PEARLS AND PITFALLS
Ramifications of Rhabdomyolysis E. Randy Eichner, MD, FACSM Introduction Rhabdomyolysis trips off the tongue and stays in the news. Recent individual cases and team outbreaks of exertional rhabdomyolysis (ER) have brought litigation and lessons. In this column, I cover some ramifications of rhabdomyolysis.
Litigation and Lessons from Hawkeye Team Rhabdo Willie Lowe is suing the Hawkeyes (8). Lowe, who played cornerback for the University of Iowa (UI), was 1 of 13 football players hospitalized for ER after an intense workout at the start of winter training 3 years ago (10). Lowe alleges that UI coaches and athletic trainers were negligent during and after the winter workout. He spent 10 d in the hospital and says he suffered for months with major weight loss, back and leg pain, headaches, high blood pressure, and mental anguish. Lowe, who was a senior at UI, never rejoined the team. This litigation is the latest twist in the Hawkeye tale, a parable for our times. In January 2011, just 2 d after a 3-wk break, the football team endured what some called the hardest 1-d training regimen in their playbook. The sternest drill was 100 timed back squats at 50% top weight for one repetition. The strength coach told the team that losing close games the prior year should concern everyone and that the workouts would determine ‘‘who wants to be here.’’ An inhouse investigation pinpointed the back squat drill as the most likely cause of the ER but cleared the coaches and trainers of wrongdoing. In other words, the UI committee found no fault by UI. They also found no evidence that the workout was for punishment, even though the last similar UI workout, in December 2007, was 1 wk after another year that, like 2010, had disappointed coaches (6). The coaches joined the defensive huddle. Even after reading the UI investigative report, head coach Kirk Ferentz could not find a ‘‘smoking gun’’ to explain things. He agreed to drop the back squat drill but not to ease up on conditioning. He said, ‘‘We have learned a little bit more about rhabdo I I don’t think anybody in this building knew much about it prior to this occurrence.’’ And he announced that head strength coach Chris Doyle was the most valuable coach of the year,
Address for correspondence: E. Randy Eichner, MD, FACSM, 321 Baudin Way, Sonoma, CA; E-mail: [email protected]. 1537-890X/1303/135Y136 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
raising the question of just what attributes a head football coach values (6). Another ramification of rhabdomyolysis is the UI study of creatine kinase (CK) levels during a preseason football camp (11). After studying the Hawkeye team ER in January 2011 (10), the question was, ‘‘What CK levels are expected from football training?’’ So blood was sampled from 32 Hawkeyes before practice on days 1, 3, and 7 of camp in August 2011. Mean CK on day 1 was 285 UILj1 (highest CK, 4,659 UILj1). By day 3, mean CK was 1,300 UILj1 (highest CK, 12,067 UILj1). By day 7, mean CK was 1,562 UILj1 (highest CK, 7,453 UILj1). These CK levels are intermediate between those of two prior studies of college football camps (4,7). The most telling comparison, however, is that between CK levels from football camp in August 2011 and those from the ER outbreak in January 2011 (10,11). CK levels in summer camp tended to be low, but those after the winter workout were high. For 10 of the 13 Hawkeyes hospitalized in January, CK levels were published (10). The lowest CK was 97,000 UILj1. The other nine were 9100,000 UILj1, four of them were 9200,000 UILj1, and the highest was 9330,000 UILj1. The mean peak CK level was about 120 times higher after the winter workout than during summer camp. This suggests the winter workout V including the back squat drill V was unphysiologic. It also suggests the winter workout was not for conditioning but for punishment or intimidation. A Pearl and a Pitfall on History and Laboratory Testing The recent tragic death of a 19-year-old Drexel University student and softball