Working Diagnosis:
Exertional Rhabdomyolysis

Treatment:
IV Fluids

Outcome:
Five of twenty-two athletes on this team were admitted and treated with intravenous fluids, with a length of stay ranging from one to five days. One was treated and released from the emergency department. Nine of the team members had creatine kinase levels > 1000. None developed acute renal failure. Two athletes did not seek evaluation. All admitted patients were discharged without long term effects. Five games were forfeited. The head coach was initially removed during an internal investigation. He was reinstated when it was determined that there was no intent to harm, but was later dismissed. Following that, the team physician and athletic training staff resigned.

All team members followed up with an independent sports medicine physician. Labs including creatine kinase and creatinine were reviewed or obtained. All athletes were provided with return to play recommendations and were able to return to full participation. Since the team forfeited multiple games while members were evaluated and treated, the remaining conference games this season were canceled by the Northern Athletics Collegiate Conference.

Author's Comments:
In this retrospective case series, we highlight the need for further education of collegiate coaching staff as well as intervention by the athletic health care team, to prevent exercise being used as punishment and to decrease the risk of exertional rhabdomyolysis. Multiple athletes were symptomatic from rhabdomyolysis sustained from this one practice which was described by the athletes as having been punitive. It is difficult to determine if players had transient acute kidney injuries as most of the team did not present for evaluation until a week after the practice. However, it is expected that they would have presented earlier if they were acutely symptomatic. If data were extrapolated back, it is expected that the peak creatine kinase levels for all players would have ranged from 187-58,489. This is significant due to the increased likelihood of acute renal failure that is seen with creatine kinase levels >40,000. This would have put 3/22 players at higher risk of acute renal failure.

Sickle cell trait was unknown for all players despite the Division III policy that had been implemented by the NCAA. This status should be documented for all players and known to medical and coaching staff, along with any other medical issues that put them at higher risk of rhabdomyolysis. Care should be taken with these players to ensure activity is not increased too rapidly, and that they stop activity if they experience any warning signs.

Editor's Comments:
Rhabdomyolysis can be divided into three large categories:
Traumatic, such as crush injury
Nontraumatic exertional
Nontraumatic nonexertional
In the above scenario, while the players clearly had significant non-traumatic exertional exposure, it is also important to consider non-traumatic nonexertional factors that could have predisposed them to exertional rhabdomyolysis especially in the setting of missing curfew. The most common of these factors include supplement/medication, including caffeine, as well as alcohol intake. Caffeine is an ergogenic agent commonly used by athletes and college students, with data supporting beneficial performance enhancement at low doses, but at higher doses it can predispose to a variety of systemic illness including nontraumatic exertional rhabdomyolysis. Furthermore, according to the NCAA National Study on Substance Use Habits of College Student-Athletes, 77% of student athletes reported drinking alcohol in the last year.

Several factors at baseline predispose individuals for rhabdomyolysis including male sex, African American race, Body Mass Index > 40, prior heat related injury, dehydration, sickle cell trait, and low physical fitness level. It is important to note that baseline creatine kinase levels can vary significantly from person to person, and there is more recent data demonstrating clear ethnic and gender differences. African Americans and male sex have higher baseline creatine kinase levels.

Knowing that baseline differences in creatine kinase levels exist, as well as the approximate timeline of peak creatine kinase and myoglobin serum levels can assist with accurately diagnosing exertional rhabdomyolysis. Myoglobin tends to peak within four hours while creatine kinase generally peaks within 24 to 72 hours from time of muscle injury.

References:
“ACSM and NCAA Joint Statement Sickle Cell Trait and Exercise.” NCAA, NCAA, 8 Feb. 2023, https://www.ncaa.org/sports/2013/12/18/acsm-and-ncaa-joint-statement-sickle-cell-trait-and-exercise.aspx.
Casa, Douglas J., et al. “The Inter-Association Task Force for Preventing Sudden Death in Collegiate Conditioning Sessions: Best Practices Recommendations.” Journal of Athletic Training, no. 4, Journal of Athletic Training/NATA, July 2012, pp. 477–80. Crossref, doi:10.4085/1062-6050-47.4.08.
CBS Chicago Team. “Concordia Basketball Coach to Return after Being Sidelined - CBS Chicago.” CBS News - Breaking News, 24/7 Live Streaming News & Top Stories, CBS Chicago, 12 Jan. 2023, https://www.cbsnews.com/chicago/news/concordia-basketball-coach-return-hospitalizations/.
“INTERASSOCIATION RECOMMENDATIONS PREVENTING CATASTROPHIC INJURY AND DEATH IN COLLEGIATE ATHLETES.” NCAA, NCAA Sport Science Institute, July 2019, https://ncaaorg.s3.amazonaws.com/ssi/injury_prev/SSI_PreventingCatastrophicInjuryBooklet.pdf.
Sheridan, Jake. “Concordia-Chicago Basketball Coach Returns after 6 Players Hospitalized – Chicago Tribune.” Chicago Tribune, Chicago Tribune, 13 Jan. 2023, https://www.chicagotribune.com/2023/01/13/concordia-chicago-basketball-coach-returns-after-6-players-hospitalized/.
Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner J. 2015 Spring;15(1):58-69. PMID: 25829882; PMCID: PMC4365849.

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