How to Protect Athletes from Cases of Rhabdomyolysis

Rhabdomyolysis is a rare condition among high school athletes; however, studies show a four-twelve-fold increase in recent years. The increase in the incidence has been linked to the popularity of high intensity workouts and social media pressure.

Rhabdomyolysis is where muscle tissue is damaged from prolonged or intense exercise that causes the muscle to release its contents into the bloodstream. When this happens, it may cause electrolyte imbalances, compartment syndrome, heart arrhythmias, blood clots, bleeding, multiple organ failures, significant disability or death.

Rhabdomyolysis is usually a perfect storm of hot/humid weather, dehydration and excessive exercise in deconditioned or athletes returning to activity after time off. The most common similarity in cases being drills designed for punishment versus conditioning.

Rhabdomyolysis Frequently Makes the News Involving Multiple Teammates.

“15-18 players, hospitalized following a workout of nearly 400 push-ups. There was no water available during the workout.”

“12-year-old boys performing 500 squat jumps”

“17-year-old male basketball player completed 800 sit-ups, 400 push-ups and a 3.2 km run.”

“Three of the players had to have surgery for triceps compartment syndrome.”

Because this condition is preventable, when it occurs because of excessive workouts coaches have resigned, been suspended or terminated following athlete hospitalizations. Lawsuits are common with claims like, “coaches forced athletes to do excessive exercises as punishment for leaving locker rooms dirty” or organizing workouts like “two hours of bear crawls for three days in a row.” After an associated death, one lawsuit concluded with: “a 10 million wrongful death settlement of a 16-year-old high school basketball player… injuries led to charges of 2nd degree murder for conducting training in dangerous heat.”

The challenge is that symptoms can be overlooked because they resemble delayed onset muscle soreness (DOMS). The two differentiating symptoms are extreme muscle soreness, even at rest, after vigorous, high intensity or prolonged exercise, and brown colored urine, whereas DOMS pain is only with movement. Other symptoms include muscle cramps, stiffness, swelling, weakness, nausea, headache, and fatigue within 24-48 hours post activity.

Factors increasing the onset of rhabdomyolysis include low fitness and lack of exercise experience; high temperature and humidity; high-intensity, longer-duration and weight-bearing exercise focusing on eccentric contraction or downhill running. Push-ups are the No. 1 cause, followed by squats/wall squats, bear crawls, and up-downs and burpees. Viral infections including those with fever, diarrhea or vomiting, sickle cell trait, low protein intake, and larger doses of creatine also increase risk. Epidemiology shows high school males have more cases.

The good news is that rhabdomyolysis is 100 percent avoidable with appropriate training methods. Reasonable training includes workouts designed and supervised by a credentialed individual. Conditioning programs are often the responsibility of a coach, as not all high schools have the luxury of a certified strength and conditioning specialist (CSCS). Coaches with limited experience in designing programs are encouraged to further educate themselves. The NFHS Learning Center (www.NFHSLearn.com) courses “Fundamentals of Coaching” and “Strength and Conditioning” teach the basic principles of program design.

Working in conjunction with an athletic trainer would be the best practice. Not only can athletic trainers recognize and manage the injury, they can also educate others, review physicals and help design programs in the absence of a CSCS.

Prevention Tips

• Follow acclimatization for heat and humidity.

• Phase in the use of equipment, exercise intensity, duration and total practice time.

• Modify workouts for athletes with previous exposure to sun, heat and/or humidity.

• Athletes should not exercise when recovering from an illness, especially with a fever.

• Remember transition periods (first 7-10 days of season and after school breaks, injury or illness) are when athletes are most vulnerable.

• Transition periods should have appropriate work-to-rest ratios for recovery, especially during consecutive, intense activity.

• Use gradually increasing conditioning to improve fitness versus an excessive overload of activity.

• Encourage hydration before, during and after activity.

• Offer free access to water throughout workouts.

• Promote the intake of fluids and nutrients after exercise to fuel muscles for recovery.

• Workout plans should be sport-specific and based on current exercise science.

• Use written plans for volume, intensity, mode and duration of each exercise. In most cases of rhabdomyolysis, workouts ended up being more intense than originally planned. Coaches should never increase exercise beyond the written plan.

• Know that teammate competition and motivation to push oneself beyond their limits raises risk.

• Realize athletes might be reluctant to report symptoms signaling the start of rhabdomyolysis.

• Educate athletes on the signs and symptoms and encourage honest communication.

• Exercise and conditioning activities should never be used as punishment or as discipline.

• Athletes should stop activity with any unusual physical distress.

• Athletes with extreme muscle pain at rest and brown urine, 24–48 hours after exercise should seek treatment.

• Act quickly. Early hospital management less than six hours from presentation improves outcomes.

Athletic administrators or coaches should not allow punitive exercise. All workouts should be reviewed and approved by a credentialed professional when at all possible. It is important to not have workouts or drills that could cause disaster. Knowing the signs and symptoms of rhabdomyolysis in addition to prevention strategies decreases liability and saves lives.

Credits
1. CDC NIOSH 2/8/23 “Rhabdomyolysis” Retrieved 3/10/24.
2. Jooyoung Kim, et al. “Exercise-induced rhabdomyolysis mechanisms and prevention: A literature review” Journal of Sport and Health Science, Volume 5, Issue 3, 2016, Pages 324-333, ISSN 2095-2546.
3. Alharbi, Kholoud F. et al. “Exercise-induced rhabdomyolysis manifestations and complications: a case report” Annals of Medicine & Surgery 85(12): p 6285-6288, December 2023. | DOI: 10.1097/MS9.0000000000001479
4. Riddle, Greg (7/13/23) “Attorney: Dangers of rhabdomyolysis Rockwall Heath case should have coaches on high alert” retrieved 4/13/24.
5. Gaffney, Christopher (7/17/20) “High-intensity workouts may put regular gym goers at risk of rhabdomyolysis, a rare but dangerous condition” retrieved 4/7/24.
6. Heilman, James Photo: “A urine sample from a person with rhabdomyolysis”
7. Jones, Todd (March 9, 2013) “Rhabdomyolysis laid low 6 athletes” Retrieved 3/12/24 from
8. Pohnl, Eliott (8/23/2010) “McMinnville Football Disaster: 14 HS Players Hospitalized After Workout” retrieved 3/10/23.
9. NATA “Prevention of Sudden Death in Secondary School Athletics: Best Practices Recommendations” Retrieved 3/9/24 from 2013
10. NCAA Sport Science Institute “Interassociation Recommendations Checklist Preventing Catastrophic Injury and Death in Collegiate Athletes” Retrieved 3/12/24.
11. Stapleton, Drue et al. “NFHS Sports Medicine Handbook: Safety in Strength & Conditioning” Fourth Edition May 2011
12. McLaughlin, Eliott (11/30/22) “Family of Georgia teen who died of heatstroke after high school basketball drill accepts $10 million settlement” Retrieved 3/13/24.