player Stephanie Ross from a fulminant type B meningococcal infection has sparked a call for wider use of the Bexsero type B vaccine (1). Several thousand students at two universities have received Bexsero vaccine in the past few months, after several cases of type B meningitis occurred on their campuses. On one campus, a rugby player worked out soon after his second dose of Bexsero and was hospitalized 2 d later with ER of the upper extremities, with CK 920,000 UILj1. Partly because the athlete described his workout as ‘‘light,’’ physicians wondered if Bexsero was a trigger for rhabdomyolysis. I doubt Bexsero triggers major rhabdomyolysis. The pearl: Any time, in the aftermath of ER, a coach or a ‘‘warrior athlete’’ says a workout was ‘‘light,’’ ask more questions. The most common cause of ER in an otherwise healthy athlete is novel overexertion. In this case, the 45-min workout was just that. The rugby player had not done ‘‘lat pulls’’ in a long time. Using ‘‘light’’ weights, he did continuous circuit training with Current Sports Medicine Reports
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
135
more repetitions than usual and no breaks between sets. Result: Rhabdomyolysis. The culprit was novel overexertion, not the Bexsero vaccination. I worry that we have less time to ask more questions. A recent time motion study of internal medicine interns in two large hospitals in Baltimore found that they spent 12% of their time on direct patient care and 40% of their time on computers. The mean time spent daily with each patient was 8 min (2). Is 8 min long enough for the art of medicine? Now a pitfall on laboratory testing: Not all ‘‘liver chemistries’’ are liver chemistries. I have seen athletes with staleness, fatigue, or ‘‘heavy legs’’ who were thought to have liver disease because of elevations in transaminases and lactic dehydrogenase. But when alkaline phosphatase and bilirubin are normal, think of rhabdomyolysis (5). A review of 215 cases of rhabdomyolysis (CK 91,000 UILj1) found that aspartate aminotransferase was elevated in 990%, and alanine aminotransferase was elevated in 75% of cases (13). These enzymes come not just from the liver but also from muscle. This is one reason why a CK should be part of the complete metabolic panel in a college health center. Think Horses, not Zebras A recent report suggests that ER and malignant hyperthermia (MH) may be related syndromes triggered by different mechanisms, and that rare gene variants affecting calcium regulation may lead to ER or MH in the same patient (3). Reported was a 30-year-old fit, muscular African American man (on a statin drug) who developed major ER of the calves after a 2.5-mile ‘‘walk.’’ He required fasciotomy, and during his second time in the operating room, for debridement, he had some signs that brought MH to mind. Further testing suggested MH; but in my opinion, the case for it is weak. Not mentioned in the report is that he is a warfighter with sickle cell trait (SCT). I know of several cases of major ER of the calf or calves in football players (not on statins) with SCT, and one such case in a Homeland Security guard with SCT who collapsed in a team competition. Two cases of ER and compartment syndrome of the lower leg in college football players with SCT were reported at the same sports
136
Volume 13 & Number 3 & May/June 2014
medicine meeting in 2010, and one of these cases was covered in the media (9). Yes, ER has been tied to MH in a few cases (12). But MH is rare and SCT is common in African Americans. When you hear hoofbeats, think horses, not zebras. The report of ER and possible MH in the same man is misleading not to cover his SCT (3). In my opinion, the rhabdomyolysis that led to his calf fasciotomies was caused by exertional sickling. References 1. Aleccia J. College student’s death sparks call for wider use of vaccine. Available from: http://www.nbcnews.com/health/health-news/college-studentsdeath-sparks-call-wider-use-vaccine-n53186. Accessed 3/18/14. 2. