Before researching the topic, I knew about rhabdomyolysis from a clinical standpoint. I had experienced caring for patients in the ICU (most of which were crush patients) who developed “rhabdo”, but was unaware of its prevalence in the non-clinical setting. Rhabdomyolysis comes from the Latin roots rhabdo meaning striated, myo refers to muscle, and lysis which means to breakdown or rupture. Put together, rhabdomyolysis is a dissolution of skeletal muscle producing a clinical syndrome that causes extravasation of toxic intracellular contents from the myocytes into the circulatory system.1 Rhabdomyolysis comes in several forms. Nonexertional rhabdomyolysis occurs after traumatic events such crush injuries, while exertional rhabdomyolysis occurs after high volumes of intense physical activity.2 Exertional rhabdomyolysis develops more frequently in athletes under heat stress and in the presence of dehydration.
Risk factors include exercising in extreme heat and humidity in a deconditioned state, and performing exercises that involve eccentric muscle contraction.3 Eichner states that the most common cause is novel overexertion: doing too much too fast of an exercise too new.4 Su classifies risk factors into factors that reduce renal perfusion such as dehydration, heat stress, sickle cell trait, and insufficient heat acclimatization, and factors that create muscle breakdown like eccentric conditioning exercises.5
Signs and acute symptoms of rhabdomyolysis are muscle pain, stiffness, fatigue, nausea, vomiting and dark colored urine with possible development of EKG changes secondary to hyperkalemia, renal failure caused by myoglobinuria.6 Disseminated intravascular coagulation (DIC) and compartment syndrome are also possible effects of rhabdomyolysis.1,5,7
Recommendations for prevention of exertional rhabdomyolysis focus on appropriate hydration before, during and after exercise with a gradual increase in intensity of work allowing for heat acclimation. Pre and post exercise body weight is a good indicator of hydration status. Preconditioning should occur several weeks before excessive exercise and should include exercising in a hot environment. This will allow the body time to improve sweating and blood flow responses, allowing for more efficient dissipation of heat.8 Increases in exercise intensity should be at a pace that allows for muscle tissue recovery.3
Treatments for rhabdomyolysis involve early detection, and then volume replacement, urinary alkalinization and aggressive diuresis. In severe cases hemodialysis may also be required to help clear toxins.1
In the case of our 2 athletes, the collegiate football player in pre-season two-a-days and the female runner training for her first marathon in Dubai my 2 best recommendations for prevention of exertional rhabdomyolysis would be the same. They would focus on adequate hydration, and on appropriate acclimation to exercising in heat and humidity. The weather in Dubai in January is similar to that of the pre-season, about 90 degrees Fahrenheit with about 65% humidity. Use of pre and post exercise body weight is a good indicator of hydration status with 1 ml of sweat loss equating to about 1 gram of body weight loss. Beginning several weeks before vigorous exertion, I would recommend lighter exercise in the heat to allow for appropriate acclimation to the heat. This will allow time for adaptation of systems that allow for better dissipation of body heat through evaporation. Other than that I would focus on education of signs and symptoms improving awareness of what to look for. This will allow for early detection and intervention if rhabdomyolysis were to present itself.
1. Criddle LM. Rhabdomyolysis: pathophysiology, recognition, and management. Crit Care Nurse. 2003;23(6):14. http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2004040053&site=ehost-live&scope=site.
2. Rosenberg J. Exertional Rhabdomyolysis: Risk Factors, Presentation, and Management. Athletic Therapy Today. 2008;13(3):11-12. http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=32160598&site=ehost-live&scope=site.
3. Brudvig TJ, Fitzgerald PI. Identification of Signs and Symptoms of Acute Exertional Rhabdomyolysis in Athletes: A Guide for the Practitioner. Strength & Conditioning Journal (Allen Press). 2007;29(1):10-14. http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=24391015&site=ehost-live&scope=site.
4. Eichner ER. Exertional rhabdomyolysis. Curr Sports Med Rep. 2008;7(1):3-4. http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=18296934&site=ehost-live&scope=site.
5. Su JK. Exertional Rhabdomyolysis. Athletic Therapy Today. 2008;13(5):20-22. http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=34180519&site=ehost-live&scope=site.
6. Cleary M, Ruiz D, Eberman L, Mitchell I, Binkley H. Dehydration, Cramping, and Exertional Rhabdomyolysis: A Case Report With Suggestions for Recovery. J Sport Rehab. 2007;16(3):244-259. http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=25999619&site=ehost-live&scope=site.
7. Sauret JM, Marinides G, Wang G. Rhabdomyolysis. American Family Physicians. 2002;65(5):907-912.
8. Criner JA, Appelt M, Coker C, Conrad S, Holliday J. Rhabdomyolysis: the hidden killer. Medsurg Nurs. 2002;11(3):138. http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2002077744&site=ehost-live&scope=site.
Tags: Acclimatization, Dehydration, Heat Illness, Renal Failure, Rhabdomyolysis
Short sale in San Diego wrote on May 1, 2010 at 12:40 am
Intriguing, how do I apply this?
Matt Trudo wrote on May 4, 2010 at 10:41 am
Strategies for application are in the last paragraph of the blog. Basic strategies on avoiding this potential life threatening condition reside in staying hydrated in during extreme exertion, and in developing a certain level of heat acclimation if you are going to be exercising in the heat. Those two strategies will go a long way in avoiding exertional rhabdomyolysis.
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