When the holiday season ends, the rhabdomyolyis season is in danger of starting…

The start of the holiday season marks the end of another season for most football programs. At the high school level, state championships have been determined by late November or early December. For collegians, unless a team has been successful enough for a bowl bid or to qualify for the playoffs, pads and helmets have been stored away, too.

Also, the first semester has come to an end. High school buildings close up for a couple of weeks. So do collegiate athletic facilities. Consequently, coaches and athletes get a 2-4 week break to spend time with family and re-charge the batteries.

For those unfamiliar with the term, translated from its Greek origin, it means the “destruction of muscle tissue.” Major traumatic injury and stroke are common causes. However, among athletes, the origin is too much strenuous exercise in one session. Way too much. 

During any workout, we break down muscle fiber. Done regularly, this stimulates the body — over the course of weeks — to build more muscle. If done way too much way too soon, the amount of myoglobin released into the bloodstream ends up being greater than the kidneys are able to handle. Worst-case scenarios include permanent muscle injury, kidney damage, and even death.

This sudden overuse triggers, according to Medline, “the breakdown of muscle fibers resulting in the release of muscle fiber contents into the bloodstream. Some of these are harmful to the kidney.” Symptoms include severe pain and swelling in the overworked area and dark brown urine, often referred to as “cola urine.”

Which is precisely what happened to 13 University of Iowa football players who required hospitalization in January of 2011. 

The team had just returned from winter break and had not lifted as a group for three weeks. During their very first conditioning session, they were required to perform 100 back squats at 50 percent of what was calculated to be their one-repetition maximum.

The strength coaches had used this high-intensity workout previously but never after a long layoff. In the post-incident investigation, the staff members claimed never to have heard of rhabdomyolysis. Odd, given a similar incident the previous August — involving 43 football players at one high school in Oregon — had generated national headlines.   

Eventually cleared of wrongdoing, the Hawkeye strength coaches stopped using the workout altogether.

Since then, despite the notoriety of the episode, similar incidents have continued. In January of 2017, multiple University of Oregon football players were similarly hospitalized.

Twelve months later, it was same story just a different location – the University of Nebraska. Both cases involved new football and strength staffs.

In January of 2023, a suburban Dallas high school head football/athletic director was placed on administrative leave – he eventually resigned — in the wake of multiple players being hospitalized with rhabdomyolysis. Somehow, a football team workout session, on Jan. 6, evolved into a punishment session that required participants to perform 300-400 push-ups in under an hour.

That same month, NCAA Division III Concordia University Chicago postponed four men’s basketball games after six players were hospitalized with rhabdomyolysis. The Cougars’ head coach was re-instated after an investigation determined a punishment workout/practice on Dec. 31, 2022 – which caused the players to become ill – was not intended to harm them.

Four members of the athletic training staff, on the other hand, resigned in the wake of the decision to re-instate the coach. Shortly thereafter, Concordia reversed course and fired the coach but the athletic trainers did not return.

The most recent notable occurrence was at Tufts University in September, when the defending NCAA Division III national lacrosse champions held an organized but voluntary workout, just days after the fall semester had started at the school. The head coach was not present according to the Boston Globe. Who was there from the Tufts staff is unclear. However, multiple outlets reported the workout was led by a recent Tufts graduate who had completed Navy SEAL training. A dozen players ended up in a local emergency room, with nine requiring hospital admission.

As these last two events illustrate, the condition is not limited to football.

Nor to male athletes. In March 2013 and in September 2014, at Ohio State, six women’s lacrosse players and six women’s track athletes were hospitalized, respectively. In August 2016, eight women volleyball players at Texas Women’s University were hospitalized with rhabdomyolysis.

The common denominators in almost all of these entirely unnecessary events have been a team re-convening after a long break and/or a workout with a punishment component.

Just one month after the 2018 Nebraska incident, the NCAA’s then chief medical officer, Brian Hainline, MD, issued the following guidelines on how to avoid rhabdomyolysis:

  • 1. Transition periods are particularly vulnerable times for athletes and demand careful attention to progression in volume, intensity, mode and duration of activity. Examples of transition periods:
    • a. Athletes new to the program.
    • b. Athletes returning after an injury or illness.
    • c. Any delayed participation relative to the team schedule.
    • d. Resumption of training after an academic break (e.g., winter, spring, summer).

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  • 2. All strength and conditioning workouts should be exercise-based, scientifically sound and physiologically representative of the sport and its performance requirements.
    • a. Athletes new to the program.
    • b. Athletes returning after an injury or illness.
    • c. Any delayed participation relative to the team schedule.
    • d. Resumption of training after an academic break (e.g., winter, spring, summer).

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  • 3. Conditioning programs should begin with a work-to-rest ratio of 1-to-4.

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  • 4. The first four days of transition periods should be separate-day workouts, and all workouts:
    • a. Should be documented in writing.
    • b. Should be intentional.
    • c. Should increase progressively in the volume, intensity, mode and duration of physical activity

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  • 5. All strength and conditioning workouts:
    • a. Should be documented in writing.
    • b. Should reflect the progression, technique, and intentional increase in the volume, intensity, mode and duration of the physical activity.
    • c. Should be available for review by athletics department staff.

Two years later, the British Journal of Sports Medicine published these guidelines as part of an inter-association consensus statement – for which Hainline was the lead author — entitled “Preventing catastrophic injury and death in collegiate athletes.”

With the NCAA and the NATA among the endorsing associations, the statement specifically addressed punishment workouts. “Physical activity should never be used for punitive purposes,” read the statement. “Exercise as punishment invariably abandons sound physiological principles and elevates risk above any reasonable performance reward. As stated in the 2014–2015 NCAA Sports Medicine Handbook, this principle has been reinforced by the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. All athletics personnel, including both sport and strength and conditioning professionals, as well as primary athletics healthcare providers, should intervene when they suspect that physical activity is being used as punishment. Although ‘intent’ of punishment may be difficult to establish, punishment workouts use unsound physiological principles.”

Despite such a pronunciation, the NCAA has no enforcement component for when the recommendation is ignored.

Back in 2011, the President of the University of Iowa, did not rely on NCAA input or assistance. In the wake of his 13 football players falling ill, he asked several professors at Iowa’s medical school to determine what went wrong.

The results of that effort were published in the Clinical Journal of Sports Medicine two years later. Among the findings? The closer the weight lifted was to a player’s actual body weight, the more likely rhabdomyolysis was to occur. Also, those who took longer to complete the task, kept working to muscle failure, and/or chose to do extra repetitions were more likely to have fallen ill. Those who consumed a protein shake in the 30 minutes following the workout were less likely to have been afflicted, with the risk decreasing by 30 percent for every shake consumed.

While fluids are a key to prevention, they are also crucial to recovery. A satisfactory outcome is dependent on rapid rehydration which flushes the myoglobin from the kidneys. According to an article published by Medscape in February, “General recommendations for the treatment of rhabdomyolysis include fluid resuscitation and prevention of end-organ complications (e.g., acute renal failure). Other supportive measures include correction of electrolyte imbalances.”

With cardiac complications due to hyperkalemia and compartment syndrome – requiring emergency fasciotomy – being early risks, hospital management is best initially.

However, a vigilant athletic trainer will know the NCAA guidelines for preventing rhabdomyolysis, step in when a coach is being overzealous, and stop such an episode before it ever starts.

John Doherty is a licensed physical therapist and athletic trainer. This column reflects solely his opinion. Reach him at jdoherty@powershealth.org. Follow him on X (formerly Twitter) @JDohertyATCPT.