterious effects, such as renal dysfunction, is critical to its management. To our knowledge there have been no previously published reports on overuse syndrome with rhabdomyolysis of the infraspinatus muscle. We present 2 cases of isolated infraspinatus rhabdomyolysis following exertional overuse after a CrossFit-style challenge known as the “Sissy Test.” This challenge involves up to 336 kettlebell swings and 336 squat-thrust push-ups (also known as “bastardo burpees”) in an allotted time frame of 30 minutes. Beginning with 15 kettlebell swings and 1 burpee, the workout challenge is repeated with a descending number of kettlebell swings and a corresponding ascending number of burpees. This is continuously repeated until the final set of 1 kettlebell swing and 15 burpees has been performed. The patients were informed that data concerning their cases would be submitted for publication, and they provided consent. Case Reports ASE 1. A 27-year-old healthy woman with a body mass index (BMI) of 22 kg/m2 presented with the chief symp-

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tom of right shoulder pain 2 days after performing the Sissy Test. She was a long-distance runner with no noteworthy medical or surgical history, and was not taking any medications. She reported completing nearly 75% (roughly 250 repetitions) of the workout challenge in the allotted time. She went to sleep the night of the challenge and awoke with severe pain over the posterior aspect of the right scapula, which she described as sharp and throbbing in nature. She reported difficulty utilizing the right upper extremity, particularly during overhead activities. She attempted self-management with nonsteroidal anti-inflammatory drugs (NSAIDs), but the pain persisted. The next day, she was evaluated by a chiropractor, who ordered magnetic resonance imaging (MRI) and referred her for orthopaedic evaluation. On examination, no neurologic symptoms were present. The patient reported some improvement in the symptoms and noted a small palpable lump over the right scapula. Palpable tenderness over the belly of the infraspinatus muscle with moderate swelling and warmth in the area, without erythema, was noted during the examination. The compartments were compressible. The active range of motion for forward flexion, abduction, and external rotation was 170°, 170°, and 80°, respectively. Internal rotation was to the level of the sacrum and limited by pain. Strength was 5 of 5 in all planes, with pain during resisted external rotation. MRI (without contrast) of the

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSCC/A645).

JBJS Case Connect 2018;8:e2

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http://dx.doi.org/10.2106/JBJS.CC.17.00020

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Fig. 1

T-2 weighted MRI without contrast demonstrated marked edema in the infraspinatus fossa approximately 15 hours after performing the Sissy Test (Case 1).

right shoulder revealed marked edema within the muscle of the infraspinatus (Fig. 1). She was treated for exertional myositis with observation, and she experienced spontaneous improvement. CASE 2. A healthy 26-year-old woman with a BMI of 34 kg/m2 presented to the emergency department with the symptom of bilateral shoulder pain after performing the

I S O L AT E D R H A B D O M YO LY S I S O F T H E I N F R A S P I N AT U S M U S C L E FO L LOW IN G T H E CRO S S FI T “ SI S S Y TE S T ”

Sissy Test 1 day prior. She reported completing approximately 50% (roughly 170 repetitions) of the workout challenge in the allotted time. Two hours after the challenge, she began to experience progressively worse pain over the posterior aspect of both shoulders, with more severe pain in the right shoulder than in the left shoulder. She reported that she was unable to lift the right arm secondary to pain. She attempted self-management with ibuprofen, hydration, topical anti-inflammatories, and a heating pad without resolution; the symptoms continued to worsen. Laboratory tests were noteworthy for an elevated creatine kinase (CK) level of 20,144 U/L; a diagnosis of rhabdomyolysis was made. She was admitted to the hospital and placed on an intravenous (IV) hydration protocol; the orthopaedics department was consulted. On orthopaedic examination, the patient had a substantial amount of swelling about the posterior aspect of the scapula, with tenderness to palpation over the infraspinatus muscle. No paresthesias were noted; the compartments about the shoulder were swollen and tender but compressible. She was unable to actively elevate the arm against gravity, secondary to pain. No pain on passive external rotation of the shoulder was noted; pain on passive internal rotation was present but was not severe. Isometric external rotation strength was 4 of 5 with pain. IV pain medication did not alleviate the pain, but a single dose of IV dexamethasone was more helpful than narcotics. Close neurovascular checks and observation of range of motion were performed every hour. MRI without contrast was performed within the first few hours of admission; it confirmed severe edema in the infraspinatus muscle (Fig. 2). The clinical examination continued to improve, with a decrease in the swelling and eventual control of the pain. Based on the steadily improving clinical examination, it was determined that compartment-pressure measurements in preparation for a fasciotomy were not warranted. The patient was hospitalized for a total of 6 days for evaluation of renal function; she was discharged with resolution of the rhabdomyolysis and the shoulder pain. At the 15-month follow-up, the patient reported no pain at rest or with normal activities, and pain rated 3 of 10 with strenuous activities. Excellent patient-reported outcomes were noted with the American Shoulder and Elbow Surgeons (ASES) score, the Subjective Assessment of Normal, and the Penn Shoulder Score at 91.6, 95, and 87, respectively. Discussion he kinesiology of the activities utilized during the Sissy Test plays a critical role in the development of increasing infraspinatus compartmental pressure. Push-ups represent a closed kinetic chain exercise that strengthens the shoulder and truncal musculature 7,8 . In a study utilizing electromyography (EMG) to determine muscle activity during push-ups, Kim et al. showed that the infraspinatus muscle had among the highest activity during narrow-based

