Exertional Rhabdomyolysis

Christopher A. Gee, MD, MPH, FACEP Department of Orthopaedics

University of Utah

Objectives

• Define history and current topics of condition

• Review pathophysiology

• Present cases and risk factors for condition

• Outline prevention, education and treatment options

Rhabdo-What is it?• Condition of muscle breakdown

from over exertion, trauma, electrocution, medications

• Intracellular components (myoglobin, CK, LDH, etc) released in the blood stream

• Normal carrying capacity of plasma proteins overwhelmed

• Components spilled into urine, collect in tubules leading to renal dysfunction and failure

History

• Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. Jour Amer Soc Neph. 2000;11(8):1553-61.

• Observed in ancient times- Consumption of quail by Israelites who later died (Book of Numbers 11:31-35). Resulted in myolysis after eating. Due to intoxication by hemlock herbs, which are consumed by quails during their spring migration

• Modern reports • 1908 Messina Earthquake-crush victims developed

ARF • WW1 German soldiers buried in trenches • 1940 Battle of Britain- 4 bombing victims, linked

ARF to rhabdo

Why Sports Medicine?

http://abcnews.go.com/GMA/video/crossfit-linked-potentially-fatal-condition-rhabdomyolysis-20380676

Uncle Rhabdo• Uncle Rhabdo

introduced by Dr Will Wright 2011

• Article meant to warn cross fit athletes of dangers of rhabdo

• Overtime, became the center of large debate within cross fit community

http://library.crossfit.com/free/pdf/CFJ_Wright_Rhabdo.pdf

Uncle Rhabdo• Some began to advise that a

“visit” to Uncle Rhabdo was the only way to make significant strength gains

• “CrossFit, at its core, is about the hard truths of life. Good things take effort. Results don’t come easy. Sometimes, to get to a really good place, you have to go through a really bad time. Heavy things are hard to pick up. Strength takes guts. And, if you’re a cheater, you’re an a*****. These are essential truths”

https://wordswithlisbeth.com/2013/01/08/in-praise-of-the-vomiting-clown/

Pukie• Opponents have pointed out the

real dangers of rhabdo

• “Coaches and trainers are the ambassadors of our clients’ health and well-being.  Given this unique position, there are predisposing conditions that trainers should be aware of; they include the types of exercises being performed, environmental conditions, and most importantly, the capabilities of the client and his or her known medical conditions need to be considered.” Dr Wright

Rhabdo• Ultimately rhabdomyolysis can occur in any athlete of any age or sport who

pushes muscles to the extreme

• Factors:

• Type of exercise (ie, downhill walking vs uphill, spin, crossfit)

• Hydration status

• Ambient temperature

• Medical conditions or medicines used by the athlete

• Conditioning status of athlete (46 cases spinning rhabdo, 42 first timers)

Rhabdo CasesAm J Med. 2017 Apr;130(4):484-487. doi: 10.1016/j.amjmed.2016.11.004. Epub 2016 Nov 29.

Freebie Rhabdomyolysis: A Public Health Concern. Spin Class-Induced Rhabdomyolysis.Brogan M1, Ledesma R2, Coffino A2, Chander P2.

• Case 1: 33-year-old woman presented with bilateral thigh pain and weakness 4 days after 15 minutes of spinning. This was her first spin class. She dismounted the bike for symptoms of lightheadedness and vomiting.

• On presentation, she had thigh weakness, tenderness, and swelling. Labs showed Cr 0.5 mg/dL, AST 1092 U/L, and ALT 282 U/L. Urinalysis showed 1+proteinuria, 3+ blood, and 0-3 red cells/hpf. She was aggressively hydrated. Her peak CPK was 60,000 U/L

Case 2A 20-year-old man with a history of Gilbert syndrome presented with bilateral thigh pain 3 days after spinning. He exercised regularly but it was his first spin class. He was unable to lift his lower extremities against gravity. There was thigh tenderness and swelling. Initial blood work showed creatinine 0.8 mg/dL, AST 1140 U/L, ALT 270 U/ L, and CPK 14,493 U/L. Urinalysis showed 2+ proteinuria, 3+ blood, and 3-5 red cells/hpf. His peak CPK was 132,832 U/L.

Case 3A 33-year-old woman p/w thigh pain, decreased urine output, n/v x 2 days after first spin class. She had thigh tenderness and swelling. Serum Cr peaked at 6.8 mg/dL, ALT 2583 U/L, AST 742 U/L, LDH 10,167 U/L, and CPK peaked at >80,000 U/L. Despite aggressive hydration with NS, required hemodialysis for oliguria. Due to the severity of her renal failure and history of NSAID use, a kidney biopsy was performed, which confirmed rhabdomyolysis. Her Cr improved to 0.7 mg/dL 5 1/2 weeks later, with normalization of her CPK.

Cases• Highlight issues

• Be aware of medical conditions and medicines used (nsaids, statins, myopathy, renal disease)

• Intensity of exercise performed-need to listen to body

• Often present few days later with n/v, pain, weakness, dark urine

• Initially, Cr and renal function preserved but can quickly deteriorate

• Tx is to aggressively hydrate and “flush” out the muscle products to limit damage

Treatment• Prevention!

• Early detection:

• Not all muscle soreness is normal

• Aggressive Hydration!

Treatment• Prevention!

• Educate athletes about the risk of exertion rhabdo and the need to ensure hydration, avoid routine nsaid use and gradually work into exercise routines

• Early Detection

• Not all muscle soreness is normal. Swelling, significant pain, weakness, dark urine, decreased urine output

• Check UA, CPK (5x Nml), LDH, AST, ALT, electrolytes (K)

• Aggressive Hydration

• Often times can require 1-2 L/hr to ensure adequate UOP (200-300 mL/hr)

Treatment• Urine Alkalization

• Some reports show a potential benefit from alkalinizing urine. (decreases formation of heme-protein complexes that block tubules)

• Only used if severe cases with rising CPK despite adequate tx

• Patient must have adequate urine output and must be in a setting where bicarb, pH and other parameters can be closely monitored

References

• Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. Jour Amer Soc Neph. 2000;11(8):1553-61.

• Wright W. ‘Rhabdomyolysis Revisited’. The Crossfit Journal. June 2011:1-4.