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Anabolic Steroids

Also known as

Roids, juice, gym candy, pumpers, andro, stackers, basement drugs, fakes, arnolds, weight trainers

Classification

Synthetic hormone

Overview

Steroids are drugs that mimic certain natural hormones in the body that regulate and control how the body works and develops. There are two main groups of natural steroids - anabolic steroids and corticosteroids. It is the anabolic steroids that tend to be misused, mainly because they are similar to the male hormone testosterone and they can improve endurance and performance and stimulate muscle growth.

Some people take the anabolic steroids to help build muscles or to try and look more 'manly'. Other people take them to improve how they perform at sports, such as sprinting and cycling [1].

The key effects of anabolic steroids include -

  • They may help sports players train harder and longer.
  • If taken alongside a strenuous exercise regime, they may help with faster recovery times and with the building up of muscle mass.
  • They can make some users feel paranoid, irritable, aggressive or even violent, and they can cause dramatic mood swings.
  • They can sometimes cause unwanted changes in appearance [1].

Anabolic steroids are available as tablets or as a liquid for injection.

In medicine, they can be used to treat anaemia and muscle weakness after surgery.

They're used by some bodybuilders, athletes and other sports people because of the performance enhancing effects, and these users may consume 10-100 times the medical dose. Some younger people use them to try and look more attractive, despite risking the negative effects on their looks [1].

What does it look like?

Steroids are readily available in many gyms and are sold as tablets/capsules or ampoules [2].

Raw steroids are supplied as white powder, though they are never sold at a street level in this form. The powder is then made up in to preparations - tablets for oral consumption, and oil (or water-based) preparations for injection.

Products intended for injection will generally come in a glass ampoule or vial. These may have a snap-off top or a rubber stopper. Vials will generally have an adhesive label or be etched with details, and distributed in printed boxes. Some of the tablet forms may come in foil packaging, in printed boxes like 'normal' medicines. Some oral steroids will be supplied in medicine-style packaging with foil-blister tablets and product leaflets. However, other tablets may well be sold simply in plastic bags, with no additional packaging to assist with identification [3].

Source

Anabolic-androgenic steroids (AAS), are manufactured steroid hormones related to the hormone testosterone. Anabolic refers to muscle-building and androgenic refers to increased male sexual characteristics. Steroids refers to the class of drugs. Diverted from pharmaceutical industry or imported into Britain [4].

Key anabolic steroids are made synthetically. Some are made for legitimate medical use and are prescribed. They may be used to treat wasting illnesses, dwarfism, gender reassignment and other conditions. Others are made to pharmaceutical standards and are then sold on the grey market for body building. Others are made in 'Underground Labs' (UG) around the world and sold for their use as performance drugs.

Most of the anabolic steroids used in the UK are manufactured abroad and imported in the UK. Some are purchased on-line; others are purchased abroad by users and imported back in to the UK for personal use. The rest are illegally imported in to the UK and then sold on by suppliers, especially through Gym circles [3].

Prevalence

Use of anabolic steroids has rapidly increased in the UK in recent years. No-one knows for sure how many users there are but some surveys show between 20% - 40% of those attending some gyms use them. Those identified as using steroids include sports people, bodybuilders, doormen and security guards.

Young men are getting involved in taking steroids not for sporting purposes or competitive body building, but to improve their body image. There are some reports of 'reverse anorexia' - people thinking they can never be big enough.

According to Home Office statistics, anabolic steroid use fell among 16 to 24 year olds from 0.5% in 2014/15 to 0.1% in 2015/16. This percentage equates to around 4,000 young adults reporting using anabolic steroids in the last year. 0.2% of adults aged 16 - 59 reported using steroids in the last year - i.e. around 8,000 people [5].

Street price

Cost is hugely variable, depending on the type of steroid bought, the quality and the quantity. Single tablets are ineffective - so people will tend to use a combination of drugs over a period of time (a cycle). A simple, short cycle that may only last a few weeks and using basic, easily sourced compounds, could cost less than £100. Longer cycles using larger combinations could cost many times this. The cost of special diets and additional compounds can make things more expensive [3].

Anabolic steroids cost approximately £20 for 100 tablets but prices can vary from region to region [1].

Why take it?

Sought after effects

  • assists the male sexual function,
  • enhances libido,
  • increases production of red blood cells (good for building muscles) [2],
  • enhanced muscle mass,
  • enhanced performance,
  • greater physical definition [4].

