Looking at Rhabdomyolysis

Foreword:

I initially wrote this back about 20 months ago for CF, but they didn’t want it so it’s been sitting on my hard drive for a while. Hope you guys have a better understanding of what this condition is and what to look for after reading this.

Also, I’m planning to try to get some more things out in the future. I have some topics on diseases of civilization, and I definitely need to get some more injury stuff out such as a more in depth look at the feet. Those two will probably be next along with my supposed rewrite of the tendonitis article.

A closer look at rhabdomyolysis

First off, this article isn’t meant to “diagnose” anything. That should be done by a qualified medical practitioner after running tests. However, awareness and especially identification of symptoms of rhabdomyolysis can not only help ward off any unnecessary deaths but also potential lawsuits (Makimba Mimms case). Additionally, this information is relevant to most people within the CrossFit community because it can most importantly give trainers something to keep an eye out for and avoid potential cases, and also enhance recovery of individuals affected when properly identified.

Physiology of rhabdomyolysis

Okay, so the first thing we need to examine is how rhabdomyolysis occurs. Simply put, rhabdomyolysis is an INJURY to the rod-shaped/striated tissue (“rhabdo”) which is muscle (“myo”) where the muscle itself is broken open (“lysis”) and the cellular contents spill out into the bloodstream. This can occur under various circumstances, but the one we are most concerned with is the exercised induced variety.

Damage can occur during concentric and isometric exercise; however, most of the damage induced to the muscles occurs during eccentric exercise or negatives.^(1-2) Eccentric exercise is the strongest form of exercise allowing the muscles to handle upwards of 120-125% of the load that can be lifted concentrically. As the muscle lengthens under eccentric load, the sarcomeres (individual contraction units of the muscle) are unable to support the tension and thus “pop” and distend uncontrollably which is the cause the disruption of the sarcomere plasma membrane.⁽¹⁾ Too much damage results in a loss of structural integrity of the sarcoplasmic reticulum which lets metabolites and intramuscular proteins spill out of the muscle cells.⁽²⁾

Delayed onset muscle soreness (DOMS) cause is very similar in nature as it is primarily caused by eccentric damage.^(2-3) What happens in DOMS is that as the muscle damage accumulates by destruction of the cell membrane which allows the metabolites leak out into the cell. This causes an immune response via chemical messengers such as prostaglandins. Prostagladins, for example, are part of the fatty acid component of the cellular membrane and released when the membrane is compromised. The immune system responds to this inflammatory call by sending white blood cells as well as release various cytokines. This results in localized inflammation as well as localized edema. Also, the sensitization of local pain receptors when the muscles are contracted are hallmarks of DOMS.⁽³⁾

Thus, in a sense, we can think of both rhabdomyolysis and DOMS as close cousins. DOMS is not an either/or effect as there are varying intensities of DOMS. We should think of rhabdomyolysis in the same way as the intensity of rhabdomyolysis can increase depending on how much muscle damage there is. For example, particularly bad cases of rhabdomyolysis occur when the urine turns a darkish-brown color as kidney function is impaired.⁽⁴⁾ If this goes on long enough acute renal failure and death may result. In addition, the metabolites from the destroyed muscle tissue pull fluid volume from the blood into the muscle causing swelling.^(3-4) On the other hand, non-severe cases of rhabdomyolysis may just result in the form of small decreases in muscle strength and some localized edema.^(3-4)

If you are confused about me not explaining rhabdo more in depth, it is basically an extreme case of of what produces DOMS. If you continually exercise the small microtears that allow DOMS to occur will eventually result in macrotears that allow large structures within the muscles to leak out. These include proteins such as myoglobin which is the main cause of rhabdomyolysis. Myoglobin leaking into the bloodstream and thus into the kidney eventually will inhibit function and eventually shut them down leading to renal failure and death.

Assessing rhabdomyolysis risk

From an anecdotal standpoint, rhabdomyolysis often occurs in former athletes or those who have had a previously high fitness or strength level who are detrained. This is because their mind has had the abilities of high performance or strength before, and they are accustomed to pushing themselves. However, this is what you often have to be wary of as they can push themselves far into a state of rhabdomyolysis as they overestimate their own abilities. If a client is a previous athlete and has been out of working out or fitness for years, it is a good idea to let them know that they should start off cautious because their minds can be far ahead of their current physical capabilities. Better to keep them safe than sorry.