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J. Gen. Intern. Med. 2013; 28:1042Y7. 3. Capacchione JF, Sambugghin N, Bina S, et al. Exertional rhabdomyolysis and malignant hyperthermia in a patient with ryanodine receptor type 1 gene, L-type calcium channel alpha-1 subunit gene, and calsequestrin-1 gene polymorphisms. Anesthesiology 2010; 112:239Y44. 4. Ehlers GG, Ball TE, Liston L. Creatine kinase levels are elevated during 2-a-day practices in collegiate football players. J. Athl. Training 2002; 37:151Y6. 5. Eichner ER. Exertional rhabdomyolysis. Curr. Sports Med. Rep. 2008; 7:3Y4. 6. Eichner ER. Rhabdo redux: ‘‘Don’t know much about history.’’ Curr. Sports Med. Rep. 2011; 10:174Y5. 7. Hoffman JR, Kang J, Ratamess NA, Faigenbaum AD. Biochemical and hormonal responses during an intercollegiate football season. Med. Sci. Sports Exerc. 2005; 37:1237Y41. 8. O’Leary J. Ex-Hawk sues over rhabdomyolysis incident. Available from: http://www.press-citizen.com/article/20140312/NEWS01/303120034/ExHawk-sues-over-rhabdomyolysis-incident. Accessed 3/17/14. 9. Schrotenboer B. Jury awards ex-Aztec $300,000. Available from: http:// www.utsandiego.com/news/2012/Mar/26/jury-awards-ex-aztec-300000/. Accessed 3/18/14. 10. Smoot MK, Amendola A, Cramer E, et al. A cluster of exertional rhabdomyolysis affecting a Division I football team. Clin. J. Sport Med. 2013; 23:365Y72. 11. Smoot MK, Cavanaugh JE, Amendola A, et al. Creatine kinase levels during preseason camp in National Collegiate Athletic Association Division-1 football athletes. Clin. J. Sport Med. 2013 (Epub ahead of print) PMID 24346738. 12. Szczepanik ME, Heled Y, Capacchione J, et al. Exertional rhabdomyolysis: identification and evaluation of the athlete at risk for recurrence. Curr. Sports Med. Rep. 2014; 13:113Y20. 13. Weibrecht K, Dayno M, Darling C, Bird SB. Liver aminotransferases are elevated with rhabdomyolysis in the absence of significant liver injury. J. Med. Toxicol. 2012; 6:294Y300.
Pearls and Pitfalls
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Ramifications of Rhabdomyolysis E. Randy Eichner, MD, FACSM Introduction Rhabdomyolysis trips off the tongue and stays in the news. Recent individual cases and team outbreaks of exertional rhabdomyolysis (ER) have brought litigation and lessons. In this column, I cover some ramifications of rhabdomyolysis.
Litigation and Lessons from Hawkeye Team Rhabdo Willie Lowe is suing the Hawkeyes (8). Lowe, who played cornerback for the University of Iowa (UI), was 1 of 13 football players hospitalized for ER after an intense workout at the start of winter training 3 years ago (10). Lowe alleges that UI coaches and athletic trainers were negligent during and after the winter workout. He spent 10 d in the hospital and says he suffered for months with major weight loss, back and leg pain, headaches, high blood pressure, and mental anguish. Lowe, who was a senior at UI, never rejoined the team. This litigation is the latest twist in the Hawkeye tale, a parable for our times. In January 2011, just 2 d after a 3-wk break, the football team endured what some called the hardest 1-d training regimen in their playbook. The sternest drill was 100 timed back squats at 50% top weight for one repetition. The strength coach told the team that losing close games the prior year should concern everyone and that the workouts would determine ‘‘who wants to be here.’’ An inhouse investigation pinpointed the back squat drill as the most likely cause of the ER but cleared the coaches and trainers of wrongdoing. In other words, the UI committee found no fault by UI. They also found no evidence that the workout was for punishment, even though the last similar UI workout, in December 2007, was 1 wk after another year that, like 2010, had disappointed coaches (6). The coaches joined the defensive huddle. Even after reading the UI investigative report, head coach Kirk Ferentz could not find a ‘‘smoking gun’’ to explain things. He agreed to drop the back squat drill but not to ease up on conditioning. He said, ‘‘We have learned a little bit more about rhabdo I I don’t think anybody in this building knew much about it prior to this occurrence.’’ And he announced that head strength coach Chris Doyle was the most valuable coach of the year,