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Fig. 2

T-2 weighted MRI without contrast demonstrated isolated infraspinatus myositis with extension of the exuded fluid into the subacromial and subdeltoid spaces (Case 2).

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push-ups 7 . To our knowledge, no studies have looked at the kinematic effects of kettlebell swings; however, the shoulder is often advocated as a utilized muscle group. It stands to reason that constant periscapular musculature activation from kettlebell swings, in addition to the pushups that are part of the burpees, may lead to increasing pressure in the infraspinatus compartment. We believe that it is important to be aware of the potential association between this high-intensity training and the development of rhabdomyolysis. This especially may be true in patients who are recreational athletes. Rhabdomyolysis is a syndrome characterized by the release of intracellular muscle constituents into the circulation following muscle necrosis. It often requires IV hydration, pain control, and close renal monitoring. Patients may present with swelling and tenderness of the posterior periscapular muscles below the scapular spine. Pain with passive internal rotation was evident, but more severe in the patient described in Case 1; however, the compartments were compressible and soft in both cases. MRI and serum levels of CK and lactate dehydrogenase help to reaffirm clinical findings. Measuring intracompartmental pressure may be useful in unconscious or obtunded patients, and may help to distinguish between rhabdomyolysis and compartment syndrome 9 ; a pressure measurement within 30 mm Hg of the diastolic blood pressure 10 is a better diagnostic criterion than absolute pressure alone 2 . To our knowledge, the only previously reported literature pertaining to exercise-related compartment syndrome isolated to the infraspinatus was in canines 11 ; surgical decompression was used. With vigorous exercise, the intensity of the exercise and the previous physical status are important. A certain degree of rhabdomyolysis normally takes place after strenuous activities, but is usually well tolerated5. Both of our patients reported pain of the involved periscapular muscles within 24 hours of the vigorous activity. Graves et al. reported 2 cases of rhabdomyolysis of the supraspinatus muscle following severe overuse5. MRI demonstrated high-intensity signal with swelling, and the CK levels were elevated. Because of the delay in presentation (24 to 36 hours) and the lack of tenseness of the compartment, intracompartmental pressure measurements and fasciotomies were not performed. Treatment consisted of rest, ice, pain medication, and physical therapy. A full recovery was made. The authors concluded that nonsurgical treatment might adequately treat severe overuse injuries of the supraspinatus muscle that result in rhabdomyolysis and not compartment syndrome. It is argued that some of the previously published literature regarding compartment syndrome of the scapula may be better described as “overuse syndrome with rhabdomyolysis” since tenseness and swelling were not noted on physical examination, and the related sequelae of compartment syndrome were not noted after nonoperative treatment2,5.

