Sports Medicine: Just the Facts

198 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE

SEVERE RHABDOMYOLYSIS

•Severe rhabdomyolysis has marked muscle soreness
and pain with any muscle activity.

• Examination reveals tight muscles that are painful to
  palpation and limited passive stretch.


• Laboratory studies reveal transient acidosis, elevated
  uric acid, and minor electrolyte alterations that resolve
  with hydration; Cr is elevated typically >2 mg/dL and
  CPK progressively rises well above 30,000; LDH,
  AST, and ALT progressively rise peaking above three
  times normal at 2–3 days after insult.
  •Treatment is IV fluids (2L bolus) and arrange for con-
  tinued IV fluid therapy and laboratory monitoring
  After several hours IV fluid therapy:
  
  
  1. Symptoms and laboratory studies improved: oral
     hydration and evaluate response over next 12–24 h.
     2.Symptoms improved, laboratory studies little
     changed: assess adequacy of hydration and need
     for additional measures (e.g., compartment pres-
     sure testing); reassess every 4–6 h.
     3.Symptoms not improving, laboratory studies rising:
     transfer to intensive care unit(ICU) addressing
     comorbid issues of electrolyte disturbances, myo-
     globinuria, and compartment syndrome.
  
  
  
  


• In subacute setting (days after injury) if stable to
  improving symptoms and labs may manage as moder-
  ate rhabdomyolysis with particular focus on renal
  injury and exclusion of myoglobinuria.

FULMINANT RHABDOMYOLYSIS

•Patient often presents with collapse and obtundation.
Extreme muscle tightness and pain with weakness and
extreme difficulty moving involved muscle(s).

• Often associated with findings typical of heat stroke,
  shock, and dehydration (Gardner and Kark, 2000).


• May manifest as progressively escalating symptoms
  refractory to less aggressive interventions.


• On examination, involved muscles are tense, very
  tender, and extremely painful to any passive stretch.


• Laboratory studies at time of collapse may manifest
  only acidosis, hypokalemia, hypocalcemia, elevated
  uric acid ±decreased phosphate. Studies in subsequent
  hours manifest shift to hyperkalemia, hypercalcemia,
  and hyperphosphatemia with rapidly rising CPK,
  LDH, AST, and ALT (Vivweswaran and Guntupalli,
  1999).
  •Treatment necessitates cardiac monitoring for dys-
  rhythmias with advance life support materials, aggres-
  sive IV fluids hydration, and transfer to ICU for
  management of the metabolic derangements (Kark
  and Ward, 1994; Baggaley).
  
  
  • Consult orthopedic surgeon for fasciotomy evaluation.
    Mild to moderate increased compartment pressures
    perpetuates muscle necrosis and condition improves
    with early fasciotomy of involved muscle areas (Wise
    and Fortin, 1997; Kuklo et al, 2000).
  
  
  
  

RHABDOMYOLYSIS OF AN ISOLATED MUSCLE

OR MUSCLE GROUP

•Typically occurs with excessive overload in weight

lifting.

• CPK levels may become elevated into the tens of
  thousands.
  •Typically this is self limited, rarely manifesting sys-
  temic effects beyond the involved muscle.

RHABDOMYOLYSIS FOLLOW UP

• Healthy individuals with uncomplicated mild to
  moderate rhabdomyolysis may return to activity
  immediately after all enzymes have returned to
  normal. It may be prudent though, to resume exer-
  cise in a graduated manner. Recurrent bouts of rhab-
  domyolysis and any severe or fulminant episodes
  warrant investigation for an underlying disease
  process (Kark and Ward, 1994; Gardner and Kark,
  2000; 2002).

CONCLUSION

•With the exception of athletic pseudoanemia, it is

uncommon to encounter significant persistent hema-

tologic alterations from running. While high inten-

sity and prolonged endurance training may result in

alterations of several hematologic parameters, and

occasionally lysis of RBCs, rarely are these of

pathologic significance; however, signs and symp-

toms of hematologic disease may manifest at an ear-

lier state in the athlete because of physiologic

demands that require maximal hematologic system

performance.

• The condition of exertional rhabdomyolysis may
  occasionally manifest in athletes advancing training
  too rapidly, but may also appear in a conditioned ath-
  lete in association with underlying disease states or as
  a consequence of severe over-exertion or exertional
  heat illness. Identification and early treatment of those
  with myoglobin release or severe myocyte injury is
  crucial to preclude serious complications.