Diagnosis and Treatment of Acute Exertional Rhabdomyolysis Richard E. Baxter, PT, DSc, OCS,ATC 1 Josef H. Moore, PT, PhD, SCS, ATC 2 BACKGROUND It is imperative that physical therapists recognize potentially life-threatening conditions that present as musculoskeletal dysfunction and refer these patients appropriately. Acute exertional rhabdomyolysis (AER) is one of these conditions. 1 This condition results from breakdown of skeletal muscle and release of the muscle intracellular contents into the plasma due to excessive exercise in an otherwise healthy indi- vidual. 1,15,24 Types and causes of rhabdomyolysis may include metabolic disorders such as McArdles Dis- ease, diabetic ketoacidosis, abnormal glycolysis, hypokalemia, and hypophosphatemia. They may also include toxins or medications, crush injury to muscle, ischemic necrosis, infection and fever, electrical shock, prolonged seizure activity, and parasite (eg, trichinosis). 4,5,7 AER can result in disseminated intravascular coagulation, acute compartment syn- drome, 1,15,26 or acute renal failure, which is the most feared complication and has been reported to occur in 5% to 16.5% of all rhabdomyolysis cases. 7,24 Renal damage can result from myoglobin obstructing the renal tubules, decreased glomerular filtration rate, and the direct renal toxic effect of ferrihemate, a breakdown component of myoglobin. 10,21 AER can even result in death. 14 The hallmark presentation of rhabdomyolysis in- cludes myalgia, muscle weakness, and brown or tea- colored urine. 1,5,13,18 In addition to a recent history of excessive exercise and physical signs (myalgia, significant muscular weakness, and brown or tea- colored urine), laboratory findings (elevated serum creatine kinase [CK] and myoglobinuria being the most sensitive indicators) confirm the diagnosis of rhabdomyolysis. 5,9 If suspected of having rhabdo- myolysis, patients should be referred immediately to a primary care physician or emergency room. When clinically significant rhabdomyolysis is confirmed, pa- tients initially receive immediate medical manage- ment consisting of evaluation of renal function, aggressive fluid replacement, maintenance of high urine output, alkalinization of urine, monitoring for the clearing of the urine, and a downward trend in serum CK levels. 2 Once patients have completed initial medical management, they should undergo physical therapy rehabilitation to regain full range of motion (ROM), muscle strength, and full function before progressing back to full physical activity. Randall et al 19 outlined a rehabilitation program for individuals to return to full physical activity following AER secondary to intense push-up training (Table 1). They developed this program while working with 10 US Army soldiers with AER during military basic training. 19 DIAGNOSIS A 20-year-old male reported to the US Military Academy Cadet Physical Therapy Clinic via direct access during walk-in sick call one morning, com- plaining of bilateral shoulder pain and weakness. During the history portion of the examination, the patient reported that he had performed ‘‘hundreds of push-ups’’ of differing types (regular, wide-arm, ‘‘diamond,’’ etc) approximately 36 hours earlier. He stated that he was extremely sore the day following his push-up session. He took over-the-counter Ibuprofen for pain relief at that time. After awaking with continued pain the next morning, he reported to physical therapy sick call for evaluation. The patient denied taking supplements or other medica- tions. Upon further discussion and questioning, the patient acknowledged that he noticed dark urine approximately 24 hours after his push-up session. 1 Physical Therapist, US Army; Student, Command and General Staff College, Combined Arms Center, Fort Leavenworth, KS. 2 Director, US Military-Baylor University Postgraduate Sports Medicine Residency, US Military Academy, West Point, NY; Chief, Physical Therapy, Keller Army Community Hospital, US Military Academy, West Point, NY. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army or Defense. Send correspondence to Richard E. Baxter, 30453 199th St, Leaven- worth, KS 66048. E-mail: [email protected] 104 Journal of Orthopaedic & Sports Physical Therapy Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on June 21, 2023. For personal use only. No other uses without permission. Copyright © 2003 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
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