Exertional Rhabdomyolysis

Treatment of exertional rhabdomyolysis in athletes: a systematic review

BACKGROUND

Exertional rhabdomyolysis (ER) is the breakdown of skeletal muscle tissue following intense physical activity that results in impairment of the cell membrane, which allows intracellular contents to be released into the bloodstream. Signs and symptoms include myalgia, myoglobinuria and increased creatine kinase (CK) levels. Athletes are vulnerable to this condition due to their increased level of physical activity. The severity and effects of this condition vary between individuals; however, all athletes are at risk of significant muscle damage, renal failure and perhaps death if not recognized and treated quickly. Effective methods for treatment and return to activity following this condition should be established.

OBJECTIVES

The objective of this review was to identify effective treatment methods associated with ER in athletes.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult and adolescent patients (15 years of age and older) in the athletic population who have been diagnosed with ER.

TYPES OF INTERVENTIONS

Fluid resuscitation/replacement or other treatment methods that aim to improve CK levels and decrease myoglobinuria and treat ER.

TYPES OF STUDIES

Due to the absence of randomized control trials, the quantitative component of the review considered descriptive studies, case series and individual case reports for inclusion.

OUTCOMES

PRIMARY OUTCOMES

CK and myoglobinuria levels.

SECONDARY OUTCOMES

length of hospital stay; length of time from diagnosis to premorbid levels of physical activity.

SEARCH STRATEGY

A comprehensive search of the following databases with no date limitation was conducted: CINAHL, PubMed, ProQuest, Embase, SPORTDiscus and Physical Education Index. Results were limited to those available in English.

METHODOLOGICAL QUALITY

Two independent reviewers evaluated the retrieved articles for methodological quality using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics and Review Instruments.

DATA EXTRACTION

Data were extracted from the articles by two independent reviewers using the standardized Joanna Briggs Institute extraction tool.

DATA SYNTHESIS

Narrative and tabular synthesis.

RESULTS

Fourteen studies with a combined total of 53 participants were included. Aggressive intravenous (IV) fluid resuscitation was found to be the most commonly utilized treatment method for decreasing CK levels and resolving myoglobinuria. The addition of compounds within the IV fluid varied between studies.

CONCLUSION

Due to the types of included studies and variation in reported treatment methods and outcomes for ER among athletes, effectiveness of treatment could not be determined. The limited evidence available indicates that IV fluid replacement, specifically normal saline, is the most commonly reported treatment for decreasing CK levels and myoglobinuria following ER. It appears that normal saline may be combined with other compounds including sodium bicarbonate, sodium chloride or potassium chloride to achieve reduction of CK levels and myoglobinuria. Clinically, early IV fluid replacement appears to be delivered at a rate of approximately 400 ml/hour, with adjustments ranging between 200 and 1000 ml/hour, depending on severity and volume states. Hospitalization time varies, depending on severity of condition, and return to activity is widely inconsistent among the athletic population.

Rhabdomyolysis in adolescent athletes: review of cases

Rhabdomyolysis is a syndrome characterized by muscle pain, weakness and myoglobinuria and ranges in severity from asymptomatic to life threatening with acute kidney failure. While a common condition in adult populations, it is understudied in pediatrics and the majority of adolescent cases are likely exercise-induced, caused by strenuous exercise in athletes. Recently, in our pediatric sports medicine practice, we have seen numerous cases of late adolescent high school athletes who present with severe muscle pain and were found to have elevated creatine kinase levels. The cases review potential contributing factors including characteristics of the workout, use of supplements, caffeine, medication, and metabolic or genetic predisposition. Treatment for exercised-induced rhabdomyolysis rarely requires more than rehydration. Return to play should be progressive, individualized, and include acclimatization and monitoring of hydration status, though guidelines require further review.

Anti-inflammatory interventions and skeletal muscle injury: benefit or detriment?

Exercise, eccentric contractions, acute trauma, and disease are all causal mechanisms of skeletal muscle injury. After skeletal muscle is injured, it undergoes sequential phases of degeneration, inflammation, regeneration, and fibrosis. Events that occur in response to inflammation trigger regenerative processes. However, since inflammation causes pain, decreases skeletal muscle function, has a negative effect on performance, and contributes to fibrosis, which is one of the leading causes of delayed regeneration, the general practice has been to reduce inflammation. The problem with this approach is that preventing inflammation may hinder recovery. Current treatment options for inflammation are not necessarily effective and, in some cases, they may be unsafe. This review focuses on the question of whether the most beneficial course of treatment should be to block inflammation or if it is sensible to allow inflammatory processes to progress naturally. If blocking inflammation is perceived as a beneficial approach, it is not yet known at what time point during the inflammatory response it is most sensible to interfere. To address these issues, this review evaluates the effects of various anti-inflammatory agents on recovery processes in response to exercise-induced, traumatic, and disease-associated models of skeletal muscle injury. A collective analysis such as this should lay the foundation for future work that systematically manipulates the inflammatory response to most effectively promote regeneration and functional recovery in injured skeletal muscle, while reducing the negative effects of inflammatory processes such as pain and fibrosis.

