Occasionally, bodybuilders develop intramuscular abscesses, septic and sterile, as a result of deep intramuscular (IM) shots. [1,2] The main difference between them is that the former develops the clinical symptoms of inflammation and deals with infection, while the later deals with hard lumps of oily solutions. In the long term, they get calcified and turn into scar tissue.
Septic abscess is a result of contaminated injectable steroid solutions or non-sterile
injection techniques (needle sharing, reusing needles and syringes). Common areas include the buttocks (gluteus maximus), shoulders (deltoid), chest (pectoralis), calves (gastrognemius).
Oily androgenic anabolic steroids (AAS) solutions usually aren’t contaminated, since the oily solution is a hostile environment for bacterial growth. On the contrary, water based suspension solutions, such as stanozolol, testosterone and recently trenbolone base are among the riskier injectables. Bacteria are likely to get cultivated in such solutions and as a result, inflammation occurs. Thigh abscesses, pectoral and deltoid abscess have been reported in bodybuilders using ‘spot shots’ or ‘site locations’, which are local injections into a specific muscle, believed to increase isolated muscle growth. Gluteal abscesses have also occurred in contaminated products. Administration of large volumes of testosterone esters in one injection (up to 5 mL) is common, exposing an individual to sterile abscess formation, where a pathogenic organism cannot be found. [1,2]
Clinical presentation, laboratory findings and Diagnosis
Reported infections associated with AAS injection include abscesses attributable to Staphylococcus, Streptococcus, Pseudomonas and atypical Mycobacteria. [3-6] The basic sings of inflammation process include: 1) local swelling-edema, 2) erythema, 3) elevated temperature/ pyrexia and 4) pain. All of these symptoms take place due to the increased blood flow, since macrophages and neutrophils are among the white blood cells responsible for phagocytosis of microorganisms. An abscess is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.[4-6]
Besides clinical and laboratory findings [leukocytosis with increased neutrophils, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)], a useful laboratory examination that reveals the existence of intramuscular abscess, is the Magnetic Resonance Image (MRI), ideal for the soft tissues (muscles, joints, ligaments, tendons) . 
Treatment and Prevention of Intramuscular Abscess
Abscesses should not be squeezed by the person concerned. If the abscess burst under the skin and the bacteria spread through the blood circulation into the body, it can result in a life-threatening blood infection such as sepsis. Sepsis symptoms include general malaise, fever, chills, nausea, vomiting, diarrhea, tachypnea, and confusion. Sepsis always requires hospitalization. 
Initially the steroid user should avoid injecting into the inflamed area, while rotating the injection spots. Quitting from injections at least for one week, will give some time for the immune system to suppress the intramuscular inflammation. The use of nonsteroidal anti-inflammatory drugs-NSAIDs (sodium diclophenac, nimesulide) could provide some aid in first place and fight discomfort. Furthermore, hypertonic solution based on aluminum, provides pain relief when applied locally with a wet towel for about 10 minutes 4 times daily. A pharmaceutical medication that has a significant role in order to prevent further edema is the rerapeptase drug. This drug is widely used in several cases that include septic, or non septic inflammation, where excessive swelling is present. Finally, the danaparoid sodium cream is a helpful material, able to suppress edema, thus providing a relief feeling. However, sometimes inflammation process is more severe and complicated and pus develops in the intramuscular abscess. Pus contains dead white blood cells, trying to control the inflammation. In the beginning, an intramuscular infection is reddish and sort of hard in touch. Later, as the inflammation proceeds and pus is gathered, it becomes softer. Usually surgeons find this a warning sign, where surgical incision and drainage is obligatory. The surgeon cuts the skin and fat beneath with a scalpel, entering the inflamed muscle. This will give the opportunity for the drug (oily) solution and pus to leave the contaminated area, which has to be excessively cleaned afterwards. As soon as the pus has drained, the surgeon will insert some packing into the remaining cavity to minimize any bleeding and keep it open for 24–48 hours. As the scar heals, the patient can expect to be out of the gym for weeks. If it is a deeper abscess, the surgeon may insert a drainage tube. Drainage is maintained for several days to help prevent the abscess from reforming.
Microbiological culture of biologic samples from the wound is performed by the biopathologist and according to the antibiogram; a proper medication shall be prescribed. In most cases, the physician supplies a combination of different antibiotics, including treatment of aerobic and anaerobic bacteria. In those cases an anti-staphylococcus antibiotic (flucloxacillin, dicloxacillin) or amoxicillin- clavulanic acid is given. Alternative antibiotics effective against community-acquired methicillin-resistant Staphylococcus aureus (MRSA) often include clindamycin, doxycycline, minocycline, and trimethoprim-sulfamethoxazole, while combination therapy with antipseudomonal antibiotics (imipenem, meropenem, aztreonam) is used to ensure treatment of resistant strains. [5,7,8] Of course, we should not neglect the possible side effects of antibiotics, especially to the gastrointestinal system (diarrhea). The diarrhea occurs due to eradication of the normal gut flora by the antibiotic and results in an overgrowth of infectious bacteria. Therefore, the patient has to follow a diet rich in lactobacillus, found in organic yogurt, or kefir. In case there is a lactose intolerance, lactobacillus is also available in pharmaceutical made capsules. Another side effect symptom involves inflammation of gingiva, giving an itching feeling in the oral cavity. Supplementation of B complex vitamins is quite helpful. Intramuscular abscess after it is surgically opened has to be cleaned up twice on a daily basis, as long as the patient follows an antibiotic medication. White blood cells (WBCs) count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory evaluations that should be considered on a weekly basis. This follow up will provide details concerning the progress of inflammation. Fever is also a good sign of inflammatory response. Creatinokinase enzyme (CPK) is a biochemical marker that is also elevated, as a result of the repeated intramuscular injections; named as rhabdomyolysis effect. Lactate dehydrogenase (LDH) is another biochemical evaluation, raised in tissue inflammation and cellular damage. When the abscess heals, scar tissue will form, therefore, no more injections in that area.
