Athletic Training and Sports Health Care

Case Reviews 

Exertional Rhabdomyolysis in a High School Athlete: A Case Review

Shawn D. Felton, EdD, ATC, LAT; Denise Heinemann, DrPH, RN; Jason Craddock, EdD, ATC, LAT, CSCS

Abstract

Following the afternoon two-a-day training session, a 15-year-old male high school football player with no prior medical history reported to the athletic trainer with bilateral triceps pain and mild swelling later diagnosed as exertional rhabdomyolysis. An infrequent diagnosis among athletes, particularly high school athletes, exertional rhabdomyolysis can occur across the lifespan as a result of muscle damage from trauma, metabolic disorders, prolonged immobilization, and unusual physical exertion. Because the condition can lead to renal failure if untreated, it is important to recognize the presenting signs and symptoms and refer the individual for medical assessment immediately. Exertional rhabdomyolysis can develop after an athlete has left practice, a particular concern among high school athletes. It is prudent to educate student athletes and their parents about the signs and symptoms of rhabdomyolysis, particularly in the southern United States where hot weather and high humidity are risk factors for the condition, notably during preseason training sessions.

Abstract

Following the afternoon two-a-day training session, a 15-year-old male high school football player with no prior medical history reported to the athletic trainer with bilateral triceps pain and mild swelling later diagnosed as exertional rhabdomyolysis. An infrequent diagnosis among athletes, particularly high school athletes, exertional rhabdomyolysis can occur across the lifespan as a result of muscle damage from trauma, metabolic disorders, prolonged immobilization, and unusual physical exertion. Because the condition can lead to renal failure if untreated, it is important to recognize the presenting signs and symptoms and refer the individual for medical assessment immediately. Exertional rhabdomyolysis can develop after an athlete has left practice, a particular concern among high school athletes. It is prudent to educate student athletes and their parents about the signs and symptoms of rhabdomyolysis, particularly in the southern United States where hot weather and high humidity are risk factors for the condition, notably during preseason training sessions.

The authors are from Florida Gulf Coast University, Fort Myers, Fla.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Shawn D. Felton, EdD, ATC, LAT, Florida Gulf Coast University, College of Health Professions-Department of Physical Therapy and Human Performance, 10501 FGCU Blvd South, Fort Myers, FL 33965; e-mail: sfelton@fgcu.edu.

Received: July 23, 2009
Accepted: November 09, 2010
Posted Online: January 31, 2011

Rhabdomyolysis is characterized by a breakdown of skeletal muscle membrane that leads to extravasation of muscle intracellular contents into the blood stream. Myoglobin, creatine kinase, potassium, phosphates, organic acids, and purines enter the circulatory system and are replaced by a concomitant influx of calcium, sodium, and water into the muscle tissue, causing it to swell.1–3 Exertional rhabdomyolysis is often the result of overexertion in a trained athlete or extraordinary exertion in an untrained individual. The condition has even been reported in a person who played computer games for several days without appropriate rest and nutrition.4 It has also been documented in athletes who use performance-enhancing drugs delivered intramuscularly.5 The use of nutritional supplements containing ephedra, creatine, and large doses of caffeine (>1 g) have been reported as a cause of rhabdomyolysis.6

The incidence of exertional rhabdomyolysis has increased with the growing involvement of people of all ages in physical exercise and bodybuilding.7 In the United States alone, 26,000 cases from all causes are reported annually; however, the actual incidence is not fully known because not all of the cases are being reported.8 The condition has been observed in victims of trauma, dehydrated individuals with high serum sodium levels, individuals with seizure disorders, and older adults who have fallen. It can be a resulting complication for anyone who has sustained a muscle injury or developed compartment syndrome. Exertional rhabdomyolysis has been documented in individuals as young as age 12 and as a complication in individuals with infectious diseases such as influenza.1,9 Most of the early reported cases of exertional rhabdomyolysis in the literature were among military, criminal justice, and fire personnel in training. Anyone who performs vigorous exercise can develop the condition, but poorly conditioned individuals are at higher risk.10 Ultimately, rhabdomyolysis can be life threatening and has been identified as the cause of death among military recruits and athletes.11–14

Exertional rhabdomyolysis has been linked to risk factors that can be identified through proper assessment and treatment of athletes. The risk factors include inadequate conditioning, strenuous prolonged activity (particularly eccentric exercises), high ambient temperature, high humidity, inadequate hydration, high altitude, a recent infection (viral or bacterial),2,15 sickle cell trait and other genetic metabolic defects,2,3 direct muscle injury,1 alcohol abuse, and certain medications (statins, steroids, illicit drugs).2,3,7

The signs and symptoms of exertional rhabdomyolysis most apparent to an athletic trainer or strength and conditioning specialist are complaints of unusual bilateral muscle tenderness, severe pain in active ranges of motion, swelling, and weakness. Some cases are reported to involve only one muscle complex, resulting in unilateral signs and symptoms.7,8 The hallmark sign of exertional rhabdomyolysis is the presence of tea-or cola-colored urine.2,3,7,15–18 Once the initial signs or symptoms are apparent, laboratory diagnostic tests should be done, including blood chemistry for creatine kinase level and a urine test for myoglobin.