Undesired effects

  • high blood pressure,
  • liver damage (especially tablet form),
  • can reduce testicle size [2],
  • inability to get an erection,
  • sterility/impotence,
  • shrinking and hardening of testicles,
  • breast enlargement,
  • enlarged clitoris,
  • disruption to menstrual cycle,
  • growth of facial hair,
  • acne,
  • deepening of the voice [4].

Who uses steroids and why?

  • competitive athletes - who are motived by their desire to succeed,
  • people concerned about their body image - recreational weight trainers and body builders and people working in the fashion and entertainment industries,
  • body building professionals - people involved in body building as a competitive sport,
  • people who need muscle strength to do their job - bodyguards, security personal, construction workers, police and members of the armed services,
  • young men - who want to increase their athletic performance or who are striving to reach the same physical appearance that is often portrayed in the media [6], [7].

Pharmacology

Anabolic Steroids are a class of synthetic drugs whose effects mimic the naturally-occurring male hormone testosterone. They are used medically and non-medically to enhance performance (mainly in sport).

They may be administered orally, injected, applied on the skin as a gel or cream and are available as patches. For more information on routes of administration, including harm reduction visit our 'safer injecting' section here.

Pharmacologically, they stimulate both the development of the male characteristics that develop after puberty in both male and female users (androgenic effects) and the production of proteins in muscle and bone tissue (anabolic effects). The extent to which each of these effects occurs is determined by minor variations in the basic chemical structure of each anabolic steroid. With a few medical exceptions, the anabolic effects of these drugs are the primary reason for their use.

Androgenic effects of anabolic steroid use include - increased body hair growth; increased aggressiveness; baldness; a deepening of the voice; acne and increased sexual drive. After stopping using anabolic steroids following regular use, body may experience difficulty in naturally-producing its own testosterone.

A main anabolic effect is an increase in protein production. This leads to an increase in skeletal muscle mass and a reduction in fat, possibly due to a mechanism causing new cells to develop into skeletal muscle cells rather than fat cells. Subsequently, this leads to an increase in strength.

Anabolic steroids are fat-soluble while the barriers of their target cells (cell membranes) are also fatty. Therefore, following administration, anabolic steroids readily enter cells in the body, particularly those in the reproductive tissue, muscle and fat as these are prime targets for their pharmacological action. Here they bind to specific steroid receptors, with the chemical structure of each steroid determining the extent of this binding. The resulting steroid-receptor complex elicits its pharmacological actions through sending signals to other parts of the cell or by activating genes that express the steroid’s effects [2].

Mechanism of action

They increase the building of cell proteins, which results in the build up of cellular tissue, especially in muscles. Anabolic steroids also have properties that include the development and maintenance of masculine characteristics such as the growth of the vocal cords and body hair [4].

The main product groups mimic the effect of the sex hormone testosterone. Using this at significant doses puts the user in to an anabolic state - where muscle cells are instructed to take protein and convert it in to muscle. The high levels of hormone, combined with a protein-rich diet and correct exercise and rest can result in rapid and significant muscular development [3].

Mode of use

  • Swallowed - tablets/capsules are swallowed (ingested),
  • Injected - ampoules are injected into muscle [2].

Steroids should never be injected into a vein [4].

Signs of usage

Steroid use is not always readily identified without testing or screening as successful 'natural' training can result in significant muscular development and be misconstrued as steroid use. Heavy training and use of dietary supplements is not an indicator of steroid use [3].

  • very rapid weight gain,
  • mood changes,
  • increased acne,
  • bloating due to water retention [3],
  • gynaecomastia,
  • hair loss,
  • body hair growth,
  • unstable emotions,
  • irritability,
  • change in behaviour,
  • loss of interest in usual activities,
  • burst of anger,
  • trouble at school, work and home,
  • withdrawal symptoms when abruptly stopping the use of steroids [1].

Effects

Sports players and body building enthusiasts have claimed that anabolic steroids -

  • make them able to train harder and longer,
  • help them to recover from strenuous exercise faster,
  • build muscle mass, when taken alongside a strenuous exercise regime,
  • anabolic steroids can make some users feel paranoid, irritable, aggressive or even violent, and it can induce mood swings,
  • they can sometimes cause unwanted changes in appearance like acne or shrunken testicles [1].

