It’s ironic that most people have never heard of rhabdomyolysis, even though you’ve probably seen it mentioned on TV every day! Rhabdomyolysis is a condition that results in the death of your muscle cells from a stress (like exercise) that overwhelms the body’s ability to adapt. Basically the muscle cells rupture and release their cellular contents into the blood. This can not only be dangerous, it can be deadly!
Rhabdomyolysis (Rab-doe-my-o-lie-sis) can occur following a variety of scenarios ranging from but not limited to car crashes, snake bites, anexorea nervosa, weight loss supplements like Hydroxycut and some cholesterol-lowering drugs and supplements that lower cholesterol like red yeast rice. Too much exercise is also known to induce rhabdomyolysis.
“If you experience any pain or weakness, see your doctor as this could be a sign of a rare but serious disorder.” Do these words sound familiar? They should because you have heard them almost every day. Every TV commercial for cholesterol lowering drugs gives this warning – which is a reference to rhabdomyolysis. See, you hear about “rhabdo” every day and just never knew it!
Rhabdomyolysis Caused By Exercise
In the past, rhabdomyolysis was, for the most part, relegated to very physical efforts like military training or other very demanding situations (police academy, fireman training, etc.). In recent years however rhabdo has – unfortunately – also been documented in those who exercise in the gym. By some older CDC estimates, there are about 25,000 cases of rhabdomyolysis each year in America. Almost 50% of these cases were due to exercise causing it.
Tip. Break the word down: rhabdo-myo-lysis. The letters “myo” means muscle and “lysis” means death. Translation: muscle cell death.
Technically called exertional (exercise induced) rhabdomyolysis, this form of the disorder occurs when people increase the intensity of exercise beyond the body’s ability to adapt. It’s important for people to understand that rhabdomyolysis can happen after only 1 workout.
Tip. Rhabdomyolysis is not the same thing as delayed onset muscle soreness that happened after exercise.
Case reports of rhabdomyolysis in people who exercise do exist. For example, in one report, a 24 year old male induced rhabdomyolysis in himself after increasing the intensity of his workout. Rhabdomyolysis is also more likely when the exercise is unaccustomed – like for example, jumping right in to an intense exercise class at the gym that you have never done before.
In others, rhabdomyolysis has occurred after a spinning class. See the comments below, for more info on spinning classes and rhabdomyolysis.
Low intensity exercise can also cause rhabdomyolysis. In another case report, rhabdomyolysis was observed in a healthy, 29 year old untrained man who performed 30-40 sit ups a day for one week.
Let me repeat. He only did 30-40 sit-ups a day for a week! Here is a report on 32 year old man who developed rhabdomyolysis after swimming only twice!
Tip. Rhabdomyolysis can happen in both athletes and beginners. It can happen in just 1 workout.
You can’t look at somebody and tell how much exercise would cause rhabdomyolysis. Some people can train to be a Navy Seal and never get it. In others, only 30 sit ups a day for a week might cause it. Therefore, it appears that some people might be more susceptible to getting rhabdo from exercise than others.
Rhabdomyolysis Signs And Symptoms
While doctors can easily diagnose rhabdomyolysis with a blood test, some of the physical signs and symptoms of rhabdo include:
- Heart attack
- kidney failure
- severe muscle pain / swelling/ weakness
- dark color urine – think dark brown “coke-a-cola” color
These symptoms – especially the first two – highlight the seriousness of rhabdomyolysis. As the kidneys stop working, there are alterations in electrolytes which can cause heart rhythm abnormalities and heart attacks. The dark color urine is caused by blood in the urine. Basically you start peeing blood.
If you ever hear of anybody whose kidneys stopped working after they exercised, it’s probably rhabdomyolysis that caused it!
The pain of rhabdomyolysis happens fast – immediately after exercise, up to 24 hours later. This pain happens more rapidly than delayed muscle soreness (DOMS) which typically happens 24-72 hours after exercise. Also, the muscle pain hurts when people are not moving. Remembering this sign – as well as dark urine color – can help you identify rhabdo.
Some people take pain killers – like aspirin or Advil (Ibuprofen) to alleviate muscle soreness but people need to understand that because these pain killers can affect how the kidneys work, using pain killers may increase the chances of rhabdomyolysis occurring.
Personal Trainers and Rhabdomyolysis
Personal trainers have – unfortunately – also been the cause of rhabdomyolysis. How many personal trainers have caused rhabdo? This is unknown because rhabdo is not always fatal (thank goodness!) and many people don’t go to the doctor / hospital when it happens – because they don’t recognize its symptoms.
That said, I am personally aware of several cases personal trainer-induced rhabdomyolysis that have arisen within the past few years. I’ve also met 2 people who accidently caused rhabdo in themselves! I believe the incidence of personal trainer-induced rhabdomyolysis is under-reported in the medical literature.
