Return to physical activity after exertional rhabdomyolysis

Contribution of medical resonance imaging in the return to physical activity after exertional rhabdomyolysis a case report

INTRODUCTION

Exertional rhabdomyolysis (ER) is the breakdown of muscle cells that occurs after intensive physical activity. Although a cautious and gradual return to physical activity (RTPA) is recommended after an episode of ER, physical sequelae are reported long afterwards.

CASE REPORT

We present the case of a 31-year-old untrained amateur runner with no prior medical history who developed heat stroke, ER, and acute kidney failure on the occasion of a half-marathon. Three months later, whereas the patient was symptom-free and CK levels were normal, an MRI revealed typical signs of rhabdomyolysis, which normalized thereafter.

DISCUSSION

Given that clinical and biological data inform RTPA decisions, the delay between clinical biological and MRI normalization may cause an RTPA to be initiated prior to full muscle recovery, which could account for the symptoms' prolonged persistence. In sportspeople who have recovered and their CK blood levels are returned to normal, MRI data could defer the RTPA if MRI abnormalities persist or, conversely, give it the green light.

Exertional rhabdomyolysis: an analysis of 321 hospitalised US military service members and its relationship with heat illness

INTRODUCTION

Exertional rhabdomyolysis is a syndrome of muscle breakdown following exercise. This study describes laboratory and demographic trends of service members hospitalised for exertional rhabdomyolysis and examines the relationships with heat illness.

METHODS

We queried the US Armed Forces Health Surveillance Center's Defence Medical Epidemiology Database for hospitalised cases of rhabdomyolysis associated with physical exertion from January 2010 July 2013. Descriptive statistics reported means and medians of initial, peak and minimal levels of creatine kinase (CK). Correlations explored the relationship between CK, creatinine, length of hospital stay (LOS) and demographic data.

RESULTS

We analysed 321 hospitalised cases of exertional rhabdomyolysis. 193 (60.1%) cases were associated with heat; 104 (32.4%) were not associated with heat; and 24 (7.5%) were classified as medical-associated exertional rhabdomyolysis. Initial, maximum and minimal CK levels were significantly lower in heat cases: CK=6528 U/L vs 19 247 U/L, p=0.001; 13 146 U/L vs 22 201 U/L, p=0.03; and 3618 U/L vs 10 321 U/L, p=0.023) respectively, compared with cases of rhabdomyolysis with exertion alone. Median LOS was 2 days (range=0-25). In the rhabdomyolysis with exertion alone group and the rhabdomyolysis with heat group, LOS was moderately correlated with maximal CK (Spearman's ρ=0.52, p<0.001, and Spearman ρ=0.38, p<0.001, respectively). There was no significant difference in median LOS between the rhabdomyolysis with exertion alone and rhabdomyolysis associated with heat groups (2 vs 2, p value=0.96).

CONCLUSION

Most hospitalisations for exertional rhabdomyolysis were associated with heat illness and presented with lower CK levels than cases without associated heat illness. These data add evidence that rhabdomyolysis with heat illness is a different entity than rhabdomyolysis with exertion alone. Differentiating exertional rhabdomyolysis with and without heat should inform future research on rhabdomyolysis prognosis and clinical management.

Neuromuscular complications of the lower extremity after thrombectomy in a patient with superficial femoral artery occlusion: Case series

BACKGROUND

Ischemia reperfusion (IR) injury may result in rhabdomyolysis and compartment syndrome when blood supply returns after thrombectomy for patients with acute limb ischemia.

OBJECTIVE

We highlight the value of early diagnosis and treatment in post-thrombectomy patients with IR injuries in their lower legs.

CASE DESCRIPTION

Two patients received thrombectomy due to left superficial femoral artery occlusion. Both patients complained of left calf pain during ambulation at the 1- and 3-day follow up post-thrombectomy, as well as a heating sensation, swelling, weakness, and sensory changes in the affected leg. For early diagnosis musculoskeletal ultrasounds were performed and in both cases revealed swelling and change of echogenicity in the left calf. To further diagnosis, magnetic resonance imaging of the left leg revealed limb IR-induced muscular injury and rhabdomyolysis, respectively. In both cases, an electrodiagnostic study revealed peripheral nerve injury in the left leg. Medications were provided for neuropathic pain control and early rehabilitation was performed to improve function. In both cases, patients reported during their follow-up that their pain and muscle weakness had improved.

CONCLUSION

When post-thrombectomy calf pain occurs early evaluation and treatment should be performed to identify any potential IR injury.

Clinical outcomes of hospitalised individuals with spin-induced exertional rhabdomyolysis

Introduction

Exertional rhabdomyolysis (ER) is caused by myocyte breakdown after strenuous physical activity. In recent years, the incidence of spin-induced ER (SER) has been increasing. We describe the clinical characteristics, management and outcomes of patients admitted for SER.

Method

A review was conducted for all patients admitted to Singapore General Hospital for SER from 1 March 2021 to 31 March 2022. All patients with the admission diagnosis of "rhabdomyolysis", "raised creatine kinase (CK) level", or "elevated CK level" with a preceding history of spin-related physical exertion were included. Patients without a history of exertion, with a history of non-spin related exertion, or with a peak serum CK <1000 U/L were excluded.

