A Run-in with Rhabdo

Imagine this…..

You are in your early 20’s, haven’t ever really worked out, but your wife’s sister and her godparents do this crazy thing called “Crossfit”  and they have convinced you that yeah…this seems like something you should try.  You schedule an appointment with the owner of the local Crossfit; it’s the same one that your wife’s godparents attend.  They have told you both how great it is and how knowledgeable, passionate and caring the staff are. After the first introduction class with the owner himself you think to yourself, “Heck yeah, I can do this,  actually I need to do this.”

So you and your wife begin your Crossfit Journey.  A lot of the stuff the coach says makes sense and in a way already applies to you.  You already eat fairly clean, you hardly ever drink alcohol, and you have no problem sleeping for (at least) 8 hours a day.  You like that he says it’s not your typical Competitive Crossfit and that he focuses on teaching proper movement patterns.   By your first official “WOD”  you feel ready to go.

After the first day it seems to be a good fit.  The coach was attentive, and he seemed to scale things conservatively so that you and your wife would not go out too hard or too long on your first few visits, though the intensity did begin to ramp up.   Then about 2 weeks in,  somewhere around your 7th or 8th workout possibly, you did something you had never done before.  It was a rough Sunday workout and you perfect full range of motion Knees to Elbows.  Ok maybe “perfected” wasn’t the right word, but you did one hell of a job that day.  It was great.

But..

Monday your abdominal wall was extremely sore and swollen.  You weren’t sure what to do.  Your wife’s sister, a Physical Therapist and avid competitive Crossfitter, advised that you check your urine to make sure you didn’t have “Rhabdo.”    Your urine was fine, but what was this Rhabdo?; you had never heard of it.

You wrote it off, since your urine was fine, and thought that this was just a really bad case of DOMS (delayed onset muscle soreness)  and decided to rest up on Tuesday.

Super sore on Tuesday….you do nothing and feel really weak in those abdominal muscles.

You can’t sleep on Tuesday night, and decide that on Wednesday, feeling incredibly weak and sore, you need to go to the Emergency Room.

Once there you inform them what you think is going on.  They do not seem as concerned as you would like.  After hours of waiting, you get in, they take your blood and urine, which gets left on a shelf next to you in the room (they never check it).  They don’t believe it has anything to do with exercise. They think it is your appendix.  So they give you a contrast solution that will show up on the CT Scan, and then they will be able to tell what’s up.   Only it doesn’t show anything.  (You later find out from a nephrologist, a kidney specialist, that the contrast solution can be toxic to the kidneys and may only have exacerbated your situation.)

They give you muscle relaxers and send you home .

The next day you feel better.

The day after that you workout.

Then you think you are ok.

But the following Monday you are so incredibly sore again, after a workout that was not intense, was not strenuous, and was heavily modified.  You check your urine and it looks more like Coca-Cola than Pee. Shit.

Your Wife’s Sis says get to the emergency room immediately and tell them you have Rhabdo.

You get there.  You tell them.  Finally they believe you.  You were right. You are kept in the hospital for 4 days, and released.  With no kidney damage, thank goodness.  What an experience for your first month at Crossfit.

Imagine that story.  Imagine how you would feel.  Imagine if you were the owner and head coach of that box.  What would you do?  What could you do?  Who’s fault is it?  Was it the programming?  Was it lack of hydration?  Was it pushing too hard? Was it the first visit to the emergency room, giving the contrast solution?  There are so many factors in a situation like this that at times it is hard to put a finger on it.

This is not a fictitious story. It happened to me 3 weeks ago.  I am that coach, and my great member Nico is that young man.

 

Nico and I  have met several times since then, and talked and tried to look back and think what went wrong; Was he working too hard? Did he do too many reps? Was he dehydrated? Should he have taken more rest time?  Obviously we know the answer to some of those questions straight away.  It’s one thing to know it in hindsight, but how can we recognize those signs better in the future?  He and I decided that a blog post to educate might be the best way.  So what is Rhabdo, or Rhabdomyolysis?

**A small disclaimer, I am not a medical doctor, and the information I gleaned here comes from hours of reading and talking to doctors, physical therapists and trainers.  So here’s what I have learned….

Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage.

What Nico had is called specifically “exertional rhabdomyolysis.””Exertional rhabdomyolysis” is a rare, but serious, complication of too much exercise. It can affect people of any race, age, or fitness level.

During rhabdomyolysis, the contents of skeletal muscle cells are dumped into the blood stream. The two most important factors are 1) creatine kinase, CK (a muscle enzyme, sometimes abbreviated “CPK”), and 2) myoglobin (a muscle protein). Extremely elevated concentrations of CK in the blood confirms the diagnosis, however, it is the presence of myoglobin in the urine that generally alerts the athlete that something is really wrong, causing them to seek medical attention. When myoglobin appears in the urine, the urine color changes to a dark brown.