Myoglobin is a protein found in muscle tissue, a respiratory pigment that carries oxygen to the muscle. Damage to muscle tissue releases myoglobin into the circulation. Other muscle cellular contents, such as serum potassium, calcium, and uric acid, can be used to diagnosis rhabdomyolysis; however, the presence of an extremely elevated creatine kinase level is the most definitive sign that an athlete is suffering from rhabdomyolysis.2–4,12,19–24 Creatine kinase is a widely accepted proxy index of skeletal muscle damage. Athletes usually have higher baseline creatine kinase levels than do nonathletes.

A recent study examined serum levels in 483 male and 245 female athletes throughout their training and competition.25 Compared with a sample of nonathletes, athletes had upper limit mean creatine kinase levels as much as twice the level of the nonathletes. The upper limits were as much as 6 times the limits in inactive individuals reported in the literature. The author recommended introducing “sport-specific reference intervals” when testing creatine kinase to address the problem of false–positive conclusions and to inform training.25(p674) It has been suggested that the use of the urine dipstick for heme can be used to detect rhabdomyolysis. A recent study in patients with documented rhabdomyolysis concluded that the urine dipstick for heme analysis lacked adequate sensitivity (14%) to be a useful screen for rhabdomyolysis.26 Magnetic resonance imaging has been demonstrated to be more sensitive than computed tomography or ultrasound in detecting muscle damage.5

Although rhabdomyolysis can occur secondary to crush injuries and prolonged immobilization, the condition by itself can produce serious complications, including electrolyte imbalance (most notably hyperkalemia), metabolic acidosis, hypovolemia, renal failure, intravascular coagulation, and compartment syndrome.2,3,15 The effects of the circulating intracellular substances toxic to the kidney are magnified in a dehydrated individual.3

Treatment of exertional rhabdomyolysis is primarily directed at preserving renal function. Immediate intravenous hydration is usually required to counter the accumulation of these substances from muscle cell breakdown and facilitate their excretion before they cause kidney damage. Forced diuresis within the first 6 hours of admission has been demonstrated to prevent acute renal failure.15 Intravenous administration of saline in the initial stage of rhabdomyolysis at 1.5 L per hour is given to produce a urine output of 300 mL per hour until the urine is clear of myoglobin. In addition to treating patients with intravenous fluids, mannitol and loop diuretics (furosemide and bumetanide) may be used. When intravenous hydration fails and the patient develops renal failure, the case is then treated with hemodialysis. Patients with exertional rhabdomyolysis can fully recover after hemodialysis, depending on the amount of renal damage sustained. The key to successfully treating rhabdomyolysis is early recognition and aggressive treatment.

Case Review

On the third day following 2 days of twice-a-day practice sessions, a 15-year-old male high school football athlete reported to the athletic training room after the morning session ended, complaining of bilateral triceps pain. The athlete could not recall any mechanism of injury; he did report performing 100 up-down type exercises following the afternoon session the day prior. Of note, the athlete also indicated he had not participated in the preseason strength and conditioning program prior to the start of the twice-a-day practice sessions. Before reporting to the athletic trainer, he had completed the morning football practice session and an upper body strength training regimen. The athlete reported constant achy pain in his upper arm region that he believed was a result of the 100 up-down exercises he completed after the previous day’s practice session. The certified athletic trainer noted mild swelling bilaterally equal in the triceps musculature. Orthopedic evaluation revealed full range of motion with equal and full strength bilaterally; however, the athlete reported slight discomfort. There were no palpable or gross deformities observed, but point tenderness was noted in the belly of the triceps bilaterally. The circulation examination, which consisted of bilateral distal pulse analysis and digit capillary refill examination, was normal. The neurological examination of C5 through T1 myotomes and dermatomes evaluation was also within normal limits. The athlete denied any other previous history or other pre-existing medical condition related to his current complaint.

After the orthopedic examination, the athlete was initially treated with cryotherapy, which consisted of ice pack application for 20 minutes. The athlete was instructed to follow up with the certified athletic trainer prior to the start of the afternoon football practice session and he went home for lunch. While at home, he voided “brown urine” and went to a local emergency department for further evaluation. His creatine kinase level was >5000 U/L (the normal creatine kinase level range is 38 to 175 U/L) and the clinical signs and symptoms led the attending physician to diagnose the athlete’s condition as acute exertional rhabdomyolysis and admit him to the hospital.

The athlete remained hospitalized for 3 nights with continuous intravenous fluids. On discharge, the athlete was instructed to begin mild conditioning exercises after 2 weeks of inactivity and potentially resume full participation in athletic practices in 4 weeks, after the physician follow-up appointment. The athlete was instructed in proper hydration and closely monitored by the certified athletic trainer while participating in controlled physical activity during the initial 4 weeks after hospitalization. At the 4-week follow-up visit with the physician, the athlete was released and allowed to return to full sport participation without limitations but with continued monitoring by the certified athletic trainer for any signs or symptoms of problems. The athlete made a complete recovery and returned to full activity without incidence the remainder of the sport season.

