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When Exercise Is Not So Healthy

By Robert Bramante
MD, FACEP

I was sitting at home one day after a long shift in the emergency department when I received a call from a family member seeking medical advice. She had been doing a new kickboxing workout routine and was complaining of muscle soreness. Not sounding too uncommon or serious, I initially recommended to her that she get rest and increase the amount of water she was drinking.

Then just before hanging up she mentioned her urine was also very dark.

Having sore muscles after a workout is a very common symptom and most often not dangerous. Delayed onset muscle soreness (DOMS) is the pain and soreness that one feels after a new or strenuous exercise. It can occur hours to days after the physical activity. Typically it will resolve within 3 days and treatment consists of rest, low intensity exercise, and warm baths/ compresses.

The concerning part of her story was the change in her urine color. I sent her to the local emergency department.  After a urine sample and blood tests were completed, the diagnosis of concern was confirmed. Her creatine kinase level was over 40,000 U/L. This level is significantly elevated and seen with a process of muscle breakdown called rhabdomyolysis. The urine changes color to a dark or even cola colored appearance.

Rhabdomyolysis can occur due to certain medications, including the statin group of cholesterol medications, after traumatic crush injuries, significant overuse of the muscles, or after prolonged compression of muscles. The mainstay of treatment is intravenous fluid hydration to dilute and flush the muscle breakdown products out through the urine. The diagnosis is important as lack of treatment can lead to kidney failure.

Luckily, when treated early, most patients make a full recovery. This family member was admitted to the hospital and received intravenous fluids over the course of a few days and made a full recovery.

Many new high intensity workout programs are around and readily available to people at various levels of conditioning. They should be encouraged to hydrate before, during, and after workouts. Additionally, both participants and workout program leaders need to be aware of the participant’s baseline activity level. This is not to say that even those who are well conditioned are immune to the development of rhabdomyolysis. This diagnosis has been described in the literature even with young healthy individuals or with less than highly intense exercise.

Is it rhabdomyolysis or DOMS? If the muscle soreness is severe or even incapacitating — if there is a change in urine color — or if there are any other concerns — you should speak with your physician. As always, we recommend that participants in physical activity consult with their physician prior to new types of activity. Hydrate regularly and slowly increase the intensity of physical activity. If symptoms occur, know that emergency physicians can evaluate, diagnose serious from benign issues, and treat patients with these diagnoses.

About the author: Robert M. Bramante, MD, FACEP is a clinical assistant professor of Emergency Medicine at New York College of Osteopathic Medicine and Associate Chairman of Emergency Medicine at Good Samaritan Hospital Medical Center in West Islip, NY