Results

There were 93 patients in our final analysis; mean age was 28.6±5.6 years and 66 (71.0%) were female patients. Mean body mass index was 25.0±5.7 kg/m2; 81 (87.1%) patients were first-time spin participants. All patients had muscle pain, 68 (73.1%) had dark urine, 16 (17.2%) muscle swelling and 14 (15.1%) muscle weakness. There were 80 (86.0%) patients with admission CK of >20,000 U/L. Mean admission creatinine was 59.6±15.6 μmol/L. Mean intravenous (IV) hydration received was 2201±496 mL/ day, oral hydration 1217±634 mL/day and total hydration 3417±854 mL/day. There was 1 (1.1%) patient with acute kidney injury, which resolved the next day with IV hydration.

Conclusion

Inpatient management of SER includes laboratory investigations, analgesia and hydration. Risk of complications is low in SER patients. SER patients without risk factors for complications can be considered for hospital-at-home management with bed rest, aggressive hydration and early outpatient review.

Exertional Rhabdomyolysis in Athletes: Systematic Review and Current Perspectives

OBJECTIVE

Exertional rhabdomyolysis results from a breakdown of skeletal muscle cells after intense exercise in otherwise healthy patients, causing increased levels of creatine kinase (CK) or myoglobin, as well as urine dipstick positive for blood, and may result in kidney insufficiency. The aim of this study was to outline the current perspectives of exertional rhabdomyolysis in athletes and subsequent treatment based on the current literature.

DATA SOURCES

We searched the MEDLINE/PubMed and Google databases for ([exercise] OR [exertional]) AND rhabdomyolysis following the PRISMA guidelines. All abstracts were reviewed by 2 independent examiners. Inclusion criteria consisted of original articles presenting studies on exertional rhabdomyolysis or exercise-induced rhabdomyolysis with 7 or more cases. All case reports, case series, or editorials were excluded.

MAIN RESULTS

A total of 1541-abstracts were screened, leaving 25 studies for final inclusion and analysing 772patients. Especially, young male patients were affected at a mean age of 28.7 years (range 15.8-46.6 years). Most of the athletes performed running, including marathons in 54.3% of cases (n = 419/772), followed by weightlifting in 14.8% (n = 114/772). At the time of presentation, the mean creatine kinase was 31 481 IU/L (range 164-106,488 IU/L). Seventeen studies reported the highest level of CK, which was 38 552 IU/L (range 450-88,496 IU/L). For treatment, hydration was the most common method of choice reported by 8 studies.

CONCLUSIONS

Exertional rhabdomyolysis seems to be underestimated, and it is essential to screen patients who present with muscle soreness/cramps and/or dark urine after heavy endurance events to avoid any further complications.

LEVEL OF EVIDENCE

II; systematic review.

Epidemiology of Exertional Rhabdomyolysis in the United States: Analysis of NEISS Database 2000 to 2019

OBJECTIVE

There have been numerous case series of exertional rhabdomyolysis (ER) but no comprehensive studies investigating the incidence of ER in the civilian athletic population in the United States (US).

METHODS

A retrospective review of patients with ER presenting to emergency departments in the US over a 20-year period between 2000 and 2019 was performed using the National Electronic Injury Surveillance System (NEISS) database.

RESULTS

The national estimate of hospital visits in the US for ER during the 20-year period was 40,654 (0.66 per 100,000 population). There was a 10-fold increase in the incidence of ER from the first to the second decade. The odds of ER were 3.77 (95% CI 3.67-3.86, P < .0001) times higher for males (31,921, 78.5%, 1.06 per 100,000) than females (8,733, 21.5%, 0.28 per 100,000) and 3.82 (95% CI 3.71-3.93, P < .0001) higher in African Americans (33.6, 0.93 per 100,000) than white patients (53%, 0.24 per 100,000). American football (3,064, 7.5%) was responsible for 43.9% of the sports-induced ER cases. The majority (67.3%) of ER cases occurred between the ages of 16 and 35 years old. The majority of patients required hospitalization (26,550, 65.3%).

CONCLUSIONS

The number of ER cases presenting to emergency departments in the US increased from 2000-2009 to 2010-2019. Young males and African Americans are at highest risk of ER. There was a high rate of hospitalization.

Gluteal Compartment Syndrome and Rhabdomyolysis after Prolonged Laparoscopic Nephroureterectomy and Treatment Strategies Including Rehabilitation: A Case Report

Background: Rhabdomyolysis is a clinical symptom caused by the rapid release of intracellular components such as myoglobin, lactate dehydrogenase, and creatine kinase into the blood circulation. It is commonly caused by muscular injury including compartment syndrome, infection, drugs, etc. Although it rarely occurs during surgery, the incidence may increase if risk factors such as long operation time, improper posture, and condition of being overweight exist. Case Presentation: A 46-year-old male patient complained of pain and weakness in the right hip area and several abnormal findings were observed in the blood sample, reflecting muscle injury and decreased renal function after prolonged urological surgery. He was confirmed as having rhabdomyolysis, which was caused by compartment syndrome of the right gluteal muscle. After the diagnosis, conservative cares were performed in the acute phase and rehabilitation treatments were performed in the chronic phase. After conservative treatment and rehabilitation, blood sample values returned to almost normal ranges and both level of pain and muscle strength were significantly improved. In addition, about 25 days after discharge, he almost recovered to pre-operative condition. Conclusion: Careful attention is required to prevent intraoperative compartment syndrome. It also suggests that not only medical treatment but also early patient-specific rehabilitation is important in patients with rhabdomyolysis after prolonged surgery.

