Post-Flight Muscle Pain / Weakness

[OneFinger]

I have a question for frequent fliers about post-flight medical issues. Every 3-6 weeks I fly between my home in Portland and my home in Utah. For the past 6 flights I've noticed that the next morning I wake up with leg pain (groin to knees), arms (elbow to shoulder), chest / back. I also have significant muscle weakness for several days. My most recent flight to Utah (19 Dec) resulted in chest / back / rib pain that made it difficult to take a deep breath.

 

I found Google searches that talk about leg-related pain after flying due to pressure changes during flight. Another site suggested it may be due to oxygen issues. Has anyone else experienced muscle pain or weakness after flying? Plan to talk with my Dr. when I return to PDX. I realize this may be a stretch but I can't identify any other cause for the pain / weakness.

[+ sniper]

Could just be a compressed nerve. I'd get into the habit of doing some stretches(cat-cow and the like) to decompress the spine a bit before/after flying.

[+ FreshFluff]

Could just be a compressed nerve. I'd get into the habit of doing some stretches(cat-cow and the like) to decompress the spine a bit before/after flying.

 

I was thinking this too, particularly if it happens after you wake up. On or after the flight, you could be sleeping in a position that irritates the disc(s). Your doctor knows your history best, but you might want to ask for a lumbar and/or cervical MRI if you haven't had one recently.

[Guest]

Yikes. Kind of a short flight for that to happen, but you're describing what could easily be a pulmonary embolus (a blood clot which breaks off from one of the veins in your thigh and lands in your lungs). If that happens again, go to the ER, get an ultrasound of the veins in your thighs, and ask them to do a blood test for D-dimer. I would be especially worried if you smoke. Some people are genetically predisposed, though.

[+ BlueSky]

Those airplane seats....oi! I'm always stiff and achy after flying.

 

I found relief for some sciatic pain I had (not specifically related to flying) by working with a good Physical Therapist. But it took a couple of tries to find the good one who really helped. Just my $0.02. Others here are better qualified to give advice I'm sure. But if your physician recommends PT and you can affortd it, I'd give it a try.

[+ augustus]

A short flight like that shouldn't cause those kinds of issues. I hope you aren't prone to blood clots. See what your doctor says.

[+ Pensant]

Re the blood clots, I agree. Please get it checked out. Deep vein thrombosis is more common than you think.

[OneFinger]

Groin to knee is likely related to the gracilis which can easily get hyper extended or painful if it remains tense (for instance, from poor car seat placement while driving). For me, the upper body issues are usually due to an arm rest hog or oversized seat mate...so, I generally fly first class to avoid that risk.

 

Looking into gracilis potential. Never heard of that before. But I did have a psoas abscess about 3 years ago that extended into my upper legs. However, that pain didn't involve arms or chest. As for airline seats, I've been flying 1st class exclusively for the past year.

Could just be a compressed nerve. I'd get into the habit of doing some stretches(cat-cow and the like) to decompress the spine a bit before/after flying.

I was thinking this too, particularly if it happens after you wake up. On or after the flight, you could be sleeping in a position that irritates the disc(s). Your doctor knows your history best, but you might want to ask for a lumbar and/or cervical MRI if you haven't had one recently.

 

Hadn't considered pinched nerve or disk issues. I did have a cervical / lumbar MRI in July and a PET scan in August. But, this could be disk or nerve-related. I'm confused that it only happens after a flight.

...But if your physician recommends PT and you can affortd it, I'd give it a try.

 

A year ago I started having weakness in my legs, loss of balance and was falling 2-3 times per week. In April my right foot became paralyzed and I now have a leg brace. Dr. recommended starting PT after the holidays.

Yikes. Kind of a short flight for that to happen, but you're describing what could easily be a pulmonary embolus (a blood clot which breaks off from one of the veins in your thigh and lands in your lungs)...

A short flight like that shouldn't cause those kinds of issues. I hope you aren't prone to blood clots. See what your doctor says.

Re the blood clots, I agree. Please get it checked out. Deep vein thrombosis is more common than you think.

 

About 7 years ago I got bilateral PEs from a DVT I didn't know I had. Have been on blood thinners since then. I immediately thought PE but pain in chest subsides in a couple of days. And, the pain from 7 years ago was in the back (shoulder-to-shoulder). Flying back to Portland on Friday. If this happens again, I definitely going to ER immediately.

