Understanding Rhabdo: Why You Should Take Exertional Rhabdomyolysis Seriously

While it feels as if high school football season has just ended, many high schools and universities have already started rigorous off-season training programs. Spring sports are ramping up their preseason workouts, and countless additional athletes are starting aggressive new gym regimens to hold true to their new year’s resolutions.

Overtraining has countless psychological, physical, and medical risks. Recently, three collegiate football players from the University of Oregon were admitted to the hospital and diagnosed with rhabdomyolysis after “grueling strength and conditioning workouts” on campus.

Exertional rhabdomyolysis (ER) or “rhabdo” is a rare, yet serious, and potentially fatal, condition if not recognized and treated appropriately. It is defined as the breakdown of normal skeletal muscle fibers due to injury or exercise. Exercise to create this reaction is typically excessive, repetitive, or prolonged, and outside of the athletes accustomed training regimen.

The muscle fiber breakdown results in the release of muscle contents into the blood which then circulate throughout the athlete’s body. These components may overwhelm normal filtration of blood, leading to injury of the kidneys. Additionally, imbalances in circulating electrolytes place the athlete at risk for abnormal heart rhythms and even death.

The severity of ER is directly related to the amount of muscle injury and breakdown. There is an increased risk of ER after excessive muscle exertion in athletes who are dehydrated, using certain medications or nutritional supplements, or exposed to extreme heat.  Additionally, athletes with sickle cell trait also carry a unique risk for this condition. While it is safe for athletes with sickle cell trait to participate in sports they may benefit from a personalized plan to increase their training intensity.

Symptoms begin with severe muscle pain, swelling, weakness, cramping, and fatigue during or after an overly intense workout. These symptoms are typically out of proportion to normal post-exercise soreness and do not rapidly improve after stopping exercise. The athlete will likely notice dark “tea” or “cola” colored urine as muscle components are filtered through the kidney. With these symptoms, an athlete should go to an emergency room where blood tests will assist in diagnosis and early treatment can begin.

Treatment includes rest from the offending activity and very aggressive hydration, usually requiring IV fluids, as more fluids are required than can be taken by mouth. As symptoms and blood tests improve the athlete is not out of the woods yet and requires a gradual return to sport. Plan to do so safely and to minimize the risk of further episodes. While each medical staff may have their own specific program for return to play, all should include a period of light exercise, at the athletes own pace, in a temperature-controlled environment. This should be followed by a gradual return to sport specific activities. The athlete should avoid max lifting and competitive or timed drills until appropriately conditioned back to their normal level of exercise.

Early and accurate recognition and treatment of exertional rhabdomyolisis is imperative to the management of this condition. Prevention of ER is just as important, by being appropriately conditioned for each workout.

Athletes should gradually build into intense pre, or off, season workouts. Any increase in exercise intensity should be met with an appropriate increase in hydration and nutrition to appropriately fuel the athlete. The Sports Medicine team at Nationwide Children’s Hospital includes physicians, athletic trainers, and dietitians to provide guidance and help prevent and treat exertional rhabdomyolysis and other conditions.

Jonathan Napolitano, MD
Jonathan Napolitano, MD, is our Sports Medicine Fellow for 2016-2017. Originally from Northeast Ohio, Dr. Napolitano grew up playing soccer, basketball and lacrosse. He attended Georgetown University where he competed on the men's lightweight crew team and studied health care management and policy. He returned to Ohio for medical school at the University of Toledo and completed his internship in Grand Rapids, Michigan. Dr. Napolitano's completed his residency in Physical Medicine and Rehabilitation at Loyola University in Chicago, with training in adult and pediatric musculoskeletal and neurologic medicine. During residency, he was actively involved in student education, clinical research and administrative responsibilities in his role as chief resident.Dr. Napolitano’s research interests include the management of back pain and emerging technologies in diagnosis and treatment of tendonopathies.He is an active member of both the American Academy of Physical Medicine and Rehabilitation and the American Medical Society for Sports Medicine, currently serving as the fellow liaison to the membership committee.

2 thoughts on “Understanding Rhabdo: Why You Should Take Exertional Rhabdomyolysis Seriously

  1. Susan Wood on said:

    Please include that this can turn into Compartment Syndrome. My son developed Rhado last summer and had emergency surgery to relieve the pressures in his muscles. Thankfully Drs. were able to save his muscles from begin permanently damaged.

    1. Diane Lang on said:

      There are many potential complications of exertional rhabdomyolysis. We stress the importance of early presentation to a health care provider for complete evaluation and testing.

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