4 Things You Didn’t Know About Rhabdomyolysis (aka Rhabdo)

A few years ago, a weird-sounding condition called rhabdomyolysis got a lot of attention as a scary—and possibly lethal—side effect of very intense workouts, like CrossFit. If you were into this kind of thing, you may have gotten a little nervous. If not, you probably moved on with your life.

But in July, The New York Times reported on an increase in cases of rhabdomyolysis from spin class, bringing it back into the limelight. What was once a condition reserved in people’s minds for the most hardcore has now left us all wondering: “Could it happen to me?”

Rhabdomyolysis, also known as rhabdo, is essentially muscle breakdown. When you exercise, some muscle breakdown is normal, and part of the process of getting stronger, explains Nayan Arora, M.D., a nephrology fellow at the University of Washington.

When people overstress their muscles, they are at risk for the muscle tissue breaking down so much that it releases the protein myoglobin into the bloodstream. Myoglobin is toxic to the kidneys, which is why rhabdo can lead to kidney damage or complete kidney failure if left untreated, Arora explains.

While rhabdo is serious—and seriously terrifying—it’s still pretty rare, he says. That means you shouldn’t let it stop you from exercising—but you should have it on your radar. Here are four things that you need to know about rhabdomyolysis.

1. It’s not just from hardcore workouts.

Arora says there has been a slight uptick in cases of exercise-related rhabdo, likely as a result of the rise in popularity of grueling workouts, from high-intensity interval training to spinning and ultrarunning. But muscle exertion isn’t the only cause. The condition can also be a result of alcohol abuse, medications including statins and prednisone, illicit drug use, muscle diseases, trauma, certain health conditions and genetic issues, seizures and immobility, research shows.

Rhabdomyolysis was studied extensively for the first time during World War II, when researchers examined soldiers with crush injuries from the 1940 London Blitz, says Arora.

“Interestingly, rhabdo-like symptoms are mentioned in the Bible. When the Jews were crossing the desert they were eating large amounts of quail,” he says. Researchers believe the birds may have eaten hemlock, resulting in rhabdomyolysis from accidental hemlock poisoning.

Exercising in hot, humid conditions or while taking creatine supplements, ephedra diet pills, or energy drinks with high doses of caffeine also increases your risk, says Arora.

2. Dehydration puts you at a higher risk.

Usually, doing a tough workout alone won’t land you in the hospital, says Arora. Most people who get rhabdo from exercise were doing something really intense and didn’t drink enough water before and during whatever activity they were doing.

“Going all the way back to 1940 with victims of crush injuries, it was people who didn’t have access to water who had the highest risk,” says Arora.

That’s why IV fluid is the No. 1 rhabdomyolysis treatment to prevent kidney damage, he says. To protect yourself from getting rhabdo in the first place, make sure you hydrate, hydrate, hydrate.

How much water you should drink depends on a lot of factors, including your weight, fitness level and the foods you eat during the day, says Arora. But a good rule of thumb during exercise is to drink some water every time you take a break—and to give yourself those breaks even if you’re in a class that doesn’t encourage rest.

3. You won’t pee blood.

One rhabdomyolysis symptom is red or brown urine, which patients often mistake for blood, says Arora. What looks like blood is actually myoglobin, that toxin that can lead to kidney damage. When this happens, your condition has gotten serious, and it’s important to seek medical help right away, he says.

4. It can take three days to set in.

You might expect to know shortly after, or even during, a workout that something is wrong. But rhabdo usually peaks at 24 to 72 hours after a workout or injury, says Arora. Delayed-onset muscle soreness, or DOMS, is normal after a tough workout, and it can sometimes be hard to differentiate between DOMS and rhabdomyolysis, he says.

If you experience muscle pain or weakness in one muscle group that seems out of proportion to the workout, it could be rhabdo, says Arora. Swelling or a cramp-like sensation that won’t go away, especially in one muscle group, are other possible signs. If you’re sore all over, you’re probably OK, but it’s always better to err on the side of caution if you’re concerned, he says.

Rhabdomyolysis Treatment and Prevention

If you think you may have rhabdomyolysis, get yourself to an emergency room right away. Rhabdo can be fatal if left untreated, says Arora.

“Basically, the whole point of treatment is to prevent you from getting kidney damage, and the way to do it is with huge doses of fluids,” he says.

Depending on the extent of toxins released, IV fluids are usually given for two to five days. At that point, most people will have recovered. A provider will recommend patients take an exercise break. This could be a couple of weeks to a couple of months, but will depend on many factors, including the severity of the condition and a person’s fitness level. Easing back in with a provider’s guidance is always recommended, Arora says.

The Takeaway

At the end of the day, no workout is worth dying over. Listen to your body, ease into new workouts, pay attention to hydration, take regular breaks and seek help right away if something feels wrong after a workout, says Arora.

Symptoms

Symptoms of rhabdomyolysis can vary depending on the extent of your muscle damage; however, the classic symptoms are severe muscle pain with weakness to the point you will have trouble moving your arms or legs, and you may experience dark red or brown urine or decreased urination. Additionally, local symptoms around the injured area can include muscle pain, weakness, swelling, extreme soreness, stiffness, cramping, bruising, and tenderness. You can also experience an overall sickly feeling with fever, abdominal pain, nausea, and vomiting. Occasionally changes in mental status, such as confusion or loss of consciousness can occur.

