Have you ever finished a killer workout and known it was going to leave you sore in another day or two? This post-workout pain and stiffness is a condition commonly known as Delayed Onset Muscle Soreness (DOMS). Many exercise enthusiasts will look to this soreness as the ultimate arbiter of whether or not they have had a good and effective workout. Admittedly, DOMS is often correlated with positive exercise outcomes, most often increases in muscular strength and power. 
 
However, DOMS is also a mild form of a much more serious condition known as rhabdomyolysis. Rhabdo, for short, is the breakdown of muscle fibers to the extent that cellular contents are released into the blood stream. Of specific concern is the release of the protein myoglobin into the bloodstream, as it is harmful to the kidneys and can cause permanent damage or even death in extreme cases. 
 
There can be many causes of rhabdomyolysis.1 Risk factors include:
  • Alcoholism 
  • Crush injuries
  • Drug use
  • Genetic muscle disease
  • Heat stroke
  • Ischemia or necrosis of the muscle (lack of oxygen to or death of the tissue)
  • Low phosphate levels
  • Seizures
  • Severe exercise exertion (marathon running or strength training)
  • Shaking chills
  • Trauma
 
For fitness enthusiasts, it is the severe exercise exertion that is the most common concern. If you are doing drugs or drinking alcohol while working out, you may have another problem all together. CrossFit is often maligned as such an intense program that it regularly causes rhabdo. In reality, any exercise routine that is misapplied can cause this condition.
 

What Causes Rhabdomyolysis in Workouts?

Rhabdo is often caused by high repetition, lighter load workouts. This is one of the reasons CrossFit workouts often get targeted as the cause. However, rhabdo has also been found in physical therapy settings when patients do high volume exercises like calf raises. On the other hand, lifting heavier loads for fewer repetitions, as in a traditional strength training program, does not usually result in rhabdo. Using such heavy loads often forces a lifter to stop before severe muscle breakdown can occur. For example: 5 sets of 5 squats at a heavy load is not a workout that carries a high risk of causing rhabdo. Whereas, performing 1 set of 100 squats as quickly as possible with a light load would carry a more substantial risk. In the end, all workouts run the risk of causing this condition, but some are more prone to it than others.
 
Just as there is no specific workout that necessarily causes rhabdo, there are no specific exercises that always cause rhabdo. Some movements do carry a slightly higher risk than others when performed by new athletes or when performed to excess. These are usually movements with a demanding and extended eccentric, or negative, component.
 
Most exercises have two parts: an eccentric phase and a concentric phase. 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 and glutes are lengthening while 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 and glutes are now contracting under the same load.
 
Stretching muscles under load for a high volume of repetitions can cause the muscle breakdown that triggers rhabdo. Jumping pull-ups, glute-ham developer (GHD) sit-ups, and weighted walking lunges are a few examples of exercises with a significant and extended eccentric component. The fact remains that these are all excellent exercises, and they will contribute to building a strong and healthy body. Just be cautious and do not jump into doing hundreds of them right away.
 
GHD sit ups
Exercises with a significant eccentric component carry a higher risk of rhabdo. [Photo credit: J Perez Imagery]
 

Who Typically Develops Rhabdomyolysis?

Not many people at all. Rhabdo is a very rare condition. But while it may be highly unlikely, if it does happen, the consequences can be severe.
 
It is often the experienced athlete that is most susceptible to rhabdo. This happens for one of two potential reasons. If an experienced athlete has been away from exercise for a while, they will often come back assuming they can pick up where they left off. This all too often is not the case. The sudden and rapid exposure to high intensity workouts is a perfect recipe for rhabdo.
 
The second issue experienced exercisers encounter is that they often have the capacity, both mentally and physically, to take on too much volume, intensity or both. The old adage that too much of a good thing becomes a bad thing certainly applies here. New exercisers tend to self-regulate, due to their lack of exposure to the signs and symptoms of exercise. When they develop a high heart rate, heavy breathing, or profuse sweating, novice athletes will often slow down or stop. More advanced athletes will recognize these signs and even embrace them as an indication of a good workout.
 

How to Prevent Rhabdomyolysis

Gradually build up volume and intensity in your workouts, especially after a long break from exercise. Your first workout after a break in training should get your heart rate up and allow you to do some work, but it should not be completely exhausting. You should leave the gym feeling better than when you arrived.
 
There is a time and a place for workouts that push your limits. Your first day back after vacation is not that time and place.
Increase intensity gradually over time. Even if you have been on a regular exercise schedule, increasing the intensity too suddenly can be dangerous. This does not mean that you should not work out at a relatively high intensity. However, you do not have go at 100% every workout. Try cycling the intensity so that some days you give 75-80%, some days you give 90%, and others you give 100%. Your body will let you know when and how far you can push, but you must pay attention to when it says to pull back a little.
 
Put weight on the bar. Do not fear lifting heavier weight, as strength training does not typically result in rhabdo. Rhabdo comes from performing too many reps at a light to medium load.
 
Always listen to your coach. Your coach is there to guide your training. When you attack your training with reckless abandon, your coach is there to prevent you from going too far. However, your coach cannot ultimately force you to stop. You are the one in control, but you need to trust your coach and recognize that his or her advice is meant to ensure the best possible outcome. Your coach will often tell you what you do not want to hear. If you listen, you will benefit in the end.
 
