Athletic Training and Sports Health Care

Pearls of Practice 

Treatment and Return to Participation Following Exertional Rhabdomyolysis in Athletes

David Tomchuk, MS, ATC, LAT, CSCS; Tamara Valovich McLeod, PhD, ATC, FNATA; Cailee E. Welch Bacon, PhD, ATC

Abstract

Rhabdomyolysis results from excessive skeletal (striated) muscle breakdown, releasing intracellular contents into the bloodstream.1,2 Excessive serum levels of creatine kinase, potassium, free radicals, and myoglobin increase physiological stress on the internal organs to maintain life.1,2 In non-athletic endeavors, rhabdomyolysis results from injuries to large portions of skeletal muscle (eg, motor vehicle accidents or crush injuries), systemic infections, metabolic myopathies, and drug abuse.1 Exertional rhabdomyolysis develops from physical effort without traumatic or systemic injury, carrying a prevalence of approximately 26,000 cases annually within the United States.1 Up to 47% of rhabdomyolysis cases result from exertion.1,2 This Pearl of Practice presents recently published resources so athletic trainers can improve their knowledge of the prevention and treatment continuum for exertional rhabdomyolysis.

Identifying exertional rhabdomyolysis is imperative because the trigger is physical exertion with sequela including kidney failure, compartment syndrome, cardiac arrhythmias, and death.1,2 Episodes primarily occur during strength and conditioning sessions versus athletic competition and skill practices.1,3,4 Athletes will present 24 to 48 hours after exercise,1,5 typically describing the session as intensive multi-joint movements of disproportionate duration with minimal rest.2

Exertional rhabdomyolysis severity increases in athletes exerting the most effort or those physically incapable of performing the activity.3 Whenever athletes present with excessive localized soreness and weakness specific to muscles used during the workout (upper or lower body), particularly early in the season or after detraining, exertional rhabdomyolysis should be considered.1,2,5 This reported muscular discomfort is more pronounced compared to after work-out or delayed onset muscle soreness and occurs with or without muscular swelling, tenderness, malaise, nausea, and vomiting.1,2,5

Urine color (pigmentation) descriptors of reddish, cola, or tea raise suspicion for exertional rhabdomyolysis because myoglobin levels are potentially elevated.1,2,5 Visible myoglobinuria corresponds to 100 grams of muscle destruction.2 However, patients seldom describe myoglobinuria, making it an inappropriate clinical diagnostic indicator of exertional rhabdomyolysis.5 A urine dip-stick analysis has a sensitivity of 80% for rhabdomyolysis.1

Myoglobin concentrations were primarily used as diagnostic indicators for exertional rhabdomyolysis, but are now considered unreliable because filtration of serum myoglobin occurs more rapidly compared to creatine kinase.2 Serum myoglobin levels peak 12 hours after exertion and normalize within 24 hours,2 creating a low negative predictive value for ruling in exertional rhabdomyolysis.5 Conversely, creatine kinase levels peak 24 to 36 hours after exertion, potentially remain elevated for 5 days, and decrease approximately 40% per day.2 Creatine kinase measurements are the most reliable marker of exertional rhabdomyolysis diagnosis and recovery.2

After exertional rhabdomyolysis is suspected or confirmed, clinicians should consider clustering (team rhabdomyolysis): when group conditioning sessions create multiple exertional rhabdomyolysis cases from the same activity. Clusters are observed within a recent systematic review of exertional rhabdomyolysis in athletics because 79% (42 of 53) of the cases evaluated resulted from three specific conditioning sessions.1 Within organized athletics, once exertional rhabdomyolysis is diagnosed or suspected, all individuals who performed the activity should be evaluated while the conditioning protocol is reviewed.

Once hospitalized, administration of normal saline intravenous fluid is the standard treatment.1 However, incorporating sodium bicarbonate or mannitol can potentially aid recovery.1 Sodium bicarbonate alkalizes the urine, decreasing myoglobin toxicity, whereas mannitol increases renal blood flow and urine output until myoglobinuria ceases.1,2 A recent systematic review determined no difference between intravenous fluid treatment with or without sodium bicarbonate on hospitalization duration, but no articles describing mannitol use met their inclusion criteria.1 Although patients can be released without overnight hospitalization, the observed range was 1 to 8 days, with 4.5 days being average.1

The athlete should be comprehensively evaluated to determine whether his or her individual risk of exertional rhabdomyolysis recurrence is elevated (Table 1).6 Following evaluation, the athlete can begin individualized…

Rhabdomyolysis results from excessive skeletal (striated) muscle breakdown, releasing intracellular contents into the bloodstream.1,2 Excessive serum levels of creatine kinase, potassium, free radicals, and myoglobin increase physiological stress on the internal organs to maintain life.1,2 In non-athletic endeavors, rhabdomyolysis results from injuries to large portions of skeletal muscle (eg, motor vehicle accidents or crush injuries), systemic infections, metabolic myopathies, and drug abuse.1 Exertional rhabdomyolysis develops from physical effort without traumatic or systemic injury, carrying a prevalence of approximately 26,000 cases annually within the United States.1 Up to 47% of rhabdomyolysis cases result from exertion.1,2 This Pearl of Practice presents recently published resources so athletic trainers can improve their knowledge of the prevention and treatment continuum for exertional rhabdomyolysis.

