East Jefferson General Hospital

Optimum Performance: Training Toward Disaster

A reader asked if I would tell the story of his near-death experience based on his encounter with Rhabdomyolysis (Rhabdo) — the breakdown of muscle fibers that leads to the release of muscle fiber contents (myoglobin) into the bloodstream. Myoglobin (a protein), according to the National Institutes of Health, is harmful to the kidney and often causes kidney damage.

"I collapsed June 10 this year in my bathroom without any warning signs, or at least any I was aware of at the time.” the reader, Robert, said, “I have since done an autopsy of the days before my illness and realize several symptoms were there, but none I would have understood were about to set off the chain of events that came about — first massive kidney failure followed by liver failure.”

From Robert’s firsthand account, he likely experienced Exertional Rhabdomyolysis (ER), which can happen during strenuous exercise and can range from mild to severe. As it turned out, Robert was a self-proclaimed “CrossFit junkie,” who was extensively overtraining. “But, it’s in my DNA,” he said.

Robert’s initial symptoms before going to the emergency room were “fatigue, muscle weakness, muscle tiredness, memory loss, confusion and loss of appetite.”

The symptoms of severe ER, according to the 2013-14 NCAA Sports Medicine Handbook, can include:

  • Muscle pain more severe and sustained than expected
  • Swelling of muscles and adjacent soft tissue
  • Weak muscles, especially in hip or shoulder girdle
  • Limited active and passive range of motion
  • Brown (“Coca-Cola”) urine from myoglobin

A physician will confirm the diagnosis by documenting an elevated creatinine kinase (CK) level, based on the gender, race and activity history of the patient.

Robert’s treatment in the hospital was “possibly the worst as I was required to undergo dialysis everyday for two weeks then every other day for the other two I was hospitalized,” in addition to numerous medications.

A recent Huffington Post story chronicled the disturbing outcome of a physical therapist, who pushed herself into a Rhabdo diagnosis by overdoing a CrossFit training session. “While in the emergency department they tested her creatinine kinase level …. (which) were more than 45,000, a number that indicated damage to the kidneys.”

According to Dr. Arthur Siegel, Associate Professor of Medicine at Harvard Medical School, “Rhabdo is virtually universal in marathon runners who continue to exercise after ‘hitting the wall’ i.e., when intra-cellular glycogen stores are depleted. This injury to skeletal muscle triggers a systemic inflammatory response, which initiates the repair process (no pain, no gain), but can also have adverse consequences. ”

Neuroendocrine response to injury, noted Siegel, “can result in exercise associated hyponatremia or water intoxication, especially in younger female runners, and cardiac arrest and sudden death by triggering atherothrombosis (formation of a blood clot inside a blood vessel) in middle-aged males with previously silent underlying coronary heart disease.”

In 2011, 13 University of Iowa football players were hospitalized as a result of Rhabdo. The players, as reported by ABC News, “were undergoing a workout, a heavy exercise program.”

Tulane head certified athletic trainer, Andrew Massey, says “Exertional Rhabdomyolysis is a preventable situation. Properly planned, incremental increase in exercise intensity and duration is the key to prevention, especially at the start of a season or after time off.“

Hydration is also very important and in my experience, dehydration is usually a factor. There will always be isolated incidents of this condition, but multiple presentations from one team at the same time should not happen.”

From a treatment standpoint, Dr. Gregory Stewart, Director of Tulane’s Institute of Sports Medicine said, “the biggest concern is the potential for renal shutdown, so you have to watch their kidney function and keep them very well hydrated. However, there are times when the kidneys will temporarily shut down and the patient requires temporary hemodialysis. It is the potential renal complications and ensuing hyperkalemia that are the risks.”

In August of 2010, NFL.com reported Washington Redskins defensive lineman Albert Haynesworth “experienced the symptoms of Rhabdomyolysis. Those symptoms included dizziness, nausea, vomiting and muscle swelling. He was treated by team doctors, with Rhabdomyolysis believed to be the likely cause.”

Haynesworth’s case was not extreme, such that he was limited in practice and played the second half of the Redskins’ next preseason game against the Ravens.

Robert’s story and that of others who trained themselves into Rhabdo reinforces the maxim: Train smart, not hard. “Feel blessed to be alive Mackie, as I was about as close to death as I ever wanna be,” Robert said.

Mackie Shilstone, a regular contributor to NOLA.com | The Times-Picayune, has been involved in the wellness sports performance industry for nearly 40 years. He is currently the fitness coach for Serena Williams and has trained numerous other professional athletes and consulted a litany of professional sports franchises. He’s the Executive Director of the Fitness Principle with Mackie Shilstone at East Jefferson General Hospital. Contact him at mackieshilstone.com