“Secret” Rhabdo

With the extensive discussion following the recent article “CrossFit’s Dirty Little Secret” by Eric Robertson, I want to add my thoughts.  My wife, Lisa, and I own a CrossFit affiliate, CrossFit Flagstaff.  I am a member of the CrossFit training staff and I am a practicing emergency physician.  I also wrote the article “The Truth about Rhabdo“, published in the CrossFit Journal in January 2010, where it remains available to the public as a free article.  (This current article is not intended as a general article about exertional rhabdomyolysis (rhabdo); if you wish to read more about the topic, I refer you there, though there are many excellent articles on rhabdo).  While I have a significant association with CrossFit, this article is entirely my own.

I do not know Mr. Robertson or the colleague he writes about in the article, nor do I have any information about the case he describes beyond what is in the article or in the accompanying interview on The Huffington Post.  I will therefore not further comment on this specific case.  I would, however, like to address some of the issues raised by Mr. Robertson.

The title of the article is misleading.  Rhabdo is anything but a secret, at least in the CrossFit community.  I believe CrossFit has done more to educate the general public and its trainers about rhabdo than any other organization, including many related to communities that also carry an association with rhabdo.  (Of note, the United States Military has published numerous excellent articles on the topic.  Their role, however, has been more to inform medical professionals about rhabdo and to develop guidelines for training and operations as opposed to educating the public or the athlete.)  As numerous other commentators have pointed out, CrossFit has published multiple articles on the topic dating back to 2005.  These are available for free to anyone with an internet connection.  Everyone who attends a CrossFit Level I Certificate Course is provided a Level I Training Guide that includes information about rhabdo and any holder of the CrossFit Level I Certificate has passed a test that includes questions about rhabdo.  There is an entire lecture in the CrossFit Level I Certificate Course devoted to the topic of good mechanics and gradual introduction to an appropriate level of intensity.

Mr. Robertson himself mentions Uncle Rhabdo, the admittedly somewhat macabre mascot introduced by CrossFit to help spread the word about the dangers of rhabdo.  One may dislike the irreverent take on a serious topic, but I would argue it is less helpful to use scare tactics that ultimately hinder rational discussion.

Mr. Robertson relates that when his colleague phoned the affiliate where she trained to cancel her membership, explaining that she was in the hospital, the trainer asked “Is it rhabdo?”  This supports the argument that the CrossFit community is informed, at least at some level, about the condition.  Additionally, he notes that “A quick search of the Interwebs reveals copious amounts of information about rhabdo purveyed by none other than CrossFit trainers.”  Mr. Robertson suggests that the number of articles by CrossFit trainers indicates that the incidence of rhabdo must be higher in athletes training with CrossFit than in other training programs, but we must consider that detection and publicity also play a role.  He refers to rhabdo as “extremely rare”, but I would counter that while uncommon, it is also likely to be under-reported and under-diagnosed.  It is also not that rare: as an emergency physician I see several cases per year from patients who have been hiking in the Grand Canyon which is near where I work, and several cases per year from other causes.

We know that CrossFit makes a significant effort to disseminate information about rhabdo.  This naturally results in more awareness, more detection and more articles and publicity.  I believe the CrossFit community is better educated about rhabdo than any other potentially susceptible community, and I know that many athletes at risk for rhabdo train outside the CrossFit community in complete ignorance of it.  (There are undoubtedly CrossFitters also unaware of rhabdo, but from my perspective CrossFit is doing everything it can to spread the word.)

Mr. Robertson states exertional rhabdomyolysis “should never happen.”  I disagree.  I want to be clear: every case of rhabdo is unfortunate, and I wish we could develop athletes and never see it happen.  We should all act to mitigate the risk, but to eliminate the risk is only possible by eliminating the stimulus, which would mean a loss of all the benefits associated with exercise, especially intense exercise.  Of course, there are also risks associated with not exercising.

