Rhabdomyolysis: If You Exercise, Read This

Last Saturday Cory and I did our morning workout.  It consisted of an easy one mile warm-up, and a circuit of squats, abs, pull-up negatives (the lowering portion of the pull-up only) and modified pushups for a number of circuits.

On Memorial Day we did a 10K hike (kind of our nod to the Bolder Boulder 10K, only in a much quieter setting and minus about 55,000 people).  :)

Then on Tuesday morning I ran my favorite 3 mile hilly loop with a client.

By Tuesday afternoon my arms started to swell around my elbows and biceps, I couldn’t straighten my arms and my fingers were starting to tingle like they were falling asleep.  That was definitely no longer just your typical “delayed onset muscle soreness”.  Yes, slight (I repeat slight) swelling can be normal, but my arms looked a bit misshapen.

Now, I know medical professionals hate it when you Google your symptoms but I needed to know:  Could I sit tight and wait it out with the help of some Advil or did I need to get to the ER?  I was worried that I was experiencing rhabdomyolysis (aka rhabdo) or compartment syndrome.  My symptoms were right on the money with both of those conditions, with the exception of dark urine.  My urine was normal.

Deep down I was scared, and because I know I have a tendency toward being an alarmist, I decided to hold off overnight.  When I woke up there was no change so I called my doc first thing and they got me in mid-morning.

At the doctor’s office they didn’t think I had rhabdo, but they said they’d run the bloodwork to rule it out and it would take a day or two to get the results back.

I left feeling only slightly better, knowing that I was at least under a doctor’s care, but still frustrated because I didn’t have any answers yet and was still worried.  It was nice to hear that they didn’t “think” I had it, but I’m stubborn and had a feeling.  I’m also impatient so I didn’t want to wait another day or two to know for sure!

The next morning (Thursday) my arms felt a little better and I went about my day, feeling fine.  Late that afternoon, I got a call from the doctor that I did indeed have rhabdo and that the local hospital was expecting me right away.

So what is rhabdomyolysis? From what I understand, basically it’s defined as the “rapid breakdown of muscle” such as when your muscles are injured in some way, typically from a trauma like an accident or severe fall, which leads to the fibers from the muscle breakdown flooding into the bloodstream and potentially causing the kidneys to clog and worse yet, fail.  When exercise induced, it’s more commonly known to be caused from extreme and lengthy exercise, like marathons.  And it’s more common in the legs than in the arms.

In my case, it was in the arms and from a relatively low number of reps of an eccentric exercise.  While this is something known in certain fitness circles, apparently it is not yet commonly known to a lot of the medical community that it can just as easily happen this way (no offense to my friends in the medical community).

A muscle contraction has a concentric phase and an eccentric phase.  For example if you are doing a pull-up, when you pull your body toward the bar that’s concentric (contraction/shortenings of the muscles involved).  When you lower the body toward the ground, that’s the eccentric phase where the muscles lengthen as the body lowers, yet still being under the ‘load’ of the weight.  (In certain exercises you might not have enough strength for the concentric phase, but you could for the eccentric phase so doing “negatives” means getting assistance lifting the weight but then lowering it of your own strength.  With pull-up negatives [or jumping pullups], if you can’t pull yourself up,  you can hop up and then slowly lower yourself.)  In negatives, the muscles are LENGTHENING and LOADED at the same time with heaver weight than you could lift, and this results in more microscopic muscle damage.   This muscular damage for the most part (in small appropriate amounts) is the goal in weight training in order to get the muscle to grow and repair itself even stronger and I’ve employed occasional intermittent eccentric training in my own workouts for 10 years with no problems.

Nothing much changed in my routine this time around except for that I kind of built up to “a perfect storm scenario” for a number of reasons.  I’d recently been sick (that crazy cold I had turned out to be pertussis, aka whooping cough) and I’d also been experiencing some fatigue, which could have been a remnant of the virus and which I saw the doctor for the week prior.  And in the days following the workout, I hiked and ran outside in the heat, and possibly could have been a little dehydrated.  Throw all those together, add in a nasty exercise like the ones I chose to do that day (if only for a total of 25 reps) and apparently I bought myself a stay at the local hospital.

Rhabdomyolysis is determined by testing for creatine kinase levels in the blood.  Supposedly it should be in the hundreds, and ideally under 400 [update: my hospital doc said they should basically be undetectable].  Mine came back last night at 27,000.  Today, after 3+ IV bags and counting, my numbers have dropped somewhat to 16,900.  Improvement, but not enough for them to release me.  So I have to stay tonight as well and get another blood draw in the morning to see if it continues to come down.  Plus an ultrasound of my liver later on today thanks to my elevated enzymes.

