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Exertional Rhabdomyolysis

By Art Horne

This past week I blogged about Rhabdo in an effort to raise an awareness between collegiate Sports Medicine and Strength Staffs as we begin to enter basketball pre-season across the country; this after 19 high school Oregon football players were treated for what appears to be Exertional Rhabdomyolysis.

Below is a summary of three articles outlining the cause, treatment (refer) along with some prevention points that should be reviewed by both the basketball athletic trainer and strength coach prior to beginning your fall training programs.

Key Points / Cliff Notes Version (modified from Clarkson)

1. “Exertional Rhabdomyolysis is the degeneration of skeletal muscle caused by excessive, unaccustomed exercise.  Symptoms of rhabdomyolysis include muscle pain, weakness and swelling; myoglobinuira (presence of myoglobin in the urine); and increased levels of muscle enzymes and other muscle constituents in the blood.”

2. Myoglobin in the urine causes your urine to become dark in color similar to cola.  “In rare cases, myoglobin can precipitate in the kidneys and cause renal failure” and ultimately death.

3. Severe episodes tend to occur at the beginning of a training program (think freshmen joining your otherwise veteran team), when exercise is extreme or excessive (boot camp style or circuits with repeated bouts to failure), and when accompanied by heat stress (summer or fall workouts) and dehydration (I would be willing to bet that the majority of our basketball athletes are more often than not, not properly hydrated).  “Insufficient acclimatization, inadequate diet and lack of specific physical conditioning may also contribute to this condition.”

4. “Certain individuals may be predisposed to rhabdomyolysis, possibly due to a latent metabolic disorder.”


What is it?

Rahabdomyolysis is defined as “a degeneration of muscle cells and is charactierized by a group of conditions including muscle pain, tenderness, weakness, and swelling; myoglobinuria (presence of myoglobin in the urine); and increased levels of sarcoplasmic (muscle) proteins and other muscle constituents in the blood.” (Clarkson)

“One of the proteins released from damaged muscle cells is myoglobin.  High levels of myoglobin in the blood (myoglobinemia) result in a “spill over” of myoglobin into the urine (myoglobinuria).  In certain situations, myoglobin can precipitate in the kidneys and cause renal failure.” (Clarkson)

“Equally dangerous can be the leakage of potassium into the bloodstream, which under certain circumstances can interfere with propagation of the heartbeat.  Another danger is posed by the possible leakage of excessive calcium into the cell, creating a state of hypocalcemia in the bloodstream, which can lead to irregular heartbeat, muscle spasms, and other symptoms.” (Claps)

Signs and Symptoms

• Symptoms of Rhabdo include: persistent muscle pain and weakness, swelling and dark urine (tea or cola colored).  
• These symptoms at first may present similarly as a case of delayed-onset muscle soreness (DOMS), however,  change in urine color and severe muscle pain often set this condition apart and should be taken very seriously.

Prevention

• During the first few days of training camp or return to school (either summer training or fall classes) never begin your program with repetitive, excessive exercise.  Strenuous activities, circuits or “mental toughness” training should only be conducted with well-conditioned athletes.
• If ambient temperature is hot, be sure to have your athletes drink plenty of water or provide additional water breaks during the training. 
• Athletes should never try to manipulate their diet suddenly heading into camp or pre-season training in an effort to lose weight or reach a goal weight set by coaches.  Any manipulation in diet should be monitored with lower intensity exercise first to make sure the athlete responds well before exposing them to strenuous exercise.
• If your athlete reports dark urine a day or two after an exercise session report them to your team physician or sports medicine staff immediately.
• If your athlete reports feeling dizzy during an exercise session, especially those in warmer weather, have them stop and rest immediately. 
• Know your athletes. Get complete medical histories of each basketball athlete you work with and discuss with your athletic trainer/strength coach who may be at risk after evaluating their baseline assessment/testing prior to beginning strenuous exercises.
• Progress training slowly.  Back off training if DOMS seems severe – don’t automatically assume your athlete  didn’t train during the summer, or are wimps.

Take Home Message

Specificity of training is important.  Just because your athlete has been playing pick-up ball all summer doesn’t mean that they are ready to endure a circuit of max dips followed by max  push-ups finishing with max tricep extensions.  Summer pick-up does not provide “protection” against this type of exercising.  Ease into max effort drills slowly. 

Ego Trip. In a world where toughness matters and quitting an exercise before your team finishes simply is not an option, some individuals will go well beyond a tolerable level of muscle injury in an effort to impress their coaches and teammates.  Start freshmen or lower trained athletes with lower weights than their older counterparts when doing circuits until a reasonable amount of adaptation and fitness has occurred.

An Ounce of Prevention.  Most reported military cases of “heat stress, rhabdomyolysis and acute renal failure have occurred during the first few days of training during which excessive repetitive exercises (e.g., push-ups, squat jumps) have been used.   In the college setting, repetitive, strenuous exercises should be limited or avoided until a base level of fitness can be established.

“Most cases of rhabdomyolysis do not require hospitalization, and individuals recover within one week.  However, in certain individuals, rhabdomyolysis can be severe.  The combination of heat stress (hyperthermia) and rhabdomyolysis can produce acute renal failure, which in rare instances can result in death.” (Clarkson)

 

References

Brudvig, T. and P. Fitzgerald, 2007. Identification of Signs and Symptoms of Acute Exertional Rhabdomyolysis in Athletes: A Guide for the Practitioner. Strength and Conditioning Journal. Vol 29, 10-14.
Clarkson. P. 1993. Exertional Rhabdomyolysis and Acute Renal Failure.  Physiology. Vol 15, Number 3, 1993.
Clap, F. 2005. Exertional Rhabdomyolysis. Strength and Conditioning Journal. Vol 27, Number 3, 73-74.