Steroids affect everyone differently. The following may be experienced -

  • water retention - leading to facial bloating, known as oedema,
  • acne - leading to permanent scarring,
  • irritability,
  • mood swings,
  • more frequent colds,
  • aggression,
  • violence,
  • increased sex drive,
  • sleeping difficulties [8], [7].

Because anabolic steroids are modelled on male hormones, they can have a masculinising effect on the body, and some of these effects may be permanent. Unwanted side-effects may be greater when steroids are taken in high doses or when used together in different combinations (known as 'stacking') [2].

Women

  • increase in body hair,
  • deepening of the voice,
  • loss of head hair,
  • enlargement of the clitoris,
  • decrease in breast size [2],
  • excessive hair growth,
  • abnormal menstrual cycles [9].

Men

  • decrease in sperm production,
  • decrease in testes size,
  • development of breast tissue [2],
  • damage to the heart,
  • impotence,
  • difficulty or pain while urinating,
  • liver disease,
  • liver cancer [9].

Short-term effects

  • acne,
  • mood swings,
  • fatigue,
  • restlessness/agitation,
  • decreased appetite,
  • trouble sleeping,
  • decreased sperm count,
  • impotence [10],
  • fluid retention,
  • rapid weight gain,
  • increased blood pressure and cholesterol levels,
  • headaches,
  • reduced sexual functioning,
  • increase in muscle size,
  • swelling of feet and ankles,
  • improved healing,
  • improved appetite [9].

Long-term effects

  • anger and aggression (so-called 'roid rage'),
  • paranoia,
  • delusions,
  • heart attack,
  • stroke,
  • kidney failure,
  • tumours in the liver,
  • blood-borne diseases from injection use [10],
  • blood clotting difficulties,
  • clotting disorders,
  • cardiovascular, liver, and reproductive organ damage,
  • reduced sexual functioning,
  • stunted growth in adolescents,
  • increased chance of injuring ligaments, tendons and muscles,
  • when injecting - bacterial infections, abscesses, cellulitis, and HIV/AIDS,
  • increase in muscle size [9].
  • kidney or prostate cancer,
  • high blood pressure,
  • depression [11], [7].

Risks

Taking anabolic steroids does involve risks. There's the harms you can do to your own body and health. But also, because anabolic steroids can make you feel paranoid, aggressive and violent for no reason, it's not that unusual for anabolic steroid users to lash out or attack family and friends [1].

Here's what else steroids can do to you -

  • If you're young, anabolic steroids can mess up how your body develops, stopping you from growing properly.
  • If you're male, regular use can lead to erection problems, growing of breasts, becoming sterile, loss of hair and development of acne. It can also make your testicles shrink.
  • If you're female, you can develop more masculine characteristics - with extra facial hair, loss of hair on the head, a deeper voice, shrinking breasts, and an enlarged clitoris; as well as risking acne, an increased risk of menstrual problems and changes in sex drive.
  • Steroids can also give you high blood pressure and increase your risk of illness and death due to liver failure, stroke or heart attack.
  • Regular users may find that they start having trouble sleeping. They may get paranoid, or may experience dramatic mood swings; and even violence can occur alongside strong feelings of aggression.
  • Injecting any drug, even steroids, can damage your veins and cause ulcers and gangrene, particularly with dirty needles or poor injecting technique. Sharing needles, syringes and other injecting works can help spread HIV, hepatitis C and other infections [1].

There are worries about the quality and safety of anabolic steroids that are sold on the black market, with falsified, substandard and counterfeit anabolic steroids not being uncommon.

Some of these counterfeit anabolic steroids may not have the effect that the buyer wanted. Some have no active ingredient at all [1].

There may also be an increased risk of coronary heart disease due to increased blood pressure and raised cholesterol levels [2].

Men may develop

  • prominent breasts,
  • baldness,
  • shrunken testicles,
  • infertility,
  • impotence,
  • prostate gland enlargement [12].

Women may develop

  • a deeper voice,
  • an enlarged clitoris,
  • increased body hair,
  • baldness,
  • infrequent or absent periods [12].

