Use of Oxandrolone as Adjunctive Therapy in Right Ischiotibial Injury

Androgen hormones serve a variety of roles, including determining and maintaining sexual traits. The effects of Anabolic Androgen Steroids (AAS) like oxandrolone on body composition and muscle mass development are intriguing. We provide a case of a 38-year-old woman who was treated with oxandrolone for multiple fractures and a current right ischiotibial injury, indicating that androgen steroid medication may aid in the recovery of bone and tendon-muscle health in injuries. The improvement in pain was significantly relevant, allowing the patient to return to her normal activities.

Androgens, as well as natural and synthetic substances derived from them and their derivatives, such as anabolic androgen steroids, play important roles in the body. Testosterone is involved in the development of the male phenotypic, intrauterine sexual differentiation, puberty, and adulthood [1]. The Androgen Receptor (AR), which is found on the X chromosome, binds to reproductive and non-reproductive tissues. Like the anabolic androgen steroids, testosterone crosses the cell membrane and locates the AR in the cytosol. Testosterone is transformed to Dihydrotestosterone (DHT) by 5 alpha reductase, and the AR complex is transported to the nucleus and binds to DNA, causing protein synthesis to be stimulated by transcription processes involving mRNA [2].

Anabolic androgen steroids, such as oxandrolone, will have actions related to nuclear protein stimulation, making them effective in the therapy of sarcopenia and skeletal muscle stimulation [3]. By increasing protein synthesis and optimizing amino acid use, the direct anabolic function promotes muscle repair [2]. The indirect anabolism produces antagonism of the glucocorticoid receptor, which is structurally identical to AR, resulting in a competitive inhibition that prevents catabolism [2]. AAS increase the number of androgen receptors, providing more connections, increasing the effects of the hormones. They also induce Insulin-like Growth Factor type 1 (IGF-1) in the liver, further stimulating protein synthesis [2]. Muscle protein synthesis is a naturally occurring process in which protein is produced to repair muscle damage caused by injury.

Weight gain following surgery, severe trauma, or chronic infections are all examples of therapeutic uses for oxandrolone, according to the FDA (Food and Drug Administration). Oxandrolone is also prescribed for patients who are unable to develop or maintain a healthy weight due to unidentified medical conditions. The hormone is also used to relieve bone discomfort in persons with osteoporosis and to prevent muscle atrophy induced by steroid medications.

A 38-year-old female patient, who engages in regular physical activities, experienced sudden, stabbing, and incapacitating pain in the posterior region of her right thigh on January 20, 2019. The pain began during her running workout at Ibirapuera Park in the Brazilian city of São Paulo, prompting her to halt and seek medical attention. She has a personal history of several injuries that have been carefully addressed (osteochondral lesion in the right medial talar domus in 2016 and stress fracture in the right fibula in 2018).

The patient complained of pain while standing and sitting during the static inspection. She also complained of pain when walking during the dynamic inspection. Although there was no edema or erythema in the ischial tuberosity region, it was uncomfortable to palpate.

Ischial fracture, ischiotibial bursitis, and piriformis syndrome were among the possibilities.

The Straight Leg Raising test was positive, the lumbosacral spine was also evaluated with the Schöber test, showing normal and preserved lumbar spine flexibility. Pain was noted on passive hip flexion accompanied with active knee flexion in counter-resistance during functional ability assessments. A magnetic resonance imaging scan of the right hip revealed tendinopathy and peritendinitis of the hamstring roots, but no rupture.

We used the psychological measure Multidimensional Pain Evaluation Scale to measure symptoms and perception of pain exacerbation. The patient reported a numerical pain intensity scale from 0 to 10, with pain ranging from 7-8 throughout treatment of the muscle injury with all treatments suggested in the guidelines-analgesics, anti-inflammatory drugs, corticosteroids, and physical therapy.

The first treatment option was the use of anti-inflammatory drugs such as diclofenac sodium 100 mg once daily for 5 days in combination with dipirone 1 g 12/12 hours for 5 days. The second drug treatment option was 3 weeks after the first treatment and also due to refractory pain. 1 ampoule of betamethasone was prescribed, with improvement in the first 5 days; physiotherapy produced slight progress in range of motion, but there was no evolution in loads. The third drug treatment occurred 4 weeks after the administration of betamethasone and was performed with acetaminophen 500 mg + codeine 30 mg, because the condition recurred with greater pain intensity, which was evaluated using the Pain Sensation Scale with a score of 8-9 on the pain scale. pain from 1 to 10.

