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Ten factors that can increase the risk of exertional rhabdomyolysis

By NCAA Sport Science Institute

Novel overexertion is the single most common cause of exertional rhabdomyolysis (ER) and is characterized as too much, too soon, and too fast. Like the Division I swim team case, team outbreaks of ER in NCAA athletes have similarities of irrationally intense workouts designed and conducted by coaches and/or strength and conditioning personnel (See Table 1). From these team outbreaks, the NCAA has learned valuable lessons, including 10 factors that can increase the risk of exertional rhabdomyolysis:

  • Athletes who try the hardest. Those who give it their all to meet the demands of the coach (externally driven) or are considered the hardest workers (internally driven) are at greater risk.
  • Workouts not part of a periodized, progressive performance development program (e.g., workouts not part of the annual plan).
  • Novel workouts or exercises immediately following a transitional period (winter/spring break).
  • Irrationally intense workouts intended to punish or intimidate a team for perceived underperformance, or to foster discipline and “toughness.”
  • Performing exercise to muscle failure during the eccentric phase, such as repetitive squats, and then pushing the athlete beyond his or her capacity.
  • Focusing an intense drill or exercise on one muscle group with progressive overload within the same workout and fast repetitions to failure.
  • Increasing the number of exercise sets and reducing the time needed to finish. (e.g. 100 squats).
  • Increasing the amount of weight lifted solely as a percentage of body weight without respect to the athlete’s conditioning status or level of fatigue.
  • Trying to “condition” athletes into shape in a day or over several days, especially with novel exercises or loads.
  • Conducting an unduly intense ad hoc workout after a game loss and/or perceived poor practice effort.


Risk Factors for Exertional Rhabdomyolysis

Exertional rhabdomyolysis in an NCAA team athlete is commonly linked to three conditions:

  • Novel overexertion.
  • Exertional heatstroke.
  • Exertional collapse with complications in athletes with sickle cell trait.

Novel overexertion is by far the most common cause of ER; with early diagnosis and proper therapy, this condition is benign. During exercise, athletes and coaches can monitor distress by watching an athlete’s posture. Figure 1 depicts green, yellow and red situations which correspond to a series of postures showing an athlete moving into a distressful condition.  


Serial Postures of Exertional Collapse

Recovery during serial sets is important for proper fitness development. Athletes who are showing signs of physical distress should be allowed to set their own pace while conditioning as depicted by the position in yellow. Taking a knee during a workout can be the universal sign for the need for additional recovery. Athletes that are allowed an active rest period while experiencing distressful symptoms may soon feel better and may continue. If symptoms do not resolve, reoccur or progress, the athlete should discontinue exercise and be assessed by a healthcare provider.

Athletes unable to stand on their own from a kneeling position or who have trouble walking normally under their own control during recovery may be in considerable physical distress and additional medical intervention should be considered. Athletes depicted in red should not be pushed to continue. Provided with enough recovery, they may be able to complete the workout at their own pace.

It is vital that all coaches, strength and conditioning personnel and athletic trainers avoid exposing athletes to risk factors for ER, while also recognizing any early signs or symptoms of ER and then activating their emergency action plan.


Division 1 Swimming Case

Tips for Prevention and Early Recognition of ER from Novel Overexertion

Moderation. Avoid too much, too soon, too fast. Educate everyone in the athletics department conducting exercise sessions on all aspects of exertional rhabdomyolysis from novel overexertion and the additive effect of all physical exertion on the athlete (See the 2013-14 NCAA Sports Medicine Handbook).

Sport performance team. The design of a workout should reflect a collaborative effort between the strength and conditioning coach, sport coach and athletics healthcare staff. However, athlete safety assumes the individual conducting the exercise session takes reasonable actions to allow recovery and prevent exertional collapse.

Set the right tone. Workouts are to enhance performance, not to punish or intimidate. Never use exercise as a form of punishment, and never push an athlete to exercise more if he or she is showing signs of physical distress. Athletes should feel free to report any symptom at any time and obtain immediate help. Athletic trainers should be authorized to step in to provide care for an athlete in distress at any time, without retribution.

Monitor hydration. Post a Assess Your Hydration Status in the locker room, athletic training room and near urinals and restroom stalls. Athletes should report dark urine immediately.

Team effort. If one athlete on a team develops early signs or symptoms of possible ER, evaluate all members of the team who participated in the exercise session for ER.

Emergency action plan. Design, file and practice an emergency action plan (EAP) for exertional heatstroke (EHS) and for exertional sickling in sickle cell trait (SCT). Coaches should be ready to intervene when athletes show signs of distress. Minutes count in these life-threatening emergencies (See the 2013-14 NCAA Sports Medicine Handbook). If you suspect that an athlete is developing ER from novel overexertion (absent EHS or SCT), the EAP should be activated, and the team physician should be promptly notified.

Last Updated: Sep 12, 2013