As in so many things, there is need to assess risk and benefit.  And not just the risk of exercise versus the benefit of exercise, but the risk of not exercising versus the benefit (such as it is) of not exercising, the risks and benefits of training one way versus another, more versus less, intense versus not and on and on.

Some might argue that if training at a level beyond light circuit training or modest distance walking elevates the risk of rhabdo beyond the miniscule (to, perhaps, the merely very small), this training should be reserved for professional athletes.  Do we really want to restrict the power of being a true athlete to only the elite?  Do we want to declare those benefits off limits?  Do we tell the numerous athletes at my gym who are stronger and fitter in their 40s, 50s and beyond than they were in their 20s that this is all reckless and foolish?  Do we send them to other training programs whose approach to rhabdo is to deny and ignore it so everyone can feel how “safe” they are?  Do we send them to training programs that we know are minimally effective so they might genuinely be safe from rhabdo, even though we know it increases their risk of diabetes, hypertension, heart disease, obesity and depression plus deprives them of the sense of vitality they have from training as a true athlete?

I would argue that the only reasonable way to approach this is to educate everyone as much as possible about the risks and benefits and let them decide for themselves.

Does this mean everyone needs to be an expert on rhabdo?  No.  It does mean however that everyone needs to understand that everything they do (or don’t do) carries a risk, and that how they behave influences that risk.  If you want strong health benefits and are okay with modest athletic gains, then be moderate in your training, whether it’s CrossFit or some other program.  Find your level.  Articles about the “extreme” culture notwithstanding, there is plenty of room for this in CrossFit.

If you are somewhat risk tolerant and desire greater fitness and athleticism, hit those workouts harder.  Note that you cannot be completely risk intolerant and realistically train to excel in competition or some other arena.  The training required to support high performance carries risk.  And despite the impression created by numerous articles, while the risks are real, they remain small.  Whatever your choice, if you work out with a trainer, coach, or training partner, make sure they are aware of your desires.

We also need to be aware of what we are at risk of.  The Dirty Little Secret article addresses rhabdo, but of course there are other risks associated with training.  If you choose to train hard for competition, your chance of sustaining orthopedic injury is actually pretty high.  There are no professional athletes in any sport that have not had some kind of injury, and many live with pain and anywhere from mild to considerable disability as a result of their training.  CrossFit is certainly not immune from this, though CrossFit’s preference for functional movement and variance makes injury rates lower than they might otherwise be.

Is injury good?  Arguments about personal growth aside, in general it is not.  But injury is okay if it is not too severe.  Any trainer will have athletes get injured.  The idea is to tune the training so that the balance of injury and performance gain is optimized for the goal of the training.

And what about rhabdo?  Rhabdo, while uncommon, is a real risk of CrossFit, any serious training or many other activities (like hiking in the Grand Canyon), and athletes and coaches should all be wary of it.  But the risk of getting ill from it at all is small, and rhabdo exists on a spectrum.  At one end, rhabdo can kill or lead to permanent disability such as chronic kidney disease and even lifetime dependence on dialysis.  On the other end, rhabdo can mean some all over body soreness, perhaps coupled with some nausea or abdominal pain, which resolves without the athlete ever seeking medical care.  (I am not advocating trying to manage “mild” rhabdo at home without professional guidance.  If you have any concern that you have rhabdo, go to an emergency department.)

So, if there is a spectrum, where do most cases fall?  There isn’t good comprehensive data, but as someone in the CrossFit community who tends to hear about rhabdo, I have yet to hear about a case involving CrossFit that unequivocally led to permanent disability or death.  I am not saying it hasn’t happened or that it can’t happen.  In fact, with hundreds of thousands of people doing CrossFit every day, it is inevitable that it will happen.  But it usually doesn’t.

