Rhabdomyolysis in a collegiate football player

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.

American Football Players in Preseason Training at Risk of Acute Kidney Injury Without Signs of Rhabdomyolysis

OBJECTIVE

This study was designed to identify changes in blood biomarkers that would indicate excessive muscle breakdown during the initial 10 days of preseason training in collegiate American football players and subsequently increase their risk of acute kidney injury (AKI).

DESIGN

Prospective cohort study.

SETTING

Preseason, heat acclimatization period.

PARTICIPANTS

Twenty-five Division I American football players.

INTERVENTION

Clinical biomarkers for muscle damage were measured during a preseason training camp. Samples were obtained before camp and approximately 5 and 10 days into camp after completion of heat acclimatization training.

MAIN OUTCOMES

Creatine kinase, myoglobin, lactate dehydrogenase, and creatinine were measured. Glomerular filtration rate (GFR) was calculated. Urine was collected at each blood draw to qualitatively identify hematuria and red blood cells.

RESULTS

A high percentage of athletes had an asymptomatic reduction in kidney function over the 10-day period. Ten of 23 athletes did have a significant, 31.6%, mean reduction in GFR, placing each at risk of AKI according to Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) classification. The plasma myoglobin for the at risk of AKI group had a mean value 8× above their baseline mean on day 5 and statistically significant mean 13× higher on day 10 than baseline. The not at risk of AKI group did not have significant differences between days 0, 5, and 10.

CONCLUSIONS

A relatively high percentage of athletes had an asymptomatic reduction in kidney function during the intense preseason training period. 43.4% of athletes in this study had a significant 31.6% mean reduction in GFR over the 10 days. According to RIFLE classification, this placed each athlete "at risk" of AKI.

Twelve cases of exertional rhabdomyolysis in college football players from the same institution over a 23-year span: a descriptive study

BACKGROUND

Rhabdomyolysis is a syndrome characterized by muscle necrosis that leads to release of the intracellular contents of muscle cells into the systemic circulation. Rhabdomyolysis due to overexertion is an uncommon but well-known severe complication of strenuous activity. Exertional rhabdomyolysis (ER) is typically described in weight lifters and military recruits undergoing basic training. Few cases have been reported in football players without known predisposing risk factors. We report our experience with this condition in college football players in a single institution.

MATERIALS AND METHODS

College football players hospitalized for heat illness complicated by rhabdomyolysis were identified over a 23-year period. Clinical and laboratory findings were collected. Clinical course was recorded.

RESULTS

Twelve patients were identified. All were Black males. One had sickle cell trait. BMI averaged 33 kg/m² (range 23-45 kg/m²). Peak creatine phosphokinase (CPK) averaged 14,850 IU/L (range 1,021-109,616 IU/L). Serum creatinine averaged 1.9 mg/dl (range 1.2-3.1 mg/dl). Ten of twelve cases occurred in August. All responded to intravenous hydration with normalization of CPK and renal function. All returned to football.

CONCLUSIONS

ER is a serious complication of strenuous physical activity that can threaten renal function. ER tends to occur in August, which coincides with the start of football practice when athletes are more likely to be detrained. The condition can occur in Black athletes in the absence of sickle cell trait. ER carries a good prognosis when recognized early and treated adequately.

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.

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.

Increased Prevalence of the IL-6-174C Genetic Polymorphism in Long Distance Swimmers

The IL-6 -174G/C single nucleotide polymorphism (SNP) functionally affects IL-6 activity, with the G-allele associated with increased IL-6 levels. The C-allele was found to be associated with exercise-induced skeletal muscle damage. The aim of the present study was to examine the association between the IL-6 -174G/C polymorphism and athletic performance among elite swimmers and runners. The study sample included 180 track and field athletes and 80 swimmers. Track and field athletes were assigned to three sub-groups: long-distance runners, middle-distance runners and short-distance runners. Swimmers were assigned to two subgroups: long-distance swimmers and short-distance swimmers. The control group consisted of 123 non-athletic healthy individuals. Genomic DNA was extracted from peripheral blood following a standard protocol. Genotyping was performed using polymerase chain reaction (PCR). The CC genotype and C-allele frequency were significantly higher in the long-distance swimmers (18 and 43%, respectively) compared to the long-distance runners (3 and 14%, respectively, p < 0.001); middle-distance runners (4 and 22%, respectively, p < 0.001); and controls (5 and 19%, respectively, p < 0.001). In addition, the CC genotype and C-allele frequency were significantly higher (p < 0.001) in long-distance swimmers compared to short-distance swimmers (18 versus 5% and 43 versus 29% for the CC genotype and C-allele frequency, respectively). The higher frequency of the C-allele and CC genotype among long-distance swimmers suggests that the rarity of exercise-associated rhabdomyolysis among swimmers is probably related to other sports-specific or water-related protective mechanisms. It is possible that swimming selection in talented endurance athletes who are C-allele carriers represents an example of genetically-dependent sports selection.