Diagnosis

Physicians use laboratory tests that detect excess muscle proteins and enzymes in the blood and urine to diagnose rhabdomyolysis. A careful history and physical exam may reveal the underlying cause or at least aid in the selection of the most appropriate diagnostic workup.

Complications

Complications from rhabdomyolysis can be numerous and severe. As the toxic fluids pour into the bloodstream from damaged muscle tissue it can affect not only local tissue but also organs throughout the body. More locally, compartment syndrome can occur when increased pressure builds up within a muscle compartment resulting in decreased oxygenation to the local tissues. Irregular heartbeats and even cardiac arrest can occur from electrolyte dysfunction as well. For example, a patient may experience high levels of potassium in the blood, which can cause an irregular heartbeat. Muscle byproducts can also cause liver dysfunction, which occurs in approximately 25% of rhabdomyolysis cases. Other complications include increased blood clotting, low blood pressure, and shock. Kidney failure is also one of the most serious complications in the days following the initial presentation of rhabdomyolysis.

Permanent kidney injury and even death can occur as a result in very severe cases.

Treatment

After muscle damage has occurred, the main treatment of rhabdomyolysis includes aggressive fluid resuscitation (IV fluids) to avoid kidney injuries. Once in a hospital setting, aggressive fluid resuscitation will continue along with a careful history and physical exam to identify and manage any complications. Management of complications can include cardiac monitoring, medications to correct electrolyte imbalances and irregular heartbeats, surgery to alleviate elevated pressures in an extremity, physical therapy, close monitoring of kidney function, and use of dialysis in severe cases of kidney injury.

Recovery

Recovery from rhabdomyolysis varies and depends on the degree of muscle damage and the specific complications that occurred. If the condition is recognized and treated early, you can avoid most major complications and expect a full recovery. Recovery from exercise-induced rhabdomyolysis, with no major complications, can take several weeks to months for the patient to return to exercise without recurrence of symptoms. More severe complications, such as those often seen in compartment syndrome, can result in multiple operations, months of rehabilitation, and permanent disability. Additionally, the kidney dysfunction that results from rhabdomyolysis often resolves, however, if you experience severe kidney injury it can result in permanent damage and a need for long-term treatments, perhaps even dialysis.

Prevention

Prevention is geared toward avoiding what causes rhabdomyolysis; but you can only avoid what you have control over. You cannot always prevent an accident or injury; however, you do have control over exercise-induced rhabdomyolysis. Exercise-induced rhabdomyolysis can be prevented by initiating a gradual training program with sufficient recovery time included, avoiding extreme exercises, preserving fluid balance, and not exercising in high heat and humidity.

A rare condition

Luckily, rhabdomyolysis is a rare condition, especially since it can have serious and long-lasting complications. While you cannot always avoid an injury, patients can steer clear of the complications by minimizing the risk factors that they can control. If a crush injury occurs or if you experience the symptoms of rhabdomyolysis, the best results will come if a physician promptly identifies and treats the condition.

Author: David Barnes, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 3, Summer 2018.

What’s to know about rhabdomyolysis?

Most cases of rhabdomyolysis are considered a part of crush syndrome, a condition that occurs as the result of traumatic skeletal muscle injury. But generally, anything that causes muscle injury, dehydration, or kidney injury increases a person’s chances of developing the condition.

Many cases not caused by direct trauma are considered to be the result of several different factors.

Researchers are still exploring the full range of factors that may influence the risk of rhabdomyolysis. Currently, cases of rhabdomyolysis are classified as one of the following:

  • acquired
  • the result of external injury, infection, or substances
  • inherited, caused by genetic conditions such as muscular myopathies

There are many causes and risk factors for rhabdomyolysis that are currently recognized. These include the following:

  • crushing damage to skeletal muscle tissues
  • not being able to move for a prolonged period of time
  • overexertion of muscles
  • heatstroke or overexertion in extreme environments
  • hypothermia
  • extensive burns that cause muscle damage
  • hereditary muscle disorders known as metabolic myopathies
  • dietary supplements or weight-loss supplements, especially those containing ephedra and creatine
  • infections, in particular bacterial and viral infections that cause blood infections
  • electrolyte disorders, especially those affecting potassium and calcium
  • endocrine disorders, such as hypothyroidism and hyperthyroidism
  • kidney disease or disorders
  • heart attack or stroke, which can lead to muscle injury and not being able to move
  • vascular or cardiac surgery, which often causes muscle damage and requires long periods of immobilization during and after it
  • sickle cell anemia
  • inflammatory muscle conditions

Another possible cause is exposure to toxins, such as excessive or long-term alcohol or drug use. This also includes exposure to environmental toxins, including reptile or insect venom, mold, and carbon monoxide.

Certain medications can also lead to rhabdomylosis. For example, the condition is estimated to arise in an estimated 0.3 to 13.5 cases out of every 1 million statin prescriptions made. Other medications include anti-psychotic medications and those used to manage muscular conditions such as Parkinson’s disease.

Rhabdo and CrossFit

Why Should I Care About Rhabdo?

