What is Rhabdomyolysis and Why Should Young Athletes Care?

When Texas Women’s University junior Briley Cole experienced an unusual delayed pain following the annual fitness test for her competitive volleyball team, she knew something was off. Cole was actually one of eight players from her team that wound up hospitalized last year for a rare condition called rhabdomyolysis (also known as rhabdo), which, in their case, was induced by extreme muscle strain during exercise.

Last week, a grueling workout that included “an hour of continuous push-ups and up-downs” sent three University of Oregon football players to the hospital with the same condition, their strength coach receiving a one-month suspension following the incident. In 2013, six Ohio State University women’s lacrosse players were hospitalized with rhabdomyolysis after their team had undergone an intense, new workout. And a strenuous regimen of squats, sled pushing, sprints and upper body exercises was enough to send 13 members of the 2011 University of Iowa football team to the ER, their rhabdomyolysis so acute that some even required dialysis. These are just a few of several reported cases in recent years.

What went wrong in the training of these athletes? The key to understanding requires a closer look at this condition, which—although rare—is entirely preventable and should never have happened.
Rhabdomyolysis is a destruction of skeletal muscle that can happen when the body is pushed too hard, too soon. While the condition may also have other causes, the focus of this article is extreme muscle strain, the likeliest culprit in young athletes. Extreme muscle strain can come from performing new exercises, too many sets and reps of an exercise, too many “negative” reps of an exercise, too much training to failure, or too high a level of exercise after a training layoff of even just a few weeks.

Extreme muscle strain actually damages the muscles. The damaged muscle membrane and connective tissue framework dumps a muscle protein called myoglobin into the blood stream. A myoglobin tsunami then reaches the kidney and blocks its filtration system, which can lead to kidney failure. When the myoglobin levels are this high in the blood, the myoglobin spills over from the kidney into the urine. As an indicator, the urine becomes tea color, brown or even the color of Coca Cola. This is a very bad sign for which people should seek immediate medical attention. Patients may be admitted into hospitals for intravenous fluids to keep the kidney filtration going, and some of them will need dialysis for days or weeks.

A muscle enzyme known as creatine kinase (CK) can also elevate in the blood from muscle damage. While this enzyme can elevate after any tough workout, it doesn’t necessarily mean you have rhabdomyolysis. In cases of rhabdomyolysis, the creatine kinase is incredibly elevated. A study of military personnel with rhabdomyolysis found the length of hospital stay related to the elevation of creatine kinase – the higher the creatine kinase levels, the longer the hospital stay. Thirty cases of rhabdomyolysis had a range of stay from one to eight days and 20 percent had acute kidney damage.

Such intense muscle damage also dumps the electrolyte, potassium, into the blood at an extremely high, pathologic level that could cause a heart attack and even death. A police recruit recently died in training, reportedly from rhabdomyolysis.

And while it is often misconstrued as a form of dehydration, the two are separate ailments that may or may not occur at the same time.

The damaged muscle may also swell, which—if occurring in a small anatomic compartment—may result in a compartment syndrome. The high pressure in a compartment syndrome is an emergency, and the compartment must be surgically decompressed (opened) before its structures (i.e., nerves and blood vessels) are crushed and permanently damaged or die.

Those who develop rhabdomyolysis experience severe muscle pain and stiffness, and sometimes describe having flu-like symptoms. Blood and urine tests confirm the diagnosis, after which time is required for the muscles to heal. Resuming activity or training too soon can lead to further muscle damage.

Fortunately, this is an avoidable problem gaining more attention, which I hope will lead to improved education to avoid it. The President of the National Strength and Conditioning Association stated, “This type of injury is 100 percent avoidable. This should have never happened. That’s absurd. People need to understand that rhabdo is not inherent with training. It’s a good indicator of a training program that is inappropriate.”

Many of us have sons and daughters who go off to college to compete in sports while earning their degrees. Sports represent a major revenue stream for these schools, so the pressure to win is high for both student athletes and their coaches. Coaches may become a little overzealous when trying to find that winning edge, but they don’t set out to injure young athletes. It’s a balance that’s very difficult.
These rhabdomyolysis injuries also reveal the individuality of the athletes. Some will develop rhabdo and some won’t. Some will have lesser degrees of the condition than others, but the bottom line is rhabomyolysis needs to stop through education and oversight.

As Dr. Kelsey Logan, a university-affiliated physician who serves on the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports said, “There are two reasons why this is important. One is that rhabdo can have potentially serious consequences: renal failure, compartment syndrome, death. Those are fairly serious. And the second thing is we know there are certain circumstances under which this is more likely to occur, and with fairly simple educational and practical techniques for prevention, those circumstances can be lessened so much.”