I've been investigating rhabdomyolysis and teaching about it for over 10 years. I'm also the author of the first book on rhabdo and exercise. I say this because even thought most have never heard of this disorder, you've seen it mentioned on TV every day! You've heard about it but were never taught about it. Rhabdomyolysis refers to a medical condition where your muscles die from too much exercise. Basically, the muscle cells rupture and release their cellular contents into the blood. This can not only be dangerous, it can be deadly! Here are the facts you need to know. Also see the review on indoor cycling classes and rhabdo.
What Is Rhabdomyolysis?
Rhabdomyolysis (Rab-doe-my-o-lie-sis) (sometimes abbreviated as “rhabdo”) literally means “skeletal muscle fiber death” 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.
When exercise causes the disorder, it's called exertional rhabdomyolysis. It is this type of the disorder that will be the focus of this review.
Rhabdomyolysis On TV
“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. Rhabdo is a rare side effect of of cholesterol-lowering drugs. See, you've heard about “rhabdo” every day and just never knew it.
Rhabdomyolysis Caused By Exercise
In the past, rhabdomyolysis was, for the most part, relegated to extreme physical exertions 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.
Tip. Break the word down: rhabdo-myo-lysis. The letters “myo” means muscle and “lysis” means death. Translation: muscle cell death.
Technically called exertional rhabdomyolysis (exercise induced), this form of the disorder occurs when people increase the intensity of
exercise too quickly. This overwhelms the body's ability to adapt. It's important for people to understand that rhabdomyolysis can happen after only 1 workout.
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!
Who Gets Rhabdo?
Anyone can get rhabdomyolysis. It does not discriminate. You can be a professional athlete or a novice, doing his/her first gym 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, performing only 30 sit ups a day for a week might cause it. Because of this, it appears that some people might be more susceptible to rhabdo from exercise than others.
How Long Does It Take To Occur?
Rhabdo can happen after just 1 workout. This is not something that takes days or weeks to show up. Case reports do exist of it occurring after too many intense workouts too close together, without adequate rest. That said, I believe most cases show up after 1 intense workout that overwhelms the body.
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 beat irregularities
- kidney failure
- severe muscle pain / swelling/ weakness/fatigue
- 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. In theory, this might lead to heart attacks. The dark color urine is caused by myoglobin in the urine. Myoglobin helps transport oxygen in the muscle cell. This is good however too much can damage the kidneys. This can cause the person to need dialysis in an attempt to help the kidneys recover.
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 sometimes help you identify rhabdo. The color of the urine has a redish-tint to it and is often described as looking like iced tea or cola-colored. The color is due to myoglobin being excreted in the urine.
Rhabdo And Advil
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. If you think you have rhabdo it's safest to get to the ER rather than take over-the-counter pain killer medications.
Rhabdo And Swelling
After exercise, you should never see swelling in your arms or legs as this can also be a sign of rhabdomyolysis. With tissue injury, fluid flows into the damaged limbs. This increases the pressure in the limbs which can cut off the circulation, resulting in further tissue death. This in turn, adds insult to injury by releasing even more kidney-damaging cellular contents into the blood stream.
In medical circles this is sometimes called compartment syndrome. In extreme cases, doctors may need to amputate the limb. It was compartment syndrome that caused CNN science reporter Miles Obrien to lose his left arm. He didn't get compartment syndrome from exercise. I use him as an example to drive him the fact of how serious this condition can be.
Rhabdo And Water Intake
In the gym, I often hear people taking about staying hydrated. This warning is especially loud among those who take part in high intensity boot-camp like workouts. I believe one the reasons people advocate water during high intensity exercise is because of rhabdo. Drinking water helps reduce the chances of the kidneys from shutting down. While dehydration does not usually lead to rhabdo, being dehydrated can make rhabdo worse or increase the chances of it happening.
That said, drinking water will not stop muscle fiber death, from too much exercise. While the water may reduce the severity of rhabdo, it won't stop rhabdo-induced muscle fiber death. I think this is a very important point to keep in mind. Exercising is healthy but if you are working out so hard that your muscle fibers are dying, are you not being healthy. Drinking water to reduce the severity of an unhealthy behavior is basically sticking your head in the sand trying to ignore the larger issue you're being confronted with.
Rhabdo And Negatives
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.
With that said, its not normally possible to take eccentric muscle actions out of the exercise. Exercise-induced rhabdo most likely is caused by exercise that puts too much stress on the muscles. Focus instead on the amount of exercise you are doing (how many sets and how many reps) rather than how many negatives you are doing.
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 believe the incidence of personal trainer-induced rhabdomyolysis is under-reported in the medical literature.