Effects of Resistance Training to Muscle Failure on Acute Fatigue: A Systematic Review and Meta-Analysis

BACKGROUND

Proper design of resistance training (RT) variables is a key factor to reach the maximum potential of neuromuscular adaptations. Among those variables, the use of RT performed to failure (RTF) may lead to a different magnitude of acute fatigue compared with RT not performed to failure (RTNF). The fatigue response could interfere with acute adaptive changes, in turn regulating long-term adaptations. Considering that the level of fatigue affects long-term adaptations, it is important to determine how fatigue is affected by RTF versus RTNF.

OBJECTIVE

The aim of this systematic review and meta-analysis was to compare the effects of RTF versus RTNF on acute fatigue.

METHODS

The search was conducted in January 2021 in seven databases. Only studies with a crossover design that investigated the acute biomechanical properties (vertical jump height, velocity of movement, power output, or isometric strength), metabolic response (lactate or ammonia concentration), muscle damage (creatine kinase activity), and rating of perceived exertion (RPE) were selected. The data (mean ± standard deviation and sample size) were extracted from the included studies and were either converted into the standardized mean difference (SMD) or maintained in the raw mean difference (RMD) when the studies reported the results in the same scale. Random-effects meta-analyses were performed.

RESULTS

Twenty studies were included in the systematic review and 12 were included in the meta-analysis. The main meta-analyses indicated greater decrease of biomechanical properties for RTF compared with RTNF (SMD - 0.96, 95% confidence interval [CI] - 1.43 to - 0.49, p < 0.001). Furthermore, there was a larger increase in metabolic response (RMD 4.48 mmol·L^-1, 95% CI 3.19-5.78, p < 0.001), muscle damage (SMD 0.76, 95% CI 0.31-1.21, p = 0.001), and RPE (SMD 1.93, 95% CI 0.87-3.00, p < 0.001) for RTF compared with RTNF. Further exploratory subgroup analyses showed that training status (p = 0.92), timepoint (p = 0.89), load (p = 0.10), and volume (p = 0.12) did not affect biomechanical properties; however, greater loss in the movement velocity test occurred on upper limbs compared with lower limbs (p < 0.001). Blood ammonia concentration was greater after RTF than RTNF (RMD 44.66 μmol·L^-1, 95% CI 32.27-57.05, p < 0.001), as was 48 h post-exercise blood creatine kinase activity (SMD 0.86, 95% CI 0.33-1.42, p = 0.002). Furthermore, although there was considerable heterogeneity in the overall analysis (I² = 83.72%; p < 0.01), a significant difference in RPE after RTF compared with RTNF was only found for studies that did not equalize training volumes.

CONCLUSIONS

In summary, RTF compared with RTNF led to a greater decrease in biomechanical properties and a simultaneous increase in metabolic response, higher muscle damage, and RPE. The exploratory analyses suggested a greater impairment in the velocity of movement test for the upper limbs, more pronounced muscle damage 48 h post-exercise, and a greater RPE in studies with non-equalized volume after the RTF session compared with RTNF. Therefore, it can be concluded that RTF leads to greater acute fatigue compared with RTNF. The higher acute fatigue after RTF can also have an important impact on chronic adaptive processes following RT; however, the greater acute fatigue following RTF can extend the time needed for recovery, which should be considered when RTF is used.

PROTOCOL REGISTRATION

The original protocol was prospectively registered (CRD42020192336) in the International Prospective Register of Systematic Reviews (PROSPERO).

Exercise-Induced Rhabdomyolysis: A Case Series of Spin-Related Rhabdomyolysis

Exercise rhabdomyolysis is a potentially life-threatening medical condition if not adequately managed early. With the increase in the popularity of indoor cycling, known as Spinning®, over recent years, there has been an increased occurrence of spin-related rhabdomyolysis observed among previously fit adults after undertaking their first spin bike class session.

They present with the triad of myalgia, muscle weakness, and dark tea-colored urine within a week of their first spin session. This case series highlights several admissions to the hospital with spin-related rhabdomyolysis and their clinical management.

Adenovirus Infection and Rhabdomyolysis as a Cause of Acute Liver Failure in a Healthy Collegiate Football Athlete: A Case Report and Proposed Return to Play Protocol for Rhabdomyolysis

Adenovirus is a common cause of upper respiratory and gastrointestinal tract infections. Though cases of significant organ failure and death have been reported in young children and immunocompromised individuals, adenovirus infections in healthy individuals are typically self-limiting without significant morbidity or mortality. Exertional rhabdomyolysis is a pathologic condition resulting from repetitive, excessive, or prolonged exercise, often in a hot environment, leading to acute muscle injury, renal injury and, rarely, death. We report a case of adenovirus infection leading to acute liver failure complicated by rhabdomyolysis in a collegiate football player presenting with nausea, vomiting, and diarrhea. We propose a protocol to safely guide the return to play progression for patients with complicated exertional rhabdomyolysis.

Effects of foam rolling for delayed onset muscle soreness on loaded military task performance and perceived recovery

Objective

The purpose of this investigation was to evaluate the effects of foam rolling (FR) and passive recovery (PR) on symptoms of delayed-onset muscle soreness (DOMS) and military-specific performance.