A cluster of exertional rhabdomyolysis affecting a Division I Football team

OBJECTIVE

To identify risk factors for exertional rhabdomyolysis (ER) among collegiate football athletes. We hypothesized that a back squat workout triggered ER in some players, and that the risk of ER was altered by players' characteristics or other exposures.

DESIGN

Case report and case-control study.

SETTING

National Collegiate Athletic Association Division I Football Program and an academic medical center.

PARTICIPANTS

National Collegiate Athletic Association Division I football players.

INDEPENDENT VARIABLES

Characteristics, performance during the implicated workout, and exposures of players.

MAIN OUTCOME MEASURES

Exertional rhabdomyolysis was the primary outcome; the hypotheses were formulated before data were collected.

RESULTS

Initial serum creatine kinase and creatinine values ranged from 96,987 to 331,044 U/L and from 1.0 to 3.4 mg/dL, respectively. The risk of ER increased as the time and number of sets needed to complete 100 back squats increased [odds ratio (OR), 1.11; 95% confidence interval (CI), 1.03-1.19; P = 0.0051 and OR, 1.33; 95% CI, 1.09-1.63; P = 0.0056, respectively]. Affected players were significantly more likely than unaffected players to report that they went to muscle failure (P = 0.006), did not think they could complete the workout (P = 0.02), and performed extra squats (P = 0.02) during the back squat assignment. For athletes playing skilled or semiskilled positions, the risk of ER increased as the percent body weight lifted increased [OR (corresponding to a 10% increase), 1.77; 95% CI, 1.06-2.94; P = 0.0292]. Drinking protein shakes after the implicated workout was associated with a decreased risk (OR, 0.70; 95% CI, 0.51-0.96; P = 0.0284); the odds decreased about 30% per shake.

CONCLUSIONS

Percent body weight lifted, the number of sets, and time needed to complete 100 back squats were significantly associated with increased risk of ER. Affected athletes were more likely to report going to muscle failure, thinking they could complete the workout, and performing extra squats during the back squat assignment. Consuming protein shakes after the implicated workout was associated with a decreased risk. Clinicians, athletes, and athletic program staff must know risk factors for ER and early symptoms of ER.

Exertional rhabdomyolysis--when should we start worrying? Case reports and literature review

Exertional rhabdomyolysis (ER) is a serious medical issue usually seen in individuals or patients after engaging in heavy exertion and physical activity. The incidence, natural course, and recurrence of ER are, by and large, unknown. Given the lack of rigorous scientific data that are specific for ER, most of the patients with ER receive treatment in an inpatient setting even with only a mild elevation of creatine phosphokinase (CPK) level. Often, patients receive inpatient treatment solely on the basis of elevated CPK (<3000 IU) even in the absence of other serious signs and symptoms of ER. We intent to describe 2 case reports that involve patients who developed ER after an intense physical exertion and were managed in an outpatient setting with close follow-up. In the discussion part, we point suggest that in patients with a relatively mild CPK elevation (<15,000 IU) and normal creatinine value and in the absence of factors such as profound dehydration, sickle cell trait, concomitant infectious cause, underlying metabolic syndrome, and current and ongoing use of analgesics, the complications after ER are low. Patients who develop ER, who can be reliably followed up, and who fulfills these criteria can be managed as outpatients.

Return to physical activity after exertional rhabdomyolysis

Exertional rhabdomyolysis (ER) is a condition characterized by muscle pain, swelling, and weakness following some exertional stress, with or without concomitant heat stress. Athletes who experience ER often present to the emergency department, the training room, or the physician's office seeking guidance and care for this condition, often feeling it is simply normal delayed onset muscle soreness. The astute clinician must perform a thorough history and focused exam, in addition to ordering a serum creatine kinase (CK) and urinalysis. In this clinical setting, a CK equal to or greater than five times normal or a urine dipstick testing positive for blood with no demonstrable red blood cells upon microscopic assessment confirms the diagnosis. A urine or serum myoglobin is more definitive when expeditiously available. After treatment for ER, the provider must risk-stratify the athlete for risk of recurrence, consider further testing, and make the difficult decision on when, if, and under what conditions the athlete can safely return to play.