Address for correspondence: E. Randy Eichner, MD, FACSM, 321 Baudin Way, Sonoma, CA; E-mail: [email protected]. 1537-890X/1303/135Y136 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
raising the question of just what attributes a head football coach values (6). Another ramification of rhabdomyolysis is the UI study of creatine kinase (CK) levels during a preseason football camp (11). After studying the Hawkeye team ER in January 2011 (10), the question was, ‘‘What CK levels are expected from football training?’’ So blood was sampled from 32 Hawkeyes before practice on days 1, 3, and 7 of camp in August 2011. Mean CK on day 1 was 285 UILj1 (highest CK, 4,659 UILj1). By day 3, mean CK was 1,300 UILj1 (highest CK, 12,067 UILj1). By day 7, mean CK was 1,562 UILj1 (highest CK, 7,453 UILj1). These CK levels are intermediate between those of two prior studies of college football camps (4,7). The most telling comparison, however, is that between CK levels from football camp in August 2011 and those from the ER outbreak in January 2011 (10,11). CK levels in summer camp tended to be low, but those after the winter workout were high. For 10 of the 13 Hawkeyes hospitalized in January, CK levels were published (10). The lowest CK was 97,000 UILj1. The other nine were 9100,000 UILj1, four of them were 9200,000 UILj1, and the highest was 9330,000 UILj1. The mean peak CK level was about 120 times higher after the winter workout than during summer camp. This suggests the winter workout V including the back squat drill V was unphysiologic. It also suggests the winter workout was not for conditioning but for punishment or intimidation. A Pearl and a Pitfall on History and Laboratory Testing The recent tragic death of a 19-year-old Drexel University student and softball player Stephanie Ross from a fulminant type B meningococcal infection has sparked a call for wider use of the Bexsero type B vaccine (1). Several thousand students at two universities have received Bexsero vaccine in the past few months, after several cases of type B meningitis occurred on their campuses. On one campus, a rugby player worked out soon after his second dose of Bexsero and was hospitalized 2 d later with ER of the upper extremities, with CK 920,000 UILj1. Partly because the athlete described his workout as ‘‘light,’’ physicians wondered if Bexsero was a trigger for rhabdomyolysis. I doubt Bexsero triggers major rhabdomyolysis. The pearl: Any time, in the aftermath of ER, a coach or a ‘‘warrior athlete’’ says a workout was ‘‘light,’’ ask more questions. The most common cause of ER in an otherwise healthy athlete is novel overexertion. In this case, the 45-min workout was just that. The rugby player had not done ‘‘lat pulls’’ in a long time. Using ‘‘light’’ weights, he did continuous circuit training with Current Sports Medicine Reports
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
135
more repetitions than usual and no breaks between sets. Result: Rhabdomyolysis. The culprit was novel overexertion, not the Bexsero vaccination. I worry that we have less time to ask more questions. A recent time motion study of internal medicine interns in two large hospitals in Baltimore found that they spent 12% of their time on direct patient care and 40% of their time on computers. The mean time spent daily with each patient was 8 min (2). Is 8 min long enough for the art of medicine? Now a pitfall on laboratory testing: Not all ‘‘liver chemistries’’ are liver chemistries. I have seen athletes with staleness, fatigue, or ‘‘heavy legs’’ who were thought to have liver disease because of elevations in transaminases and lactic dehydrogenase. But when alkaline phosphatase and bilirubin are normal, think of rhabdomyolysis (5). A review of 215 cases of rhabdomyolysis (CK 91,000 UILj1) found that