Both men and women might experience

  • severe acne,
  • increased risk of tendinitis and tendon rupture,
  • liver abnormalities and tumours,
  • increased low-density lipoprotein (LDL) cholesterol (the 'bad' cholesterol),
  • decreased high-density lipoprotein (HDL) cholesterol (the 'good' cholesterol),
  • high blood pressure (hypertension),
  • heart and circulatory problems,
  • aggressive behaviours, rage or violence,
  • psychiatric disorders, such as depression,
  • drug dependence,
  • infections or diseases such as HIV or hepatitis if you're injecting the drugs,
  • inhibited growth and development, and risk of future health problems in teenagers [12].

Short-term

  • psychiatric symptoms,
  • aggression,
  • violence,
  • mania,
  • mood swings [4].

Long-term

  • dependence,
  • tolerance,
  • liver damage,
  • heart disease,
  • paranoia,
  • increased aggression,
  • harmful changes in cholesterol,
  • acne,
  • high blood pressure,
  • dangerous changes in the structure of the heart,
  • vein damage,
  • ulcers,
  • gangrene [4].

Purity

Genuine pharmacy-grade products should be sterile, of known strength and quality. However faking of pharma-grade products is widespread. Counterfeits and underground lab products may vary widely in composition, strength and may not be sterile. Analysis routinely finds products on sale that contain no active product, is under (or over) dosed, or contains a different drug to that stated. As with any other non-medical compound, the quality of product is an inevitable risk [3].

There are worries about the quality and safety of anabolic steroids that are sold on the black market, with falsified, substandard and counterfeit anabolic steroids not being uncommon.

Some of these counterfeit anabolic steroids may not have the effect that the buyer wanted. Some have no active ingredient at all [1].

Many PIEDs sold in gyms are counterfeit or designed for veterinary use. Counterfeit PIEDs pose additional risks. Many are made without the controls of legitimate drugs, and so vary in purity and also safety. Like most illicit drugs, you can never be sure of what is in them. Because PIED users often inject their drugs, sometimes in large quantities over a long period of time, they bypass their body's natural defences to impurities and infections and run considerable risks. Counterfeits also vary in strength, which again can affect the safety of short and long-term use [5].

Addiction

Can you get addicted

You can easily become psychologically dependent on anabolic steroid use (meaning you develop an increased tendency to keep taking the drug even in spite of possible harmful effects).

Withdrawal symptoms have been reported soon after stopping, including headaches, lethargy and depression [1].

Anabolic steroid use may lead to dependency. Dependency on the drug is illustrated in the feeling that you cannot function normally without the steroids in your system. Overuse leads to an increase of the hormones in the body, and it can cause more severe side-effects than lower doses.

When the drug is stopped, you may be left with a strong feeling that you need to take them again. This occurs even though there are unpleasant and sometimes severe side-effects taking place. In these cases, withdrawal treatment may be necessary. Withdrawal should be monitored by medical professionals to help eliminate side-effects or reduce their impact [10].

Each user experiences their own unique feelings when using steroids and coming off the drug. Evidence for steroid addiction is certainly not as strong as it is for other drugs like cocaine or heroin. Though it is clear that people develop a tolerance and dependence on them and willingly experience negative consequences when using steroids - both of which are signs for drug dependence [9].

Withdrawal

Anabolic steroid withdrawal treatment is usually done through a tapering programme to minimise the withdrawal symptoms that can include -

  • apathy and depression,
  • difficulty concentrating,
  • insomnia,
  • a decreased sex drive,
  • headaches,
  • joint and muscle pain,
  • anxiety,
  • anorexia,
  • fatigue [10],
  • mood swings,
  • restlessness,
  • loss of appetite,
  • craving [9],
  • dizziness,
  • intestinal upset,
  • nausea,
  • vomiting,
  • diarrhoea [13].

Depression could be the most dangerous effect of withdrawal because it can be intense and long-lasting. In some case, suicidal thoughts or attempts may occur during withdrawal.

Seeking treatment from medical and mental health professionals can help to ensure safety during withdrawal and avoid the negative consequences. Most treatment can be accomplished on an outpatient basis. If other substances are being abused in combination, inpatient or residential rehab programmes may be more appropriate.

Fortunately, treating abuse, addiction, and dependence on anabolic steroids is manageable and safe in the short-term. Ongoing treatment will help to reduce the risks of relapse and help understand the motivating factors that lead to steroid abuse [10].

