Skeletal Radiology

, Volume 37, Issue 5, pp 481–483

Magnetic resonance imaging of acute “wiiitis” of the upper extremity

Authors

  • Michael P. Nett
    • Department of Orthopedic SurgeryMayo Clinic
    • Department of RadiologyMayo Clinic
  • John W. Sperling
    • Department of Orthopedic SurgeryMayo Clinic
Case Report

DOI: 10.1007/s00256-008-0456-1

Cite this article as:
Nett, M.P., Collins, M.S. & Sperling, J.W. Skeletal Radiol (2008) 37: 481. doi:10.1007/s00256-008-0456-1

Abstract

We present the first reported case of acute “wiiitis”, documented clinically and by imaging, of the upper extremity, caused by prolonged participation in a physically interactive virtual video-game. Unenhanced magnetic resonance imaging (MRI) demonstrated marked T2-weighted signal abnormality within several muscles of the shoulder and upper arm, without evidence of macroscopic partial- or full-thickness tearing of the muscle or of intramuscular hematoma.

Keywords

WiiitisMuscle edemaDelayed-onset muscle soreness (DOMS)MRI

Introduction

Video-game related overuse syndrome was first reported by Brasington et al. [1] in 1990 and coined “nintendinitis.” This, specifically, was due to overuse tendinitis of the extensor pollicis longus tendon and caused by the prolonged and repetitive thumb motion utilized while a Nintendo game is being played. More recently, Bonis [2] described an overuse injury in a resident physician after the physician had been playing a video-game simulating tennis on the newer Nintendo entertainment system called “Wii.” This established a new diagnosis, “wiiitis.” With the use of a handheld controller containing accelerometers and gyroscopes, Wii allows the player to control the video-game by sensing the player’s spatial movements in three dimensions. The player thus makes movements similar to those of an athlete participating in the simulated sport. However, physical fitness, strength, and training are not prerequisites. In addition, little resistance is offered by the light 200 g handheld controller to the aggressive maneuvers made by the participant, which may lead to awkward deceleration forces being applied to the upper extremity. This may cause upper extremity overuse syndrome, delayed-onset muscle soreness (DOMS), and, possibly, acute muscular and myotendinous strain. We present the first clinically documented case of upper extremity wiiitis that includes an evaluation by magnetic resonance imaging (MRI).

Case report

A healthy 22-year-old man attended our clinic with a 1-week history of left posterior shoulder and arm pain, along with significant swelling of the upper extremity. He noted that approximately 1 week prior to presentation, he was aggressively playing “Brunswick Pro Bowling” on the Nintendo Wii entertainment system. During an attempt to throw the ball, the patient experienced a tearing sensation in the posterior aspect of his left shoulder and had significant immediate pain. The next morning the patient noted swelling in his left arm, extending inferiorly below the elbow joint line. The swelling and pain persisted over the next 5 days. The patient denied prior shoulder pain or injury.

Physical examination demonstrated diffuse swelling of the left upper extremity, beginning proximally at the level of his left shoulder and extending inferiorly to the mid-forearm and including his posterior shoulder, upper arm, and elbow region. His strength was noted to be 5/5 in all directions including elbow flexion, extension, pronation, and supination; wrist flexion and extension; and shoulder elevation, external rotation, and internal rotation. His arm was neurovascularly intact, with excellent capillary refill and symmetric radial and ulnar pulses. There was no evidence of any overlying erythema or ecchymosis. Clinical photographs were taken to demonstrate the significant edema involving the patient’s left upper extremity (Fig. 1). Findings of a conventional radiographic series of the shoulder were normal.
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Fig. 1

a, b. Clinical photographs taken over 1 week following the patient’s injury. Note the persistent edema involving the patient’s entire arm, extending inferiorly to the level of the mid-forearm

