Case 14 – Don’t Feel Well
October 30, 2017
Lecture – Ulnar Sided Wrist Pain
December 21, 2017

Journal Club – Exertional Rhabdomyolysis

Exertional Rhabdomyolysis – Journal Club
Date: Oct. 24, 2017
By: John C. Presvelos

See below for topic review.

Article #1

Stanfa MR, Silles NN, Cooper A, Arena S, Landis-Piwowar K, Aprik C, Hew-Butler T. Risk factors for collegiate swimmers hospitalized with exertional rhabdomyolysis. Clinical Journal of Sports Medicine 27:37-45 (2017).

This was a retrospective cohort study with the goal of identifying midseason risk factors for symptomatic exertional rhabdomyolysis in swimmers after a novel upper body workout. The authors concluded that the swimmers that were hospitalized in the study shared certain personality characteristics that made them exceptionally motivated.
• Outlined clear relationship between physical activity to the point of exertion and exertional rhabdomyolysis
• Described some of the personality characteristics that may put some athletes at higher risk than others
• Helped to raise awareness for future prevention

• Survey based on self-report data 6 months after event which could be subject to recall bias
• Small homogenous sample size – difficult to extend conclusions to larger population (external validity)
• Authors drew conclusions based on results that were not statistically significant
• Study may have garnered more interesting results as a qualitative study

Article #2

Nelson DA, Deuster PA, Carter R, Hill OT, Wolcott VL, Kurina LM. Sickle cell trait, rhabdomyolysis, and mortality among U.S. Army soldiers. The New England Journal of Medicine 375:435-442 (2016).

This was a large retrospective cohort study with the goal of quantifying the associations between sickle cell trait and the risk of exertional rhabdomyolysis. The authors concluded that sickle cell trait was not associated with a higher risk of death than absence of the trait, but it was associated with a significantly higher risk of rhabdomyolysis.
• Very large cohort to analyze, previously, data on the topic has generally been limited to case reports
• Clarifies risk factors for exertional rhabdomyolysis
• Methodologically sound study
• Different (i.e. non-sports), very specific, study population
• Details lacking on chart review process (i.e. protocol form, what other factors were considered?)

Description:  Exertional Rhabdomyolysis is a condition that can occur in athletes due to over exertion or overuse of muscle groups.  It leads to pain, tenderness, fatigue, hypo/hyperthermia and necrosis of skeletal muscle.  The breakdown of skeletal muscle results in release of muscle contents into the athlete’s blood, mainly creatine kinase (CK) and myoglobin.   These elevated muscle products in the blood can lead to acute renal failure/acute kidney injury.  Other complications include temperature fluctuations, dysrhythmias, and compartment syndromes.1,2

Risk Factors:  increased body mass, altitude, extremes of temperature, sickle cell trait/disease, deconditioned athlete 1,2

Differential Diagnosis:  Delayed onset muscle soreness, fatigue, anemia, sickle cell trait/disease, heat stroke, hyponatremia
acute renal failure (prerenal (dehydration) or renal (NSAIDs)), acute mountain sickness, influenza, underlying myopathy.

High v. Low Risk for recurrence
A list of high risk features on assessment:3

  1. Delayed recovery (more than 1 wk) when activities have been restricted
  2. Persistent elevation of CK (greater than five times the upper limit of the normal lab range) despite rest for at least 2 wk
  3. ER complicated by acute renal injury of any degreePersonal or family history:
  4. Exertional Rhabdomyolysis
  5. Recurrent muscle cramps or severe muscle pain that interferes with activities of daily living or sports performance
  6. Malignant hyperthermia, or family history of unexplained complications or death following general anesthesia
  7.  Sickle cell disease or trait
  8. Muscle injury after low to moderate work or activity
  9. Personal history of significant heat injury (heat stroke)
  10. Serum CK peak >= 100,000 U/L

Extended electrolytes – hyperkalemia other electrolyte abnormalities are possible
Creatinine – May be elevated if resultant acute kidney injury
Creatine Kinase – >5 times the normal limit has been suggested as diagnostic for exertional rhabdomyolysis
Urine – myoglobinuria
Compartment testing as needed


It is typically treated with rest and in severe cases aggressive hydration (Normal saline 400-2L/hour depending on severity) 1,2 however in severe cases may require hospitalization for advanced supportive care.
It is important to monitor kidney function, electrolytes, body temperature and urine output (aim for 200mL/h).1
Return to sport may be gradual once asymptomatic in low risk athletes.   For high risk athletes, closer observation is recommended which may include follow-up investigations to ensure resolve of CK, myoglobinuria etc.   3

Dr. Neil Dilworth ( November 7, 2017)


1. Tietze DC, Borchers J.  Exertional rhabdomyolysis in the athlete: a clinical review.  Sports Health. 2014 Jul;6(4):336-9. doi: 10.1177/1941738114523544.

2. Manspeaker S1, Henderson K, Riddle D.  Treatment of exertional rhabdomyolysis in athletes: a systematic review.  JBI Database System Rev Implement Rep. 2016 Jun;14(6):117-47. doi: 10.11124/JBISRIR-2016-001879.

3.  O’Connor FG, Brennan FH Jr, Campbell W, Heled Y, Deuster P.  Return to physical activity after exertional rhabdomyolysis.  Curr Sports Med Rep. 2008 Nov-Dec;7(6):328-31. doi: 10.1249/JSR.0b013e31818f0317.