Methods

Twenty men and women (age: 23.6 ± 4.1 years, height: 176.4 ± 5.6 cm, and body mass: 84.7 ± 13.4 kg) completed a DOMS-inducing exercise protocol (DIP), followed by FR or PR. Four loaded military tasks (LMT) were performed 24 h later. Rating of perceived exertion (RPE) was measured during DIP and after each LMT. Rating of muscle pain (RMP) was measured prior to the LMTs and after the recovery protocols. A repeated measure analysis of variance and partial eta squared were used to compare LMT performance across baseline, FR and PR sessions. Friedman tests compared perceptual variables across baseline, FR, and PR. Wilcoxon matched-pairs signed-ranks test evaluated RPE during DIP, post-DIP, and post-recovery RMP between FR and PR.

Results

LMT performance times were significantly faster after FR compared to PR (stair climb: p = .038, cover position sprint: p = .011, simulated ammunition can carry: p = .003, Shuttle Run: p = .034). RPE measured during LMTs was similar across all data points. Post-recovery RMP for FR (3.0 (2.3, 4.0)) and PR (4.0 (3.0, 6.0)) were not significantly different.

Conclusion

FR reduced the impact of DOMS on three loaded tactical performance tasks without significant reduction in perceived soreness.

Clinical Practice Guidelines for Exertional Rhabdomyolysis: A Military Medicine Perspective

ABSTRACT

Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Caffeine and heat have additive but not interactive effects on physiologic strain: A factorial experiment

This study tested the interactive effects of heat and caffeine on exercise-induced physiological strain by using a 2x2 within-subjects factorial design. Thirty-five physically fit Caucasians underwent a bout of exercise under four conditions wherein ambient conditions (heat vs no heat) and caffeine (placebo vs caffeine; double-blinded) were manipulated. Exercise consisted of a 60-min walk and 5-min step/squat test while wearing weighted backpack. Primary outcomes include measures of physiologic strain (Core temperature [T_r] and heart rate [HR]). Secondary measures included blood pressure, markers of sweat loss, and creatine kinase (CK). Repeated measures models were created to evaluate the individual and combined effects of heat and caffeine. Key results indicated that heat and caffeine significantly increased T_r and HR after walking and stair-stepping. No significant heat by caffeine interactions were detected, and caffeine's main effects were relatively low (≤0.17 °C for T_r and ≤6.6 bpm for HR). Of note, heat and caffeine exhibited opposite effects on blood pressure: caffeine increased both systolic and diastolic blood pressure (by 6-7 mmHg) and heat decreased them (by 4-6 mm Hg; ps < 0.05). In summary, heat and caffeine affected physiologic strain during exercise but exhibited no synergistic effects. In contrast, neither factor affected muscle damage. Clinical implications for heat illness risk in the military are discussed.

Exertional Rhabdomyolysis: A Retrospective Population-based Study

PURPOSE

This study aimed to evaluate the incidence and characteristics of exertional rhabdomyolysis (ER) in a population-based cohort.

METHODS

A retrospective cohort study was performed in Olmsted County, Minnesota, from 2003 to 2015. Incident ER cases were ascertained through the Rochester Epidemiology Project medical record linkage system through electronic searches of the International Classification of Diseases, Ninth Revision, codes and clinical note text. Population incidence rate was calculated using the corresponding Rochester Epidemiology Project census populations specific to calendar year and sex. Descriptive statistics were used.

RESULTS

Of the 430 patients, 431 cases met the inclusion criteria for rhabdomyolysis; 4.9% of cases (n = 20; males n = 18; Caucasian n = 17) were ER, with one recurrence. There were no deaths secondary to ER. The age- and sex-adjusted incidence rate of ER was 1.06 ± 0.24 (95% confidence interval = 0.59-1.52) per 100,000 person-years. Endurance activity (n = 7), manual labor (n = 5), and weight lifting (n = 4) were common causes. Complications included kidney injury (n = 5), mild electrolyte abnormalities (n = 10), elevated transaminases (n = 12), and minor electrocardiographic abnormalities (n = 4). A majority of patients were hospitalized (n = 16) for a median of 2 d, had mild abnormalities in renal and liver function and electrolytes, and were discharged without sequelae.

CONCLUSION

ER in the civilian population occurs at a much lower incidence than the military population. The most common causes were endurance exercise, manual labor, and weight lifting. The majority of cases were treated conservatively with intravenous fluid resuscitation during a brief hospital stay, and all were discharged without sequela. Only one case of recurrence occurred in this cohort, indicating the recurrence rate was low.

Diagnostic biomarkers of muscle injury and exertional rhabdomyolysis

Early recognition of muscle injury, up to development of exertional rhabdomyolysis (ER), is essential for many clinical and practical reasons, such as planning the suitable period of recovery and deciding an appropriate time for return to exercise. Albeit magnetic resonance imaging (MRI) remains the reference technique for assessing muscle injuries, and ultrasonography (US) may be a complementary approach for easy, inexpensive and fast screening, the potential drawbacks of both techniques may be overcome by some laboratory tests, which may help guiding both diagnostic reasoning and clinical decision making. Current evidence attest that creatine kinase remains the most validated test across the clinical spectrum of muscles injuries, as its measurement may be helpful for screening subjects with suggestive signs and symptoms, its concentration substantially reflects the amount of injured muscle and its kinetics appears suitable, combined with clinics and results of imaging testing, for making decisions on return to exercise. Relatively low cost and widespread availability are additional advantages of this test. In athletes with ER, myoglobin assessment may provide adjunctive useful information, due to high predictive value for development of acute kidney injury. Regarding other historical biomarkers, namely aldolase and lactate dehydrogenase, the kinetics, correlation with injury severity, laboratory standardization and availability make their measurement unsuitable and redundant. Some innovative biomarkers have also been tested in recent years, including fatty acid-binding proteins and carbonic anhydrase III, myosin light chain 3 and muscle micro RNAs. However, their clinical effectiveness, standardization, availability in clinical laboratories and costs are still regarded as major drawbacks.