Because of the amount of clinical pain, discomfort, and swelling, MRI was ordered by the clinical service. The noncontrast study was performed on a 1.5 T magnetic resonance imaging unit (Signa; GE Medical Systems, Milwaukee, WI, USA) using a dedicated phased array shoulder extremity coil. The shoulder was imaged in three orthogonal anatomic planes using paired proton density and fat-suppressed T2-weighted fast spin-echo sequences utilizing a 14 cm field of view, slice thickness of 4 mm with a 0.5 mm interslice gap, and a matrix of 256 pixels × 256 pixels. The parameters for the proton density-weighted images were TR/TE 3,200/32 ms, ETL 8, and two signal averages. The parameters for the T2-weighted sequences were TR/TE 3,500/50, echo train length (ETL) 8, and 2 signal averages. Extended axial fat-suppressed T2-weighted sequences of the mid- and distal shaft of the humerus were also included. The study demonstrated diffuse areas of increased intramuscular T2 signal intensity involving the posterior deltoid, teres minor, triceps, and latissimus dorsi muscles (Figs. 2 and 3). There was no evidence of macroscopic disruption of the involved muscles, myotendinous junctions, or tendons, and no focal intramuscular hematomas or fluid collections. Nonspecific edema was present within the subcutaneous soft tissue compartment (Fig. 3).
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Fig. 2

Axial (a) and coronal (b) fat-suppressed T2-weighted fast spin-echo sequences of the left shoulder demonstrate diffuse areas of increased T2 signal intensity within the teres minor, posterior deltoid, triceps long head and latissimus (arrows) compatible with muscle edema. No macroscopic tears of the muscle, tendon, or myotendinous junction are seen

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Fig. 3

Axial fat-suppressed T2-weighted fast spin-echo images of the mid- (a) and more distal (b) humerus demonstrate diffuse areas of bright signal intensity of muscle edema within the long and lateral heads of the triceps, and within the visualized latissimus (arrows). Also, nonspecific edema is present within the subcutaneous compartment of the distal humerus (arrowhead). No macroscopic tears of muscle, tendon, or myotendinous junction are seen

The patient was diagnosed with acute wiiitis and was treated with rest, nonsteroidal anti-inflammatory drugs, and a lymphedema wrap for his left arm. The patient continues to recover without further event.

Discussion

Overuse injury and tendinitis from the playing of video-games is a well-established diagnosis. However, virtual sport and physically interactive video-games represent a new era of recreational technology. These games are rapidly becoming more popular. The risk of acute sports-related injury with these games is currently unknown. We feel that the risk of injury, whether related to overuse, delayed-onset muscle soreness (DOMS), or acute injury, is likely much higher than previously reported in the literature, due to the physical nature of the newest entertainment systems. Sport-simulating games currently available include soccer, bowling, baseball, tennis, boxing, and fighting. Wiiitis, initially described clinically by Bonis, involved tendinitis of the infraspinatus following prolonged participation in Wii tennis. Our case presentation involved multiple muscles of the upper extremity specific to the mechanics of Wii bowling. Although similar muscular abnormalities have not previously been documented clinically or by imaging, it is reasonable to assume that they could be seen in the other Wii sports if prolonged, forceful movements were employed. Theoretically, the exact pattern and distribution of the muscle abnormalities would vary, given the expected differences in technique unique to each Wii sport. One may expect to see video-game related injuries which mimic injuries common to the traditional participation in these recreational sports. The rate of injury may be even higher in these simulated sports, due to the lack of appropriate training and physical fitness.

When deconditioned amateur athletes participate in recreational sports such as tennis, they typically discontinue the activity due to fatigue as determined by their level of strength and fitness. This may indirectly protect them from experiencing more serious muscle injury. As Bonis [2] has described, physical strength and endurance are not limiting factors in the Nintendo Wii sports-related video-games. This enables the patient to participate in the activities for several hours on end without fatigue and further increase their risk of injury. In addition, the aggressive movements made by the individual when participating in these activities, with little resistance from the 200 g handheld controller, can result in significant strain and edema within the muscles of the upper extremity, as documented in our patient. The delayed onset of clinical soft tissue edema and the magnetic resonance imaging features would be compatible with a previously described clinical entity, DOMS [3]. DOMS is particularly associated with eccentric muscle contractions, is linked to ultrastructural muscle damage, and is more common in deconditioned athletes. DOMS is characterized by delayed-onset muscle pain, elevated plasma levels of muscle proteins, including creatine kinase, and edema-like changes on magnetic resonance images. It is likely that, during the deceleration phase of swinging the Wii controller, there is significant eccentric loading on the participant’s muscle groups, causing the ultrastructural damage, as demonstrated in this case.

In conclusion, we present this case of acute wiiitis, documented clinically and by imaging, as an example of the potential muscle injury and edema of the upper extremity caused by prolonged participation in a physically interactive virtual video-game. Not only should physicians be aware of the possible presentations of wiiitis, but, perhaps, the public should be informed that prolonged aggressive participation in these sports-related video-games can result in significant injury.

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