Because it can kill you. Rhabdomyolysis (rhabdo) is a rare but serious health condition sometimes caused by working out at very high intensity. CrossFit workouts, just like all high intensity workouts, have the potential to cause rhabdo under the right circumstances. Rhabdo is very, very rare. You’re more likely to spot a Bigfoot playing cards with Elvis than to ever cross paths with rhabdo. But even though it’s very rare, it’s also very serious. So reading this article is an important step towards keeping you safe while still experiencing all the great things CrossFit has to offer.

If you feel terrible after a workout, then the next day extreme swelling and soreness starts, and then you start peeing brown urine—you have rhabdo. Go to the ER immediately. This is no joke. It can be fatal if not treated. Rhabdo happens when your muscles break down to the point that muscle tissue enters your bloodstream. Your kidneys can’t handle this. They freak out and eventually shut down. This is how rhabdo can be fatal—kidney failure. The most important thing you can learn fom this entire article is this: If you experience dark urine after a grueling workout, then go to the ER immediately.

Brown Urine is a Symptom of Rhabdo

What are the Symptoms of Rhabdo?

  • extreme muscle pain and soreness
  • swelling
  • difficulty moving the affected muscles
  • weakness in the affected muscles
  • dark urine (brown, cola-colored)

Dude, I get extreme soreness and muscle pain after every workout…

I understand, believe me. Some muscle soreness is simply a part of exercise. But if you have rhabdo, the soreness will reach a whole new level. You’ll be almost unable to move the affected area, and you’ll feel like you got hit by a truck. But yes, we’re all a little sore after most workouts. That’s not rhabdo. Be on the lookout for dark urine. That’s the tell-tale sign you actually have rhabdo, and not the usual muscle soreness.

What type of workouts cause rhabdo?

Using light loads for many, many repetitions in a long workout is the usual culprit. Performing many reps of one movement in a row without changing movements or resting can also be a factor. However, heavy lifting generally does not cause rhabdo. Lifting heavy loads forces you to stop before severe muscle breakdown occurs. For example: performing 5 sets of 5 squats at a heavy load is not a workout that carries a rhabdo risk. However, performing 1 set of 100 squats as quickly as possible with a light load would carry a rhabdo risk.

Who generally gets rhabdo?

Not many people at all. Rhabdo is very rare. It’s like the opposite of winning the lottery. It’s highly unlikely, but if it does happen, the consequences are severe. Classic literature often tells us that men have higher risk of rhabdo than women. While this is historically true, I think this may be rooted in past social norms, and not biology. As CrossFit continues to build strong, determined women, they too need to be cognizant of rhabdo. Next, rhabdo usually strikes someone who has been away from intense exercise for a while and then jumps back in with too much volume and intensity. Someone who has been very fit in the past and has taken six months off must ramp up volume slowly as he returns to intense exercise. This type of athlete has the mind and the determination to push himself beyond his body’s capabilities—where rhabdo lives.

What movements cause rhabdo?

Well, there’s no magic movement that always causes rhabdo. But some movements are higher risk than others when performed by new athletes or when performed to excess repetition. These are usually movements with a demanding eccentric motion. Stay with me. This really isn’t too complicated. Most movements have two parts: an eccentric part and a concentric part. Eccentric means that muscles are stretched under load. As you lower into the bottom of a squat, you are performing the eccentric portion of the squat. Your hamstrings are lengthening under load. Concentric means that muscles contract under load. As you drive out of the bottom of the squat you are performing the concentric portion. After being stretched, your hamstrings are now contracting and driving the load upwards. Eccentric motion is very demanding on muscles. Stretching muscles under a load with lots of repetition can cause the muscle breakdown that triggers rhabdo. Here are a few examples of movements with a strong eccentric portion: jumping pullups, GHD situps, walking lunges. Now these are all excellent movements that have their uses in building a strong and healthy body. Just don’t jump into doing hundreds of them, unless you’re a strong and experienced athlete that has worked up to that level of ability.

Below is a case study that can help us learn about rhabdo.

In January 2011 the University of Iowa football team returned to training from a three week winter break. On Thursday about 85 players performed a workout that involved 100 back squats at 50% of 1-rep max followed by a series of sled pushes, all done as quickly as possible. This same workout had been performed by the team in previous years with no ill-effects–once during late spring training and once during the fall after a one-week break. Later Thursday evening many of the players felt extreme soreness. On Friday they performed another workout focusing on the upper body, with a similar rep scheme. They then had the weekend off before returning for another light workout on Monday that involved calisthenics and stretching. By Monday night 13 of the 85 players were admitted to the hospital suffering rhabdomyolysis. What can we learn from this? By the way, I’m not interested in finding blame or criticizing anyone in hindsight. I’m interested in learning how to prevent future rhabdo injuries, so shelve the judgment and focus on learning.

  • Warning Sign: Athletic, strong, mentally-determined men who just took three weeks off from training
  • Warning Sign: Light load performed for high repetitions (100 squats at 50% 1RM)
  • Warning Sign: Team atmosphere where each player would push himself to his limits

Let’s also look at some of the details of how the situation unfolded:

  • Delayed onset: Players experienced extreme soreness the same night of the workout, but many did not realize hospitalization was necessary until four days later.
  • You can have rhabdo and still workout: Many players performed more workouts between the rhabdo-inducing workout on Thursday and hospitalization on Monday.
  • Stretching and calisthenics were the last straw: Rhabdo often is not fully realized until immediate swelling subsides and myoglobin from the affected muscles begins to flood the blood stream. Stretching can make this release of myoglobin even worse. Many of the players were not hospitalized until after the light workout on Monday that involved stretching.