Damage protective effects conferred by low-intensity eccentric contractions on arm, leg and trunk muscles

PURPOSE

Low-intensity eccentric contractions with a load corresponding to 10% of maximal voluntary isometric contraction strength (10% EC) attenuate muscle damage in a subsequent bout of higher-intensity eccentric contractions performed within 2 weeks for the elbow flexors, knee flexors and knee extensors. However, it is not known whether this strategy could be applied to other muscles. This study investigated whether 10% EC would confer damage protective effect on high-intensity eccentric contractions (80% EC) for nine different muscle groups.

METHODS

Untrained young men were placed to an experimental or a control group (n = 12/group). Experimental group performed 50 eccentric contractions with a load corresponding to 10% EC at 2 days prior to 50 eccentric contractions with 80% EC for the elbow flexors and extensors, pectoralis, knee flexors and extensors, plantar flexors, latissimus, abdominis and erector spinae. Control group performed 80% EC without 10% EC. Changes in maximal voluntary isometric contraction strength (MVC) and muscle soreness, plasma creatine kinase (CK) activity and myoglobin concentration after 80% EC were compared between groups by a mixed-factor ANOVA.

RESULTS

MVC recovered faster (e.g., 6-31% greater MVC at 5 days post-exercise), and peak muscle soreness was 36-54% lower for Experimental than Control group for the nine muscles (P < 0.05). Increases in plasma CK activity and myoglobin concentration were smaller for Experimental (e.g., peak CK: 2763 ± 3459 IU/L) than Control group (120,360 ± 50,158 IU/L).

CONCLUSIONS

These results showed that 10% EC was effective for attenuating the magnitude of muscle damage after 80% EC for all muscles, although the magnitude of the protective effect differed among the muscles.

Damage and the repeated bout effect of arm, leg, and trunk muscles induced by eccentric resistance exercises

This study compared nine resistance eccentric exercises targeting arm, leg, and trunk muscles in one session for changes in maximal voluntary isometric contraction strength (MVC), delayed onset muscle soreness (DOMS), plasma creatine kinase (CK) activity, and myoglobin (Mb) concentration after the first and second bouts. Fifteen sedentary men (20-25 years) performed 5 sets of 10 eccentric contractions with 80% of MVC load for the elbow flexors (EF), elbow extensors (EE), pectoralis, knee extensors (KE), knee flexors (KF), plantar flexors (PF), latissimus, abdominis, and erector spinae (ES) in a randomized order and repeated the same exercises 2 weeks later. MVC decreased at 1 (16%-57%) to 4 (13%-49%) days, DOMS developed (peak: 43-70 mm), and CK activity (peak: 23 238-207 304 IU/L) and Mb concentration showed large increases after the first bout. The magnitude of decrease in MVC was greater (P < 0.05) for EF, EE, and PEC than others and for KF than KE, PF, and ES. DOMS was greater (P < 0.05) for EF, EE, and ES than others. Changes in all measures were smaller (P < 0.05) after the second than the first bout, and the magnitude of the repeated bout effect was similar among the muscles. Plasma CK activity and Mb concentration did not increase significantly after the second exercise bout. It was concluded that muscle damage was greater for arm than leg muscles, and muscle proteins in the blood increased to a critical level after unaccustomed whole-body resistance exercises, but the magnitude of damage was largely attenuated for all muscles similarly after the second bout.

How to do it: investigate exertional rhabdomyolysis (or not)

Rhabdomyolysis is the combination of symptoms (myalgia, weakness and muscle swelling) and a substantial rise in serum creatine kinase (CK) >50 000 IU/L; there are many causes, but here we specifically address exertional rhabdomyolysis. The consequences of this condition can be severe, including acute kidney injury and requirement for higher level care with organ support. Most patients have ‘physiological’ exertional rhabdomyolysis with no underlying disease; they do not need investigation and should be advised to return to normal activities in a graded fashion. Rarely, exertional rhabdomyolysis may be the initial presentation of underlying muscle disease, and we review how to identify this much smaller group of patients, who do require investigation.

