Rhabdomyolysis is a serious but often under-recognised condition that can occur in athletes following extreme exercise, heat stress, or muscle injury. Understanding the symptoms, risks, and management of rhabdomyolysis is crucial for athletes, coaches, and healthcare professionals. How do we recognise rhabdomyolysis and how do we manage it? 

What Is Rhabdomyolysis?

Rhabdomyolysis occurs when skeletal muscle breaks down rapidly, releasing muscle proteins into the bloodstream. While some degree of muscle breakdown is normal after exercise, in rhabdomyolysis the damage is severe, overwhelming the body’s ability to clear the muscle breakdown products. This massive breakdown can lead to dangerous complications, particularly acute kidney injury, which may require hospital treatment.

Symptoms of Rhabdomyolysis

The symptoms vary depending on severity, but athletes should be alert for:

  • Severe muscle pain – often described as out of proportion to expected post-exercise soreness

  • Muscle weakness or difficulty moving affected areas

  • Swelling of muscles, sometimes with tightness or pressure

  • Dark coloured urine due to muscle protein release

  • Fatigue, tiredness or confusion in more advanced cases

It is essential to distinguish rhabdomyolysis from simple delayed onset muscle soreness (DOMS). DOMS is diffuse, mild, and peaks 24–48 hours after activity, while rhabdomyolysis pain is typically severe, focal, and associated with body symptoms.

Complications of Rhabdomyolysis

Without early recognition and treatment, rhabdomyolysis can lead to life-threatening complications:

  • Acute kidney injury: Myoglobin is toxic to the kidneys and can cause kidney failure.

  • Electrolyte disturbances: High potassium can cause dangerous heart rhythm abnormalities.

  • Compartment syndrome: Severe swelling may increase pressure within muscle compartments, compromising blood supply and nerve function.

  • Disseminated intravascular coagulation (DIC): In rare, severe cases, widespread clotting abnormalities may occur.

These complications highlight why early diagnosis and the correct management of rhabdomyolysis are essential.

Clinical Assessment and Diagnosis

A sports doctor will typically assess:

  • History: Recent intense or unaccustomed exercise, heat exposure, dehydration, or trauma.

  • Examination: Muscle swelling, tenderness, or reduced range of movement.

  • Blood tests: Creatine kinase (CK) is markedly elevated (often thousands of units above normal- usually > 1000 units/L). Kidney function, electrolytes, and urine myoglobin levels are also assessed.

  • Urine analysis: Dark urine is a hallmark feature.

Other advanced testing might be needed to determine possible causes:

  • Muscle MRI: can identify the extent and distribution of muscle involvement, especially in recurrent or exertional cases.

  • Genetic/metabolic testing: in athletes with recurrent exertional rhabdomyolysis (e.g. McArdle’s disease, carnitine palmitoyltransferase deficiency). Testing may include nerve conduction studies and muscle biopsies. 

  • Endocrine screen: thyroid, cortisol, and adrenal function if systemic causes are suspected.

These advanced tests help distinguish between isolated exertional rhabdomyolysis and underlying predispositions that increase the risk of recurrence.

Management of Rhabdomyolysis

The management of rhabdomyolysis depends on severity but always begins with early recognition and hydration.

  • Immediate rest and cessation of exercise to prevent further muscle breakdown.

  • Aggressive hydration – intravenous fluids are usually required in the hospital to protect kidney function and flush muscle protein out of the system.

  • Monitoring salt levels – potassium, calcium, and phosphate are closely monitored and corrected where necessary.

  • Urine monitoring – ensuring adequate urine output.

  • Consider hospital admission – in moderate to severe cases, especially with kidney impairment and electrolyte disturbances. CK levels of > 5000 units/L are more likely to progress to kidney failure. 

In milder cases without systemic involvement, careful monitoring, hydration, and blood tests may be sufficient. 

Prevention in Athletes

From a sports medicine perspective, preventing rhabdomyolysis is as important as treating it.

  • Avoid sudden increases in training intensity or volume.

  • Stay well-hydrated, especially during hot or humid conditions.

  • Allow adequate recovery between high-intensity sessions.

  • Recognise early warning signs of severe muscle pain or dark urine and seek urgent assessment.

Final Word from Sportdoctorlondon about the Management of Rhabdomyolysis

Rhabdomyolysis is a rare but serious condition that all athletes and coaches should be aware of. The key to safe outcomes lies in early recognition, rapid investigation, and appropriate management of rhabdomyolysis, particularly to protect kidney function and prevent life-threatening complications. If you are an athlete experiencing severe muscle pain or notice dark urine after exercise, you should seek medical assessment immediately. With prompt treatment and appropriate rehabilitation, most athletes can fully recover and return to sport.