Muscle injury from mild untreated DCS?

[crispix]

I'm posting a new thread although I have a previous related post.

The first question for Dr. Deco: what do you think?

Background: did a single dive 2 weeks ago. Max depth 31 fsw, average depth 28', bottom time 47 min. 3 min safety stop at 15', computer shows nothing out of the ordinary. Was also using EAN 28.

Symptoms/treatment: Felt great after the dive. About 3 hours post dive, after packing up everything, my left arm hurt, like I hit my funny bone. Over the next several hours it got worse and started to feel like a burning tendonitis. The next morning it felt much better but started to get worse as the day progressed.

I called DAN, though much later. Because of the conservative dive, the fact that more than 24 hours had passed, the complete lack of other symptoms, and that I felt better with rest, hurt with movement, the DAN medic said not to worry and treat it like tendonitis. I was scheduled to fly in a few days and he said ok.

The day of my flight, with my left hand and arm still hurting, 7 days post dive, my right arm started to hurt with the exact same symptoms. (this started before the flight after dragging suitcases through the airport).

Now, almost 2 weeks post dive, both arms are still sore and burning. It always feels better in he morning and gets worse as the day progresses.

Went to see a sports medicine doc yesterday. He said that I almost definitely injured the muscles with microbubbles. He said muscles are prone to this type of damage, especially if one is dehydrated during the dive. He said he's not surprised DAN did not diagnose DCS since the symptoms were not typical.

He also said it will heal on its own, no need for a chamber, and no permanent damage done. I'm leaving out some details about the prescribed treatment, this post is long enough already.

Second question for Dr. Deco: could DCS make my right arm start to hurt a week after the dive? I asked my doctor and he said: "well, I don't have an explanation for that."

In hindsight, I was perhaps under-hydrated for the dive, but given the conservative dive profile, I'm surprised at the diagnosis.

Moral of the story: drink 'til you pee in the wetsuit.

 

[DocVikingo]

Hi crispix,

Before responding in detail, a few questions:

1. Have you any prior history of injury to the arms, most particularly the elbows or wrists?
2. Have you any prior history of tendonitis, arthritis, disorders of muscle or similar conditions?
3. Are you taking any medications? Have you recently taken any antibiotics?
4. Are you generally physically fit?
5. Have you ever sustained DCI?

Regards,

DocVikingo

 

[Rick Murchison]

He said that I almost definitely injured the muscles with microbubbles.

I seriously, seriously doubt it.
My bet is you pulled a few strands honking the gear/tanks around.
Rick

 

[crispix]

Hi crispix,

Before responding in detail, a few questions:

1. Have you any prior history of injury to the arms, most particularly the elbows or wrists?
2. Have you any prior history of tendonitis, arthritis, disorders of muscle or similar conditions?
3. Are you taking any medications? Have you recently taken any antibiotics?
4. Are you generally physically fit?
5. Have you ever sustained DCI?

Regards,

DocVikingo

1. No.
2. Short answer: no, nothing ever like this before. Long answer: Sometimes I get a mild tendonitis in a hand or foot that resolves in a day or two. (One foot tends to get a mild tendonitis after flying, I assume from tight shoes.)
3. I take Naproxen occasionally. No recent antibiotics.
4. Yes, I am fit and in very good health, just had a physical and passed with flying colors. (age 33)
5. No.

Additional info: doc put me on baclofen, 10mg at night for 5 nights. It's a trip, but after two nights my arms are burning much less and I can tell I'm healing up. Also did a myoglobin blood test that I assume came back negative since I did not hear from the lab.

Thanks!

 

[DocVikingo]

Hi crispix,

Thanks for the additional info.

Important points in sorting out the cause of such discomfort include:

1. Reported is a single dive on EAN28 to a max depth 31 fsw/average depth 28 fsw with a bottom time of 47 min, followed by a 3 min safety stop at 15'. The dive computer showed nothing out of the ordinary.