How do my coaches at CrossFit Impulse help me prevent rhabdo?

First, they provide you a program that limits the risk of rhabdo. Every workout we perform has been evaluated for rhabdo risk. Next, they know how to identify at-risk athletes and prevent rhabdo before the workout begins. Scaling workouts to your ability level is also important in preventing rhabdo. Your coaches will provide you several suggested scaled versions of the workout and help you select one that is right for you. Your coaches may modify the workout on the fly or simply tell you to stop working if your movement patterns display a high risk of rhabdo during the workout. Finally, time cutoffs are used judiciously during high intensity work to ensure you are not under stress for too long. All of these measures limit the risk of rhabdo, but they cannot eliminate it. Each athlete must still take her own preventative measures.

What should I do to prevent rhabdo?

  • Gradually build up volume and intensity in your workouts, especially after a long break from exercise. Your first workout after a break in training should get your heart rate up and allow you to do some work, but it shouldn’t be crushing. You should leave the gym feeling better than when you arrived. Note that there is a time and a place for workouts that push your limits. Your first day back after a cruise to the Bahamas is not that time and place.
  • Even if you have been exercising regularly, jumping to a much higher intensity too suddenly can be dangerous. This doesn’t mean that you should not work out at high intensity. This means that you should ramp up your intensity slowly, over several weeks or even months.
  • Don’t fear putting weight on the bar. Lifting heavy weight forces you to stop and prevents rhabdo. Rhabdo comes from performing way too many reps at a light to medium load.
  • Listen to your coach. Your coach is your co-pilot for training. When you press the gas pedal to the floor with reckless abandon, your coach is there to prevent a catastrophic crash. He can’t ultimately control the vehicle. You’re the pilot. But he will exert as much influence as you will allow, so trust him and allow him to guide you.
  • Give your coach information. Your coach doesn’t live in your shirt pocket. He doesn’t know that you drank a thimble of water over the past two days and ran a half-marathon for fun after yesterday’s deadlifts. Be honest with your coach about how you feel that day. You’ll get thoughtful concern in return—not scolding—I promise.
  • Hydrate before, during, and after your workout. Does that mean you should visit the water fountain during short metcons? Sometimes. If you hydrate adequately before your workout, then you probably don’t have to visit the water fountain during a 10-minute effort. If you didn’t hydrate well prior to beginning your workout, then you should indeed visit the water fountain as much as needed. But this isn’t always necessary if you drink water throughout the day. For a 20-minute workout or more, get some water during strategic rest breaks. And after the workout is over, drink copious amounts of water–always.
  • Even if you and your coach does everything right, sometimes the perfect storm of circumstances can conspire against you. That’s why it’s important that you know the warning signs, symptoms, and what to do if you think you have rhabdo.

What should I do if I think I have rhabdo?

Start drinking water and go to an emergency room– immediately. Rhabdo can be fatal. This is very simple: If you have dark urine then go to the ER, because if you don’t then you could die. I’m not trying to be dramatic. I’m just being blunt.

I have rhabdo. What now?

The fact you’re able to ask that question is a good sign. It means you’ve identified your condition, and presumably have sought help from a hospital. The good news is that almost all rhabdo victims that seek treatment make a 100% recovery. You’ll be in the hospital a few days sucking down fluids while your kidneys flush the toxins. After that you’ll get released and take a little break from working out. After your doctor clears you, then you can start working out again at very low intensity. You can eventually ramp up your intensity (slowly) until you’re training at full intensity again.

Well now I’m scared of stepping into the gym and doing anything…

Is it possible for us to be part of a horrible car accident that puts us in the hospital? Absolutely. Every day we drive, we take that risk. But we all drive. Because we know that if we do our part to keep ourselves safe, and we work with others who have our safety in mind, then we can avoid most catastrophic crashes. So we drive and we usually avoid calamity. Such is the case with exercise and rhabdo. Rhabdo is extremely rare. Yes, if we get behind the wheel and act like a maniac and ignore the advice of professionals, we can create the rhabdo car crash. And unfortunately, even if we do our part and do everything right, if the odds strike us just right, then we could end up in a crash. But when executed properly, the odds of catastrophe are far outweighed by the positive effects we get from training. So there’s no need to be scared of rhabdo. You and your coaches are actively working every day to give you a well-coached program that keeps you safe while responsibly pushing your limits and achieving your goals. But part of that safety mechanism is educating you. So if the worst happens now you know how to identify rhabdo, and you know what to do. I hope this education has helped you feel more comfortable about exercising at high intensity. You are now empowered with knowledge. You are working with coaches who are also empowered with knowledge, and they are actively working to protect you at every turn. I hope that is liberating. See you in the gym.

What is it?
“Exercise-induced hematuria” is a benign condition in which blood is present in the urine (“hematuria”) following exercise. This has also been called “runner’s bladder,” “marathoner’s hematuria,” and “stress hematuria.”

