A Tale of Rhabdomyolysis

One day, a very fit, young, physical therapist colleague of mine went to CrossFit. She had been many times before. On this warm Texas evening, she performed a partner workout, where each would trade off performing sets of 10 for each exercise. The workout consisted of pushups. Lots of them. Copious amounts of overhead press were also included.

She performed hundreds of repetitions of each. She was a champ!

“I didn’t want to not match my partner. Normally I may have rested a little, but the partner workout kept me going.”

Most people who experience exertional rhabdomyolysis are very fit. This is not a case of out-of-shape newbies doing too much. (Photo by Victoria Garcia via Flickr)

Both of these activities heavily involve the triceps muscles and so she wasn’t surprised to have her beautiful, sculpted arms feel like poorly set bowls of JELL-O® on the way home from CrossFit. Perhaps it was the heat. Maybe it was the sheer number of exercises she did. Her muscles were in crisis. She iced and hydrated when she got home, like a good little exerciser, but the damage was already done.

As physical therapists, we’re finely tuned detection machines looking for normal versus abnormal response to exercise and activity. “Is this supposed to hurt?” is a question we respond to hundreds of times in a week. Sometimes the answer to this question is yes and we encourage the individual to press on, and other times it’s a signal to initiate some rest and recovery. This signal detection is one of the things that’s deeply embedded into physical therapists. We can’t help it. And so when my friend awoke the next morning, her abnormal response alarms were blaring. She couldn’t bend her elbows! She couldn’t even reach her mouth to brush her teeth.

Still entrenched in the CrossFit culture of deplete, endure, repeat, she quieted the alarms and stoically pressed on to go to work. It didn’t take long to realize she not only couldn’t bend her arms, they also had no strength. She wasn’t able to treat her patients. By that evening, her slender arms had continued to swell into plump hotdogs of ache and regret, and she was starting to come to the realization that the morning’s danger alarms were legitimate.

Unbelievably, it took another 24 hours for her professional sense to break through the grip of the CrossFit culture, and seek medical attention. She was diagnosed with acute rhabdomyolysis, and ended up in the hospital for over a week. While in the emergency department they tested her creatinine kinase (CPK) levels. Normal is about 100. Her CPK levels were more than 45,000, a number that indicated damage to the kidneys.

While in the hospital, she called to cancel her CrossFit membership. As is standard when something is cancelled, the CrossFit coach asked the reason for her decision. She replied, “I’m in the hospital.” The instructor quickly asked, “Is it rhabdo?”

And here we have arrived at CrossFit’s dirty little secret. The coach was unusually familiar with what is normally a very rarely seen disorder. It’s so rare that one study reported the overall annual incidence of rhabdomyolysis to be 0.06%. That represents single digits of cases out of hundreds of thousands of patients. How, I wondered, is it possible that the layperson exercise instructor is on a first-name basis with a serious, yet rare medical condition? Is this a thing with CrossFit? It turns out it is.