If anything is going to cause U.S. personal trainers to one day get a personal trainer license, it will be a personal trainer causing rhabdomyolysis in a high profile individual.
I think personal trainers cause rhabdomyolysis in their clients for several reasons including:
1. never having been educated about it
2. thinking that more sets /greater intensity is best for everybody
3. being shy about stopping a training session when the client has had enough
4. failure to recognize the benefits of circuit training
An unfortunate fact is that rhabdomyolysis is not discussed in many personal trainer certification textbooks. In fact, my book, was one of the first personal training books in the US (and maybe THE first!) to educate fitness trainers about this condition. My book is also the official textbook for the Interactive Fitness Trainers of America.
PE teachers also need to know about rhabdomyolysis because there is some evidence of young children getting rhabdo from gym class.
Sometimes you hear people say that dehydration causes rhabdomyolysis but this is not true. Being dehydrated can make rhabdo worse or increase the chances of it happening but saying you got rhabdo because you were dehydrated is incorrect. The dehydration must be combined with intense or unusual physical activity that overwhelms the body.
One aspect of rhabdomyolysis and exercise that does not get the attention it deserves is its relationship to eccentric muscle actions (“negatives“). These types of muscle contractions occur when the muscle is lengthened as force is applied to it. An example would be the lowering phase of a dumbbell curl. Negatives put more stress on the muscle and cause more muscle damage, hence their connection to rhabdo. Exercises that involve lots of negatives (like plyometrics) have a greater chance of causing rhabdomyolysis.
Eccentric muscle actions (negatives) do result in greater strength and elevations of resting metabolic rate. This is why you hear so many people in the gym saying “Get the negative.” But, performing intense exercises that involve a lot of negatives in someone who is not used to – or increasing the intensity of the workout too fast - it can be a recipe for disaster.
Personal Trainers: With Great Power…
Personal trainers need to understand that they have a power over others. Nobody talks about it but it’s there. The power is that most of their clients will never tell a personal trainer “no.” In other words, most people will never tell the personal trainer when they think they have had enough. Most will keep working out as long as the trainer gives them things to do, for as long as the training session lasts!
This power is great and as Peter Parker (aka Spider-Man) says “with great power, comes great responsibility.” If you’re a personal trainer with big, hulking muscles or a boisterous personality, you need to know that you might intimidate your clients – without even trying to – leading, unintentionally, to a greater risk of rhabdo.
One case report of personal trainer-induced rhabdo occurred in a doctor. Doctors are VERY well aware of rhabdomyolysis yet this physician allowed the personal trainer to push him to the point of muscle cell death.
Of all personal trainers out there, female personal trainers have the greatest power. I say this because most men will never tell a woman they can’t do what the woman can do! No man wants to appear weak in the eyes of a woman. Female personal trainers must be aware of this power when they train male clients. When you think somebody has had had enough. End the training session.
Rhabdomyolysis And Statin Drugs
It is well known that in some people, cholesterol lowering drugs (statins) can increase the risk of rhabdomyolysis. This is why they give that warning in TV commercials for these drugs. Intense exercise – esp those that contain negatives – can also increase rhabdomyolysis risk. Therefore, would people who take statin drugs have an greater risk of rhabdo when they exercise intensely? Yes. There is some evidence that people taking statins have more rhabdomyolysis than those not taking statins.
I believe personal trainers who do fitness bootcamp classes should consider statin use when they work with people and tailor exercise intensity accordingly to reduce its risk.
Rhabdomyolysis And Sickle Cell Anemia
The risk of rhabdomyolysis seems to be increased in people who have sickle cell anemia and those who are carriers of the sickle cell anemia gene (these people don’t have sickle cell anemia. They just have the gene for it). In 2010 a healthy, 19 year old college football player with sickle cell trait developed rhabdo during training, which contributed to his death. This is but one of several incidences of sickle cell trait contributing to the occurrence of rhabomyolysis.
The presence of sickle cell trait does not mean that exercise-induced rhabdomyolysis will occur and it does not mean that people with this genetic marker can not exercise. Rather it only means that the risk of rhabo is increased. To reduce the risk, fitness trainers may want to ask about sickle cell trait (and sickle cell anemia) in their health history questionnaires. This will allow the personal trainer to modify the exercise intensity to reduce the risk.
Rhabdomyolysis And McArdle Disease
McArdle disorder is a genetic condtion where people do not store glycogen, our bodies reserve storage form of carbohydrates. People who have this condition have an elevated risk of rhabdomyolysis.
How To Reduce Rhabdo Risk?
The easiest way to reduce the risk of exercise-induced rhabdomyolysis is to introduce exercise slowly and give the body time to adapt between workout sessions. Tossing an overweight novice into a fitness boot camp class and on the first day having her do 250 lunges, crunches and squats is a recipe for rhabdomyolysis. This is actually a true story told to me by the woman this happened to. She got rhabdo from this workout.