Make sure you are forthcoming with your coach and provide them with any pertinent information. Your coach does not spend 24/7 in your company, so you need to fill them in constantly. Always be honest with your coach about how you feel that day. You should expect to receive thoughtful counsel in return.
 
Hydrate before, during, and after your workout. If you are adequately hydrated before your workout, then you probably do not have to drink too much water during shorter sessions. If you are not well hydrated prior to the start of your workout, then you should indeed drink water often during your workout. If your workout is on the longer side, make sure you get some water during strategic rest breaks. And after the workout is over, drink significant amounts of water. One technique to weigh yourself before and after longer workouts, and replenish fluids based upon any weight loss resulting from your training session.
 
girl doing pistol squats
Always listen to your body. If it says stop, don't ignore that. [Photo credit: J Perez Imagery]
 

Rhabdo Signs, Symptoms, and Treatment

Even if you everything right, sometimes circumstances can conspire against you. That is why it is so important that you know the warning signs, symptoms, and what to do if you think you have rhabdo.
 
The signs and symptoms of rhabdomyolysis2 include:
  • Abnormal dark urine color (think Coca-Cola)
  • Decreased urine production
  • General weakness
  • Excessive muscle stiffness or aching
  • Muscle tenderness
  • Fatigue
  • Joint pain
  • Seizures
  • Weight gain
 
If you think you have developed rhabdomyolysis, start drinking copious amounts of water and go to an emergency room immediately. In extreme cases, rhabdo can lead to kidney failure (renal failure), and can therefore be fatal. It is very simple: If you have any of the signs or symptoms, then you must seek medical attention immediately. If you think you may have rhabdo based on muscle soreness, stiffness or aching, do not continue to work out. It is possible to develop rhabdo and continue to work out under the notion of simply being sore before a proper diagnosis has been made. Try and avoid stretching the affected area, as this can make the release of myoglobin into the blood stream even worse.
 
Assuming you immediately seek proper medical attention, you are almost guaranteed a full recovery. You will likely be kept in the hospital for a few days. During that time, you can expect to receive large amounts of intravenous fluids that will help your kidneys flush out the toxins from your blood. After you get released, you will need to take a little break from working out. Once you have been cleared to resume exercising, you will have to gradually ease yourself back into things. You will need to start off very light and at a low intensity. If you are sufficiently patient, you will be able to get to full intensity before too long. 
 

Is It Safer to Just Stay Home?

This would be a reasonable conclusion to draw from reading this article, but you can rest assured it is not the better option. We all fully recognize the abundant health benefits to be gleaned from exercise. However, everything comes with a risk. Can you get hit by a car crossing the street? Sure you can. If you are cautious, use a crosswalk and look both ways before crossing, you will certainly minimize the risk, but it will always be there.
 
The same is true with exercise. Yes, you can get hurt when you exercise, and yes, you can develop rhabdomyolysis if you are not careful. If you take the proper precautions and follow the guidance provided by your coaches and instructors, then you should be confident that the risks involved with exercise will be minimal. After all, the only activity that is devoid of the risk of injury is being a couch potato, and that is certainly not a good option at all! There is no need to be scared of rhabdo. Instead, you and your coaches can collaborate on a daily basis to design a program that is safe while simultaneously helping you achieve your fitness goals.
 

Coaching Strategies to Lower Rhabdo Risk

Always emphasize mechanics, consistency, then intensity. This gradual build up with an emphasis on quality technique will ensure longer term success and avoid injuries. While often regarded as a sort of short cut to fitness, intensity should be the last variable added to the equation. An athlete must first demonstrate a solid foundation with the movements on a consistent basis.
 
Always be sure to recognize and appreciate the movements that have a higher rate of rhabdomyolysis incidence. This is especially important for exercises that have a significant eccentric component to them. Be mindful of the total volume that is programmed with these exercises and introduce them slowly to newer athletes.
 
Scale workouts for athletes appropriately. Every exercise has an option that is easier and one that is potentially harder. Make sure there are options for all athletes, so that they have an appropriate starting point and a challenging goal to shoot for as well.
 
Educate clients on the symptoms of rhabdomyolysis and when it is appropriate to seek medical attention. Arming them with this information will help them to better understand the rationale behind scaling workouts. It will also assure them that you have their best interest in mind.
 

Rhabdo Doesn’t Have to Happen

If you are new to exercise, returning from an extended layoff, or looking to increase the intensity of your current program, consult your physician before starting this new routine. Then do your homework and seek out a coach or gym with a good reputation and knowledgeable, experienced staff. Make sure you are provided with some sort of introductory workout routine that will identify strengths, but more importantly weaknesses. Make sure you address weaker areas and progress slowly toward more advanced levels. Lastly, listen and pay attention to what your body is telling you. If you feel tired, take a day and rest. That is often more important than the workout.
 
Working out until you're injured is never a good thing:
 
References:
1. Khan, F. Y. "Rhabdomyolysis: a review of the literature." Neth J Med 67, no. 9 (2009): 272-83.
2. Torres, Patrick A., John A. Helmstetter, Adam M. Kaye, and Alan David Kaye. "Rhabdomyolysis: pathogenesis, diagnosis, and treatment." The Ochsner Journal 15, no. 1 (2015): 58-69.
 
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