Identification and Patient History

Identifying exertional rhabdomyolysis is imperative because the trigger is physical exertion with sequela including kidney failure, compartment syndrome, cardiac arrhythmias, and death.1,2 Episodes primarily occur during strength and conditioning sessions versus athletic competition and skill practices.1,3,4 Athletes will present 24 to 48 hours after exercise,1,5 typically describing the session as intensive multi-joint movements of disproportionate duration with minimal rest.2

Exertional rhabdomyolysis severity increases in athletes exerting the most effort or those physically incapable of performing the activity.3 Whenever athletes present with excessive localized soreness and weakness specific to muscles used during the workout (upper or lower body), particularly early in the season or after detraining, exertional rhabdomyolysis should be considered.1,2,5 This reported muscular discomfort is more pronounced compared to after work-out or delayed onset muscle soreness and occurs with or without muscular swelling, tenderness, malaise, nausea, and vomiting.1,2,5

Clinical Diagnosis

Urine color (pigmentation) descriptors of reddish, cola, or tea raise suspicion for exertional rhabdomyolysis because myoglobin levels are potentially elevated.1,2,5 Visible myoglobinuria corresponds to 100 grams of muscle destruction.2 However, patients seldom describe myoglobinuria, making it an inappropriate clinical diagnostic indicator of exertional rhabdomyolysis.5 A urine dip-stick analysis has a sensitivity of 80% for rhabdomyolysis.1

Myoglobin concentrations were primarily used as diagnostic indicators for exertional rhabdomyolysis, but are now considered unreliable because filtration of serum myoglobin occurs more rapidly compared to creatine kinase.2 Serum myoglobin levels peak 12 hours after exertion and normalize within 24 hours,2 creating a low negative predictive value for ruling in exertional rhabdomyolysis.5 Conversely, creatine kinase levels peak 24 to 36 hours after exertion, potentially remain elevated for 5 days, and decrease approximately 40% per day.2 Creatine kinase measurements are the most reliable marker of exertional rhabdomyolysis diagnosis and recovery.2

After exertional rhabdomyolysis is suspected or confirmed, clinicians should consider clustering (team rhabdomyolysis): when group conditioning sessions create multiple exertional rhabdomyolysis cases from the same activity. Clusters are observed within a recent systematic review of exertional rhabdomyolysis in athletics because 79% (42 of 53) of the cases evaluated resulted from three specific conditioning sessions.1 Within organized athletics, once exertional rhabdomyolysis is diagnosed or suspected, all individuals who performed the activity should be evaluated while the conditioning protocol is reviewed.

Treatment and Return to Play

Once hospitalized, administration of normal saline intravenous fluid is the standard treatment.1 However, incorporating sodium bicarbonate or mannitol can potentially aid recovery.1 Sodium bicarbonate alkalizes the urine, decreasing myoglobin toxicity, whereas mannitol increases renal blood flow and urine output until myoglobinuria ceases.1,2 A recent systematic review determined no difference between intravenous fluid treatment with or without sodium bicarbonate on hospitalization duration, but no articles describing mannitol use met their inclusion criteria.1 Although patients can be released without overnight hospitalization, the observed range was 1 to 8 days, with 4.5 days being average.1

The athlete should be comprehensively evaluated to determine whether his or her individual risk of exertional rhabdomyolysis recurrence is elevated (Table 1).6 Following evaluation, the athlete can begin individualized physical activity progression with the assistance and supervision of an interprofessional collaborative health care team.6,7 The systematic review described athletes returning to physical activity within 14 to 30 days following hospitalization, with 7 days being average.1 Recently, information discussing return-to-play criteria following exertional rhabdomyolysis became available.6,7 Asplund and O'Connor6 described a generalized protocol (Table 2) and Schleich et al.7 presented their program implemented on athletes.