 

I also bought a pulmonary oximeter to measure my oxygen levels during flight. If it drops, that could account for the symptoms, too.

 

Thanks so much for the swift and caring responses. I'm concerned with my health and you guys provided some thoughts and insights that are helpful.

[Guest]

...About 7 years ago I got bilateral PEs from a DVT I didn't know I had. Have been on blood thinners since then. I immediately thought PE but pain in chest subsides in a couple of days. And, the pain from 7 years ago was in the back (shoulder-to-shoulder). Flying back to Portland on Friday. If this happens again, I definitely going to ER immediately.

Well, that certainly causes additional warning bells. Most certainly, I would not let the fact that the duration of the pain or location of the pain was different from your prior episode lead you to believe that these are not new DVT's/PE's. The duration of the pain would depend on the size and number of clots thrown, and the location would depend on where in your lungs the clots were thrown. You don't mention what blood thinner you're on, but if it's not warfarin and you haven't been tested for genetic causes of increased clotting, the blood thinner probably won't protect you if your problem is from a genetic excessive clotting disorder (thrombophilia). You also didn't mention if there was a cause of your prior PE's. If you had recently had hip surgery, and your surgeon was too dumb to put you on blood thinners, that's probably the explanation. However, if your PE came out of the blue, then you probably should have been tested for genetic causes.

I have asked a couple of the pharmaceutical manufacturers if their product was tested on people with genetic thrombophilia, and the answer was no. The newer agents are much easier to take and prescribe than warfarin, but they only target one clotting parameter, and don't help for certain conditions, most commonly artificial heart valves, but also genetic clotting problems. The newer agents are certainly not FDA approved for these, and they probably don't work (not tested for genetic problems, and known to be useless for people with mechanical heart valves).

If this hasn't already been done, I would ask to be tested for Factor V Leiden deficiency, Protein C/S deficiencies, and anti-thrombin III deficiency. Unfortunately, you do have to be off your blood thinners for 2 weeks in order to do these tests. However, testing positive means you will probably need to be on warfarin for the rest of your life, so this testing has life-long consequences and really must be done in my professional opinion. If your primary doctor disagrees, I would seek another opinion from a clotting specialist, such as a hematologist.

 

https://en.wikipedia.org/wiki/Thrombophilia

Edited December 25, 2019 by Unicorn

[+ Pensant]

It just occurred to me, have you been tested for Factor 5 Leiden?

[gallahadesquire]

You need to see your PCP and probable a hematologist. I agree with Unicorn: you probably ought to be on warfarin (coumadin) and possible a platelet inhibitor: aspirin or plavix

[Islesguy]

 

I also bought a pulmonary oximeter to measure my oxygen levels during flight. If it drops, that could account for the symptoms, too.

 

Thanks so much for the swift and caring responses. I'm concerned with my health and you guys provided some thoughts and insights that are helpful.

If you bought a finger oximeter, be aware the increased pressure in the cabin may throw off the reading. I tested it once for someone. At 36k, I couldn't get the number above 88%. As we decended back down, the reading steadily rose back up to normal levels. I only did it once so this is completely anecdotal, but you may want to ask your doctor if this typical.

[gallahadesquire]

If you bought a finger oximeter, be aware the increased pressure in the cabin may throw off the reading. I tested it once for someone. At 36k, I couldn't get the number above 88%. As we decended back down, the reading steadily rose back up to normal levels. I only did it once so this is completely anecdotal, but you may want to ask your doctor if this typical.

The pressure in most flights is like being at 8,000 ft altitude, and the pressure is 560 mm Hg. Sea level is 760 mm Hg. Air is 21% Oxygen. So the partial pressure of Oxygen at sea level is 160 mm Hg, but at 36k feet it’s 126 mm Hg.

 

8,000 was chosen so as to give the smallest pressure gradient across the fuselage, to reduce metal fatigue. The Boeing 787 uses composite materials that don’t suffer fatigue, and is pressurized to 6,000 feet. Apparently, additional lowering or altitude ( thus increasing the internal pressure) has no additional benefit.

 

There’s an obligate gradient between alveolar oxygen, which is about 713 mm Hg (humidification is about 47 mm Hg). This gives most people a partial pressure of 713 mmHg in the lungs, and 95-100 in the blood. This corresponds to a saturation ( what the pulse oximeter measures) of 98% or so.

