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Exertional Rhabdomyolysis: a Practical Recovery Guide

Rhabdomyolysis :

A condition in which skeletal muscle breaks down extremely fast.

Symptoms :

  • muscle pains, weakness, vomiting, confusion.
  • The break down of muscle produces an environment harmful to the kidneys and may lead to kidney failure.
  • Tea colored urine.
  • Irregular heartbeat.



Exertional Rhabdomyolysis (ER):

‘Exercise-induced rhabdomyolysis’ : is the breakdown of muscle from extreme physical exertion – the exact prevalence and incidence of which is unclear…



Reasons (Why it happens) :

  • Long-lasting muscle compression which stops blood flow, causing the muscle to break down – “Rhabdomyolysis is associated with hyper- and hypothermia, sickle cell trait (and other ischemic conditions), exertion, crush syndromes, infection, autoimmune and metabolic disorders, and certain drugs.” (Sports Health)


(ER) Recovery :

Extreme cases

*Return to Sport

Phase 1

  • Rest for 72 hours and encouragement of oral hydration
  • 8 hours of sleep nightly
  • Remain in a thermally controlled environment if the episode of *ER was in relation to heat illness
  • Follow-up after 72 hours with a repeat serum *CK level and *UA
  • If the CK has dropped to below 5 times the upper limit of normal and the UA is negative, the athlete can progress to phase 2; if not, reassessment in 72 additional hours is warranted
  • Should the UA remain abnormal or the CK remain elevated for 2 weeks, expert consultation is recommended
Phase 2

  • Begin light activities, no strenuous activity
  • Physical activity at own pace/distance
  • Follow-up with a care provider in 1 week
  • If there is no return of clinical symptoms, the athlete can progress to phase 3; if not, the athlete should remain in phase 2 checking with the health care professional every week for reassessment; if muscle pain persists beyond the fourth week, consider expert evaluation to include psychiatry
Phase 3

  • Gradual return to regular sport/physical training
  • Follow-up with care provider as needed

(*Source; Consortium for Health and Military Performance. *ER; exertional rhabdomyolysis. *CK; creatine kinase. *UA; urinalysis.)




This Return to Sport guide provides no indication of what exercises to do, and which ones to avoid. This is because each case is different.

In the rest of this article I will attempt to provide a generalized movement program for Rhabdo-recovery.

The table ABOVE and the table BELOW can be superimposed: Phase 1 of the table ABOVE roughly matches up with Phase 2 of the table BELOW. Phase 2 of the table ABOVE matches up with phases 4/5 in the table BELOW.




Generalized Movement Program for Rhabdo-Recovery

Phase 1

15 minutes of movement at MOST

1-2 weeks = depends on DOMS, hydration levels, CK, UA, etc…

Isometric/Isotonic Movements Only = Really Slow!


Phase 2

15-20 minutes @ most

1-2 weeks in duration + Isotonic/Isometric movements only


+ Lower Abdominal Exercise = Leg Lifts/switches – (Kyle again)

+ Plank

+ Waiters Bow


Phase 3

20-30 minutes @ most

2-3 weeks in duration + slowly ramping up the speed.


+ Deadlift :

  • week 1 – no more than 8 sets of 1 rep, increasing in weight.
  • week 2 – no more than 8 sets of 1-2 reps, waving in load.
  • week 3 – no more than 21 reps total @ 1-3 reps/set.


Phase 4

30-40 minutes @ most

2 weeks – Slow ramping of volume and intensity / reducing rest – Nervous System and DOMS need to be assessed.



+ Swing:



Phase 5



  • get an FMS screen + required correctives.
  • work on progressing a SKILL, gradually increasing in volume  EX: – Simple and Sinister




*SUMMARY – Priscilla M. Clarkson, Ph.D. Has this to say :


“Why are some individuals more susceptible to rhabdomyolysis?

From the literature it is well documented that a novel strenuous exercise will produce muscle damage (Clarkson, 1990).

Therefore, the specificity of exercise training is important.

Even if an individual is trained in one activity (e.g., endurance running), this training may provide little or no “protection” if 100 push-ups or repetitive squat-jumps are performed.

Some individuals may have an hereditary sub-clinical muscle enzyme anomaly or other defect (Noakes, 1987).

Under normal exercise stress their condition would probably go unnoticed.

However, performance of very strenuous, repetitive, unaccustomed exercise may exacerbate muscle damage such that the defect becomes apparent.

Also, in a competitive event the zeal to win or the shame of quitting may provide the coup de grace that will allow some individuals to go beyond a tolerable level of muscle injury (Knochel, 1990)

For strenuous exercise in the heat, precautions such as adequate fluid intake and acclimatization are critical.

All exercise training programs should start with mild to moderately intense exercise and should progress gradually.

These safeguards will not only prevent subsequent muscle pain and optimize performance, but they may also save lives”

(* SPORTS SCIENCE EXCHANGE: ‘Worst Case Scenarios: Exertional Rhabdomylosis and Acute Renal Failure.’)




  1. Kyle Gentle: Primal Performance TrainingYouTube FaceBookInstagram
  2. Eyal Muscal, MD, MS Assistant Professor, Section of Pediatric Immunology, Allergy, and Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital.
  3. Priscilla M. Clarkson, Department of Exercise Science University of Massachusetts Amherst, MA. Member, Sports Medicine Review Board Gatorade Sports Science Institute. SSE#42, Vol.4 (1993), Number 42.
  4. Tietze, David C., and James Borchers. “Exertional Rhabdomyolysis in the Athlete: A Clinical Review.” Sports Health 6.4 (2014): 336–339. PMC. Web. 16 Jan. 2017.