'Secret' Rhabdo: CrossFit, Exercise and Risk

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.
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With the extensive discussion following the recent article "CrossFit's Dirty Little Secret" by Eric Robertson, I want to add my thoughts as a physician and CrossFit trainer. 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 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.)

CrossFit has published multiple articles on rhabdomyolysis 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 a lecture in the CrossFit Level I Certificate Course devoted entirely 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 suggests that the number of articles on rhabdo by CrossFit trainers indicates that the incidence 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. 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.

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.

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.

Some might argue that if training at a level beyond light circuit training or walking modest distances 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 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 feel 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. 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 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.


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