Rhabdo and CrossFit

Why Should I Care About Rhabdo?

Because it can kill you. Rhabdomyolysis (rhabdo) is a rare but serious health condition sometimes caused by working out at very high intensity. CrossFit workouts, just like all high intensity workouts, have the potential to cause rhabdo under the right circumstances. Rhabdo is very, very rare. You’re more likely to spot a Bigfoot playing cards with Elvis than to ever cross paths with rhabdo. But even though it’s very rare, it’s also very serious. So reading this article is an important step towards keeping you safe while still experiencing all the great things CrossFit has to offer.

If you feel terrible after a workout, then the next day extreme swelling and soreness starts, and then you start peeing brown urine—you have rhabdo. Go to the ER immediately. This is no joke. It can be fatal if not treated. Rhabdo happens when your muscles break down to the point that muscle tissue enters your bloodstream. Your kidneys can’t handle this. They freak out and eventually shut down. This is how rhabdo can be fatal—kidney failure. The most important thing you can learn fom this entire article is this: If you experience dark urine after a grueling workout, then go to the ER immediately.

What are the Symptoms of Rhabdo?

• extreme muscle pain and soreness
•  swelling
• difficulty moving the affected muscles
• weakness in the affected muscles
• dark urine (brown, cola-colored)

Dude, I get extreme soreness and muscle pain after every workout…

I understand, believe me. Some muscle soreness is simply a part of exercise. But if you have rhabdo, the soreness will reach a whole new level. You’ll be almost unable to move the affected area, and you’ll feel like you got hit by a truck. But yes, we’re all a little sore after most workouts. That’s not rhabdo. Be on the lookout for dark urine. That’s the tell-tale sign you actually have rhabdo, and not the usual muscle soreness.

What type of workouts cause rhabdo?

Using light loads for many, many repetitions in a long workout is the usual culprit. Performing many reps of one movement in a row without changing movements or resting can also be a factor. However, heavy lifting generally does not cause rhabdo. Lifting heavy loads forces you to stop before severe muscle breakdown occurs. For example: performing 5 sets of 5 squats at a heavy load is not a workout that carries a rhabdo risk. However, performing 1 set of 100 squats as quickly as possible with a light load would carry a rhabdo risk.

Who generally gets rhabdo?

Not many people at all. Rhabdo is very rare. It’s like the opposite of winning the lottery. It’s highly unlikely, but if it does happen, the consequences are severe. Classic literature often tells us that men have higher risk of rhabdo than women. While this is historically true, I think this may be rooted in past social norms, and not biology. As CrossFit continues to build strong, determined women, they too need to be cognizant of rhabdo. Next, rhabdo usually strikes someone who has been away from intense exercise for a while and then jumps back in with too much volume and intensity. Someone who has been very fit in the past and has taken six months off must ramp up volume slowly as he returns to intense exercise. This type of athlete has the mind and the determination to push himself beyond his body’s capabilities—where rhabdo lives.

What movements cause rhabdo?

Well, there’s no magic movement that always causes rhabdo. But some movements are higher risk than others when performed by new athletes or when performed to excess repetition. These are usually movements with a demanding eccentric motion. Stay with me. This really isn’t too complicated. Most movements have two parts: an eccentric part and a concentric part. 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 are lengthening 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 are now contracting and driving the load upwards. Eccentric motion is very demanding on muscles. Stretching muscles under a load with lots of repetition can cause the muscle breakdown that triggers rhabdo. Here are a few examples of movements with a strong eccentric portion: jumping pullups, GHD situps, walking lunges. Now these are all excellent movements that have their uses in building a strong and healthy body. Just don’t jump into doing hundreds of them, unless you’re a strong and experienced athlete that has worked up to that level of ability.

Below is a case study that can help us learn about rhabdo.

In January 2011 the University of Iowa football team returned to training from a three week winter break. On Thursday about 85 players performed a workout that involved 100 back squats at 50% of 1-rep max followed by a series of sled pushes, all done as quickly as possible. This same workout had been performed by the team in previous years with no ill-effects–once during late spring training and once during the fall after a one-week break. Later Thursday evening many of the players felt extreme soreness. On Friday they performed another workout focusing on the upper body, with a similar rep scheme. They then had the weekend off before returning for another light workout on Monday that involved calisthenics and stretching. By Monday night 13 of the 85 players were admitted to the hospital suffering rhabdomyolysis. What can we learn from this? By the way, I’m not interested in finding blame or criticizing anyone in hindsight. I’m interested in learning how to prevent future rhabdo injuries, so shelve the judgment and focus on learning.