Discussion

The true incidence of exertional rhabdomyolysis is not known, but the complications resulting from rhabdomyolysis can be life threatening. The pathology is the result of striated muscle cell damage that allows seepage of the contents of muscle cells into extracellular compartments and the circulatory system, producing serious electrolyte imbalance. Leakage of intracellular myoglobin, creatine kinase, potassium, phosphorous, organic acids, and purines out of muscle tissue allows calcium, sodium, and water from the extracellular space to enter the muscle cell, resulting in swelling. The increase in circulating potassium from the damaged muscle causes hyperkalemia, a life-threatening consequence of rhabdomyolysis that can lead to cardiac arrhythmias and cardiac arrest.3 The release of lactic acid, uric acid, phosphate, sulfate, and potassium from the muscle into the general circulation causes metabolic acidosis. In addition, hypovolemia can result from dehydration and the destruction of capillaries in the muscles damaged by rhabdomyolysis, further contributing to kidney damage.2,3,15

Renal failure is a late and serious complication of rhabdomyolysis, a consequence of the circulating myoglobin from muscle breakdown, which is toxic to the renal tubules. Renal failure develops in 15% of individuals with rhabdomyolysis11 and is the cause of most fatalities associated with exertional rhabdomyolysis.15 Myoglobin alone does not lead to myoglobinuric renal failure; renal vascular resistance caused by hypovolemia and an acidic environment caused by elevated levels of uric acid actually lead to acute tubular necrosis and renal failure.11,15

Implications for Clinical Practice

Rhabdomyolysis is preventable in most cases. Educating athletic trainers, strength and conditioning specialists, coaches, and athletes about the risk factors for exertional rhabdomyolysis is the best form of prevention. Education should emphasize general principles, such as gradual progression in intensity and duration of exercise to allow the athlete to become acclimated and properly adapt to increased training regimens.24 Evidence has suggested that regular and progressive training programs can act as a protective strategy in reducing an athlete’s risk of developing rhabdomyolysis. Therefore, implementing well-designed, high quality off-season training programs may be an effective strategy to decrease the likelihood of an athlete developing a case of exertional rhabdomyolysis.7,18

It is important for athletic trainers and strength professionals to adjust training activities for extreme weather environments. Exercising in environments of high heat, humidity, and altitude requires special attention. It is essential to gradually increase the intensity of activity to promote acclimatization. In addition to the environment, the athlete’s nutritional status and fluid intake must be monitored and regulated with particular attention to hydration. Sports medicine professionals must develop athletes’ trust and encourage open lines of communication so athletes feel comfortable alerting their coaches or athletic trainers that they are experiencing muscle symptoms or periods of extreme fatigue.

Proper preseason screening can help identify athletes who may be at a greater risk for exertional rhabdomyolysis and help prevent the condition. Athletes with hemoglobinopathies and untrained athletes are more at risk for exertional rhabdomyolysis.10 After the sports medicine staff has identified the at-risk athletes, specific adaptations should be made to educate and monitor them to help ensure that an athlete with manageable risk factors does not develop a life-threatening condition. It is essential for health care professionals to be familiar with the signs and symptoms of the condition to diagnose and treat exertional rhabdomyolysis to minimize its course.

Athletic trainers must be familiar with the signs and symptoms of the condition to prevent it. Should it occur, prompt diagnosis and treatment of exertional rhabdomyolysis early in its course should lead to full recovery. Coaches and athletic trainers should educate student athletes about the value of preseason training, adequate hydration and rest, avoidance of overexertion, and moderation in consumption of caffeinated beverages and alcohol and provide the same information to their parents.

Conclusion

Exertional rhabdomyolysis is a condition that can affect people across the lifespan for a multitude of reasons. If not diagnosed and treated quickly, it can lead to muscle necrosis, acute renal failure, cardiac arrest, and death. The actual incidence of exertional rhabdomyolysis is likely underreported, which challenges health care professionals’ understanding of the condition and associated risk factors. This case highlights exertional rhabdomyolysis in a male high school football athlete. Although this athlete made a full recovery, it calls attention to the need for certified athletic trainers, team physicians, and other team medical personnel to know the clinical signs and symptoms of exertional rhabdomyolysis to recognize the syndrome early and provide proper treatment to prevent complications. In the case of high school athletes, special attention should be given to educating athletes and their parents or guardians about the risk factors for the condition, principles of training to avoid it, and the signs and symptoms of the condition to initiate a proper treatment plan if the condition develops after the athletes have left the supervision of athletic staff.

References

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Authors

The authors are from Florida Gulf Coast University, Fort Myers, Fla.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Shawn D. Felton, EdD, ATC, LAT, Florida Gulf Coast University, College of Health Professions-Department of Physical Therapy and Human Performance, 10501 FGCU Blvd South, Fort Myers, FL 33965; e-mail: sfelton@fgcu.edu

10.3928/19425864-20110131-01

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