aspartate aminotransferase was elevated in 990%, and alanine aminotransferase was elevated in 75% of cases (13). These enzymes come not just from the liver but also from muscle. This is one reason why a CK should be part of the complete metabolic panel in a college health center. Think Horses, not Zebras A recent report suggests that ER and malignant hyperthermia (MH) may be related syndromes triggered by different mechanisms, and that rare gene variants affecting calcium regulation may lead to ER or MH in the same patient (3). Reported was a 30-year-old fit, muscular African American man (on a statin drug) who developed major ER of the calves after a 2.5-mile ‘‘walk.’’ He required fasciotomy, and during his second time in the operating room, for debridement, he had some signs that brought MH to mind. Further testing suggested MH; but in my opinion, the case for it is weak. Not mentioned in the report is that he is a warfighter with sickle cell trait (SCT). I know of several cases of major ER of the calf or calves in football players (not on statins) with SCT, and one such case in a Homeland Security guard with SCT who collapsed in a team competition. Two cases of ER and compartment syndrome of the lower leg in college football players with SCT were reported at the same sports
136
Volume 13 & Number 3 & May/June 2014
medicine meeting in 2010, and one of these cases was covered in the media (9). Yes, ER has been tied to MH in a few cases (12). But MH is rare and SCT is common in African Americans. When you hear hoofbeats, think horses, not zebras. The report of ER and possible MH in the same man is misleading not to cover his SCT (3). In my opinion, the rhabdomyolysis that led to his calf fasciotomies was caused by exertional sickling. References 1. Aleccia J. College student’s death sparks call for wider use of vaccine. Available from: http://www.nbcnews.com/health/health-news/college-studentsdeath-sparks-call-wider-use-vaccine-n53186. Accessed 3/18/14. 2. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J. Gen. Intern. Med. 2013; 28:1042Y7. 3. Capacchione JF, Sambugghin N, Bina S, et al. Exertional rhabdomyolysis and malignant hyperthermia in a patient with ryanodine receptor type 1 gene, L-type calcium channel alpha-1 subunit gene, and calsequestrin-1 gene polymorphisms. Anesthesiology 2010; 112:239Y44. 4. Ehlers GG, Ball TE, Liston L. Creatine kinase levels are elevated during 2-a-day practices in collegiate football players. J. Athl. Training 2002; 37:151Y6. 5. Eichner ER. Exertional rhabdomyolysis. Curr. Sports Med. Rep. 2008; 7:3Y4. 6. Eichner ER. Rhabdo redux: ‘‘Don’t know much about history.’’ Curr. Sports Med. Rep. 2011; 10:174Y5. 7. Hoffman JR, Kang J, Ratamess NA, Faigenbaum AD. Biochemical and hormonal responses during an intercollegiate football season. Med. Sci. Sports Exerc. 2005; 37:1237Y41. 8. O’Leary J. Ex-Hawk sues over rhabdomyolysis incident. Available from: http://www.press-citizen.com/article/20140312/NEWS01/303120034/ExHawk-sues-over-rhabdomyolysis-incident. Accessed 3/17/14. 9. Schrotenboer B. Jury awards ex-Aztec $300,000. Available from: http:// www.utsandiego.com/news/2012/Mar/26/jury-awards-ex-aztec-300000/. Accessed 3/18/14. 10. Smoot MK, Amendola A, Cramer E, et al. A cluster of exertional rhabdomyolysis affecting a Division I football team. Clin. J. Sport Med. 2013; 23:365Y72. 11. Smoot MK, Cavanaugh JE, Amendola A, et al. Creatine kinase levels during preseason camp in National Collegiate Athletic Association Division-1 football athletes. Clin. J. Sport Med. 2013 (Epub ahead of print) PMID 24346738. 12. Szczepanik ME, Heled Y, Capacchione J, et al. Exertional rhabdomyolysis: identification and evaluation of the athlete at risk for recurrence. Curr. Sports Med. Rep. 2014; 13:113Y20. 13. Weibrecht K, Dayno M, Darling C, Bird SB. Liver aminotransferases are elevated with rhabdomyolysis in the absence of significant liver injury. J. Med. Toxicol. 2012; 6:294Y300.
Pearls and Pitfalls
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