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.

Short-Wave Diathermy Pretreatment and Inflammatory Myokine Response After High-Intensity Eccentric Exercise

CONTEXT

Various modalities have been used to pretreat skeletal muscle to attenuate inflammation.

OBJECTIVE

To determine the effects of short-wave diathermy (SWD) preheating treatment on inflammation and stress markers after eccentric exercise.

DESIGN

Controlled laboratory study.

SETTING

University laboratory setting.

PATIENTS OR OTHER PARTICIPANTS

Fifteen male (age = 22 ± 4.9 years, height = 179.75 ± 9.56 cm, mass = 82.22 ± 12.67 kg) college-aged students.

INTERVENTION(S)

Seven participants were selected randomly to receive 40 minutes of SWD heat treatment (HT), and 8 participants served as the control (CON) group and rested without SWD. Both groups completed 7 sets of 10 repetitions of a high-intensity eccentric exercise protocol (EEP) at 120% of the 1-repetition maximum (1-RM) leg extension.

MAIN OUTCOME MEASURE(S)

We biopsied muscles on days 1, 3 (24 hours post-EEP), and 4 (48 hours post-EEP) and collected blood samples on days 1, 2 (4 hours post-EEP), 3, and 4. We determined 1-RM on day 2 (24 hours post-SWD) and measured 1-RM on days 3 and 4. We analyzed the muscle samples for interleukin 6 (IL-6), tumor necrosis factor α, and heat shock protein 70 and the blood for serum creatine kinase.

RESULTS

We found a group × time interaction for intramuscular IL-6 levels after SWD (F2,26 = 7.13, P = .003). The IL-6 decreased in HT (F1,6 = 17.8, P = .006), whereas CON showed no change (P > .05). We found a group × time interaction for tumor necrosis factor α levels (F2,26 = 3.71, P = .04), which increased in CON (F2,14 = 7.16, P = .007), but saw no changes for HT (P > .05). No group × time interactions were noted for 1-RM, heat shock protein 70, or creatine kinase (P > .05).

CONCLUSIONS

The SWD preheating treatment provided a treatment effect for intramuscular inflammatory myokines induced through high-intensity eccentric exercise but did not affect other factors associated with intense exercise and inflammation.

Creased hydrogels as active platforms for mechanical deformation of cultured cells

Cells cultured in vitro using traditional substrates often change their behavior due to the lack of mechanical deformation they would naturally experience in vivo. To mimic the in vivo mechanical environment, we design temperature-responsive hydrogels with patterned surface creases as dynamic cell stretching devices. A one-step photolithographic method is first employed to pattern integrin-binding peptides on the gel, causing single cells or several-cell clusters to adhere to the surface in registry with creases. A variety of crease patterns are prescribed on a single substrate, enabling the mechanical deformation of cultured myoblast cells with different strain states and achieving tensile strain as high as 0.2. As creases provide large amplitude local deformation of the gel surface without the need for macroscopic deformation, can be formed on gels covering a wide range of modulus, and can be actuated using a variety of stimuli, they hold the potential to enable the design of high throughput and versatile platforms for mechano-biological studies.

Neurologic emergencies in sports

PURPOSE OF REVIEW

Sports neurology is an emerging area of subspecialty. Neurologists and non-neurologists evaluating and managing individuals participating in sports will encounter emergencies that directly or indirectly involve the nervous system. Since the primary specialty of sports medicine physicians and other practitioners involved in the delivery of medical care to athletes in emergency situations varies significantly, experience in recognition and management of neurologic emergencies in sports will vary as well. This article provides a review of information and elements essential to neurologic emergencies in sports for the practicing neurologist, although content may be of benefit to readers of varying background and expertise.