So when focusing on how to recognize possible rhabdo you should look to three important markers:

  1. Severe, incapacitating muscle pain (not like, “I’m having trouble walking,” but “I can’t even get up because I’m stuck in bed and cannot move.”)
  2. Elevated levels of creatine kinase (CK) in the blood (only can find this out by doctor)
  3. Myoglobin in the urine (Coca-Cola colored urine)

So, why do most athletes only experience the benign and predictable “DOMS” after strenuous exercise while others develop the very serious condition known as rhabdomyolysis?

-First off, it’s important to understand that it is extremely difficult to give yourself rhabdo.  It is not in any way “easy” to get. It requires complete obliteration of your muscle tissue, and most of us stop before we take things that far.

– However, studies have shown that some people may have a genetic predisposition. People  with “CPT II deficiency,” an inherited trait, have a higher likelihood of developing rhabdomyolysis. This genetic condition is common among Ashkenazi Jews.

– Eccentric exercise: Eccentric exercise means the skeletal muscle fibers are lengthening while exerting force. It is well known that eccentric exercise causes more muscle soreness and muscle trauma than concentric exercise. (Think about doing a high rep- like 40-50 rep- WOD, where you slowly lower yourself from flexed arm hangs, for example.)

– New to exercise : The physical conditioning of the athlete does appear to make a difference.

-Hot weather/heat stroke: Heat stroke is associated with rhabdomyolysis. This may be an aggravating factor in some cases of exercise-induced rhabdomyolysis.

Even though exercise-induced rhabdomyolysis is extremely  rare, it is important to be aware of it and to consider prevention strategies:

Train properly: Research shows that when athletes and unfit subjects participated in the same amount of exercise, CK levels rose only in the unfit subjects (Karamizrak SO, et al. 1994). Thus, the intensity of exercise is not the only variable…an abrupt increase in exercise intensity relative to your current fitness level is an important factor.

Focus on proper hydration before and after workouts, and in fact, every day:  Do your best not to participate in binge drinking after extremely difficult workouts.

Consume a recovery drink immediately after exercise: Several recent studies show that CK levels post-exercise are lower in athletes who consume a sports drink that contains protein (aka: “recovery” drinks).

Cool down and Rest properly.

You may be asking yourself,  “How can I tell if I have simple post-exercise DOMS or if it is the more serious rhabdomyolysis?”  If you are moving and sore, then it is a pretty good chance that it is simply DOMS and not rhabdomyolysis.  In all this talk, and even though it absolutely happened to Nico,  don’t forget that Rhabdo is EXTREMELY rare, and if you have been training for a while, and are continuing to do the things mentioned above, then you will more than likely never get it. 

Remember the diagnosis of rhabdomyolysis is made by measuring CK levels and myoglobin levels in the blood. If your muscle soreness is super severe, and, if your urine turns dark brown (“Coca-Cola urine”), then you should seek medical attention immediately. The release of massive amounts of muscle proteins into the circulation can lead to kidney failure, which can be life-threatening. Fortunately, with early and proper treatment, most athletes who develop rhabdomyolysis will make a complete recovery.

I can not really put into words how this makes you feel as a coach. It makes you question your programming, question your judgment, and question how it can even be possible. I watched how he moved, I scaled his weights, his reps, his intensity. And never did it look for a second like he was working hard enough to do this to himself. It causes you to “what if?” yourself to death.

Since then I have read volumes, more than I knew existed, spoken with doctors, other CF coaches, and read blogs by athletes who have experienced  rhabdo before, and the one thing that all of the instances had in common were, surprisingly enough, nothing. That’s infuriating as a coach. I found it cited that cases of rhabdo were somewhat more prevalent in endurance events, such as marathons and Iron Man training/events.  Some attention has been called to cases at Crossfit Boxes, but there have even been cases resulting from conga drumming, karate kicking, mechanical bull riding, hiking and cheerleading training. I read a blog (which I could not find again to recall the specifics) from one individual who was in training consistently for an event of some sort and had done nothing irregular, monitored everything and after a long run, he got it. His quote (or a close summary of it) went like this,”Sometimes, things happen.”

As a coach, that’s terribly unhelpful.  As a coach, I need to keep everyone in my box well-trained, taken care of, and above all else, safe. It was difficult for me to write this without having a definite, “here is exactly how you prevent this from happening to you” answer. But I felt the need to put it out there nonetheless. So, in summary, here’s what have I learned:

-Make sure you are doing the preventative things to take care of yourself.

-Find comfort in the fact that in all of the time I have coached and worked in the fitness industry, I have only seen it personally twice and have only heard of one other person getting it.  That’s 3 cases over the last 12 years among all my thousands of friends and online acquaintances, who compete in Crossfit, Iron Man, marathons, martial arts…the list goes on and on.  So the chance of you getting it is very small. For the majority of us, we need not worry about getting rhabdomyolysis, but we should know the warning signs, not only for ourselves but for anyone around us.

I would like to take the time to personally thank Nico and Laura, and say that I know he is looking forward easing back into his workouts in a couple of weeks. I can’t wait to have him back.

In closing, here is a pretty in-depth article on Breaking Muscle.  If you have time and eyes after this, give it a read.

http://breakingmuscle.com/health-medicine/a-scientific-look-at-rhabdo-and-why-its-not-exclusive-to-crossfit