I have corresponded or spoken with a fair number of athletes who have been hospitalized for rhabdo, some CrossFitters and some not.  I have had the opportunity to review the blood work of many of them.  While they have all had elevated levels of creatine phosphokinase (CPK), few of them have had even mildly elevated levels of creatinine and all that did elevate returned quickly to normal.  CPK indicates the release of muscle cell contents into the bloodstream.  Contrary to what Mr. Robertson says in his article, there is no level of CPK that is unequivocally associated with kidney injury.  We generally assess kidney injury by looking at creatinine levels.  A mildly elevated creatinine is associated with mild kidney injury, a more elevated one, more serious injury.  If that elevated creatinine returns to normal, that indicates recovery of the kidneys.  If it stays high, that suggests permanent injury.  There are other forms of injury that may result from rhabdo.  In the experience of the athletes with which I am familiar, these have also been temporary and mild, though we know they won’t be in every case.

We can mitigate the risk and severity of rhabdo by training smart.  Every athlete and trainer should educate themselves about this.  Scale appropriately, hydrate appropriately, minimize or avoid high-risk movements, and above all, listen to your body.

So if we are interested in training like an athlete, thus elevating our risk of rhabdo from miniscule to very small, and most of the very small number of rhabdo cases, even those that result in hospitalization, result in only temporary disability, how much risk are we really taking?  I do not mean to minimize the experience of those who have had rhabdo and recovered.  They have experienced significant pain and discomfort, lost time at work or school and training, may have had a prolonged recovery and might have large hospital bills.  But they didn’t die.  They are not on lifelong dialysis or seeking a kidney transplant.  Most of the athletes with whom I have corresponded have also returned to training.

I believe CrossFit represents a paradigm shift in how we view fitness and health.  The holy grail of the fitness industry used to be to find some low-effort exercise program or machine or some pill that people could plunk down their money for and suddenly have the body of their dreams.  CrossFit has turned that on its head.  It doesn’t promise easy results but rather hard work.  We pursue not the appearance of absurdly stick-thin fashion models but rather athletic performance and in the process are changing the aesthetic of what is beautiful in both women and men.

Similarly, we consider everyone an athlete.  We understand the give and take of training and recognize the reality that we all live with risk regardless of what we do.  Rhabdomyolysis has always been there; CrossFit has had the courage to bring it into the light.  The way to deal with that risk is to understand it and to manage it, not to deny it or completely avoid it.  To shun that risk all together is to deny ourselves the opportunity to realize much of the potential that is within us.

October 3, 2013: A version of this article is now up on The Huffington Post.

14 thoughts on ““Secret” Rhabdo

  1. Dan Hollingsworth

    Great article, Mike. I’m a former member of 2 communities where rhabdo is known to happen, the military and endurance racing. In nearly 19 years of military service the only time I heard anything about rhabdo was when I was in physical therapy school. Heck, one of my classmates spent 3 days in the hospital just before our oral boards from a case of rhabdo that he got doing the Army Physical Fitness Test. In 10 years of fairly serious training/racing in triathlons and marathons I never heard rhabdo mentioned once. Not 1 article, not 1 warning from a race director or coach.

    Thanks for your reasoned response to all the hysteria.

    1. Dana

      You can get rhabdo doing the APFT?

      OK, I’m not scared of rhabdo anymore. Good to know.

      (No, that’s not sarcasm.)

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  3. Jeff Lynch

    Thanks for writing on this topic from an educated, experienced perspective. That “CrossFit Culture” attack article practically gave me Rhabdo in my massiters (Jaw muscles) from clenching so hard while reading the inaccurate statements made by someone just looking to grab a headline and without a clue for what he spoke. That guy needs penalty burpees for sure!
    Well done.

  4. Michael

    Well thought out and articulated points. Education is key. There is quite obviously a cause for concern when a condition that is considered rare becomes more commonplace in association with this type of exercise protocol. That alone should raise a lot of red flags for people considering Crossfit. As with any form of training involving general population clients (which most crossfitters are), a thorough orientation/instruction/assessment session should be mandatory prior to allowing full participation. It is the responsibility of the owners and trainers of these facilities to ensure the safety of their clients to the best of their ability.