RECENT FINDINGS

Both common neurologic emergencies and less common but noteworthy neurologic emergencies are reviewed in this article. Issues that are fairly unique to sports participation are highlighted in this review. General concepts and principles related to treatment of neurologic emergencies that are often encountered unrelated to sports (eg, recognition and treatment of status epilepticus, increased intracranial pressure) are discussed but are not the focus of this article. Neurologic emergencies can involve any region of the nervous system (eg, brain, spine/spinal cord, peripheral nerves, muscles). In addition to neurologic emergencies that represent direct sports-related neurologic complications, indirect (systemic and generalized) sports-related emergencies with significant neurologic consequences can occur and are also discussed in this article.

SUMMARY

Neurologists and others involved in the care of athletes should consider neurologic emergencies in sports when planning and providing medical care.

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 a collegiate american football player after preventive cold-water immersion: a case report

OBJECTIVE

To describe a case of exertional rhabdomyolysis in a collegiate American football player after preventive coldwater immersion.

BACKGROUND

A healthy man (19 years old) participated in full-contact football practice followed by conditioning (2.5 hours). After practice, he entered a coach-mandated postpractice cold-water immersion and had no signs of heat illness before developing leg cramps, for which he presented to the athletic training staff. After 10 minutes of repeated stretching, massage, and replacement of electrolyte-filled fluids, he was transported to the emergency room. Laboratory tests indicated a creatine kinase (CK) level of 2545 IU/L (normal range, 45-260 IU/L), CK-myoglobin fraction of 8.5 ng/mL (normal < 6.7 ng/mL), and CK-myoglobin relative index of 30% (normal range, 25%-30%). Myoglobin was measured at 499 ng/mL (normal = 80 ng/mL). The attending physician treated the athlete with intravenous fluids.

DIFFERENTIAL DIAGNOSIS

Exercise-associated muscle cramps, dehydration, exertional rhabdomyolysis.

TREATMENT

The patient was treated with rest and rehydration. One week after the incident, he began biking and swimming. Eighteen days later, the patient continued to demonstrate elevated CK levels (527 IU/L) but described no other symptoms and was allowed to return to football practice as tolerated. Two months after the incident, his CK level remained high (1900 IU/L).

UNIQUENESS

The athlete demonstrated no signs of heat illness upon entering the cold-water immersion but experienced severe leg cramping after immersion, resulting in a diagnosis of exertional rhabdomyolysis. Previously described cases have not linked cold-water immersion with the pathogenesis of rhabdomyolysis.

CONCLUSIONS

In this football player, CK levels appeared to be a poor indicator of rhabdomyolysis. Our patient demonstrated no other signs of the illness weeks after the incident, yet his elevated CK levels persisted. Cold-water immersion immediately after exercise should be monitored by the athletic training staff and may not be appropriate to prevent muscle damage, given the lack of supporting evidence.

Acute exertional rhabdomyolysis and triceps compartment syndrome during a high school football cAMP

Background:

Acute exertional rhabdomyolysis has been infrequently reported among adolescents. In August 2010, several high school football players from one team developed rhabdomyolysis and triceps compartment syndrome following an upper arm exercise held in a non-air-conditioned wrestling room.

Purpose:

To confirm the diagnoses, characterize the spectrum of illnesses, and determine the factors contributing to rhabdomyolysis and triceps compartment syndromes.

Study Design:

Descriptive epidemiology study.

Methods:

The authors reviewed hospital medical records and interviewed players, coaches, school administrators, and hospital staff, using a standardized questionnaire that assessed symptoms, exposures, and activities.

Results:

Among 43 players, 22 (51%) experienced rhabdomyolysis (peak creatine kinase range, 2434-42 000 U/L): 22 patients had upper arm myalgia; 12 were hospitalized; 3 experienced triceps compartment syndrome; none experienced renal failure. Illnesses started 1 to 3 days after the triceps exercise. Forty players (93%) completed questionnaires. Among 19 players receiving at least 1 vote from a teammate as 1 of the 3 hardest working players, 13 (68%) experienced rhabdomyolysis versus 7 (33%) of 21 not considered hardest working (relative risk, 2.1; 95% confidence interval, 1.04-4.0). Of 40 players, 10 (25%) reported creatine supplement use, which was not associated with rhabdomyolysis. No player acknowledged use of alcohol, illicit drugs, or performance-enhancing drugs; results of performance-enhancing drug tests on the 4 players tested were negative. Environmental investigation did not identify additional factors contributing to illness.

Conclusions:

The upper arm exercise, possibly exacerbated by heat, led to rhabdomyolysis and compartment syndrome. Greater awareness of specific exercise hazards and prevention strategies can minimize risk for clinically significant muscle injury.

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.