Case Reports

Acute Exertional Upper-Extremity Rhabdomyolysis in 3 Female Trainees

Early diagnosis and comprehensive management of exertional rhabdomyolysis are crucial to ensure full recovery and avoidance of complications.

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Acute exertional rhabdomyolysis (AER) is the breakdown/destruction of muscle tissue from extreme physical exertion. Risks that lead to AER include exercise in hot and humid conditions, improper hydration, inadequate recovery between bouts of exercise, intense physical training, and inadequate fitness levels. Other risk factors include sickle cell trait, ingestion of performance enhancing agents, anabolic steroids, and previous history of AER. This article, describes 3 cases of AER after a vigorous, upper body, organized, and supervised training session.

Rhabdomyolysis is not uncommon in competitive athletics,1-3 military training,4-8 and individual training.9-12 It is more common in the lower extremities after intense training or marathons. Creatine kinase (CK) levels rise within 12 hours of muscle injury, peak in 24 to 36 hours, and decrease at a rate of 30% to 40% per day.13 The serum half-life of CK is about 36 hours. The CK levels decline 3 to 5 days after resolution of muscle injury.14 Failure of CK levels to decrease suggests ongoing muscle injury or development of a compartment syndrome. The peak CK level, especially when it is > 15,000 U/L, may be predictive of renal failure.15

Total CK elevation is a sensitive but nonspecific marker for rhabdomyolysis. A CK level that is 1.5 × above the reference range suggests rhabdomyolysis, although CK levels in rhabdomyolysis often are as high as 100 times the reference range or more.12 Health care providers (HCPs) should suspect early rhabdomyolysis and initiate a full laboratory workup for patients with serum CK levels > 2 × the reference range and risk factors for rhabdomyolysis. Because the total CK may increase from the initial values, draw it is important to repeat total CK levels every 6 to 12 hours until a peak level is established.

Case Presentations

An upper body physical training session was conducted with a group of trainees (men and women, aged 24-35 years) 12 weeks into a 21-week program. The training session consisted of 125 push-ups and 85 pull-ups (assisted) performed within a 12-minute period in an indoor, climate-controlled facility. Liberal hydration with water or sports drinks was not allowed. On day 3 following the training session, 1 woman, and on day 4, 2 additional women presented to the clinic with extreme bilateral upper extremity muscle weakness, pain, and marked swelling of their upper-extremities from the shoulder to the forearm. None had firm compartments of the arm or forearm. Further, none had signs of compartment syndrome. There were trace blood and protein in their urine, and their serum CK ranged from 10,000 to 78,000 U/L.

Case 1

The first case to present to the clinic was a 26-year-old white female without any underlying disease. She was taking oral contraceptive medication. She usually exercised by running 10 to 12 miles/week with upper body workouts as required by the training program and was in excellent physical health at the halfway point in the training program.

Following the workout of 125 push-ups and 85 pull-ups, the patient experienced muscle soreness and fatigue and took ibuprofen 800 mg that evening. Over the next 2 days, she experienced continued muscle soreness/pain, increasing weakness, and marked swelling of her arms. On day 3 after the workout, she presented to the clinic in moderate distress, unable to raise her arms above chest level. Her urine showed trace blood and protein, and her serum CK level was 73,044 U/L (Table 1).

The patient was diagnosed with rhabdomyolysis and admitted to the hospital. She received IV therapy, improved, and was discharged after 8 days, and had no sequelae.

Case 2

The second case involved a 27-year-old white female without any underlying disease who was not taking any medications and was in excellent physical health. Following the workout of 125 push-ups and 85 pull-ups, she experienced muscle soreness and fatigue. Over the next 3 days, she experienced continued muscle soreness/pain, increasing weakness, and marked swelling of her arms. On day 4 postworkout, she presented to the clinic in moderate distress. Her urine showed trace blood and protein, and her serum CK level was > 8,000 U/L (the hospital stopped dilutions when the CK level exceeded 8,000 U/L) (Table 2).

The patient was diagnosed with rhabdomyolysis and admitted to the hospital. She received IV therapy, improved, and was discharged after 7 days, and had no sequelae.

Case 3

The third case involved a 33-year-old white female without any underlying disease who was taking oral contraceptive medication and was in excellent physical health. Following the 125 push-ups and 85 pull-ups workout, she experienced muscle soreness and fatigue. Over the next 3 days, she experienced continued muscle soreness/pain, increasing weakness, and marked swelling of her arms. On day 4 postworkout, she presented to the clinic in moderate distress. Her urine showed trace blood and protein, and her serum CK level was 10,971 U/L (Table 3).

The patient was diagnosed with rhabdomyolysis and admitted to the hospital. She received IV therapy, improved, and was discharged after 7 days, and had no sequelae.

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