• Warning Sign: Athletic, strong, mentally-determined men who just took three weeks off from training
• Warning Sign: Light load performed for high repetitions (100 squats at 50% 1RM)
• Warning Sign: Team atmosphere where each player would push himself to his limits

Let’s also look at some of the details of how the situation unfolded:

• Delayed onset: Players experienced extreme soreness the same night of the workout, but many did not realize hospitalization was necessary until four days later.
• You can have rhabdo and still workout: Many players performed more workouts between the rhabdo-inducing workout on Thursday and hospitalization on Monday.
• Stretching and calisthenics were the last straw: Rhabdo often is not fully realized until immediate swelling subsides and myoglobin from the affected muscles begins to flood the blood stream. Stretching can make this release of myoglobin even worse. Many of the players were not hospitalized until after the light workout on Monday that involved stretching.

How do my coaches at CrossFit Impulse help me prevent rhabdo?

First, they provide you a program that limits the risk of rhabdo. Every workout we perform has been evaluated for rhabdo risk. Next, they know how to identify at-risk athletes and prevent rhabdo before the workout begins. Scaling workouts to your ability level is also important in preventing rhabdo. Your coaches will provide you several suggested scaled versions of the workout and help you select one that is right for you. Your coaches may modify the workout on the fly or simply tell you to stop working if your movement patterns display a high risk of rhabdo during the workout. Finally, time cutoffs are used judiciously during high intensity work to ensure you are not under stress for too long. All of these measures limit the risk of rhabdo, but they cannot eliminate it. Each athlete must still take her own preventative measures.

What should I do to prevent rhabdo?

• 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 shouldn’t be crushing. You should leave the gym feeling better than when you arrived. Note that there is a time and a place for workouts that push your limits. Your first day back after a cruise to the Bahamas is not that time and place.
•  Even if you have been exercising regularly, jumping to a much higher intensity too suddenly can be dangerous. This doesn’t mean that you should not work out at high intensity. This means that you should ramp up your intensity slowly, over several weeks or even months.
• Don’t fear putting weight on the bar. Lifting heavy weight forces you to stop and prevents rhabdo. Rhabdo comes from performing way too many reps at a light to medium load.
• Listen to your coach. Your coach is your co-pilot for training. When you press the gas pedal to the floor with reckless abandon, your coach is there to prevent a catastrophic crash. He can’t ultimately control the vehicle. You’re the pilot. But he will exert as much influence as you will allow, so trust him and allow him to guide you.
• Give your coach information. Your coach doesn’t live in your shirt pocket. He doesn’t know that you drank a thimble of water over the past two days and ran a half-marathon for fun after yesterday’s deadlifts. Be honest with your coach about how you feel that day. You’ll get thoughtful concern in return—not scolding—I promise.
• Hydrate before, during, and after your workout. Does that mean you should visit the water fountain during short metcons? Sometimes. If you hydrate adequately before your workout, then you probably don’t have to visit the water fountain during a 10-minute effort. If you didn’t hydrate well prior to beginning your workout, then you should indeed visit the water fountain as much as needed. But this isn’t always necessary if you drink water throughout the day. For a 20-minute workout or more, get some water during strategic rest breaks. And after the workout is over, drink copious amounts of water–always.
• Even if you and your coach does everything right, sometimes the perfect storm of circumstances can conspire against you. That’s why it’s important that you know the warning signs, symptoms, and what to do if you think you have rhabdo.

What should I do if I think I have rhabdo?

Start drinking water and go to an emergency room– immediately. Rhabdo can be fatal. This is very simple: If you have dark urine then go to the ER, because if you don’t then you could die. I’m not trying to be dramatic. I’m just being blunt.

I have rhabdo. What now?

The fact you’re able to ask that question is a good sign. It means you’ve identified your condition, and presumably have sought help from a hospital. The good news is that almost all rhabdo victims that seek treatment make a 100% recovery. You’ll be in the hospital a few days sucking down fluids while your kidneys flush the toxins. After that you’ll get released and take a little break from working out. After your doctor clears you, then you can start working out again at very low intensity. You can eventually ramp up your intensity (slowly) until you’re training at full intensity again.

Well now I’m scared of stepping into the gym and doing anything…

Is it possible for us to be part of a horrible car accident that puts us in the hospital? Absolutely. Every day we drive, we take that risk. But we all drive. Because we know that if we do our part to keep ourselves safe, and we work with others who have our safety in mind, then we can avoid most catastrophic crashes. So we drive and we usually avoid calamity. Such is the case with exercise and rhabdo. Rhabdo is extremely rare. Yes, if we get behind the wheel and act like a maniac and ignore the advice of professionals, we can create the rhabdo car crash. And unfortunately, even if we do our part and do everything right, if the odds strike us just right, then we could end up in a crash. But when executed properly, the odds of catastrophe are far outweighed by the positive effects we get from training. So there’s no need to be scared of rhabdo. You and your coaches are actively working every day to give you a well-coached program that keeps you safe while responsibly pushing your limits and achieving your goals. But part of that safety mechanism is educating you. So if the worst happens now you know how to identify rhabdo, and you know what to do. I hope this education has helped you feel more comfortable about exercising at high intensity. You are now empowered with knowledge. You are working with coaches who are also empowered with knowledge, and they are actively working to protect you at every turn. I hope that is liberating. See you in the gym.