3 Keys to Preventing Rhabdomyolysis

(Originally published on Stack.com)

On March 10, the Associated Press reported that William Lowe, a former University of Iowa football player, filed a lawsuit against the university accusing the coaching staff of negligence. According to the AP report, Lowe alleges he was the victim of injuries sustained from a high-intensity off-season workout supervised by Hawkeye coaches and trainers on Jan. 20, 2011.

Lowe was one of 13 Iowa football players hospitalized and diagnosed with external rhabdomyolysis, a severe condition of the liver due to the release of muscle fiber contents into the bloodstream. Rhabdomyolysis has an assortment of causes, from car accidents to severe hydration. It can also be caused by extreme amounts of exercise, like an Ironman triathlon. Warning signs are extreme muscle soreness and dark-colored urine, caused by a substance known as myoglobinuria.

The reported culprit in the Hawkeyes football story was a Squat workout that lasted nearly 20 minutes: 100 Back Squats with a load equaling 50% of a one-rep max. In the lawsuit, Lowe is pursuing monetary damages for physical and mental anguish, contending that, “the injuries and damages [he] sustained . . . arose from the same general types of danger that [he] should have avoided through safe and proper athletic training and supervision.”

When the original story broke in 2011, rhabdomyolysis became the subject of much reporting and analysis in the mainstream sports media. As Iowa head football coach Kirk Ferentz acknowledged in a 2013 interview, the Squat workout had been performed several times in previous years with no adverse consequences, and it was only in the aftermath of the 2011 incident that they heard of the disorder.

“That whole incident is unfortunate in a lot of regards,” Ferentz said. “If you look back, no one really knew what rhabdo was at that point.”

“It can kill you.”

Indeed, college football is not what has been most frequently associated with rhabdomyolysis in the media. That dubious honor most certainly goes to the popular strength and conditioning program known as CrossFit. One of the first articles in the national press that identified rhabdomyolysis as a potential hazard of CrossFit appeared in The New York Times in 2005. In that article, CrossFit founder Greg Glassman spoke about the dangers of rhabdo. “It can kill you,” he said. “I’ve always been completely honest about that.”

In a more recent story, “CrossFit’s Dirty Little Secret,” Eric Robertson, an assistant professor of physical therapy, rekindled the controversy—in light of CrossFit’s spectacular growth over the last 5 years—trying to make the case that a future epidemic of CrossFit-created rhabdo cases will be the downfall of the program. He wrote, “My prediction: in a few years, the peer-reviewed scientific literature will be ripe with articles about CrossFit and rhabdomyolysis. Health providers will be there to scoop up the pieces, but who is there to protect those people unknowingly at risk?”

Robertson’s assertion prompted a fact-check by Mitra Hooshmand, Ph.D., a neuroscientist who publishes the blog, ScientiFit.com. Hooshmand, who says she is not associated with CrossFit, reviewed the medical literature and concluded that rhabdo is not exclusive to CrossFit: “The populations affected by exercise-induced Rhabdo and reported in peer-reviewed journal articles and case studies range anywhere from teenage athletes to professional football players, fire-fighters, Army and Air Force personnel, bodybuilders and swimmers. Therefore, it appears that exercise-induced Rhabdo can afflict individuals in almost any form of intense exercise.”

Hooshmand also ran the available numbers to see whether claims about the rate of rhabdo incidents in CrossFit, Robertson’s or otherwise, have any evidence to support them. “Let’s do the math,” she writes, calculating from the known cases of rhabdo over the first 10 years of CrossFit’s existence. “[It] equates to less than 1 case per year, accounting for 0.00000036% of the U.S. population averaged over those 10 years.” Hooshmand also says the Centers for Disease Control and Prevention does not appear to be keeping stats on rhabdo, “suggesting the condition is either extremely rare or poorly documented.”

Dr. Leon Chang, an MD specializing in anesthesiology, is a co-owner of CrossFit Elysium in San Diego. Chang has a unique point of view on the controversy, given his combination of CrossFit knowledge and time spent in the hospital helping to treat victims of the disorder. “As far as rhabdo, I am mildly concerned as an owner,” he says. “In general, rhabdo is very rare in the CrossFit population. If you look at youth sports, like high school football, distance running and such, you’ll see there are far more cases of rhabdo or generalized injury from over-exertion in those activities compared to CrossFit. Unfortunately, due to CrossFit’s reputation for intensity, coupled with a laissez-faire attitude on the part of some in the community and playful jokes like Pukey the Clown and Uncle Rhabdo, cases of rhabdo in CrossFit get blown out of proportion.”

Chang says exercise-induced rhabdo bears little resemblance to the condition caused by something like a car crash. “I have seen and taken care of many patients in the hospital with rhabdo,” Chang says. “When serious, it truly is a life-threatening condition—the cases I’ve seen in the hospital make the CrossFit examples pale by comparison.”