Perspectives on Exertional Rhabdomyolysis

Exertional (exercise-induced) rhabdomyolysis is a potentially life threatening condition that has been the subject of research, intense discussion, and media attention. The causes of rhabdomyolysis are numerous and can include direct muscle injury, unaccustomed exercise, ischemia, extreme temperatures, electrolyte abnormalities, endocrinologic conditions, genetic disorders, autoimmune disorders, infections, drugs, toxins, and venoms. The objective of this article is to review the literature on exertional rhabdomyolysis, identify precipitating factors, and examine the role of the dietary supplement creatine monohydrate. PubMed and SPORTDiscus databases were searched using the terms rhabdomyolysis, muscle damage, creatine, creatine supplementation, creatine monohydrate, and phosphocreatine. Additionally, the references of papers identified through this search were examined for relevant studies. A meta-analysis was not performed. Although the prevalence of rhabdomyolysis is low, instances still occur where exercise is improperly prescribed or used as punishment, or incomplete medical history is taken, and exertional rhabdomyolysis occurs. Creatine monohydrate does not appear to be a precipitating factor for exertional rhabdomyolysis. Healthcare professionals should be able to recognize the basic signs of exertional rhabdomyolysis so prompt treatment can be administered. For the risk of rhabdomyolysis to remain low, exercise testing and prescription must be properly conducted based on professional standards.

Cluster of exertional rhabdomyolysis in three young women

Three young women, aged 18-24 years, presented to general practice with signs and symptoms of exertional rhabdomyolysis in 2016. All attended the same gym and had undertaken an intensive physical workout. Presenting symptoms were severe muscle pain and swelling, significantly reduced range of motion in affected muscles and, in two cases, dark-coloured urine. One case had presented to the out-of-hours service 4 months previously with similar symptoms but rhabdomyolysis was not considered, although retrospective history taking suggests that was the likely diagnosis. All three women were admitted to hospital, treated with intravenous fluids and discharged between 1 and 6 days later. All made a full recovery with no renal sequelae. The cases were questioned about potential risk factors, and the only commonality was unaccustomed strenuous exercise.

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.

Neurologic Injuries in Noncontact Sports

Noncontact sports are associated with a variety of neurologic injuries. Concussion, vascular injury (arterial dissection), and spinal cord trauma may be less common in noncontact sports, but require special attention from the sports neurologist. Complex regional pain disorders, muscle injury from repetitive use, dystonia, heat exposure, and vascular disorders (patent foramen ovale), occur with similar frequency in noncontact and contact sports. Management of athletes with these conditions requires an understanding of the neurologic consequences of these disorders, the risk of injury with return to play, and consideration for the benefits of exercise in health restoration and disease prevention.

Risk Factors for Collegiate Swimmers Hospitalized With Exertional Rhabdomyolysis

OBJECTIVE

To identify midseason risk factors for symptomatic exertional rhabdomyolysis (sER) in swimmers after a novel upper body workout.

DESIGN

Retrospective (1) survey and (2) analyses of observational laboratory data conducted over a 16-week training period, 2 months before sER.

SETTING

Midwest University.

PARTICIPANTS

Thirty-four collegiate swimmers.

INDEPENDENT VARIABLES

(1) Motivation, symptoms, and supplements for survey variables. (2) Changes (midseason minus preseason) in body composition, blood pressure (BP), urinary measures, and protein shake ingestion for laboratory variables.

MAIN OUTCOME MEASURES

Swimmers were categorized in hospitalized (H), treated and released from hospital (RH), and nonhospitalized (NH) groups for analyses.

RESULTS

(1) Six swimmers were in the H group (17.6%; 3 male/3 female) and 7 in the RH group (20.6%; 3 male/4 female). Nonsignificant trend toward H swimmers relating more upper body soreness (≥9/10) than RH (8/10) and NH (6/10) swimmers (P > 0.05) while reporting "felt bad and workout went poorly" (P = 0.009). H and RH swimmers reported more arm locking during the workout (P = 0.04) and brown urine after arm competition compared with NH-group swimmers (P = 0.03). (2) Increases in right systolic (P = 0.01) and left diastolic (P = 0.02) BP, with trends toward decreased left arm lean mass (P = 0.06) in H compared with RH and NH swimmers. Female H swimmers had more acidic urine (pH = 5.50 vs 6.9; P = 0.004), less volume, and higher specific gravity than RH + NH swimmers. All H swimmers regularly ingested protein shakes after workouts.

CONCLUSIONS

Risk factors for sER included exceptional motivation, extreme soreness, increased resting BP, acidic urine (females), and regular ingestion of protein shakes.

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.

RYR1-related rhabdomyolysis: A common but probably underdiagnosed manifestation of skeletal muscle ryanodine receptor dysfunction

Mutations in the skeletal muscle ryanodine receptor (RYR1) gene are associated with a wide spectrum of inherited myopathies presenting throughout life. Malignant hyperthermia susceptibility (MHS)-related RYR1 mutations have emerged as a common cause of exertional rhabdomyolysis, accounting for up to 30% of rhabdomyolysis episodes in otherwise healthy individuals. Common triggers are exercise and heat and, less frequently, viral infections, alcohol and drugs. Most subjects are normally strong and have no personal or family history of malignant hyperthermia. Heat intolerance and cold-induced muscle stiffness may be a feature. Recognition of this (probably not uncommon) rhabdomyolysis cause is vital for effective counselling, to identify potentially malignant hyperthermia-susceptible individuals and to adapt training regimes. Studies in various animal models provide insights regarding possible pathophysiological mechanisms and offer therapeutic perspectives.

Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy?