I’ll keep you posted on the outcome.

What I want you to take away from my experience:

  • Just being aware of what rhabdomyolysis is so that you can aim to prevent it.  Whether you are an avid exerciser or a beginner, do some reading on it to get familiar.  Kidneys are serious business!
  • Listen to your body and especially to your gut instincts.  I may have just ignored my symptoms by “wait and see” if I hadn’t done a little reading first.  I know I drive my doc crazy sometimes, but we work well together that way.  We have to be advocates for our own health because we are the ones that live in our bodies!  And I’ve learned something very important in this process.
  • This is by no means a thorough article on the condition so do some additional reading.  Most of the articles you will find don’t talk about it happening from the short, intense bodyweight training.  Most will talk about traumatic injuries or marathon-type reasons.  Google Crossfit and rhabdo together and you’ll see a lot of experiences people have had with this way of getting it.

This was a long post friends – so thanks for hanging in there with me if you made it to the end!  I’ll post again when I have new info to update!

- Shari B. =)

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UPDATE January 2013:

At the time of this update, it has been 19 months since my hospitalization for rhabdo.  I have received so many comments here as well as private emails and I am so thankful to hear from each person that writes.  It means so much to me to learn from some of the commenters that this post helped them, whether by getting them to get to a doc faster or by knowing which test to ask for.  If you are reading this post for the first time (and especially if you suspect you may have rhabdo or are post-rhabdo), I strongly encourage you to read down through the comments section as well for additional experiences from readers with their own types of symptoms.

The most common questions I receive are along the lines of how long was my recovery, how long did I have to wait to work out again and whether I have experienced any lasting effects.

In many ways I feel I am still working through the recovery.  The doc put me on activity restriction for 2 weeks after my creatine kinase numbers had returned to normal – I could do some light walking but nothing strenuous.  Because I’d also read that muscles affected during a bout of rhabdo may be at increased risk of a recurrence, let’s just say I was beyond cautious.  Maybe more than necessary, but I do NOT want to end up back in the hospital.  For a long time afterward, I just focused on things like yoga and hiking.  I did incorporate strength training but I kept it pretty light.  About a year later, when I felt I had to be in the clear and thought it could be time to start really progressing in weights, I twice experienced some post-workout symptoms in my biceps that were scarily similar to rhabdo.  I never have a workout anymore where I don’t have it in the back of my mind.  You’ll read in a comment below from Scott that 8 months post-rhabdo, he finds:  “There is a considerable amount of anxiety that is part of exercise now and I feel like I can’t really push myself where I want to be because of the fear of a recurrence.”  I understand exactly where he is coming from.  I have had to really work around my biceps when lifting weights, and if I want to do a lat movement I try to work them from a straight-arm position as much as possible to keep the biceps from really engaging.

Another commenter did go to the doctor suspecting rhabdo, was told it couldn’t be and then proceeded to order their own blood test directly.  And as it turned out, rhabdo was indeed the diagnosis (see the comment from Sky).

Just today, I worked my biceps in my workout (and only used 5 lb weights for crying out loud) and this afternoon my left fingers felt a bit of numbness and tingling.  I am hypersensitive to all of that stuff now.  I try to really stay on top of my hydration, staying mindful during my workouts if I might have had a glass of wine the night before (which a few commenters mentioned so now we are wondering if that might be a risk factor) and focusing on rest.

Please share your story as well.  We are all able to learn something new each time we hear from someone.  Also check back in during your recovery and let us know what your experience has been like.  The more info we have out here, the more people might be helped.   Rhabdo is NO JOKE.  People do die from it.

Thank you again to everyone who is reading and to those of you who have taken time to share your own journey.  You have no idea how much I appreciate hearing from you.

– Shari B. =)

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All content on this blog is meant for informational purposes only. While I am a certified personal trainer, I need be clear that I am not a physician.  The ideas, procedures and suggestions contained in this blog are not intended as a substitute for consulting with your physician.  No intent is made to diagnose, treat, cure or prevent any disease, pain, injury, deformity or physical or mental condition. No statements made, inferences, including videos and links to other sites, should be construed as a claim for cure, treatment, or prevention of any disease or as a substitute for professional health care.

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