I S O L AT E D R H A B D O M YO LY S I S O F T H E I N F R A S P I N AT U S M U S C L E FO L LOW IN G T H E CRO S S FI T “ SI S S Y TE S T ”

Our findings are consistent with those of Graves et al.5. Both of our patients lacked tenseness of the involved compartment; this, in addition to the delay of presentation, justified not performing intracompartmental pressure measurements or fasciotomies. We feel that these 2 cases represent overuse syndrome with rhabdomyolysis of the infraspinatus muscle; we are not aware of any previous publications describing this problem. Consistent with the recommendation of Graves et al.5, nonoperative management adequately treated the severe overuse injuries of the infraspinatus muscle. It is important to discern between this and compartment syndrome because their treatment is drastically different. We acknowledge that there are limitations to our report. The patient described in Case 1 presented in a delayed fashion with improving symptoms. We did not obtain CK levels for this patient because of the improving symptoms and the findings of the clinical examination. Retrospectively, we should have obtained CK levels in this patient. Although the mechanism of injury, the symptoms, the clinical examination, and the MRI findings all supported the diagnosis of overuse rhabdomyolysis, CK levels would have further confirmed the diagnosis and provided information regarding the severity of muscle injury. We encourage obtaining CK levels in patients with suspected overuse rhabdomyolysis. Additionally, this patient was lost to follow-up, and we were not able to assess longer-term functional outcomes. With the increasing popularity of extreme and plyometric fitness programs that are focused on upper-body weight-bearing exercises, providers should become familiar with the unusual diagnosis of isolated rhabdomyolysis. Monitoring for rhabdomyolysis and potential renal dysfunction is essential. n

Howard D. Routman, DO1 Jacob J. Triplet, DO2 Jennifer Kurowicki, MD3 Neil Singh, DO4 1Atlantis

Orthopaedics, Palm Beach Gardens, Florida

2Department

of Orthopedic Surgery, OhioHealth Doctors Hospital, Columbus, Ohio

3Department

of Orthopaedic Surgery, Seton Hall University, South Orange, New Jersey

4St.

Anthony Hospital, Oklahoma City, Oklahoma

E-mail address for H.D. Routman: hdr@floridashoulder.com E-mail address for J.J. Triplet: [email protected] E-mail address for J. Kurowicki: [email protected] E-mail address for N. Singh: [email protected] ORCID iD for J. Kurowicki: 0000-0002-1966-2157

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I S O L AT E D R H A B D O M YO LY S I S O F T H E I N F R A S P I N AT U S M U S C L E FO L LOW IN G T H E CRO S S FI T “ SI S S Y TE S T ”

References 1. Fisher J, Sales A, Carlson L, Steele J. A comparison of the motivational factors between CrossFit participants and other resistance exercise modalities: a pilot study. J Sports Med Phys Fitness. 2017 Sep;57(9):1227-34. Epub 2016 May 11. 2. Kenny RM, Beiser CW, Patel A. Supraspinatus and infraspinatus compartment syndrome following scapular fracture. Int J Shoulder Surg. 2013 Jan;7 (1):28-31. 3. Takakuwa T, Takeda M, Tada H, Katsuki M, Nakamura S, Matsuno T. Acute compartment syndrome of the supraspinatus: a case report. J Shoulder Elbow Surg. 2000 Mar-Apr;9(2):152-6. 4. Stahlfeld KR, Parker JE, McClain EJ 3rd. Supraspinatus compartment syndrome. Am J Orthop (Belle Mead NJ). 2004 Dec;33(12):615-7. 5. Graves RM, Machen MS, Zubak JJ, Warme WJ. Rhabdomyolysis attributable to severe overuse of the supraspinatus muscle: a report of two cases. Mil Med. 2007 Dec;172(12):1306-9.

6. Landi A, Schoenhuber R, Funicello R, Rasio G, Esposito M. Compartment syndrome of the scapula. Definition on clinical, neurophysiological and magnetic resonance data. Ann Chir Main Memb Super. 1992;11(5):383-8. 7. Kim YS, Kim DY, Ha MS. Effect of the push-up exercise at different palmar width on muscle activities. J Phys Ther Sci. 2016 Jan;28(2):446-9. Epub 2016 Feb 29. 8. Lehman GJ, Gilas D, Patel U. An unstable support surface does not increase scapulothoracic stabilizing muscle activity during push up and push up plus exercises. Man Ther. 2008 Dec;13(6):500-6. Epub 2007 Jul 20. 9. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000 Mar;82(2):200-3. 10. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975 Nov-Dec;113:43-51. 11. Devor M, Sørby R. Fibrotic contracture of the canine infraspinatus muscle: pathophysiology and prevention by early surgical intervention. Vet Comp Orthop Traumatol. 2006;19(2):117-21.