  5. Doug

    I have to agree. As a 47 (almost 48) year old Crossfitter, I’ve always been athletic and fit. I NEVER really knew anything about rhabdo and strangely enough, felt as if I was definitely more informed than your casual gym-goer. I’ve been doing Crossfit for a little over a year and I like what it’s given me. I still hit the regular gym 3 to 5x in addition to my 3-4x Crossfit in the evenings. I know my body, don’t try to overdo it and generally won’t let myself get in over my head (although I do push myself). The ongoing and seemingly more frantic Crossfit haterade going around is telling. It works, it’s popular, and it really is a paradigm shift for fitness–three things guaranteed to upset the status quo. From my point of view, that’s all you need to know. Also, as an aside, I’ve been extraordinarily impressed with the quality of training and attention to detail provided by our guys and gals. I’m sure there are exceptions to this, but, again as a person who has been active, fit, and a gym rat for a many number of years, I’m impressed by the training and focus on safety I’ve personally witnessed.

  6. Dale Saran

    Michael (comment of 9/29) – I’m calling bullsh!t on your comment. You acknowledge Doc Ray’s “well thought out and articulated points” about which you cannot argue, then you commit exactly the same logical fallacy of which Eric Robertson is guilty in his hit piece. Your sentence that starts “there is quite obviously a cause for concern…” is nonsense. It is the exact fallacy that Dr. Ray is writing in response to. Where is your proof that this “rare” condition (it’s not “rare” in the ultra-marathon, triathlon, marathon community at all) has become “more commonplace in association with this typer of exercise protocol[?]” Do you have a single ounce of data to support your claim of “more commonplace?” More common than what? From what? What are you comparing? You then extract from that unsupported, inane sentence the conclusion “that alone should raise red flags.” No, what should raise red flags is terrible, unsupported assertions, and horrible, grade-school level logic, which are somehow passed off as “well-meaning discussion.” Which they are not. Just state your agenda up front and get it out there. You’re an NSCA trainer and you have your own competing program (FitPro Integrated Fitness) on which you’ve published the Robertson piece. Sheez, man.

  7. JD Cochran

    I am also an emergency physician and consumer of the Koolaid that is CrossFit. Your comments are spot on. I personally don’t understand all the panic about the “dangers of CrossFit”. Sure, we can be dismissive, and chalk it up to jealousy and the like, but there seems to be something deeper out there. Working in the ED, like you, I see a number of cases of rhabdo each year. Most of the exertional cases I’ve seen have been occupational, ie. roofers, firefighters, etc. (most of whom were not appropriately conditioned for what they were doing). If we want to point to the dangers of things people do for exercise and recreation, lets look at cycling, for example. Some of the worst injuries I’ve seen have involved auto vs. cyclist or dog vs. cyclist or cyclist vs. pavement. Pelvic fractures, pneumothoraces, traumatic brain injuries, amputations, you name it. I don’t point this out to bag on cycling, but simply to point out that there are infinite ways to injure oneself and CrossFit seems to be taking an unfair beating in the public arena. For what it’s worth, I’ve never had a CrossFitter in the ED as a patient for anything related to CrossFit…anecdotal and meaningless, I know, but I’m just sayin.

  8. Sarah

    Really? You claim “Less effective” exercise regimens increase your risk of hypertension, obesity, etc.? In an article with the purpose of supporting the proported benefits of CrossFit, perhaps you should chill with the hyperbole and the shaky, misleading claims. They only serve to further exhibit your bias toward the work you do.

    1. Michael Ray Post author

      I claim minimally effective exercise programs increase the risk of those disorders versus effective exercise programs. I do not paint all exercise other than CrossFit with that brush. I merely point out that if someone is doing CrossFit and has reduced risk of diabetes, hypertension etc. as a result, if they switch to a program that is minimally effective – and therefore vanishingly unlikely to cause rhabdo – they will lose that benefit.

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