Exertional rhabdomyolysis is characterised by muscle breakdown associated with strenuous exercise or normal exercise under extreme circumstances. Key features are severe muscle pain and sudden transient elevation of serum creatine kinase (CK) levels with or without associated myoglobinuria. Mild cases may remain unnoticed or undiagnosed. Exertional rhabdomyolysis is well described among athletes and military personnel, but may occur in anybody exposed to unaccustomed exercise. In contrast, exertional rhabdomyolysis may be the first manifestation of a genetic muscle disease that lowers the exercise threshold for developing muscle breakdown. Repeated episodes of exertional rhabdomyolysis should raise the suspicion of such an underlying disorder, in particular in individuals in whom the severity of the rhabdomyolysis episodes exceeds the expected response to the exercise performed. The present review aims to provide a practical guideline for the acute management and postepisode counselling of patients with exertional rhabdomyolysis, with a particular emphasis on when to suspect an underlying genetic disorder. The pathophysiology and its clinical features are reviewed, emphasising four main stepwise approaches: (1) the clinical significance of an acute episode, (2) risks of renal impairment, (3) clinical indicators of an underlying genetic disorders and (4) when and how to recommence sport activity following an acute episode of rhabdomyolysis. Genetic backgrounds that appear to be associated with both enhanced athletic performance and increased rhabdomyolysis risk are briefly reviewed.

Exercise-induced rhabdomyolysis mechanisms and prevention: A literature review

Exercise-induced rhabdomyolysis (exRML), a pathophysiological condition of skeletal muscle cell damage that may cause acute renal failure and in some cases death. Increased Ca²⁺ level in cells along with functional degradation of cell signaling system and cell matrix have been suggested as the major pathological mechanisms associated with exRML. The onset of exRML may be exhibited in athletes as well as in general population. Previous studies have reported that possible causes of exRML were associated with excessive eccentric contractions in high temperature, abnormal electrolytes balance, and nutritional deficiencies possible genetic defects. However, the underlying mechanisms of exRML have not been clearly established among health professionals or sports medicine personnel. Therefore, we reviewed the possible mechanisms and correlated prevention of exRML, while providing useful and practical information for the athlete and general exercising population.

Return to Play After Exertional Rhabdomyolysis

OBJECTIVE

To outline a 4-phase progressive program that safely and successfully enabled athletes to return to sport without recurrence of exertional rhabdomyolysis symptoms.

BACKGROUND

In January 2011, a large cluster of National Collegiate Athletic Association Division I football athletes were evaluated and treated for exertional rhabdomyolysis. After the athletes were treated, the athletic trainers and sports medicine providers were challenged to develop a safe return-to-play program because of the lack of specific reports in the medical literature to direct such activities.

TREATMENT

A progressive 4-phase program based on existing recommendations, including guidelines for continued clinical and laboratory monitoring.

CONCLUSIONS

Although the actual process of reintegrating players will differ based on each athlete's unique circumstances, this program provides a safe and effective foundation that can be modified based on the response to activity and sport.

Challenging Return to Play Decisions: Heat Stroke, Exertional Rhabdomyolysis, and Exertional Collapse Associated With Sickle Cell Trait

Context:

Sports medicine providers frequently return athletes to play after sports-related injuries and conditions. Many of these conditions have guidelines or medical evidence to guide the decision-making process. Occasionally, however, sports medicine providers are challenged with complex medical conditions for which there is little evidence-based guidance and physicians are instructed to individualize treatment; included in this group of conditions are exertional heat stroke (EHS), exertional rhabdomyolysis (ER), and exertional collapse associated with sickle cell trait (ECAST).

Evidence Acquisition:

The MEDLINE (2000-2015) database was searched using the following search terms: exertional heat stroke, exertional rhabdomyolysis, and exertional collapse associated with sickle cell trait. References from consensus statements, review articles, and book chapters were also utilized.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

These entities are unique in that they may cause organ system damage capable of leading to short- or long-term detriments to physical activity and may not lend to complete recovery, potentially putting the athlete at risk with premature return to play.

Conclusion:

With a better understanding of the pathophysiology of EHS, ER, and ECAST and the factors associated with recovery, better decisions regarding return to play may be made.

Creatine kinase levels during preseason camp in National Collegiate Athletic Association Division I football athletes

OBJECTIVE

To investigate mean creatine kinase (CK) levels in National Collegiate Athletic Association (NCAA) Division I football athletes and the relationship between mean CK levels and demographic variables.

DESIGN

Observational cohort.

SETTING

NCAA Division I football program.

PARTICIPANTS

NCAA Division I football athletes.

INTERVENTIONS

Blood and urine samples were obtained from 32 athletes on the first (time 1), third (time 2), and seventh (time 3) days of football camp.

MAIN OUTCOME MEASURES

Mean CK levels. The hypotheses were formulated before the data were collected.

RESULTS

All urine samples tested negative for blood. Mean CK levels were 284.7 U/L at time 1, 1299.8 U/L at time 2, and 1562.4 U/L at time 3. The increases in means were statistically significant (P < 0.005 for all pairwise comparisons). Most demographic variables were not related to mean CK levels. The number of days in the precamp conditioning program was negatively associated with mean CK levels (P = 0.0284).

CONCLUSIONS

Mean CK levels in NCAA Division I football athletes during camp were higher than the serological criteria for rhabdomyolysis commonly used in clinical practice. More data are needed to assess if the number of days of participation in precamp conditioning is related to lower CK levels in NCAA Division I football athletes during camp.

Exertional rhabdomyolysis in the athlete: a clinical review

CONTEXT

Exertional rhabdomyolysis is a relatively uncommon but potentially fatal condition affecting athletes that requires prompt recognition and appropriate management.