Read the comments below for more cases of trainers causing rhabdo.
I believe 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
If you are a personal trainer, you need personal trainer liability insurance. I have spoken to attorneys who are suing trainers who caused rhabdo.
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.
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.
Gyms Causing Rhabdo
I believe gyms can contribute to rhabdo without knowing it. Here’s why I say this. When people join a gym, they usually get a free/complimentary personal training session. I’ve been told on several occasions that personal trainers are instructed to beat the daylights out of the person who gets the free session. Why? Because, by making the person “think” they are out of shape, they are more likely to sign up for more personal training sessions.
I just made some people mad by telling this dirty little secret, but I don't care. Don't let ANYONE push you beyond your limits with exercise.
By subjecting people to lots of exercise that the person is likely not used to doing, gyms – and personal trainers – run the risk of causing rhabdo in their members.
The 30 Minute Workout
At most gyms, personal training sessions are only 30 minutes long. Gyms do this because:
1. Most beginners may lack the endurance and desire to last longer than this
2. The trainer can make more money by theoretically training 2 people per hour
That said, the 30 minute training session might increase the risk of rhabdo. Here’s why: The personal trainer, wanting people to get the most for their money, thinks they have to do the best job they can in 30 minutes.
Thinking like this – as well meaning as it is – might lead the trainer to fall back on aggressive training programs like super sets. In beginners,
super sets, drop sets, interval training etc. might cause rhabdo in some people.
Beginners are best suited with a full body circuit training workout. This keeps the overall exercise stress low, reducing the risk of rhabdo. Circuits also cause less DOMS than more intense workouts and allow the trainer to put the person through a wider variety of exercises. When you only have 30 minutes, circuits are the most efficient way to train someone.
Rhabdo And Cholesterol 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.
Rhabdo 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 The 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 a 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.
The easiest way to reduce the risk of rhabdo is to not overload the person with too much exercise. When exercising, one way to achieve this
is to follow this rule:
- First increase the reps you can do
- Then increase the sets you can do
- Then increase the weight you can lift
For example, when you can do 1 set of 15 reps, then do 2 sets of 15 reps. Then do 3 sets of 15 reps. After that, then try increasing the weight you can lift by a little bit (5-10 pounds for example). By increasing the weight, this should decrease the reps you can do. So again, start at one set and progress to 3 sets, before increasing the weight again.
In this step-wise progression, you are giving the body the time it needs to adapt to the exercise. Remember, rhabdo occurs when people do too much exercise that they are not used to doing.
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 referred to as “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. It should not be made fun of. Anyone who has found themselves in the hospital knows how serious it is.
Crossfit trainers: is rhabdomyolysis covered in the Crossfit certification exam? Please let me know.
Update. 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.
If you are going to take part in CrossFit, P90X, Insanity or any boot camp-type fitness program, I recommend starting with only 1 session per week. Start with 1 session per week for the first week or two. Then 2x per week in the second or 3rd week and so on.
Remember, the body needs time to adapt to intense exercise. I dont feel Cross Fit or other intense programs should be done more than 3 times per week. In my opinion, anyone who recommends that beginners start intense exercise programs 2-3 or more times per week, does not know what they are talking about.
How Likely Is Rhabdo?
I wish I could tell you what the odds are rhabdo are. I can't. I don't know – and nobody else does either right now. Unfortunately, the CDC has not released any recent statistics on this condition. Its sometimes estimated that there are 26,000 cases of rhabdo in the US each year but that is an older statistic from the 1990s and it considers ALL the causes – not just exercise. Back then, they estimated that half of those rhabdo cases – 13,000 – were due to exercise. Here's the thing; the 1990s predates most of the boot-camp style workouts that are popular today. Is rhabdo more or less likely today? I can't tell you.
Hopefully the CDC will eventually put out some better statistics on rhabdo.
Can You Have A Mild Case Of Rhabdo?
When we remember what rhabdo is – muscle fiber death – I don't think there is such a thing as a “mild case.” Once those muscle fibers die, they dont grow back. That said, there are people who have gotten rhabdo who never went to the hospital or seen their doctor. They had all the tell tail signs and symptoms but they just grinned through the pain and dealt with it. I believe those people just got lucky.
What To Do If Rhabdo Occurs?
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 this more. This is the safest course of action.
Telling somebody to “go to the hospital” might make things worse – if the person got into an accident or passed out 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 accidentally cause this disorder. This is one reason why I feel ALL trainers should have personal trainer insurance. Click here to get a quote now.
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.
Here is my book on Rhabdo which goes beyond what was covered in this review. It may be the most important book you ever read.
Please share this review with your friends so they know these facts too.