Causes
Exercise-induced hematuria may have various causes, ranging from relatively harmless ones to more worrisome ones. In general, if the urine clears 72 hours after exercise, there is no need to further investigate. However, some causes do need to be investigated, particularly if the blood in the urine keeps appearing, or does not clear after 72 hours. Sometimes, the breakdown products of red blood cells and muscles may appear in urine, making the urine appear much darker, and this may be mistaken for actual blood. Some foods may color the urine reddish, and some medications, such as blood thinners, may lead to actual blood in the urine. For most cases of exercise-induced hematuria, the causes are related to the intensity and duration of activity, as well as the hydration status of the athlete. Longer and more intense events have been known to more likely cause hematuria. It is most common in runners, especially those running more than 10,000 meters. Sometimes, hematuria is related to a traumatic injury, such as a direct blow or a fall.

Risk Factors
Risks of developing hematuria after exercise include long endurance events, very intense events, and/or poor hydration. Weight-bearing, intense activities appear to place an athlete at higher risk than other, less weight-bearing, forms of exercise. Any of these factors alone or any combination of them may result in hematuria. Any direct impact to the kidneys, bladder or urethra could potentially cause traumatic hematuria as well. Hematuria in itself can be caused by other factors apart from exercise, such as urinary tract infections, the presence of a stone in the urinary tract, kidney disease, among others; athletes with such conditions may be at higher risk of exhibiting blood in their urine after exercise. As above, taking some medications may predispose an athlete to exhibiting blood in his/her urine.

Symptoms
Apart from having blood in the urine, athletes with exercise-induced hematuria usually have no other symptoms. Occasionally, athletes will have pain just above the front region of the hip. If the hematuria is related to direct trauma, then pain at the site of impact is expected.

Sports Medicine Evaluation
The sports medicine physician will perform a thorough history and physical exam of the athlete, often focusing on the genitourinary and gastrointestinal systems of the patient. Evaluation of a urine sample is needed to investigate hematuria. This will be done with both a urinalysis (which looks for abnormal urine contents) and with a microscope, for a more detailed look at the urine. Further investigation may be needed depending on the results of these tests. Athletes may require repeat urinalysis testing until their hematuria has resolved. In cases where trauma is involved, imaging such as a computed tomography (CT) scan or ultrasound may be needed.

Treatment
In cases where there is no trauma, exercise-induced hematuria usually resolves within 24-72 hours of rest after the athletic event. In these cases, no specific treatment is necessary. If hematuria persists longer than 72 hours or continues to occur with strenuous exercise, further investigation may be needed. In cases where trauma is involved, treatment will depend on the severity of the trauma.

Injury Prevention
Recommendations for preventing hematuria include staying well hydrated and running with a bladder that is not completely empty. In contact sports, wearing the proper protective equipment is necessary.

Return to Play
In cases where there are no symptoms, athletes may return to play if the hematuria has resolved within 72 hours. If not, medical clearance from health care personnel is advised. In cases where trauma is involved, returning to play may take longer and will depend on the severity of the injury.

AMSSM Member Authors
Matthew Hilton, DO and George Pujalte, MD

Brown urine 3 days later

edit by Ops wife: I took to er when I got home. He has an iv and they still haven’t come back with results. We’ve been here 3 hours now. They do think his kidneys are having trouble flushing his system. His heart rate was also up when we arrived. 6:28p.m.

How concerned should I be?

My friend took me weight lifting the other day, Sunday night and suggested some exercises, focused on pectorals and triceps. It’s been about 10 years since I lifted. I worked out until I was tired, drank a lot of water during the workout.

In the last couple days my doms are getting better, but my urine is pretty dark. I don’t feel sick, but some previous posts and internet searches have me concerned.

Thanks

update

Thanks for your concern guys. I’m going to drink a couple liters of water and give it a couple hours just to see if it starts clearing up. If it’s not back to somewhat normal, I’ll hit up an urgent care clinic that’s within walking distance from my apartment.

update 2

Alright, heading to the urgent care clinic guys. I’ll post updates when I have them. Thanks again for all of your input.

update 3

Urgent care clinic didn’t have a lab, I don’t have a car to get somewhere for a while. Trying to sort out my options.

update 4

Got a ride to another clinic with a lab from a friend, waiting to see a doctor.

Update 5 (11:37 am 10/08/2014)

Saw a doctor after they took a urine sample, he told me blood protein in urine after a workout is pretty normal, and didn’t seem fazed when I told him I was concerned it might be rhabdomyolysis due to my dark brown urine this morning. Said to keep drinking more water. They drew a phial of blood and took a urine sample and are sending them off for “stat labs” and will call me in an hour or two with the results. I’m back home now with a paper that says the Ribdo labs are pending, and a disclaimer that says that I’ve “received urgent care only” and that I “may be released before all medical problems are known or treated.” Also, I have a fever of 99.5

Update 6 (1:31 pm 10/08/2014)

Still waiting. This sucks.

Update 7 (1:31 pm 10/08/2014)

CK levels are at 78,000. Going to try to get this taken care of.

Update 8 (9:15 pm 10/08/2014)

Hey guys, thanks. I’m in the ER still, have an iv hooked up, and it sounds like I’ll be here overnight. I’m still feeling fine, luckily. I tried so hard to avoid the er because it’s cripplingly expensive. We still have outstanding bills from a couple trips in the past. Even with insurance. In the end that struggle was futile, because here I am. But most importantly it’s I’m being taken care of properly now, thanks to your encouragement.

