Can Exercise Bring on Rhabdomyolysis?

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Last week, 12 players on the men’s lacrosse team at Tufts University in Boston were diagnosed with an unusual condition after a 45-minute workout with an alum and former Navy SEAL trainee. Nine were hospitalized, and three remain in the hospital.

According to the university, players were suffering from rhabdomyolysis, or rhabdo, which can sometimes stem from overexertion of muscles.

Christopher Tanayan, MD, a sports cardiologist at Northwell Health in New York, told MedPage Today that rhabdomyolysis occurs when injury to myocytes causes leakage of myoglobin through cell walls into the bloodstream, which can then cause renal tubular obstruction. This, in turn, can bring on nephrotoxicity.

“Obviously, we’re not privy to what has happened to these players, but understand: anyone can have rhabdo if you’re not being very sensible with how you exercise,” he said. “If you don’t recover enough, there’s always damage that you can cause to your muscles that can cause subsequent complications, particularly kidney injury, if you’re not aware of this.”

Patients with rhabdo have telltale darkened urine, pigmented by excess myoglobin being filtered out of the blood. Other symptoms include muscle aches and weakness. Tests for creatine kinase levels, which rise suddenly with muscle injury and last longer in the blood than myoglobin, can help to diagnose rhabdomyolysis.

The usual treatment is intravenous fluid resuscitation, Tanayan said.

Rhabdo isn’t just caused by overexertion. Cardiovascular conditions, muscle trauma, extreme heat, and dehydration can all contribute. For example, if an older person falls and is unable to stand up for an extended period of time, pressure against their muscles can deprive them of blood supply and lead to rhabdo, Tanayan noted.

He said exercise-induced rhabdo can come from pushing beyond one’s physical limit without having given your body enough time to physically adjust. As a cardiologist, he recommends exercise to his patients through gradual progression to allow the body to adapt.

“Running a marathon from not doing anything is bad, the same way that, if it’s your first time doing a spin class and you’re not used to doing spin classes, if you push yourself to be the same level as someone who’s already been doing this for years, then your risk for developing rhabdomyolysis is high,” Tanayan explained. “Because, again, you’re pushing your muscles and you don’t have those adaptations yet.”

Though a challenging workout is often the goal, intense group exercises can sometimes lend themselves to this kind of exertion. “So spin classes, some other classes … they’re supposed to motivate you, right?” he said. But “if you have a teacher that’s very strict and very motivational, some people tend to overdo it.”

One such person was Ellen Battles, an administrative manager at a Houston philanthropic foundation, who went to a spin class in 2017 with a group of friends. She hadn’t tried the workout before, she told MedPage Today. “We signed up for a 60-minute class, and so it’s really hard, and I definitely pushed myself way more than I should have, but really didn’t think anything of it.”

“I do remember feeling like being in the group setting and having the instructor encouraging us to, like, go harder, push harder — ‘Now, stand up here. Now come on, let’s get over this hill’ — I remember that being motivating,” she said.

Within the next 2 days, Battles was in so much pain she couldn’t sleep. Her thighs hurt so much she couldn’t sit down at her desk to work — much more than normal muscle soreness. In her car, her legs were so swollen she had to raise the steering wheel to drive. After her urine turned dark, “like the color of soda,” she decided to go to the emergency department (ED).

Clinicians tested her creatine kinase levels, which were elevated, and she spent 2 nights in the ED, then transferred to a hospital for 2 more nights, where she was given fluids, morphine, and had her kidney levels monitored.

“I will say the whole experience totally destroyed the strength in my legs,” Battles said. “I was very weak for quite some time after that happened, and very gradually got back into strength training.” A year later, she ran a half-marathon with no problems, but looking back, “up until I had my baby just this past year, that was by far the most uncomfortable, most painful experience I had ever endured,” she said.

“After the fact, I was definitely assigning most of the blame to myself,” Battles noted. “But me being a beginner, I wish that they had flagged that, because I don’t know if that was anything that was noted at any time by anybody.”

Still, she added, “I definitely learned a little bit better, because of this horrible experience, how to pace myself and not push too far.”

Details about the Tufts lacrosse team workout remain unclear.

In a statement, Patrick Collins, executive director of media relations at Tufts University, wrote that the university “is appointing an independent investigator to conduct a thorough investigation as quickly as possible to determine exactly what happened before, during, and after the workout; assess the university’s response; and review its procedures and policies to determine what changes it should make to prevent this from happening again.”

Tanayan noted that “it looks like the graduate who led the exercise apparently completed Navy SEAL training. … Whoever that person is, guy or girl, is very fit and used to really hard exercise regimens.” It’s hard to know, he added, how frequently the team was training, if they had done similar workouts before, or if they were coming off a long break.

But one thing is clear: “Obviously, if they have had rhabdo, there was a threshold that got breached,” he said.