A case of arm swelling and muscle Wii-kness

Case report

A 27-year-old man was admitted with a 24-hour history of right testicular pain and tenderness consistent with epididymo-orchitis. He was treated successfully with oral ciprofloxacin. Subsequent ultrasound of testes following treatment was unremarkable, urine culture sterile and chlamydia polymerase chain reaction testing was negative.

On admission he also reported right arm pain and swelling, and on questioning reported excessive and unaccustomed exercise through the use of a newly purchased Nintendo Wii games console. He estimated that in the 72 hours prior to admission, he had used the Wii for up to 34 hours in total and often for several hours continuously. Examination showed painful swelling of the entire arm (3 cm circumferential difference proximal to and 2 cm difference distal to the elbow). Neither overlying erythema nor dilated venous supply was noted and power was reduced to 4+/5 using the MRC (Medical Research Scale) muscle strength scale. Temperature was not elevated, C-reactive protein (CRP) normal at <0.2 mg/L and hepatic transaminases were elevated (alanine aminotransferase 215 U/L and aspartate aminotransferase 79 U/L) with normal bilirubin (21 μmol/L) and alkaline phosphatase (81 U/L). There was no history of excessive alcohol intake, newly prescribed medication or risk-taking behaviour predisposing to viral hepatitis. Subsequent peak total creatine kinase (CK) was 8020 U/L. 12-lead electrocardiogram was normal as was Troponin I. There was no history suggestive of systemic upset, myalgia or generalized muscle weakness. CK subsequently fell to 3151 and 1769 U/L within 24 and 48 hours, respectively. CK normalized at 165 U/L along with hepatic transaminases and a return of full muscle power at review, two weeks after admission. Doppler ultrasound carried out of whole-arm muscle groups 14 days later was normal.

Discussion

Since its release in 2006, injuries constituting a spectrum of severity^1-3 sustained through the use of this gaming console have been widely reported. This is the first case described of a Wii-related injury with associated CK rise. His presentation most likely represents a traumatic muscle injury and whereas the lack of weakness, anaesthesia and spontaneous improvement are against a complete compartment syndrome, nevertheless substantial muscle injury with recovery occurred. A previously described case report of a similar injury ⁴ underscores the likely ‘iceberg concept’ of imaging findings that, if sought, may exist if brought to the attention of healthcare providers. However, observing a prompt symptomatic improvement and CK fall within 72 hours constitutes a conservative approach, obviating the need for extensive imaging.

The Wii console is the leading selling home games console, which involves brisk physical exertion through the use of a motion-sensitive controller to replicate sports such as tennis, golf and boxing. The true energy expenditure associated with such exercise is unlikely to be truly beneficial without accompanying dietary measures and certainly falls short of true exercise. ⁵ As an introduction to physical activity, however, the Wii should be encouraged. In a similar way, the scope for employing more widespread use is currently being explored with ongoing trials, particularly in the rehabilitation field. ⁶ More imaginative training techniques highlight the potential for incorporation within the medical field.^7,8

The manufacturer does offer clear advice at regular intervals in an attempt to avoid injury and encourages rest periods and warm-up. However, the increasing prevalence of sedentary lifestyles, coupled with obesity and similar such forms of sudden and unaccustomed exercise, should prompt the physician to consider the use of home gaming consoles when presented with atypical musculoskeletal complications.