Although steroids are not addictive, people can find themselves relying on them to build confidence and self-esteem18. This reliance can make it difficult to stop using them in the longer term. Fear of losing muscle size or definition can lead to depression and the pressure to continue use [8].

It can take up to four months to restore the body's natural testosterone levels (if taking high doses for an extended period of time) [7].

Legality

  • Anabolic steroids are Class C drugs to be sold only by pharmacists with a doctor's prescription.
  • It's legal to possess or import steroids as long as they're for personal use. Importation or exportation of steroids for personal use can only be carried out in person. Importation or exportation of steroids for personal use using postal, courier or freight services is now illegal.
  • Possession or importing with intent to supply (which includes giving them to friends) is illegal and could lead to 14 years in prison and an unlimited fine [1].

Many sporting organisations have banned the use of certain steroids. These organisations carry out tests for the banned steroids. If someone tests positive they can be disqualified from competing for certain periods of time, or even banned for life [1].

Did you know?

  • A conviction for a drug-related offence could have a serious impact. It can stop you visiting certain countries - for example the United States – and limit the types of jobs you can apply for [1].

Harm reduction

Steroids may be used in two forms, either orally in tablet form or injected in a water based or oil based solution. There are serious risks associated with injecting, which are explained below.

Courses of steroids, known as 'cycles', last between 4 and 12 weeks. It is common to use a combination of steroids at the same time, which is known as 'stacking'. This can cause an increase in adverse side effects (see below).

If you are using steroids, it is important that you give your body a break after each cycle of at least 4 weeks, or at least of the same duration as the last cycle [2].

What are the risks of injecting steroids & how you can inject more safely?

Injecting is never completely safe.

Where steroids are injected and syringes are shared, there is a risk of infection with blood borne viruses such as HIV/AIDS and Hepatitis. Those continuing to inject can protect themselves to some degree by using clean equipment and not sharing with anyone else. Always use a new syringe. Swabbing the area for injection with alcohol wipes beforehand is advised. All this equipment is available from needle exchanges and some pharmacies.

Injecting oily liquids into veins can be fatal. It is safer to inject into large muscle areas ('intra-muscular injection'), e.g. the upper, outer buttock quadrant on each side (other areas of the buttock can be very dangerous, risking paralysis), upper arm or thigh. It is dangerous to use small needles for intra-muscular injection as they may break off in hard muscle. A detachable needle/barrel combination should be used. It is advisable to use a long (green or blue top) needle, leaving the upper ¼ of the needle exposed upon insertion.

Injecting large amounts of oil based steroids in one dose may lead to an infection developing under the skin [2].

Steroids should only be injected with a prescription for a specific medical reason or under medical supervision.

Injecting more than the recommended dose does not create larger muscles - the muscle simply becomes saturated. Higher doses only raise the risks of more adverse side effects without providing any additional benefits [14].

It is not necessary to inject directly into specific muscles as the steroids are transported to all muscle groups via the bloodstream [15].

There are many steps that can be taken to reduce the risk of harm caused by long-term steroid use.

These include -

  • using lower doses to reduce the risk of side effects,
  • never injecting steroids directly into biceps, calf muscles or pectorals, to avoid causing permanent nerve damage,
  • avoiding repeatedly injecting steroids into the same area of the body,
  • limiting cycles to 8 to 10 weeks to rest the kidneys, liver and endocrine system,
  • avoiding sharing injecting equipment with others to reduce the risk of contracting a blood-borne virus such as HIV or Hepatitis C,
  • using a clean needle from an unopened package with every injection,
  • avoiding combining steroids with diuretics such as caffeine, alcohol and other drugs like amphetamines (such as 'ice' and 'speed'),
  • injecting steroids in a sterile location,
  • discussing steroid use with a doctor, even if it is without a prescription,
  • discussing the perceived need to take steroids with a counsellor [14], [15], [7].


Paraphernalia

If injected, needles and syringes [4].

Trends

There is widespread agreement in the drugs field that there has been an increase in the number of people presenting to services, especially for needle exchange. It is likely that this is in part due to increased use of anabolic steroids, but may also be because some services are making more of an effort to engage with steroid users.

Increased interest in steroids, and easy access to both information and drugs via the internet has made steroids more readily available to a wider audience.