 

At 8,000 feet, the alveolar oxygen will be about 80 mm Hg, to give an arterial partial pressure of oxygen of about 60 to 65.

The oxygen dissociation curve is rather non-linear. A PaO2 (partial pressure of oxygen) of 60 will give a saturation of 90%, and (for the sake of example), a PaO2 of 30 will give a saturation of 60%.

 

This is in normal people. When I had my pulmonary embolism, I had no perfusion to three out of five lobes of my lungs, and scattered occlusion in the remaining two lobes. [Yes, it should have killed me.] Off oxygen, my SpO2 (pulse oximetry measurement of oxygen saturation) was 85% or less.

 

It isn’t an increase in cabin pressure, it’s that the cabin pressure is reduced, and thus the oxygen content in flight.

 

Just to clarify “ ... the increased pressure in the cabin ...” in the quote above.

 

(I was an anesthesiologist in another life, and we had to know this stuff.)

[OneFinger]

Well, that certainly causes additional warning bells. Most certainly, I would not let the fact that the duration of the pain or location of the pain was different from your prior episode lead you to believe that these are not new DVT's/PE's. The duration of the pain would depend on the size and number of clots thrown, and the location would depend on where in your lungs the clots were thrown. You don't mention what blood thinner you're on, but if it's not warfarin and you haven't been tested for genetic causes of increased clotting, the blood thinner probably won't protect you if your problem is from a genetic excessive clotting disorder (thrombophilia). You also didn't mention if there was a cause of your prior PE's...

You need to see your PCP and probable a hematologist. I agree with Unicorn: you probably ought to be on warfarin (coumadin) and possible a platelet inhibitor: aspirin or plavix

 

My previous PEs occurred when I flew to PDX from work in San Diego. Didn't know it happened but I felt pain in my back and shortness of breath as I walked home from the light rail station to home (about 1-1/2 miles which I had done several times before). But that Friday night I could barely make it up the hill to my condo and actually passed out at my front door. When I regained consciousnesses I crawled into bed and awoke with lots of aches and pains.

 

Didn't realize the seriousness of the situation and didn't seek medical care in PDX. Flew back to San Diego on Sunday. When I went to work on Monday, co-workers said I looked like shit and encouraged me to call the 24-hour nurse with our insurance company. I gave her the symptoms and flight data and asked if I should go to my Dr. She said, "No, don't go to your doctor and you should NOT go to an instacare facility. Go immediately to the ER because I think you've got blood clots in your lungs."

 

Went to ER and she was right. Was in hospital almost a week on heparin and then sent home with warfarin. But, we had trouble regulating warfarin. I did weekly tests and levels would stay between 2-3 for a couple of weeks. Without change in meds or diet, it would jump up to 7+. So off the meds until it dropped and the cycle started again.

 

After 2 years of the warfarin yo-yo, Dr put me on Pradaxa. I remained on that until about 6 months ago. Insurance raised my co-pay for 3-month supply from $125 to $600. Dr then switched me to Xarelto which remained at $125.

It just occurred to me, have you been tested for Factor 5 Leiden?

 

Not sure I've had testing for that. Will definately bring that up to the Dr. But in the past year there have been some genetic tests, MRIs, CTs, muscle biopsy and bone marrow biopsy.

 

Thanks again for your responses.

[Guest]

The fact that your first PE was precipitated by such a short flight, an almost unprovoked PE, makes me feel quite strongly that you probably have an excessive clotting disorder (thrombophilia). You should be checked for the enzymes I mentioned in my long prior post, but you probably will need to go on warfarin permanently regardless of the results (even if they're negative), since it looks as though you have failed the newer direct-acting anticoagulants. Assuming it's on your insurance formulary, most physicians prefer that their patients who are on the DOAC's go on Eliquis rather than Xarelto. That's because Eliquis is twice a day, so, if there's a bleeding problem (such as you're in a car accident or have a bleeding ulcer), it's out of your system far quicker than if you're on a once-a-day medication like Xarelto. The only time I put patients on a once-a-day agent is if the insurance won't cover Eliquis, or if they're in some situation in which they can only remember to take medication once a day (such as being taken care of by a child who's only in the house once a day).

I know it's a pain in the ass, but I think you'll have to go back on warfarin, since whatever your condition is, it looks as though the DOAC's aren't addressing the problem. You will simply need to consult with a dietician to find out how diet affects your levels, and not take any medication, supplement, or vitamin without talking to your pharmacist about how it might affect your warfarin levels. Of course, if you're smoking, you must quit or die.