Update 9 (11:07 pm 10/08/2014)

Looks like CK levels are down to 52,000, and I’ve finally been admitted to the hospital. My poor wife stuck by my side tonight all this time. Time to try to sleep and let the saline drip take care of me for the night. I’ll update in the morning when I wake up.

Update 10 (10:00 am 10/09/2014)

Ck levels are back up by 5000. That’s… disheartening.

Update 11 (10:10 am 10/10/2014)

Hospitals are boring, and I’m peeing clear. I’ve gone through tons of liters of iv fluids. My hair and skin is all silky smooth, it’s kind of weird. Soon I hope to hear what my latest levels are.

Update 12 (2:41 pm 10/10/2014)

CK levels are down to 45,000 as of a blood test taken early this morning. There’s talk of potentially being discharged before this evening is over. Still waiting to talk to the doctor this evening. Fingers crossed. 🙂

Update 12 (6:54 pm 10/10/2014)

Not happening. Guess my ck levels are where they’d be ok with them, but apparently my liver enzymes are still a bit high. Doctor said if I had a general practitioner I could have left if I got some follow-up labs done on Monday but since I haven been ill in the last 4 years since I moved here, I don’t have one. Really wish I could have gotten outta here though, my wife, dog and friend miss me. Missing out on a trip to Vancouver BC because of this, and it’s nobody’s fault but mine.

Final Update (5:45 pm 10/11/2014)

I’m finally back home. Chugging water still, liver levels are a bit high yet but getting lower, CK levels are down quite a bit as well, but still pretty high. Looks like I’ll survive if I keep myself waterlogged. You guys most likely saved my kidneys and liver. I appreciate each of your responses. Even the RemindMe! posts asking if I was dead were enough to give me a chuckle during a pretty scary time. Never change, Reddit. Never change.

Variety of Causes Can Be at Root of Rhabdomyolysis

October 21, 2011

Dear Mayo Clinic:

What is rhabdomyolysis? How common is this condition, and who’s at risk for getting it?

Answer:

Rhabdomyolysis is a rare condition in which muscle cells break down and release a substance into the blood that can lead to kidney failure. Most often, it’s seen in people who have suffered major injuries or trauma. Rhabdomyolysis may also develop in response to certain medications, dietary supplements or drugs. In some cases, rhabdomyolysis may affect athletes such as weight lifters and marathon runners.

When a muscle is severely damaged, its fibers may break down and leak a protein pigment called myoglobin into the bloodstream. Myoglobin, when it reaches the kidneys, can block the tiny tubes within the kidneys, leading to serious kidney damage and, in some cases, kidney failure. In addition, a muscle that suffers extreme damage often retains a large amount of fluid from the blood, lowering the body’s fluid supply and reducing blood flow to the kidneys. That can cause further kidney damage.

Symptoms of rhabdomyolysis include extremely painful muscle aches, muscle weakness, and dark or cola-colored urine. Rhabdomyolysis requires immediate medical attention, and people who have this condition are usually hospitalized. Treatment involves giving intravenous fluids to flush the myoglobin through the system, rehydrate the body and prevent kidney failure. If treatment isn’t started quickly, injury to the kidneys can be permanent.

Rhabdomyolysis has a variety of causes. Many cases result from crush injuries to the muscles that can be seen in people who have been in vehicle accidents or have suffered other serious trauma. Heatstroke can cause rhabdomyolysis, as can a bite from some types of snakes whose venom causes severe muscle damage.

Some medications and drugs may also lead to rhabdomyolysis. For example, cholesterol lowering statin medications have been linked to rhabdomyolysis, although this side effect is uncommon. The higher the dose of the statin drug, the greater the risk. Excessive alcohol use and overdoses of drugs such as cocaine, heroin and amphetamines may cause the severe muscle damage that triggers rhabdomyolysis. There also have been reports that some nutritional supplements, as well as performance-enhancing drugs such as creatine supplements and anabolic steroids, are associated with rhabdomyolysis and kidney failure.

Athletes who push their bodies beyond their physical limits are at particular at risk for developing this disorder. For instance, people who do a lot of weight lifting may develop rhabdomyolysis if they lift more than their muscles can physically handle. If they lift in a confined space with poor ventilation where their bodies may become dehydrated, the risk of rhabdomyolysis is even higher.

Marathon runners are also at risk for rhabdomyolysis. Some studies have shown that at the end of a marathon, runners’ kidney function can drop by almost 60 percent and many experience profound dehydration, which can quickly lead to full-blown rhabdomyolysis.

To prevent rhabdomyolysis, pay attention to your body as you work out and stay within your limits. If you’re involved in strenuous weight lifting or if you’re training for a marathon for the first time, consider working with a sports trainer. The trainer can help you find and respect your body’s boundaries. In addition, drinking plenty of fluids when you exercise and being wary of supplements, particularly performance-enhancing substances, can help you avoid muscle damage that may lead to rhabdomyolysis.

— John Graves, M.D., Nephrology and Hypertension, Mayo Clinic, Rochester, Minn.