This is a very benign dive profile. It is almost inconceivable that inert gas loading could have reached a level or been released in a manner that could put a diver at risk for DCS.

2. The first symptom did not appear until about 3 hours following the dive, after packing away gear.

This is not only a somewhat delayed onset for DCS, but the sensations of soreness and burning in the left arm area appeared after physical activity which could account for it.

3. About a week later, the right arm developed the same sensations after dragging suitcases through the airport.

Given onset a week after the dive described, it is virtually impossible to ascribe the symptoms to DCS or any other gas bubble-related phenomenon. Also, there again is reported physical activity which could account for it.

4. Almost 2 weeks post dive, both arms are still sore and burning. It always feels better in the morning and gets worse as the day progresses/better with rest, hurts with movement.

While DCS-related joint pain could present as described, it is not typical for it to be described as sore and burning. More commonly it is described a dull ache.

It is not the typical pattern for DCS-related joint pain to increase as the day progresses. More commonly it is steady across the day with gradual improvement over time

5. DAN was contacted and responded that because of the conservative dive, the fact that more than 24 hours had passed, the complete lack of other symptoms, and that it felt better with rest, hurt with movement, you should not worry and to treat it like tendonitis.

DAN Medical Services' personnel don't always get it right, but most often they do and their take on the likelihood of symptoms being DCS-related or not shouldn't be casually dismissed.

It also is noted that in a posting of 09-06-06 you reported, "I had a physician (family member) check it out, who examined my fingers and hand and promptly diagnosed tendonitis. (Signs: feels better with rest, hurts more with movement, pressing up with the fingers hurts.)" Thus, it seems that both DAN and an examining physician believe the clinical picture is consistent with tendonitis, which generally is considered a malady of connective tissue, not muscle.

In summary, I, too, am surprised at the diagnosis given by the sports medicine doctor.

Hopefully Dr Deco will be able to formulate a more concise and definitive response. I'd be especially interested in his comments regarding the assertion that muscles are prone to damage from scuba-related microbubbles.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

Regards,

DocVikingo

 

[crispix]

Hopefully Dr Deco will be able to formulate a more concise and definitive response. I'd be especially interested in his comments regarding the assertion that muscles are prone to damage from scuba-related microbubbles.

Thanks very much for the comments. I did a google on "muscle bends" and couldn't find much.

 

[DocVikingo]

Hi Crispix,

F'sure.

I've emailed Dr Deco and requested his input.

Regards,

DocVikingo

 

[MB]

Gentlemen - This is interesting and very informative. I aso recognize that its very personal, so let me thank you for sharing this info in such a no nonsense way.

 

[Saturation]

Concur fully with DocVikingo. The issue can be many things, but persistent injury from muscle microbubbles is not one of them. It has never been described, and occam's razor suggests common and known diseases are likely first before the new. If you are in SD there is no better doctor there than the one who put the issue of muscle injury in relation to diving: Tom Neuman, M.D., at the USCD ER. He is the current editor of Bennett & Elliott's diving text and sees quite a number of diving injuries. As background, its surmised in severe DCS, bubble emboli do cause some injury to muscles than can be found as chemical in the blood, or as severe as rhabdomyolysis. The disease is self limited once the bubbles are resolved, and can be tracked as a resolution of these abnormal chemicals in the blood.

In summary, I, too, am surprised at the diagnosis given by the sports medicine doctor.

Hopefully Dr Deco will be able to formulate a more concise and definitive response. I'd be especially interested in his comments regarding the assertion that muscles are prone to damage from scuba-related microbubbles.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

Regards,

DocVikingo

 

[DocVikingo]

Good info, Saturation.

So if I have it right, microbubble-related injury to muscle is conjectured occur, but only in severe DCS.

Moreover, the damage is self-limited once bubbles resolve and the condition is tracked via the presence of such proteins as myoglobin.

Thanks,

Doc