EVIDENCE ACQUISITION

A search of the PubMed database from 2003 to 2013 using the term exertional rhabdomyolysis was performed. Further evaluation of the bibliographies of articles expanded the evidence.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Exertional rhabdomyolysis (ER) is a relatively uncommon condition with an incidence of approximately 29.9 per 100,000 patient years but can have very serious consequences of muscle ischemia, cardiac arrhythmia, and death. The athlete will have pain, weakness, and swelling in the muscles affected as well as significantly elevated levels of creatine kinase (CK). Hydration is the foundation for any athlete with ER; management can also include dialysis or surgery. Stratifying the athlete into high- or low-risk categories can determine if further workup is warranted.

CONCLUSION

Exertional rhabdomyolysis evaluation requires a history, physical examination, and serology for definitive diagnosis. Treatment modalities should include rest and hydration. Return to play and future workup should be determined by the risk stratification of the athlete.

STRENGTH-OF-RECOMMENDATION TAXONOMY SORT

C.

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 in an adolescent athlete during preseason conditioning: a perfect storm

Cleary, MA, Sadowski, KA, Lee, SY-C, Miller, GL, and Nichols, AW. Exertional rhabdomyolysis in an adolescent athlete during preseason conditioning: a perfect storm. J Strength Cond Res 25(12): 3506-3513, 2011-The purpose of this brief review is to present a case of a healthy, male adolescent athlete (age = 16 years, body mass = 67.9 kg, height = 165.5 cm) who participated in a 3-day preseason wrestling camp which resulted in hospitalization for exertional rhabdomyolysis. As part of the preseason conditioning program directed by the coaches, the athlete completed 60 minutes of short, intense intervals of wall-sits, squats, sit-ups, push-ups, lunges, and plyometric jumps. The following day, the athlete continued his vigorous training consisting of running drills. That night he noticed voiding dark brown urine the color of cola. The day after the camp ended, the athlete reported to his Athletic Trainers with the chief complaint of severe bilateral leg pain in his quadriceps. Two days after the initial assessment, he was admitted to the hospital where he was diagnosed with exertional rhabdomyolysis based on creatine kinase (CK) levels that peaked at 146,000 IU·L, elevated far beyond normal (normal range = 58-280 IU·L). The athlete was hospitalized for 6 days where he received intravenous normal saline for rehydration, and his CK levels were assessed daily. Athletic Trainers, personal trainers, physical education teachers, and coaches should be aware that exertional rhabdomyolysis is the most common form of rhabdomyolysis and affects individuals who participate in novel and intense exercise to which they are unaccustomed. Stressful ambient conditions may lead to dehydration and exacerbation of the condition, particularly when the individual is not accustomed to the exercise intensity.

Natural history of exertional rhabdomyolysis: a population-based analysis

Exertional rhabdomyolysis is a potentially catastrophic syndrome with an incidence and rate of recurrence that are unknown. In this study patients with rhabdomyolysis were identified retrospectively from the Wilford Hall Medical Center records. A population-based analysis was performed on exertional rhabdomyolysis patients enrolled in basic military training. A retrospective cohort was analyzed for rate and risks of recurrence. Of 177 rhabdomyolysis patients, 63 were exertional in mechanism. The rate of renal failure was lower in exertional rhabdomyolysis patients (odds ratio 0.45, 95% confidence interval 0.22-0.95, P = 0.04). There were 44 cases of exertional rhabdomyolysis from a population of 198,399 total military trainees over the study period, or 22.2 cases per 100,000 per year. A cohort of 22 exertional rhabdomyolysis patients was followed for a mean of 31.2 months, with only 1 recurrence (recurrence risk of 0.08% per person per year). Exertional rhabdomyolysis is associated with lower rates of complications than other causes of rhabdomyolysis. Among young, physically active patients, the incidence of exertional rhabdomyolysis is low, as is the risk of recurrence.

Exertional rhabdomyolysis and acute kidney injury

Skeletal muscle breakdown occurs normally with exercise, followed by muscle repair and physiologic adaptation. Strenuous, unaccustomed, prolonged, and repetitive exercise, particularly when associated with other risk factors such as hot and humid climate or sickle cell trait can cause clinically significant exertional rhabdomyolysis (ER). Although most cases are asymptomatic and resolve without sequelae, ER is the most common cause of exercise-related myoglobinuric acute renal injury and acute renal failure in athletes. Exercise-related muscle pain, elevated serum creatine kinase (CK), and "cola-colored" urine have been described as a classic presentation of ER. The exact mechanism of ER has not been clearly elucidated. Most studies suggest a cascade of events that include depletion of adenosine triphosphate (ATP), impaired function of the Na+- K+ ATPase system, intracellular excess calcium accumulation, sarcolemma damage, and release of intracellular proteins and other substances into blood. Excess myoglobin that is filtered at the glomerulus can lead to myoglobinuric acute renal injury. Cessation of physical activity, relative rest during clinical recovery, and early aggressive fluid replacement are mainstays of treatment. Return to play after recovery from ER is influenced by associated risk factors that may predispose the athlete to recurrence and is guided by signs, symptoms, and CK levels. This article reviews the definitions, pathophysiology, diagnosis, and management of ER with specific relevance to acute kidney injury.