Rhabdo and CrossFit
Crossfit, the popular hard core exercise program, has also resulted in rhabdomyolysis in some of its participants. Among CrossFit trainers, the syndrome is often called “Uncle Rhabdo” however I don’t like this term. I feel calling it “Uncle Rhabdo” undervalues and water-downs this serious disorder.
In the June 2011 CrossFit Journal, they likened the phrase Uncle Rhabdo to Smokey The Bear because Smokey reminds us about forest fires while Uncle Rhabdo reminds us of rhabdomyolysis. I disagree totally with this analogy. Referring to a potentially life threatening disorder with a euphemism like Uncle Rhabdo, downplays the significance and, I feel, leads CrossFit trainers to think rhabdo not such a big deal.
I feel rhabdomyolysis is one of the most serious disorders facing fitness bootcamp trainers today!
In a conversation I once had with a reporter researching CrossFit, I was told that many of CrossFit trainers either did not know what rhabdomyolysis was or could only give a superficial description of it. If this is true for the majority of CrossFit trainers, it means that clearly CrossFit is dropping the ball and needs to improve their education of trainers about this syndrome.
Crossfit trainers: is rhabdomyolysis covered in the Crossfit certification exam? Please let me know.
Update. On 2/28/12 I was informed by a cross fit personal trainer that there are are 10 pages devoted to rhabdomyolysis in the cross fit manual (the manual is 117 pages in length). I was informed also that there are 2 questions about rhabdo on the cross fit exam. It appears that Cross Fit is taking rhabdo much more seriously and I commend them for this.
My #1 question test for ALL personal trainers: “Tell me what rhabdomyolysis is.” If they can’t tell you or only give you a superficial description, walk away. That is not the person you should entrust your health to.
Let me be clear. I am not beating up on CrossFit. I am aware of rhabdomyolysis occurring in other lesser known fitness boot-camp facilities as well. Heck, personal trainers – not doing boot camp workouts – have caused it too. To their credit – Cross Fit has discussed this disorder openly in their Crossfit journal.
The fact is that ANY extreme workout – P90X, Insanity, plyometrics, football combine camps – or other intense exercise routines can cause rhabdomyolysis. Here are some tips on how to set up a safe exercise program.
Update. 7/26/14. I don’t know how likely Cross Fit is to cause rhabdo – and nobody else does either right now. Unfortunately, the CDC has not released any recent statistics on this condition. The last release I saw was from 1988 where 25,000 total cases of rhabdo were noted from all causes in the US. Of those, 12,5000 cases were attributed to exercise (all types of exercise).
I mention this because there there are some people who down play its significance and try to prove this to you by quoting studies and doing lots of math. With respect, no matter how many letters they have behind their name or how smart they sound, they suffer from the same lack of information I do. They don’t know any more than I do what the rate is.
I do feel a lot of cases are caused by personal trainers (and non-trainers who train friends on the side) who have no idea about rhabdo and/or who think “no pain/no gain” is the way to train people.
I think the rate would depend on many factors such as:
- Is the trainer cross-fit certified vs. non-certified.
- How many days per week does the person do cross fit.
- Beginner vs non beginner.
- Medications the person is taking.
- Past history of previously getting rhabdo.
Hopefully the CDC will eventually put out some better statistics.
What To Do If Faced With Rhabdo?
Personal trainers basically only have 2 ways of “seeing” rhabdo.
1. Somebody has very intense muscle soreness which hurts even when the person is not moving and which happens very fast (immediately after exercise up to 24 hrs later).
2. The person’s urine looks dark brown colored – like maple syrup or cola-colored.
If you are a personal trainer and these symptoms are brought up in conversation, I recommend you stay calm – and call an ambulance. I can’t stress more. This is the safest course of action.
Telling somebody to “go to the hospital” might make things worse – if the person had a heart attack on the way to the hospital.
I know for some, calling an ambulance may seem over the top. Heck, I’d bet most personal trainers working in gyms today have not even been told about the gym’s emergency procedures! I’m sorry but being a personal trainer means that you may have to “take the bull by the horns” from time to time.
I look at it this way: At the end of the day, I want to be able to look myself in the mirror and say I did my best. I tried to do good.
All personal trainers and group fitness instructors need to be aware of rhabdomyolysis and work to reduce its risk. ANY personal trainer or other individual who doesn’t know what he / she is doing can accidently cause this disorder. Reducing exercise-induced rhabdomyolysis is best done by considering the health of the person and by slowly increasing exercise intensity and frequency where appropriate, and knowing that no single exercise routine or program is best for everybody. Remember, they call it personal training for a reason.
What do you think?