Workouts that contain a high volume amount of eccentric movements carry considerable risk for rhabdomyolysis. A couple of the more potent offenders are Michael – 3 rounds for time of run 800 meters, 50 Back Extensions, 50 Sit-ups – anything with copious amounts of negatives such as jumping pullups, or “long” 20 minute efforts such as Cindy especially for newer clients who have not adapted to the considerable intensity AND volume. Similarly, high volume efforts on similar movements may be a poor idea such as a combination of squats, thrusters and wall ball.

The offender in Michael tends to be the GHD situps which have considerably more range of motion than people are used to for abdominal exercises, as well as a long descending eccentric component. Couple this with a high number of total repetitions (150), and it presents a large risk for rhabdomyolysis. In addition, many athletes in particular tend to overestimate their abdominal fitness level and are therefore susceptible to rhabdomyolysis from this workout alone even with a fair amount of CrossFit experience. When in doubt, especially with movements that have a large range of motion, it is better to be conservative and scale the workout.

It is important for any trainer, especially CrossFit trainers, to recognize their client’s ability levels from the start. For safety reasons, it would be a good idea to start clients with short workouts of less than 5-10 minutes (or even less!) on movements that do not have considerable eccentric components. Movements that involve movements that tax cardiovascular capability such as burpees are always preferable to movements that substantially tax the muscles – as long as the client has a heart healthy for physical activity. On that note, always have your clients check with their doctor before rigorous physical activity. Allowing the body to adapt by “ramping into intensity” with shorter efforts is a good idea to help stave off any rhabdomyolysis that may occur. Also, it will help limit the amount of DOMS a client has to allow them progress to higher frequency work much faster.

In my opinion, after an initial workout we can think DOMS as an indicator for rhabdomyolysis. Let me explain. Muscle damage is both related to DOMS and rhabdomyolysis; thus, as the intensity of DOMS increases we will also “tend” to see increases in the seriousness/risk for rhabdomyolysis as well. This is my preference for trying to ascertain if there is any possible rhabdomyolysis. If we gauge it according to this, it is very easy to tell when decreased volume or more rest may be needed to prevent rhabdomyolysis from occurring. Remember, rhabdomyolysis can be caused as an acute event – a single workout – however, it can also be caused from the accumulation of multiple workouts, especially high volume, if the body is not allowed much time to recover.

Reducing Rhabdo Risk

After discussing rhabdo more in this thread, I think proper working programming is the key to reduction in rhabdo for your clients.

Many people use an On Ramp program for new clients where volume and intensity of workouts can be reduced. However, from recent information even 10 minute Cindy or shorter AMRAP workouts can be an issue for clients, especially if they are former athletes who are used to pushing through workouts.

Thus, for the first 2-3 weeks it may be a good idea to only use X rounds of Y,Z movement type workouts.

This cuts down on the amount of “restrictions” you may have to place on athletes such as eliminating the eccentric from pullups or capping the rounds of AMRAP workouts. This should then allow people to focus more on form and improving their workouts.

Properly programmed “X rounds” workouts are a good enough stimulus for new clients, and thus you can more accurately limit the amount of volume and thus the amount of DOMS and other negative factors associated with high intensity workouts. Additionally, since the volume is limited you can include strength work before the workouts which will help improve their abilities much quicker.

So all around this is probably the better option for potential beginner programs.

Soreness as an indicator of potential risk

As I stated in the previous paragraph, after an initial workout I like to tend to use DOMS as an indicator of assessing rhabdomyolysis risk. I follow a specific protocol to assess how many, if any, workouts should be done either consecutively or when the person wants to train again. One exception is that after ~3 or so days the client should be fine regardless of how much DOMS is. This is because DOMS can last up to 7-10 days while the muscles themselves are for the most part healed within 48-72 hours.

