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Publish date: Apr 21, 2011

Rhabdo requires prompt diagnosis, treatment

By Marta Lawrence
NCAA.org

Rhabdomyolysis, a serious complication of extreme muscle exertion, should be aggressively managed to prevent potentially catastrophic results for student-athletes, experts say.

The condition, commonly known as “rhabdo,” causes muscle fiber to break down and release myoglobin into the bloodstream. It can produce dangerous side effects, including kidney damage and compartment syndrome − a compression of nerves, blood vessels and muscle inside a closed space within the body.

Training recommendations

To reduce the risk of rhabdomyolysis, experts suggest following many of the recommendations found in the NCAA Sports Medicine Handbook for student-athletes with sickle cell trait:

  • Allow student-athletes to set their own pace.
  • Engage in a slow and gradual preseason conditioning regimen to be prepared for sports-specific performance testing and the rigors of competitive intercollegiate athletics.
  • Build up slowly while training (for example, paced progressions).
  • Use adequate rest and recovery between repetitions, especially during “gassers” and intense station or “mat” drills.
  • Do not urge student-athletes to perform all-out exertion of any kind beyond two to three minutes without a breather.
  • Be excused from performance tests such as serial sprints or timed mile runs, especially if those are not normal sport activities.
  • Stop activity immediately when student-athletes struggle or experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness.
  • Keep student-athletes well hydrated at all times, especially in hot and humid conditions.
  • Maintain proper asthma management.
  • Student-athletes should refrain from extreme exercise during acute illness or while experiencing a fever.
  • Supplemental oxygen at altitude should be accessed as needed.
  • Seek prompt medical care when student-athletes experience unusual distress.

Milder cases may go undetected, said former University of Oklahoma team physician Randy Eichner, leading to the possibility that severe complications can develop later. Treatment for rhabdo typically involves a hospital stay and the use of intravenous fluids.

The danger of not finding and treating an instance of rhabdo could have catastrophic results, Eichner said, especially for student-athletes with sickle cell trait. Many experts suggest adhering to the sickle cell trait guidelines found in the NCAA Sports Medicine Handbook to reduce risk.

There is evidence that reacting to signs of rhabdo early may help reduce sudden death due to complications from sickle cell trait. A recent analysis found that 22 athletes who experienced sudden death had the trait. Eleven of those 22 incurred rhabdomyolysis as a complication of sickle cell trait.

“Originally, the sickle cell trait was considered a benign condition,” said Kevin M. Harris, M.D., the study’s lead author and director of the echocardiography laboratory at the Minneapolis Heart Institute at Abbott Northwestern Hospital in Minneapolis. “However, studies began to demonstrate that in extreme physical situations, such as military recruit training, some individuals with SCT can be at risk for dying suddenly. Then, we began to see the same occurrences in athletes.”

Symptoms of rhabdo include pain, weakness and swelling of the impacted muscles. The release of the myoglobin can cause an imbalance in electrolytes that can result in vomiting, nausea, confusion and (in extreme cases) cardiac arrhythmia.

One of the most commonly reported symptoms, however, is dark or “tea-colored” urine. As damage to the kidneys continues, urine production can be affected.

In 2008, seven University of South Carolina swimmers were diagnosed with rhabdo and in January, 13 Iowa football student-athletes were sent to the hospital after several players reported dark urine after a strenuous workout. According to a report issued by Iowa, the players, who were returning from a three-week break, participated in a squat drill that required they back squat 100 times at 50 percent of their last recorded maximum weight.

 “It’s always the same thing in these epidemics − and there are a lot more of them than people think − too much, too soon, of an exercise that’s too novel for them,” Eichner said.

The Iowa report indicated that “the number of sets required to complete the workout, the time required to complete the workout, and the percent body weight lifted (for skill and semi-skill players) were the strongest risk factors.” University officials have said they will no longer ask student-athletes to complete that type of drill.

“The Iowa incident should serve as an important reminder to all strength coaches that they should not only be educated about rhabdomyolysis, its causes and its symptoms but also on how to appropriately manipulate training program variables that reduce the risk for these unwarranted outcomes,” said Jay Hoffman, board president of the National Strength and Conditioning Association.

Experts say acclimating athletes after a break is extremely important. Although many programs, including Iowa’s, create training programs for athletes during a break, most athletes return to campus somewhat deconditioned.

Starting slowly and progressing toward demanding workouts is key. “You don’t have to build Rome in a day,” Eichner said.

Administrators and coaches should also educate their student-athletes and staff about the signs of rhabdo. Eichner recommends posting a urine color chart near every urinal and stall. He said coaches and trainers should encourage student-athletes to report dark urine immediately.

The NCAA will send color charts to every member institution before the start of the summer conditioning period.

Lack of knowledge and education on the dangers of rhabdo was a complicating factor in the Iowa case, according the university investigation. Some student-athletes vomited after the drills, several experienced dark urine and many complained of unusually severe pain and stiffness in their legs. Some told staff they had difficulty climbing stairs and putting on shoes.

The report said staff did not initially suspect rhabdo and did not send anybody to a doctor until high blood pressure was detected in the first player, four days after the initial drill. During interviews with the strength and conditioning staff, investigators found that the coaches “were very aware of heat injury and dehydration but they did not know about exertional rhabdo (rhabdo caused by exertion) until the cluster occurred.”

Because the impact of rhabdo can be limited if it is caught early, prompt communication and testing are especially important. Eichner said it might be a good idea to test an entire team if one person is diagnosed.

He cautioned, however, that testing should be done quickly before the condition becomes too severe. “Test the team and test them fast,” he said. “Don’t want until day five to test them because then you’re behind the 8-ball.”

Once multiple athletes were found to have rhabdo in Iowa, staff sent a text message to the entire team, urging them to go to the hospital if they experienced any symptoms. The use of current technology to communicate directly with players meant the message was quickly received. Eight players sought medical care, most saying they would not have done so if the message had not been sent.

Although Iowa acted promptly once a problem was identified, the text message put the decision to seek medical help in the hands of the student-athletes. For the future, the Iowa report recommended testing all members of a team if one player becomes ill or reports serious muscle injuries “to make sure that, although they do not have the most pronounced symptoms or signs of the ailment, they do not suffer from the same condition.”

The report suggested several other improvements, including educating staff and student-athletes about the causes and symptoms of rhabdo and greater communication among medical and training staffs. Ideally, the report said, “physicians and athletic trainers should specify to coaches the activities athletes should not do, and they should not rely on the players to tell coaches or athletic trainers when they cannot tolerate an activity.”

Eicnher and others hope the Iowa case is a wake-up call.

“A lot of people don’t think about rhabdo,” Eichner said, adding that people need to start paying attention because the demands on elite athletes are likely to increase.