NO PAIN, NO GAIN: A WORKOUT
GONE AWRY
Herbie Yung MD1
Lindsey Kowalski DO2
Eric Anish MD2
1
University of Pittsburgh Medical Center Department of Physical Medicine and Rehabilitation
2
University of Pittsburgh Medical Center Department of Internal Medicine

I have no financial disclosures or conflicts of
interest
PATIENT 1
25 year old female with no medical history
presenting to the hospital 3 days after a personal
training session as a new client at a local fitness
center with complaints of muscle aches and cola
colored urine
 Her self reported exercise regimen is about 40
minutes of cardio followed by 20 minutes of
weight lifting 5 days a week
 On exam she had diffuse tenderness to palpation
in her back, arms, chest, but most tender in
bilateral thighs with mild edema. Distal lower
extremity pulses intact

PATIENT 1

Her workout session that day included:






8 sets of 20 squats with dumbbells with 30 seconds of
rest
5 sets of 30 pushups
Lunges with dumbbells
Deadlifts with dumbbells
Core exercises
Her entire session lasted between 1 to 1.5 hours
PATIENT 2
20 year old male with a past medical history of
pyloric stenosis presenting to the hospital 2 days
after a personal training session as a new client
with the same trainer at the same fitness center
with complaints of thigh tightness, cramping and
cola colored urine
 His self reported exercise regimen is college
recreational sports and weight lifting
 On exam he had tenderness to palpation in
bilateral thighs and calves. Full range of motion
in lower extremities.

PATIENT 2

His workout session that day included :
8 sets of 20 squats with the trainer providing
resistance on his shoulders
 5 sets of pushups
 After the set of pushups he was unable to continue as
his legs “locked up.”
 The trainer told him to walk on the treadmill for the
next 45 minutes


His entire session lasted about 1 hour
PATIENT 3
35 year old male with no medical history
presenting to the hospital 3 days after a personal
training session as a new client with the same
trainer at the same fitness center with
complaints of bilateral thigh pain, leg cramps
and brown urine.
 He reports he hasn’t been active for the past 6
months and was hoping to get in shape, but did
play recreational soccer in the past
 On exam he had tenderness to palpation in
bilateral thighs, decreased range of motion in the
hips and knees. Distal lower extremity pulses
intact

PATIENT 3

His workout session that day included:






100 squats
70 pushups
Medicine ball toss sit ups
After the sit ups, he was unable to continue due to
nausea and lightheadedness
Of note, he reports having 5 alcoholic drinks the
night prior to his session
His entire session lasted about 25 minutes
LABORATORY DATA
Patient 1: 25 yo F
Patient 2: 20 yo M
Patient 3: 35 yo M
CPK 77,386
CPK: 109,300
CPK: 65,904
ALT/AST : 383/972
ALT/AST: 393/1794
ALT/AST 323/1667
UA: dark yellow
urine, 2+ blood, 2+
protein, no cells
UA: yellow urine, 3+
blood, 1+ protein, no
cells
UA: yellow urine, 3+
blood, trace protein,
no cells
Aldolase: 317
DIFFERENTIAL DIAGNOSES
Exertional Rhabdomyolysis
 Infectious Rhabdomyolysis
 Drug Induced Rhabdomyolysis
 Delayed Onset Muscle Soreness
 Compartment Syndrome
 Metabolic Myopathies
 Dystrophinopathy
 Sickle Cell Anemia/Trait

DIAGNOSIS

Exertional Rhabdomyolysis
Myalgias, edema, weakness
 CPK greater than 5 time upper limit of normal
 Myoglobinuria
 Elevated creatinine

HOSPITAL COURSE
Patient 1: 25 yo F
Patient 2: 20 yo M
Patient 3: 35 yo M
Given 0.9% normal
saline, electrolytes,
I/O monitored daily
Given 0.9% normal
saline, electrolytes,
I/O monitored daily
Given lactated
ringers, electrolytes ,
I/O monitored daily
Discharged on
hospital day 5
Discharged on
hospital day 5
Discharged on
hospital day 3
CPK 10,708 (77k on
admission)
CPK 7,693 (109k on
admission
CPK 21,187 (65k on
admission)
Follow up CPK of
1,160 3 days later
(day 8)
Follow up CPK of
1,181 3 days later
(day 6)
RISK STRATIFICATION
Low Risk
High Risk
Rapid recovery with normalization of CPK
level
Delayed recovery (>1 week)
Physically fit athlete with history of
vigorous workouts
Muscle injury after low or moderate work
No personal or family history of
rhabdomyolysis, severe muscle cramps,
weakness or heat stroke
Personal or family history of malignant
hyperthermia, sickle cell
Other people in same group or team with
related cases of ER during the same
session
Exertional rhabdomyolysis complicated by
acute renal failure
Documented consumption of drug/dietary
supplement known to exacerbate ER
(caffeine, amphetamines, ephedra
Reoccurence or family history of exertional
rhabdomyolysis or severe muscle
cramping interfering with ADLs
Documented infectious illness
Persistently elevated CPK (>5x normal for
2 weeks)
Peak CPK >100,000
RETURN TO PLAY
Phase 1
Phase 2
Phase 3
•Follow up with provider
in 72 hour for repeat CPK
and UA
•Progress when CPK is
less than 5X normal
•Begin light activities at own
pace and distance
•Follow up with provider in 1
week
•Progress when there is no
weakness, soreness, swelling
or pain
•Gradual return to sporting
activities and physical
training
•Follow up with provider as
needed
CONCLUSION
Given the size and popularity of this fitness
center, this could be a potential health concern as
3 patients presented within a 1 week period
 A phone call was made to the fitness center to
alert them of the 3 hospitalizations
 The manager reported this workout was a new
fitness evaluation tool implemented by their
newly hired director of personal training for new
clients
 A phone call was also made to the Director of the
Allegheny County Health Department who then
visited the fitness center

Thank you!
Questions?
REFERENCES
1.
Bosch X, Poch E, Grau JM. Rhabdomyolysis and Acute Kidney Injury. New England Journal of
Medicine. Jul 2 2009; 361 (1): 62-72.
2.
Wise JJ, Fortin PT. Bilateral, Exercise-Induced Thigh Compartment Syndrome Diagnosed as
Exertional Rhabdomyolysis. American Journal of Sports Medicine. 1997; 25 (1): 126-129.
3.
Woodrow G, Brownjohn AM, Turney JH. The clinical and bicohemical features of acute renal
failure due to rhabdomyolysis. Ren Fail. 1995; 17: 467-474.
4.
Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in College
Conditioning Sessions: Best Practices Recommendations. Journal of Athletic Training. Aug
2012; 47 (4): 477-480.
5.
O’Connor et al. Return to Physical Activity After Exertional Rhabdomyolysis. American College
of Sports Medicine. 2008. 7 (6): 328-331.