Understanding Rhabdo

Workout of the Day--November 5, 2015

CrossFit Total Part 3: Deadlift--1 Rep Max

Then, 3 Rounds for Time
400m Run
20 Power snatch (115/75)

Understanding Rhabdo

Last week I wrote a post about preventing injury. Injuries can and do happen; and sometimes, all the prevention in the world can't stop it. Still, there are many factors that we can control to help mitigate our risk. Today I want to address another serious topic that goes hand in hand with injury prevention. There is still much that is not known about rhabdo, but it is important to use what is known to help reduce our risks and educate ourselves. 

 Rhabdomyolysis (rhabdo) is a rare but serious health condition sometimes caused by working out at very high intensity. CrossFit workouts, just like all high intensity workouts, have the potential to cause rhabdo under the wrong circumstances. While rare, it’s also very serious and requires medical intervention. Rhabdo happens when damaging proteins from muscle breakdown are released into your bloodstream in quantities that your kidneys cannot handle. If left untreated, kidney failure and even death can occur. Knowing the symptoms and what to look for are critical in getting the treatment required.

What are the Symptoms?

• Extreme muscle pain, soreness, and swelling;
• Overall feeling that something just isn't right or general malaise;
• Weakness and difficulty moving the affected muscles;
• Dark urine (brown, cola-colored)

Some muscle soreness is simply a part of exercise and CrossFit can take that to new levels. Extreme soreness combined with just generally feeling lousy is cause for concern. Dark-colored urine is a tell-tale sign that things are not right and you should seek medical attention.

Who generally gets it?

Rhabdo is very rare. While highly unlikely, the consequences are severe. Classic literature often tells us that men have higher risk of rhabdo than women. While this is historically true, it may be rooted in past social norms rather than biology. Women should not consider themselves exempt. Next, rhabdo usually strikes someone who has been away from intense exercise for a while and then jumps back in with high volume and intensity. Someone who has been very fit in the past and has taken six months off must ramp up volume slowly as he returns to intense exercise. This type of athlete has the mind and the determination to push himself beyond his body’s capabilities—where rhabdo lives.

What movements/types of workouts cause rhabdo?

Well, there’s no magic movement that always causes rhabdo. But some movements are higher risk than others when performed by new athletes or with excessive repetitions. These are usually movements with a demanding eccentric motion. Eccentric means that muscles are stretched under load. As you lower into the bottom of a squat, you are performing the eccentric portion of the squat. Your hamstrings are lengthening under load. Concentric means that muscles contract under load. As you drive out of the bottom of the squat you are performing the concentric portion. After being stretched, your hamstrings are now contracting and driving the load upwards. Eccentric motion is very demanding on muscles. Stretching muscles under a load with lots of repetition can cause the muscle breakdown that triggers rhabdo. Jumping pull ups, GHD sit ups, and walking lunges are examples of exercises with a strong eccentric phase. Now, these are all excellent movements that have their uses in building a strong and healthy body. Just don’t jump into doing hundreds of them, unless you’re a strong and experienced athlete that has worked up to that level of ability.

Using light loads for many repetitions in a long workout can be a contributing factor as can performing many reps of one movement without changing movements or resting. Heavy lifting generally does not cause rhabdo. Lifting heavy loads forces you to stop before severe muscle breakdown occurs. For example, performing 5 sets of 5 squats at a heavy load poses less of a risk than 500 squats as quickly as possible with a light load. 

case study

In January 2011 the University of Iowa football team returned to training from a three week winter break. On Thursday about 85 players performed a workout that involved 100 back squats at 50% of 1-rep max followed by a series of sled pushes, all done as quickly as possible. This same workout had been performed by the team in previous years with no ill-effects–once during late spring training and once during the fall after a one-week break. Later Thursday evening many of the players felt extreme soreness. On Friday they performed another workout focusing on the upper body, with a similar rep scheme. They then had the weekend off before returning for another light workout on Monday that involved calisthenics and stretching. By Monday night 13 of the 85 players were admitted to the hospital suffering rhabdomyolysis. What can we learn from this? By the way, I’m not interested in finding blame or criticizing anyone in hindsight. I’m interested in learning how to prevent future rhabdo injuries, so shelve the judgment and focus on learning.

• Warning Sign: Athletic, strong, mentally-determined men who just took three weeks off from training
• Warning Sign: Light load performed for high repetitions (100 squats at 50% 1RM)
• Warning Sign: Team atmosphere where each player would push himself to his limits

Let’s also look at some of the details of how the situation unfolded:

• Delayed onset: Players experienced extreme soreness the same night of the workout, but many did not realize hospitalization was necessary until four days later.
• You can have rhabdo and still workout: Many players performed more workouts between the rhabdo-inducing workout on Thursday and hospitalization on Monday.
• Stretching and calisthenics were the last straw: Rhabdo often is not fully realized until immediate swelling subsides and myoglobin from the affected muscles begins to flood the blood stream. Stretching can make this release of myoglobin even worse. Many of the players were not hospitalized until after the light workout on Monday that involved stretching.

What can we do to prevent rhabdo?

• Gradually build up volume and intensity in your workouts, especially after a long break from exercise. 
•  Even if you have been exercising regularly, jumping to a much higher intensity too suddenly can be dangerous. This doesn’t mean that you should not work out at high intensity. This means that you should ramp up your intensity slowly, over several weeks or even months.
• Listen to your coach and share information with your coach. We can't know that you are still dehydrated from a hangover two days ago and that you skied your legs off yesterday. Be honest with your coach about how you on any given day. You’ll get thoughtful guidance in return.
• Hydrate before, during, and after your workout. 
• Even if you and your coach do everything right, sometimes the perfect storm of circumstances can conspire against you. That’s why it’s important that you know the warning signs, symptoms, and what to do if you think you have rhabdo. If you think you have it, seek medical attention immediately.

wrap up

Keeping you guys safe is our highest priority. We plan, coach, test workouts, question each other, and seek outside input to put together the best strength and conditioning program we can for our community. Part of keeping you safe is educating you on what dangers may be lurking. Are there risks? Absolutely. Real ones. With serious consequences. We take them seriously and so should you. We also believe that the benefits outweigh the risks and that overall we are providing an avenue to improve health and fitness. There are dangers in any exercise program and even greater dangers to staying on the couch. So, take this knowledge, your good judgement, and the guidance of your coaches,  and use it to plot a healthy path forward. 

See you in the gym.