American Journal of Physical Medicine & Rehabilitation:
From the Department of Physical Medicine and Rehabilitation, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
All correspondence and requests for reprints should be addressed to: Myron M. LaBan, MD, Department of Physical Medicine and Rehabilitation, Oakland University William Beaumont School of Medicine, 3601 W Thirteen Mile Road, Royal Oak, MI 48073.
As a problem in search of a solution, an enigma invites thoughtful consideration and comment. The authors present a singular clinical case and one other, which seems to be comparable, after a literature search of the last 20 yrs.
Case 1: A 50-yr-old otherwise healthy woman presented to the hospital's emergency center with an acute onset of elbow pain and diffuse forearm swelling, which occurred 20 mins after a vigorous session of resistive arm exercise using free weights, forearm curls, and "chin-ups." Twenty-four hours later, she developed marked swelling of the forearm with nonreferred pain at the lateral epicondyle. A negative venous Doppler was obtained in the emergency center for a subclavian vein thrombosis. A magnetic resonance image of the forearm was subsequently obtained (Fig. 1).
Case 2, as found online: A man reported that shortly after using free weights, that is, 6-kg dumbbells and a weight machine, "my left forearm became swollen from the elbow to the wrist." There was no pain, no discoloration or change in sensation. He further noted that "The swelling is definitely not muscle, as it moves slightly and leaves a definite indentation when pressed down."1
Initially, the two cases seem similar with respect to presentation, that is, postexercise forearm edema. However, they differed significantly: the lack of pain in the second case. Multiple diagnoses were initially considered. The most likely, subclavian vein occlusion, had been excluded. There was no clinical evidence of thoracic outlet syndrome. We failed to note sensory or motor evidence of peripheral nerve compromise to suggest a "compartment syndrome." The patient did have limited shoulder internal range of motion with elbow pain at the lateral epicondyle, suggesting a tear at the origin of the extensor expansion with a forearm bleed.2 However, a forearm magnetic resonance imaging revealed only a "strain" of the extensor expansion with nonhemorrhagic edema in the subcutaneous tissue. With a rapid recovery, we had limited opportunity for further diagnostic evaluation. A recent report from Iowa of 12 football players who developed systemic rhabdomyolysis after a strenuous workout3 has prompted us to consider a localized variant of this phenomenon as a likely diagnosis. Vigorous exercise, even limited to a single limb, can provoke significant muscle injury, that is, as evidenced by baseball pitchers with elevated creatinine kinase levels after their rotation.4 After a release of muscle protein into the subcutaneous tissue, osmotic gradient differences can draw edema fluid from the circulatory system into the interstitial space. Other suggestions as to etiology are welcomed!
2. LaBan MM, Iyer R, Tamler MS: Occult periarthrosis of the shoulder: a possible progenitor of "tennis elbow." A brief report. Am J Phys Med Rehabil
4. Wang C-C, Tsai C-Y, Lin H-W, et al: Skeletal damage after pitching real games in collegiate baseball pitches. Int J Sports Exerc Sci