DISORDERS OF PROLONGED EXERTION.
Dr Chris Ellis M Sc, MRCGP, MFSEM
“We have won.”
Pheidippides:
490 BC
AND THEN HE DIED!

EXERTIONAL DISORDERS FOR DISCUSSION TONIGHT.
SUDDEN DEATH
PHYSIOLOGICAL
(Extreme variations of
normal).
PATHOLOGICAL
(Abnormal/disease
states).
SYSTEMIC

Cardiac arrest > 35yrs (post heart attack).

Cardiac arrest < 35yrs (hereditary heart defect).

Other medical disorders.

Exercise associated postural hypotension (EAPH).

Exertional rise in temperature.

Rhabdomyolysis (uncomplicated).

Moderate weight loss (2-4%).

Exertional low blood sugar/hypoglycaemia.

Exercise associated low sodium/hyponatraemia (EAH).

Dehydration/raised sodium.

Rhabdomyolysis with complications (ARF).

Heatstroke.
LOCALISED

Compartment syndrome.

Stress fracture.

CARDIAC ARREST/SUDDEN DEATH.
•
•
•
Rare.
Usually (but not exclusively) cardiac.
When cardiac, cause usually governed by age:
Under 35 years-Inherited cardiac defect.
Over 35 years-Diseased arteries
Marc-Vivien Foe (Deceased) Jimmy Fixx (Deceased)

EXERCISE ASSOCIATED POSTURAL HYPOTENSION (EAPH).
Commonest cause of post-exertional collapse, often over-treated and not recognised for what it is.
Features:
• Immediately on stopping activity
• No prior symptoms
• Rapid spontaneous recovery
• No active treatment needed, just let lie and observe.
COLLAPSE: RULE OF THUMB
• Collapse shortly after finishing the race or a stage is usually EAPH if the runner finished symptom free.
• Collapse while running, or considerably after, is usually serious and needs medical assessment

EXERTIONAL RISE IN CORE TEMPERATURE IS COMMON, UN-NOTICED & USUALLY INNOCENT .
THIS IS NOT HEATSTROKE, THIS IS A NORMAL, BUT NOT UNIVERSAL, RESPONSE TO HEAT LOAD .
Byrne et al (2006). Data from Singapore 1/2M.

RHABDOMYOLYSIS IS UNIVERSAL AND USUALLY INNOCENT.
RACE NO.
CK(<200).
63 12,174
42
145
7
99
54
4,756
7,528
8,357
8,735
5,536
11
108
5
56
141
22
150
90
62
94
144
118
101
41
19
111
52
7,711
3,644
7,648
2,924
9,171
2,793
5,257
13,309
19,487
11,485
19,790
3,902
12,553
10,066
26,345
6,346
6,582
RACE NO.
CK(<200).
124
135
49
48
50
44
121
27
132
40
86
34
31
75
148
130
29
128
38
2
70
67
8,429
30,243
17,097
9,276
2,584
3,897
26,723
14,773
7,147
13,169
3,565
17,695
4,925
15,029
17,697
2,354
25,671
6,371
6,765
2,800
10,530
7,365
Creatinine Kinase levels in 67 healthy WHWR 2009 finishers.
Cuthill, Ellis & Panarelli.
RACE NO.
CK(<200).
67 7,365
126
80
78
26
37
29,837
14,603
14,952
3,209
9,909
6
71
127
84
120
103
122
55
113
21
20
1
109
81
134
79
27,277
1,499
6,624
8,060
132,645
29,490
19,310
1,124
50,347
13,547
3,501
65,724
68,852
14,738
13,864
42,670

2
% Wt.
change.
0
-2
-4
-6
6
4
-8
WEIGHT LOSS (2-4%): Normal and ? desirable.
% WEIGHT CHANGE IN 66 HEALTHY 2009 WHWR FINISHERS.
Cuthill, Ellis & Panarelli.