Rhabdomyolysis: What Can Happen When You Work Out Too Much

Muscle pain and tenderness can be the first sign of rhabdo. (Photo: )

Overdoing anything is bad, whether it is collecting unicorns, eating broccoli, giving massages, or exercising. Working out until you feel the burn is one thing. Working out until you destroy your muscle fibers, the contents of the muscle fibers damage your kidneys, you go into kidney failure, and you die is another totally different thing. The latter would not be a good slogan for training program. Dying from a workout should be purely metaphorical.

Rhabdomyolysis is a rare but possible risk from overdoing it when working out or doing some form of potentially muscle damaging exercise. Recently, 17 year old Jared Shamburger from Texas began feeling “super duper sore” after intensely lifting weights with his arms as reported in this WXYZ Detroit Channel 7 news segment:

Fortunately, he survived this bout of rhabdomyolysis or rhabdo for short. In rhabdo, damage to the muscles goes beyond the typical tears that occur during most work-outs. Muscle fibers actually die and then release their contents such as myoglobulin, a protein building block of muscle, creatine kinase, and electrolytes such as potassium and calcium into the bloodstream. Destroying a muscle fiber is akin to busting open a pinata filled with stuff in the bathroom. This can cause imbalances throughout your body that can wreak havoc such as leading to an irregular heartbeat and even cardiac arrest or messing with your liver and brain function. It also can overload your kidneys, which are not used to filtering all of this stuff. This can lead to kidney failure (a bit like trying to shove newspapers and clothes down someone’s toilet and running away, which you really should not do). Kidney failure can also lead to death. In case you are wondering, all of this is not good, making rhabdo a medical emergency. When people are diagnosed and receive treatment quickly, they can make a full recovery.

Working out too much or too vigorously can cause such muscle damage. So can dehydration, getting crushed by a car, a falling building, or Superman/Supergirl, falling and laying motionless for a long time especially when intoxicated, getting electrocuted, or suffering a venomous snake bite. Seizures, various drugs and medications, and certain diseases and infections can also cause rhabdo.

During winter workouts, University of Nebraska receiver Tyjon Lindsey and defensive lineman Dylan… Owen were hospitalized with rhabdomyolysis. (Photo by Steven Branscombe/Getty Images)

So what can you do to avoid getting rhabdo, besides not working out ever and layering yourself with bubble wrap (which I wouldn’t recommend, although bubble wrap can be fun)? Here are some suggestions:

  • Don’t overdo exercise. Moderation is the key to wearing make-up, engaging the pasta bar, and life.
  • Gradually work up to higher intensity exercise. If your idea of a squat is what you do to get down to a toilet seat, you shouldn’t run out and do hundreds of squats in a gym the first time. Your body and muscles have to get used to increasing workloads. Incremental change is much better than drastic changes. Exercise is like growing a beard. If a big change occurs overnight, something is really wrong.
  • Drink, drink, drink. Not alcohol, which can even lead to rhabdo, but water. Be careful, some drinks can have caffeine and actually make you more dehydrated because caffeine can make you pee.
  • Avoid too much repetition. If your trainer says, “now I want you to do a million push-ups,” walk away. You should not exercise a particular body part repeatedly without rest, until it “falls off,” so to speak.
  • Be careful with eccentric training: Eccentric training is not weird, Greenwich Village-like training. It is maintaining pressure on a muscle while it changes length, such as slowly extending your arm while maintaining a bicep curl with a dumbbell. Doing so can really challenge a muscle and cause tears in the muscle that eventually allow it to grow. But when you are not careful, it can lead to more serious damage.
  • Listen to your body. Your muscles can’t actually speak to you verbally. (If they do, please see a doctor immediately). But they will use non-verbal communication to say, “please stop.” Don’t listen to the phrase, “failure is not an option.” Yes, it is. Failure is always a possibility. So is pooping in your pants. Some of these training catchphrases go beyond motivating and can distract you from hearing what your body is trying to tell you.
  • Don’t be too hot. Yes, I realize that being too sexy is such a burden for you. But in this case I mean hot temperature-wise. When a gym tells you that they are purposely maintaining sauna-like conditions, it could be just that they don’t want to pay for air conditioning. Also, don’t wear or carry too much stuff. Football pads and chain mail armor can overwork your muscles and prevent you from getting proper cooling ventilation.
  • Beware of drugs and supplements that may affect your muscles. For example, a paper in the Journal of Sports and Health Science pointed out how excessive intake of creatine supplements can lead to an imbalance in body water, muscle cramps, or dehydration.

If you have concerns that you may have rhabdo, call your doctor immediately. Here’s the “classic triad” of rhabdo signs and symptoms:

  • Myalgias: which is a fancy way of saying muscle pain
  • Muscle weakness: If you have difficulty moving any part of your body.
  • Tea-colored urine: Meaning dark red or brown urine. Also, be concerned if you are urinating less than expected.

Also, watch out for other signs such as fever, abdominal pain, nausea or vomiting, increased heart rate, extreme thirst, confusion, or loss of consciousness. You don’t have to have muscle-related symptoms to have rhabdo.

Again, rhabdo is not common so don’t think that you necessarily have rhabdo after feeling some discomfort by doing a single squat. It may just be that you are using those muscles for the first time in a long time or just farted. But do take the precautions listed above. Getting regular exercise is very important and provides extensive health benefits. But remember moderation. Overdoing anything can leave you in deep doo-doo.