Chang disagrees with the fundamental point that critics like Robertson try to make—that unknowing newbies entering a CrossFit box are a high risk. “The new athlete is essentially not at risk for rhabdo. In a nutshell, they simply are incapable of pushing themselves hard enough to cause muscle breakdown and real injury. Lack of cardiovascular conditioning, strength and mental willpower will kick in and cause them to slow down way before they are at risk for rhabdo, which is a protective mechanism. Similarly, an athlete who has ‘trained up’ appropriately has developed their capacity in step-wise fashion: They can handle what they can do, because they practiced and developed the ability to get to where they are. So they’re a safe population as well.”

“This is a recipe for rhabdo.”

Who is at risk then? Which athletes participating in CrossFit are potentially in danger? The answer, according to Chang, is former athletes who are out of shape. He says, “An ex-military individual or former CrossFitter are perfect examples. These people have pushed hard before and they have the mental toughness to keep going when their bodies say stop. Unfortunately, they are physically de-conditioned and no longer equipped to handle such high intensity. This is a recipe for rhabdo, and for those people, we watch them very carefully, and make sure they don’t push too hard on their first few workouts.”

This may have been the case in the Iowa Hawkeyes football episode. As the Cedar Rapids Gazette reported, the Squat session (which apparently was followed by Sled Drags), was one of the first workouts in the off-season training schedule, right after winter break. As a father of one of the hospitalized football players acknowledged in a press conference, concerning how much training his son had performed over the break, “I could tell you he didn’t do anything except eat a lot and lie around, and then this was kind of the first day back.”

John Welbourne is a nine-year veteran of the NFL and creator of CrossFit Football. He commented on the Iowa football affair in a blog post, suggesting that a number of factors may have contributed to the incident in which so many athletes suffered rhabdo at once—but most likely it was just too much, too soon for players who showed up out of shape. “Had [the coaches] prepared their athletes for a workout consisting of 100 Back Squats at 240 pounds and a 100-Yard Sled Drag done as quick as possible? I guess not, as rhabdo usually follows a dramatic increase in volume. The problem is, these athletes might not have been ready to handle this workload, and the coaches should have realized it. Many times as a coach you design something that looks great on paper only to change it dramatically once the workout starts.”

Welbourne also openly wondered whether the workout was on a Wednesday, Thursday or Friday morning—following a “dollar drink night,” which is not uncommon in a university town at the beginning of the semester. A night of drinking could have set the stage for rhabdo via dehydration, he wrote. (Jan. 20, 2011 was a Thursday.)

Keys to prevention

Whether it’s a first week of CrossFit training or an early season football practice, how can athletes and coaches reduce the risk of rhabdomyolysis?

Gradual exposure to high-intensity training. In a 2005 CrossFit Journal article, Glassman explored the nature of the five CrossFit-induced rhabdo cases that had been reported to date. To reduce risk, Glassman advocated “On-Ramp” beginner programs for anyone new to CrossFit, even those coming from more standard physical fitness programs where workout intensity was relatively low. “Elite CrossFitters are performing 18,000 foot-pounds of work per minute for three or four minutes (that’s nearly half of one horsepower!),” Glassman wrote. “This is what our top tier athletes are doing in workouts like ‘Fran.’ Without deliberately training for maximum expression of effective work against a wide-ranging time domain, it is virtually impossible to deliver power output as high as our athletes do.”

“Hydrate or Die.” In an article written for the CrossFit Journal, Eugene Allen enumerates some of the other known causes for inducing rhabdo, including heavy alcohol consumption. Allen suggests dehydration is the most prominent threat for athletes. For the athlete, hydrating before a workout, especially in hot weather, is a preventative measure. “The Camelbak tag line ‘Hydrate or die’ is more meaningful in light of some understanding of rhabdo,” he says.

Beware of eccentric movements. Dr. Chang says that with respect to rhabdo, an emphasis on eccentric movements, with high repetitions, is particularly dangerous. “Any movement with a pronounced eccentric component can potentially cause rhabdo, out of proportion when compared to other movements,” he says. “An eccentric movement is when the muscle is ‘loaded’ and under tension but is not contracting. So for example, when one deadlifts, the pull from the floor is concentric. Once at the top, lowering the weight under control to the ground is an eccentric load. Hamstrings lengthen, back muscles tighten up, but no contraction occurs.” Some exercises have a pronounced eccentric phase, and a good CrossFit coach will be aware of the danger and temper the volume levels for beginners.

“The classic offenders are Kettlebell Swings and Jumping Pull-Ups,” Chang adds. “In the Kettlebell Swing, controlling the bell on the way down represents a very long, loaded eccentric phase. For the Jumping Pull-Up, what often happens is the individual does the Pull-Up, but then slowly lowers themselves back down, which represents eccentric work for the forearms and lats.”

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In Inside the Box, veteran journalist and marathoner T.J. Murphy goes all in to expose the gritty, high-intensity sport of CrossFit®. From staggering newcomer to evangelist, Murphy finds out how it feels, why it’s so popular, and whether CrossFit can fix his broken body.

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