[gallahadesquire]

Of course, if you're smoking, you must quit or die.

Well! THAT’s putting it mildly.

 

At the hospital I worked at, the anticoagulation clinic had a system for monitoring you coats at home. You take a measure then phone it in.

 

Dr. Unicorn, isn’t there a genetic test to figure out how you’ll respond to Warfarin?

 

I was stable on 10 mg per day. It bothered them no end. Then I hit my calf on the car sill and bleed a pint or two into my calf, and went off warfarin.

[Guest]

...

Dr. Unicorn, isn’t there a genetic test to figure out how you’ll respond to Warfarin?

...

I don't think so. One thing I forgot to mention in my last post is that, in addition to what one would traditionally think of as our diet/food, alcohol also strongly affects warfarin dosing, so that may have been a factor in his wildly changing INR's. I don't know, just suggesting. Also, to addend my 1st post, I mentioned the D-dimer to rule out a DVT. While in most situations, a normal D-dimer rules out a DVT with 99% accuracy (high negative predictive value and sensitivity), when the patient is very high-risk, guidelines call for going straight to a spiral CT. Even if his symptoms don't come back on this particular flight that he's about to take, I would work on the assumption that his subsequent symptoms were probably due to DVT/PE's. I would even give serious thought to postponing any flying until I was back on warfarin and had a documented INR of over 2.

[+ FreshFluff]

Once you have the medications figured out and are stable, would it help to walk around during flights? I was on high dose tranexamic acid (which promotes blood clots) for almost four years, and I tried to do that on every flight. I also made sure I had a lot of leg room on days when I was taking TE.

[gallahadesquire]

Once you have the medications figured out and are stable, would it help to walk around during flights? I was on high dose tranexamic acid (which promotes blood clots) for almost four years, and I tried to do that on every flight. I also made sure I had a lot of leg room on days when I was taking TE.

Tranexamic acid is unknown to most physicians. I had one patient on it in thirty years and I had to educate the pharmacy on it.

[+ Billsboy4]

As I am also DVT prone, besides the good advice above, I wear compression socks.

[OneFinger]

Flew back to Portland without any problem or muscle pain. Have appointments in January with my multiple doctors. Will discuss with them my pains / weakness after flying. Very curious that I didn't have those problems on my last flights.

[Epigonos]

On long flights, five or more hours, which I do with some frequency, I ALWAYS wear compression socks.

[Guest]

Flew back to Portland without any problem or muscle pain. Have appointments in January with my multiple doctors. Will discuss with them my pains / weakness after flying. Very curious that I didn't have those problems on my last flights.

I'm glad you had no trouble this time. It's probably safest to assume, however, that you did have PE's those other times. Your symptoms are classic, and you have a history of documented PE's. If you went on a longer flight without proper protection, it could be a big problem. I just want to make sure that I have my story straight, in that all of the times you had the thigh and chest pain with difficulty breathing, you were on Xarelto, and you never had any problems when you had an INR of over 2 on warfarin...

[OneFinger]

I'm glad you had no trouble this time. It's probably safest to assume, however, that you did have PE's those other times. Your symptoms are classic, and you have a history of documented PE's. If you went on a longer flight without proper protection, it could be a big problem. I just want to make sure that I have my story straight, in that all of the times you had the thigh and chest pain with difficulty breathing, you were on Xarelto, and you never had any problems when you had an INR of over 2 on warfarin...

Went my Dr today. He felt the chest pain was NOT PE since it is not ong-going. Told me to keep track of chest pain / traveling. Since I'm already on blood thinners, he felt PE was not likely. But, I'm going to keep track and followup if it continues near flight times.

[OneFinger]

I'm glad you had no trouble this time. It's probably safest to assume, however, that you did have PE's those other times. Your symptoms are classic, and you have a history of documented PE's. If you went on a longer flight without proper protection, it could be a big problem. I just want to make sure that I have my story straight, in that all of the times you had the thigh and chest pain with difficulty breathing, you were on Xarelto, and you never had any problems when you had an INR of over 2 on warfarin...

Went my Dr today. He felt the chest pain was NOT PE since it is not ong-going. Told me to keep track of chest pain / traveling. Since I'm already on blood thinners, he felt PE was not likely. But, I'm going to keep track and followup if it continues near flight times.