1. If the client is too sore to move you should have them at least exercise lightly to get blood flowing to elicit faster healing. Your client should also be hydrating, self massaging, foam rolling, ice baths/contrast showers, or whatever else they can do to alleviate the symptoms and speed up recovery.

2. If the client is not too sore to workout then go for it. But DO NOT overdo it. Depending on how intense the soreness is, it might be a good idea to refer back to #1.

3. Otherwise, if the soreness level is manageable don’t worry about it too much.

If client is training ENOUGH (at least 3x a week), DOMS should start to go away as they become more conditioned. If it doesn’t this indicates a problem in the client or individual’s recovery. Too little sleep, poor and/or hypocaloric diet, or too many daily stressors may be factors. It is also possible that the volume is too much and needs to be ramped back into instead.

Remember, while soreness can be a badge of honor, it does not indicate whether someone has had a good workout that would increase their performance (or muscle gain or fitness for that matter). It only tends to indicate that the body is not used to a certain load or volume. Significant gains in performance can be made while an athlete is not sore hence why I personally tend to think of it as a hindrance only when coming back from a break or recovery period where deconditioning occurs.

Signs of rhabdomyolysis

It is imperative that if you see signs or symptoms of rhabdomyolysis in your client (or yourself for that matter) that you get the client checked out at a hospital because of the potential pitfalls of acute renal failure in particular. If you suspect rhabdomyolysis, you should hydrate a lot to help flush the kidneys of myoglobin.

Hydration is extremely important because it helps preserve kidney function and is also a potential risk factor for rhabdomyolysis in the first place. If you’re trying to be hard on your clients to get the most out of them that is good, but if they want a drink of water ALWAYS allow them to do so.

1. Dark-brownish colored urine (does not always occur as it is a continuum of damage.. however, if you get this symptom drink lots of water with eletrolytes and GO TO A HOSPITAL!).

2. Localized edema (swelling/puffy looking areas). Watch out for compartment syndrome which is so much swelling/edema that it impedes drainage of the veins and lymphatic system thus increasing pressure leading to ischemia (lack of oxygen) to the limb. You can possibly lose a limb or die.

3. Constant muscular and joint soreness (regular scheduled workouts -> soreness doesn’t go away). Chronic DOMS indicates insufficient recovery of the muscles and gives the client a higher susceptibility to get an acute case of rhabdomyolysis.

4. Muscle weakness. Now, DOMS is associated with decreased muscle strength; however, if a client has significantly decreased muscle strength after recovery with no soreness there is a strong chance they had at least a mild form of rhabdomyolysis.

Even if you’re a very good trainer, be aware of the indicators of rhabdomyolysis in clients and even in other people who do intense physical activity. It could potentially save lives!

References and links

1. Morgan DL, Proske U. Popping sarcomere hypothesis explains stretch induced muscle damage. Proceedings of the Australian Physiological and Pharmacological Society (2004) 34: 19-23. Accessible at www.apps.org.au/Proceedings/34/19-23/19-23.pdf

2. Koh, Timothy J. “Physiology and Mechanisms of Skeletal Muscle Damage.” Skeletal Muscle Damage and Repair: Mechanisms & Interventions. Ed. Peter M Tiidus. New York: Human Kinetics, 2008. Pages 5-12.

3. Cleary MA, Sitler MR, Kendrick ZV. Dehydration and Symptoms of Delayed-Onset Muscle Soreness in Normothermic Men. Journal of Athletic Training 2006;41(1):36–45. Accessible at http://www.nata.org/jat/readers/archives/41.1/i1062-6050-41-1-36.pdf

(discussion about DOMS causes is in discussion – one of the more complete summaries I’ve seen among journal articles which is why I chose this one).

4. Muscal, Eyal and contributors. “Rhabdomyolysis.” Medscape. 2009. E-medicine from WebMD. 28 Jan 2008. Acessible at http://emedicine.medscape.com/article/1007814-overview.

Previous CF journal:

http://www.crossfit.com/journal/library/33_05_killer_workouts.pdf

Wikipedia information (generally most science on Wiki is accurate because of citing):

http://en.wikipedia.org/wiki/Rhabdomyolysis

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