After numerous trials with unstable pain conditions, treatment with the drug oxandrolone was suggested as an aid in the treatment and stabilization of the painful condition because it potentiates the synthesis of muscle proteins and allows effective tissue repair. After 60 days of oxandrolone use, the pain scale rating improved significantly, resulting in improvement of the condition.

The patient was given the option of utilizing oxandrolone due to a paucity of therapeutic options. Oxandrolone was recommended at a dosage of 5 mg twice a day, with the goal of restoring bone and tendon health. When we changed the strategy and used a drug designed to optimize protein synthesis and improve tissue repair, the patient responded extremely positively, configuring a significant reduction in painful symptoms and an improvement in muscle recovery. Biceps femoris muscle amplitude and limitations resulting from pain were factors limiting the progress of treatment, as the patient had a constant recurrence of muscle injury.

Throughout the treatment, physiotherapy took place, focusing on eccentric strengthening of the hamstrings and ASTYM, as hamstring muscle injuries are associated with a long treatment period. After 4 months of treatment, she was able to return the sports activities with no pain to report. Creatine Phosphokinase (CPK) was assessed before and after treatment, ranging from 537 U/L before treatment to 95 U/L after treatment and the Lactate Dehydrogenase (LDH) varying between 345 UI/L to 201 UI/L.

Accidents, improper warm-up, poor technique, and overexertion are all causes of sports injuries. Muscles, bones, tendons, joints, and connective tissues can all be injured, but ankles and knees are particularly vulnerable [4].

A modest sports injury is often treated by resting the injured body part for the first 72 hours. Pain relievers like ibuprofen or paracetamol can assist to alleviate the discomfort produced by the injury. Medical practitioners may recommend an individual to specialised care, such as physiotherapy, for more serious ailments. Some major injuries may necessitate surgical intervention, such as the repair of fractured bones and torn ligaments.

In healthcare settings, anabolic steroid use can be used to treat a variety of ailments, diseases, and health issues. Unfortunately, because some institutional review boards are hesitant to approve anabolic steroid use in a non-clinical population, research on the effects of steroid use in injury is limited. However, anabolic steroids as treatments for contusion and strain injuries have been investigated for a long time in animal models. One of these studies used rat models with reproducible muscle contusion injuries. There were control, an anabolic steroid, and corticosteroid groups.

The authors concluded that corticosteroids were beneficial in the short term effects, but detrimental in the long term repair, and that anabolic steroids could improve muscle repair and aid in the healing of muscle contusion injuries [5].

More research and reviews have emphasized the importance of anabolic steroids in helping to repair damaged skeletal muscles following an injury. Anabolic steroids have been shown to aid in the repair of snake venom-induced muscle injury and improve the natural muscle repair process [5].

Furthermore, anabolic steroids have also been shown to be very effective with aiding the repair of orthopedic injuries by directly aiding in skeletal repair and aiding in muscle repair which allows for the strengthening of bones [6].

Human studies have also found a link between anabolic steroids and injury repair. In little study with six healthy young men, oxyandrolone was used. The study found that a moderate dose given for five days was enough to stimulate protein synthesis. The efficient reuse of amino acids was significant, demonstrating a link between protein breakdown and construction. Increased levels of androgen receptors - AR and AR mRNA - resulted in an increase in the androgen-tissue-specific interaction, which regulated the transcription of hormone-responsive target genes [7].

The use of oxandrolona in burn patients has been well documented. In addition to skin damage, severe burns cause significant physiologic changes. Hypermetabolism with loss of lean body mass, generalized weakness, alterations in immune function with increased infectious complications, peripheral insulin resistance, and poor wound healing are just a few of them. Oxandrolone improves muscle protein metabolism in burn victims by increasing protein synthesis efficiency [8].

All these findings suggest the efficacy of oxandrolone in impeding muscle protein catabolism in critically injured patient.

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee

Consent to publish

Informed consent was obtained from all individual participants included in the study.

Competing interest

The authors declare no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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