Boyd W. Haynes III, MD
Is it me or does it seem that folks are working out more these days? Many are participating in hard core workouts or extreme athletics. Crossfit®, Rezist, Soul Cycle, Boot Camps, Training Gyms, or gyms that mimic Crossfit®, are popping up everywhere and have helped many thousands of people get fit beyond what they ever thought possible.
Some physically fit folks decide that they want to take their fitness to the next level and begin a regimen of intense muscle building, seeking ever more muscle size and/or definition. Along with heavy workouts, they may adhere strictly to Keto or Paleo diets, with protein shakes and body-building supplements thrown in for faster muscle building. As long as these athletes work with a qualified trainer/gym, get adequate muscle rest between workouts which S-L-O-W-L-Y intensify and lengthen, change their work outs regularly, and maintain good hydration and nutrition, they shouldn’t encounter “Rhabdo”.
Here’s the flip side. For some, the workouts keep getting tougher, longer and more strenuous, and the rest periods get shorter and shorter, or cease altogether. Even fitness newbies, who are overeager to achieve a lean, toned look quickly, may choose to lift, cycle or dance right through warning signs. Excessive sweating, dehydration and exhaustion during exertion are signals that the body is being overworked and needs to rest. When these bodily “red-flag” alerts are shrugged off or ignored completely, negative consequences, such as “Rhabdo”, may occur.
“Rhabdo” is not only being talked about in fitness circles, but is also being seen more often in America’s Emergency Rooms. An orthopaedic intern, who recently followed me as I saw patients during office hours, reported seeing three cases in one month in the ER where she works. But what exactly is “Rhabdo” and why should anyone be concerned about it?
Rhabdomyolysis is a death of muscle tissue caused by a variety of reasons (more on those shortly). When muscle tissue breaks down and dies, it releases an overload of creatine kinase (a muscle enzyme), myoglobin (a red protein which oxygenates muscle cells), potassium and free radicals into the blood stream. These normally innocuous substances become dangerous waste when dumped into our blood stream together and in large quantities. The kidneys are unable to process such large amounts of toxic material and begin to fail. A cascade of organ failure typically follows. Death may happen unless the correct diagnosis is made quickly and treatment is administered in a hospital.
There are two types of Rhabdomyolysis, traumatic and non-traumatic. In the first category, Rhabdo can be caused by crush injury, such as being trapped under a building or car with the inability to move, third degree burns, electric shock, or from a venomous snake bite that causes muscle tissue to die. Non-traumatic Rhabdo is caused by extreme muscle exertion by a seasoned athlete or overexertion when the athlete is not physically capable of doing the activity, the use of alcohol or illegal drugs, some statin medications, and viral or bacterial infections. All are diagnosed and treated much the same way, but I will focus on Exertion Rhabdomyolysis here.
Symptoms of Rhabdo typically involve red or dark urine (as the kidneys can’t break down the toxins), extreme muscle soreness in the upper thighs, lower back or shoulders, and weakness in the arms and legs. About 50% of people with Rhabdo will not present with muscle symptomology. There may also be nausea, vomiting, abdominal pain, dehydration, fever, confusion and a rapid heart rate.
Blood tests at the hospital will determine if there are elevated levels of the four substances referenced above, although about half of these will test negative for excess myoglobin and still have Rhabdo. It’s vitally important for the patient to communicate with the ER physician about recent intense workouts and any excessive muscle soreness or weakness in the limbs post-workout.
Complications can include very high levels of potassium, which may lead to cardiac arrest or kidney failure. About half of all Rhabdo patients will have at least some level of kidney damage. A quarter of those will go on to develop liver issues. Some patients may also develop Compartment Syndrome, which causes internal tissues to swell inside a certain body area or compartment. These compartments are divided by fascia, which is a type of non-elastic connective tissue which cannot expand to accommodate the swelling. As a result, the increased pressure compresses nerves, veins and arteries, compromising blood flow and causing tissue death. This typically occurs in the abdomen, legs or arms.
Treatment for Rhabdo is usually successful if a correct diagnosis is made quickly. It is vital that IV fluids be administered immediately to dilute and flush toxins from the blood, thereby minimizing damage to the kidneys. By doing so, kidney damage can even be reversed in most cases. Dialysis may be needed to help the kidneys rid the blood of waste during the initial phase of treatment. Electrolyte imbalances will be corrected to get blood chemistry back to normal and to protect major organs. If Compartment Syndrome occurs, surgery may be needed to release the fascia, to eliminate pressure on muscles, nerves and blood vessels. Sometimes, a brief stay in the ICU will be necessary to ensure that all organ systems are working well and that any Compartment Syndrome is being successfully treated.
As a fellowship-trained Sports Medicine physician, I don’t see Rhabdo in my office practice. It’s a life-threatening syndrome that must be treated at a hospital. Based on the information I’ve presented here, it’s NOT a condition that any person, athletic or otherwise, wishes to experience in their lifetime, no matter how dedicated they are to fitness. This syndrome can happen during the first really exhaustive workout a person ever does or it can occur whenever warning signs are given no heed.
In my opinion, the best treatment for Rhabdo is to prevent it from ever occurring. As I tell my athletic patients, never increase your workouts (intensity and/or duration) by more than 10% a week. This gives your muscles time to build and recover from exertion in a healthy way. You have to be your own monitor – if your muscles are sore, PAY ATTENTION. Some soreness is to be expected; however extreme soreness is never good and indicates that you need more rest between workouts or a change to your workout.
Delayed Onset Muscle Soreness (DOMS) is a normal part of muscle building and is an indicator that the muscle is actually getting stronger. It used to be thought that the soreness was caused by a build-up of lactic acid in the muscles, but it is really caused by tiny micro-tears in the muscle tissue which occur after working the muscle to exhaustion. The healing of these micro-tears allows for muscle growth and an increase in strength.
Soaking in a whirlpool or a hot bath with Epsom salts is a great way to treat sore muscles. Alternatively, an ice bath or ice pack may feel great to you. A massage or self-administered massage using a foam roller is another way to loosen and soothe tight and sore muscles. It’s okay to take an OTC NSAID, such as Aleve™, to relieve the pain and inflammation. Again, some mild soreness is okay, but you shouldn’t have to utilize these at-home treatments daily to cope with the physical aftermath from your workouts. Listen to your body, rest when you need to, and seek professional help immediately if you have the symptoms of Rhabdo.