However, credible information about levels of steroid use in the UK is not easy to come by. Users rarely present for treatment, do not tend to commit trigger offences which would result in testing on arrest, and people are not tested for steroids anyway. Not all steroid users inject; of those that do not all use needle exchanges, and not all needle exchanges reliably record if steroids were being used.

Some steroid users are concerned that statistical evidence of growing steroid use will result in legal changes and so actively discourage use of needle exchange and of any surveys about steroid use. The Crime Survey of England and Wales reports that around 0.3% of 16 - 24 year olds used anabolic steroids in the last year, but this is liable to be a significant under-estimate [3].

History

It has been suggested that the roots of interest in boosting strength or endurance capacity by supplementing the human hormonal system through ingesting the testicles of animals of power or endurance such as the bull or goat before dangerous or arduous physical tasks lies in the ancient world.

It was not until 1931 that a German chemist, Adolph Berthold, discovered the hormone androstenone by extracting this hormone from urine. It was already known that the testes contain a more powerful androgen than androstenone. This hormone was first identified in a May 1935 research paper called On Crystalline Male Hormone from Testicles (Testosterone). They named the hormone testosterone, from the stems of testicle and sterol and the suffix of ketone. The chemical synthesis of testosterone was achieved in August that year, when Butenandt and G. Hanisch published a paper describing A Method for Preparing Testosterone from Cholesterol. Unfortunately for them, a race had developed in three counties by competing scientists for this breakthrough and it was the German pair of Ruzicka and Butenandt who, although pipped to the publishing post, were offered the Nobel Prize for this ground breaking achievement.

In a nice slice of irony, the Nazi administration suggested they refuse (the award was accepted post-War), while it appears that Hitler himself, according to his physician, was injected with testosterone derivatives to treat various ailments.

In a variant on the USA/USSR Cold War competition, Dr John Ziegler, the U.S Olympic team doctor, developed methandrostenolone, which is known as Dianabol or 'd'bol'. Ciba Pharmaceuticals was the first to market Dianabol in 1958, although its competitive use pre-dates this. Unfortunately, Ziegler soon discovered that those having over-used Dianabol suffered from enlarged prostates and atrophied testes.

The issue of 'doping in sport' has rarely been out of the news since then, as trainers and team doctors devise new compounds and masking agents. Steroids are commonly used in cycles by people looking to 'bulk up', by competition body builders and by people with body dysmorphic issues [2].

Use of performance enhancing drugs has been going on ever since the Olympic Games of ancient Greece. Anabolic steroids were first used by athletes in the mid 1950's and by the 1960's their use was widespread.

They were banned by the International Olympic Committee in the 1970's, but this didn't stop their use and in the 1980's doping became a big issue at the Olympic games and other sporting events. Drug testing came into many sports and a number of famous athletes failed tests and were banned from competing. As drug testing became more sophisticated new ways were found to avoid being found positive [5].


References

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  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Anabolic Steroids, 2017, http://www.kfx.org.uk/drug_facts/drug_facts_anabolic_steroids.php
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  6. Peters, R. and Copeland, J. and Dillon, P., Steroid Facts, 1999, isbn 0 7334 2180 6, https://ndarc.med.unsw.edu.au/resource/steroid-facts
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  8. 8.0 8.1 Hartgens, F. and Kuipers, H., Effects of androgenic-anabolic steroids in athletes, Sports Medicine, 2004, 34, 8, 513-554, https://www.ncbi.nlm.nih.gov/pubmed/15248788
  9. 9.0 9.1 9.2 9.3 9.4 9.5 Anabolic Steroids, 2013, http://www.cesar.umd.edu/cesar/drugs/steroids.asp
  10. 10.0 10.1 10.2 10.3 10.4 The Effects of Steroid Use, 2016, http://drugabuse.com/library/the-effects-of-steroid-use/
  11. Kanayama, G. and Hudson, J. I. and Pope Jr, H. G., Long-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: A looming public health concern?, Drug and alcohol dependence, 2008, 98, 1, 1-12, doi 10.1016/j.drugalcdep.2008.05.004, https://www.ncbi.nlm.nih.gov/pubmed/18599224
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  15. 15.0 15.1 Busche, K., Neurologic disorders associated with weight lifting and bodybuilding, Physical medicine and rehabilitation clinics of North America, 2009, 20, 1, 273-286, doi 10.1016/j.ncl.2007.11.008, https://www.ncbi.nlm.nih.gov/pubmed/18295098