Sometimes, when the abscess is localized into the gluteal area, the athlete is unable to perform a hip flexion. This particular movement happens during the negative-eccentric phase of the leg press for example, or the squat. The reason is because of the extensive intramuscular abscess that forces press against the sciatic nerve. The hip flexion stretches the sciatic nerve, giving a painful sensation. As well know from human anatomy, the particular nerve is the largest in the peripheral nervous system. When sciatic nerve undergoes irritation, pain reflects on the head of the fibula; the bone located on the outer area of tibia. As the sciatic nerve proceeds down to the posterior femoral region, it splits into the posterior tibial nerve and the peroneal nerve.
Rarely, poor septic conditions (needle sharing, reusing needles and syringes) are responsible for the entrance of microbes into the muscle. Pure ethanol 95% must be used for sterilization of epidermis, both before and after the shoots. Of course we have to change the needles and better to use another syringe, in case we shoot on different areas on the same day. Subcutaneous injections are rarely to develop any kind of infection, since the adipose tissue has lesser amount of vessels and contamination spreads slower. Peptides are usually injected into the fat, as somatropin (human growth hormone- hGH), insulin and human chorionic gonadotropin. [1,3,4]
Personally, I have once experienced a localized inflammation, dealing with a subcutaneous injection of hGH. It was something inevitable, since I had not followed strictly the sterilization circumstances and wrongly used the same needle twice. According to my personal experience, as a former steroid abuser during my bodybuilding competitive career, I faced two intramuscular abscesses, that both had to be surgically opened, while I was following an effective combination of antibiotics. For the first time, I decided to switch from the pharmaceutical brand (Winstrol Depot-Desma) of stanozolol, manufactured in Spain. Instead, I wrongly chose to use an underground product of Biogen Labs. After a couple of weeks, both my deltoid and gluteus were infected, giving a feeling of discomfort and nausea. At first, I tried to self-care at home, by applying the initial steps of abscess treatment; but there was no progress. I was lucky that it was during my residency practice at the hospital, so I was treated successfully by my colleagues. General surgeon’s cooperation, along with biopathologists, helped me to heal within four weeks. I fondly remember during the surgical procedure, the smell of burning flesh, as doctors were trying to stop the excessive bleeding. As I was told later, the steroid abuse costed me in terms of blood coagulation, so my bleeding time was prolonged (INR>1.3). In such cases, vitamin K and plasma factors are administrated IV. Two years later, during my final competition at the ?asters ?ationals, there was a visible scar on my buttocks, although I was pretty well tanned and colored by spray.
Medical Data & References:
- Anabolic steroid related abscess-A risk worth taking?P. Marquis, N. Maffulli
Injury Extra 2006; 37(12):451–454
- Current Concepts in Anabolic-Androgenic Steroids. Nick A. Evans. J. Sports Med.2004; 32; 534
- Counterfeiting in performance- and image-enhancing drugs.
Graham MR, Ryan P, Baker JS, Davies B, Thomas NE, Cooper SM, Evans P,
Easmon S, Walker CJ, Cowan D, Kicman AT. Drug Test Anal. 2009; 1 (3):135-42.
- The infectious complications of anabolic-androgenic steroid injection.
Rich JD, Dickinson BP, Feller A, Pugatch D, Mylonakis E. Int J Sports Med. 1999; 20(8):563-6.
- Abscess related to anabolic-androgenic steroid injection.Rich JD, Dickinson BP, Flanigan TP, Valone SE. Med Sci Sports Exerc. 1999 Feb; 31(2):207-9.
- Mycobacterium fortuitumskin infection as a complication of anabolic steroids: a rare case report. R Pai, U Parampalli, G Hettiarachchi, and I Ahmed. Ann R Coll Surg Engl. 2013 ; 95(1): e12–e13.
- Rhabdomyolysis of the Deltoid Muscle in a Bodybuilder Using Anabolic-Androgenic Steroids: A Case ReportUri Farkash, Nogah Shabshinand Moshe Pritsch (Perry)J Athl Train. 2009; 44(1): 98–100.
- Pyomyositis due to anabolic steroid injection. Shiber JR. J Emerg Med.2013;44(1):e69-70.