WEIGHT LOSS: Statistically significant association with favourable performance.
-8
COMPARATIVE DATA FROM WHWR AND SA IRONMAN
WEIGHT CHANGE v. PERFORMANCE.
WHWR, 2009.
Cuthill, Ellis, Panarelli & Sharwood.
SA Ironman Triathlon, 2001 & 2.
2500
2000
1500
1000
500
-6 -4 -2
Body weight change (%).
0
0 2

WEIGHT LOSS: Protective against hyponatraemia (EAH).
Noakes et al, Pooled results from multiple ultras.

EXERCISE ASSOCIATEDHYPONATRAEMIA (EAH).
• EAH is low blood sodium.
Sodium < 135.
Cause is TOO much fluid, NOT lack of sodium.
• EAH symptoms .
Mild: (sodium > 130).
Severe: (sodium < 130)
Confusion, fits, coma, death, others.
• EAH is real .
Boston marathon study 13% runners, 0.5% critical. 9 known deaths worldwide. 4 known cases in WHWR since 2005.
• EAH risk factors .
Drinking more than need, weight gain, female, slow pace, over 4 hour event, anti-inflammatory medication (NSAIDs).
• EAH is substantially avoidable.
Drink by thirst. Avoid NSAIDs.
Weight monitor during race.
• EAH has low incidence in NZ and SA.
Where “keeping ahead” with fluids and
“maintaining weight” are no longer advocated.
David Rogers (Deceased), London Marathon, 2007

153
148
143
138
133
128
123
*
COMPARATIVE SODIUM LEVELS IN HEALTHY FINISHERS WHWR v. WSER, 2009.
Cuthill, Ellis, Panarelli & Hew-Butler.
WHWR, 2009.
n=66
* Pre-race sodium, 131. NOT EAH.
153
148
143
138
133
128
123
WSER, 2009.
n=47
WHWR, 2009.
(from 66 finishers tested.)
• Asymptomatic Hyponatraemia (EAH) - Nil.
• Asymptomatic Hypernatraemia - 4.
WSER, 2009.
(from 47 finishers tested.)
• Asymptomatic Hyponatraemia (EAH) - 19.
• Asymptomatic Hypernatraemia - Nil.

• Generalised muscle breakdown and liberation of contents into body is universal and usually innocent.
• Occasionally becomes pathological (abnormal).
• Rhabdo symptoms.
Muscle pain. Dark urine. Lack of urine. Lack of well-being.
• Rhabdo complications.
Acute kidney (renal) failure (ARF), others, death.
• Rhabdo is real.
Two cases of ARF from WHWR since 2005.
• Rhabdo prevention.
Less preventable than EAH.
Anti-inflammatories and viral illness are risk factors.
Suspect early to minimise complications.
Report : chocolate or reduced urine & excessive muscle pains.

EXERTIONAL HEATSTROKE
Elevation of CORE temperature above 40 degrees, PLUS brain impairment.
• Exertional Heatstroke is NOT same as “hot”.
Exercise can cause the core temperature to rise without symptoms or significance.
• Exertional Heatstroke is rare. Not seen so far in WHWR.
• Exertional Heatstroke symptoms are initially vague.
Non-specific confusion/lack of well-being.
Mortality, once established, is high.
• Exertional Heatstroke causes.
Abnormal overproduction of heat by muscles with which body can’t deal.
A combination of, exercise, inherited disposition and further unknown trigger.
• Exertional heatstroke prevention.
Disposition if previous severe “heat reaction” to Anaesthetic or other prescribed or street drugs.
High suspicion needed. Treat early and aggressively and accept unneccessary treatment.

ACUTE COMPARTMENT SYNDROME
Localised s welling of muscle group, usually of leg, within enclosed sinew (fascia), following injury or overuse and may be associated with constricting bandage or plaster cast.

SITE
RUNNING INDUCED STRESS FRACTURES.
Noakes T. (Lore of Running.)
55
23
2
2
14
4
0.1

CONCLUSIONS
• Read and learn the guidelines (runners & crew).
• Drink by thirst.
• Avoid NSAIDs.
• Monitor weight.
• Heat exhaustion doesn’t exist.
• Diagnose dehydration cautiously.
• Take guidelines (& urine) if need medical help.
• Insist on blood tests.
• No iv fluids without sodium.

THANK YOU & QUESTIONS