Risk Variables for Recurrent Exertional Rhabdomyolysisa

Table 1:

Risk Variables for Recurrent Exertional Rhabdomyolysis

Return to Play Guidelines for Individuals With a Low Risk of Recurrence of Exertional Rhabdomyolysisa

Table 2:

Return to Play Guidelines for Individuals With a Low Risk of Recurrence of Exertional Rhabdomyolysis

Prevention and Preparedness

Evaluating comprehensive medical histories and pre-participation physicals examinations for potential myopathies (Table 1) can aid exertional rhabdomyolysis prevention efforts.6 Strength and conditioning sessions must be properly designed, implemented, and supervised by individuals educated in programming principles.4 Discussing exertional rhabdomyolysis with emergency medical services and emergency department personnel increases the likelihood of proper identification and prepares medical entities for potential clusters. Athletic trainers are qualified to identify situations with elevated exertional rhabdomyolysis risk and should possess the authority to alter or end strength and conditioning activities.

References

  1. Manspeaker S, Henderson K, Riddle D. Treatment of exertional rhabdomyolysis in athletes: a systematic review. JBI Database System Rev Implement Rep. 2016;14:117–147. doi:10.11124/JBISRIR-2016-001879 [CrossRef]
  2. Scalco RS, Snoeck M, Quinlivan R, et al. Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy?BMJ Open Sport Exerc Med. 2016;2:e000151. doi:10.1136/bmjsem-2016-000151 [CrossRef]
  3. Eichner ER. “A stitch in time” and “if 6 was 9”: preventing exertional sickling deaths and probing team rhabdomyolysis outbreaks. Curr Sports Med Rep. 2016;15:122–123. doi:10.1249/JSR.0000000000000251 [CrossRef]
  4. Casa DJ, Anderson SA, Baker L, et al. The inter-association task force for preventing sudden death in collegiate conditioning sessions: best practices recommendations. J Athl Train. 2012;47:477–480. doi:10.4085/1062-6050-47.4.08 [CrossRef]
  5. Hummel K, Gregory A, Desai N, Diamond A. Rhabdomyolysis in adolescent athletes: review of cases. Phys Sportsmed. 2016;44:195–199. doi:10.1080/00913847.2016.1170582 [CrossRef]
  6. Asplund CA, O'Connor FG. Challenging return to play decisions: heat stroke, exertional rhabdomyolysis, and exertional collapse associated with sickle cell trait. Sports Health. 2016;8:117–125. doi:10.1177/1941738115617453 [CrossRef]
  7. Schleich K, Slayman T, West D, Smoot K. Return to play after exertional rhabdomyolysis. J Athl Train. 2016;51:406–409. doi:10.4085/1062-6050-51.5.12 [CrossRef]

Risk Variables for Recurrent Exertional Rhabdomyolysisa

High riskb

Delayed recovery (> 1 week) despite rest

Persistent creatine kinase elevation despite 2+ weeks of rest

Complications from acute renal injury

Personal or family history of myopathy, recurrent muscle cramps, or significant exertional rhabdomyolysis

Personal history of sickle cell trait or family history of sickle cell disease

Personal or family history of malignant hyperthermia or unexplained complications following general anesthesia

Low riskc

Rapid clinical recovery with creatine kinase and urine normalization following exercise restriction

Sufficient fitness level with history of intense exercise prior to exertional rhabdomyolysis

No personal or family history of myopathy, recurrent muscle cramps, or significant exertional rhabdomyolysis

Other cases of exertional rhabdomyolysis simultaneously occurred (clustering event)

Concomitant viral illness or infectious disease

Dietary supplements or medications contributed to exertional rhabdomyolysis

Return to Play Guidelines for Individuals With a Low Risk of Recurrence of Exertional Rhabdomyolysisa

Phase 1

72 hours of rest and oral hydration

Encourage patient to have a minimum of 8 hours of sleep each night

Avoid hot environments

At 72 hours

If creatine kinase is < 5× upper limit of normal with clear urine, progress to Phase 2

If creatine kinase/urine is abnormal after 72 hours, follow up every 72 hours until cleared

If creatine kinase/urine is abnormal after 2 weeks, seek expert consultation

Phase 2

Begin light activities, allowing patient to set his or her own pace and distance for 2 weeks

If no symptoms occur, progress to Phase 3

If symptoms persist for 4 weeks, seek expert consultation

Phase 3

Gradual and supervised return to sport activities

Follow up as needed

Authors

From the Division of Health Sciences, Missouri Valley College, Marshall, Missouri (DT); and the Athletic Training Programs and School of Osteopathic Medicine, A.T. Still University, Mesa, Arizona (TVM, CEWB).

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

Correspondence: David Tomchuk, MS, ATC, LAT, CSCS, Division of Health Sciences, Missouri Valley College, 500 East College, Marshall, MO 65340. E-mail: tomchukd@moval.edu

10.3928/19425864-20190102-01

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