Overexertion Can Cause Serious Harm

Two days after an intense training session, an apparently healthy client experiences such extreme muscle soreness that she seeks emergency care. Her urine is very dark. At the hospital, she is diagnosed with exertional rhabdomyolysis. What does this mean? And could her trainer have prevented it?

Rhabdomyolysis is a medical condition that results from direct muscle injury or an altered metabolic relationship between energy production and energy consumption in muscle. Causes include drug toxicity, heat stress, muscle trauma and physical exertion.

Exertional, or exercise-induced, rhabdomyolysis (ER) is a rare but sometimes catastrophic condition in which muscle fibers break down in response to exertion and release their breakdown products into the circulation. In any given year a busy emergency room will treat seven to 10 cases of ER. Moderate cases can be triggered by endurance events—such as triathlons, marathons and basic military training—or by other exercise for which a participant is not well adapted (for example, excessive resistance training). In moderate cases participants have unusually high myoglobin levels in their blood but not enough muscle damage to cause renal—kidney—failure or insufficiency. (Myoglobin is a protein, similar to hemoglobin, that binds oxygen in the muscle.) Severe cases of ER can be life threatening.

Personal trainers should clearly be familiar with the symptoms of ER and know how to prevent and respond to occurrences. Described below are ER’s central features and important preventive measures. The sidebar summarizes two case studies in which personal trainers were directly implicated.

Primary Features
of Rhabdomyolysis

Rhabdomyolysis has four primary features:

Muscular Symptoms and Signs. The most common symptoms include muscle pain, weakness, tenderness, stiffness and occasionally contractures.

Myoglobinuria (Filtration of Myoglobin Into the Urine). ER especially damages red (type 2) muscle fibers. After muscle injury and necrosis (cell death), myoglobin is released, along with other cellular contents. When released in large amounts, myoglobin is filtered into the urine. A change in urine color is usually the first sign of myoglobinuria. Dark urine, typically brown in color, is often the first clueto rhabdomyolysis.

Laboratory Features. The hallmark of muscle damage is elevated creatine phosphokinase, or creatine kinase (CK). Normal CK levels are between 20 and 200 units per liter (U/L), perhaps slightly lower in females. CK levels begin to rise 2 to 12 hours after muscle injury or extreme muscular exertion and may rise as high as 20,000-300,000 U/L.

Constitutional Symptoms. These symptoms include generalized malaise, fever, tachycardia, nausea and vomiting. Altered mental status (e.g., confusion) and low urine output can also be characteristics. ER complications can include acute renal (kidney) failure and, in some cases, death. Life-threatening complications other than renal failure include hyperkalemia (higher-than-normal levels of potassium in the blood) and disseminated intravascular coagulation ( a blood clotting condition). How often cases result in these complications largely depends on the level of rhabdomyolysis and the speed at which the persons affected seek and receive medical help. The medical literature reports that up to 40 percent of patients may end up with renal failure; however, one report on 35 male patients with ER seen in a Brooklyn, New York, emergency center (Sinert 1994) did not observe any renal failure – likely thanks to rapid, aggressive medical therapy.

Preventive Measures
for Personal Trainers

What do personal trainers need to do to lessen their clients’ risk of experiencing the symptoms and complications of ER?

1. Understand the Causes and Symptoms of ER.

2. Be Prepared for Expedient Client Management. For most personal trainers this means immediately referring an affected client to qualified medical care (e.g., by a competent physician). Medical treatment can include hydration, diuretics, electrolyte correction, dialysis and other supportive therapy.

3. Know the Common Triggers. In nearly all cases of ER, the exercise stimulus is an “unusual exercise load” or an abrupt transition to a much greater exercise load. Dramatic increases in exertional load (duration and/or intensity) or exposure to unaccustomed heat stress can increase risk. Monitor perceived effort in the early stages of training and observe for signs of excessive fatigue or overexertion. An excessive level of delayed-onset muscle soreness is always a reasonable indication that training loads experienced a day or two earlier were excessive.

4. Recognize That Some Individuals Are More Susceptible to ER Than Others. More susceptible clients require closer supervision, especially in the early stages of resistance training. This group includes clients with previous histories of ER or ER-like symptoms, clients with low initial levels of fitness, older individuals and clients with muscle disease (e.g., muscular dystrophy). However, most cases of ER involve apparently healthy and reasonably fit individuals. Note also that performance-enhancing drugs (e.g., anabolic steroids) have been implicated in ER (Sandhu 2002). And other drugs – among them statin drugs, used to lower blood cholesterol – can increase the likelihood that ER symptoms will occur during a bout of resistance exercise involving eccentric contractions.

Knowledge Is Key

ER is a relatively rare clinical phenomenon. However, in the course of a personal training career, the chances of observing one or more cases of ER or at least some ER symptoms are quite high—perhaps 30 to 50 percent. It is therefore crucial for personal trainers to understand the condition. Clearly, the line between a systematic and progressive approach to exercise training and a method that imposes excessive repetitive force or intensity can sometimes be a fine one. Trainers need to be cautious about pushing clients to unnecessary limits of intensity, especially in resistance and anaerobic-based training programs.

How long does rhabdo take to set in?

Leave a Reply

Your email address will not be published. Required fields are marked *