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Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy?
  1. Renata S Scalco1,
  2. Marc Snoeck2,
  3. Ros Quinlivan1,
  4. Susan Treves3,4,
  5. Pascal Laforét5,
  6. Heinz Jungbluth6,7,8,
  7. Nicol C Voermans9
  1. 1MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
  2. 2MH-investigation Unit, Department of Anesthesia, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
  3. 3Departments of Anesthesia and of Biomedicine, Basel University Hospital, Basel, Switzerland
  4. 4Department of Life Sciences, General Pathology Section, University of Ferrara, Ferrara, Italy
  5. 5Institut de Myologie, Hôpital Pitié-Salpêtrière, Paris, France
  6. 6Department of Paediatric Neurology—Neuromuscular Service, Evelina Children's Hospital, Guy's & St Thomas’ NHS Foundation Trust, London, UK
  7. 7Randall Division of Cell and Molecular Biophysics, Muscle Signalling Section, London, UK
  8. 8Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
  9. 9Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
  1. Correspondence to Dr Renata Scalco; r.scalco{at}


Exertional rhabdomyolysis is characterised by muscle breakdown associated with strenuous exercise or normal exercise under extreme circumstances. Key features are severe muscle pain and sudden transient elevation of serum creatine kinase (CK) levels with or without associated myoglobinuria. Mild cases may remain unnoticed or undiagnosed. Exertional rhabdomyolysis is well described among athletes and military personnel, but may occur in anybody exposed to unaccustomed exercise. In contrast, exertional rhabdomyolysis may be the first manifestation of a genetic muscle disease that lowers the exercise threshold for developing muscle breakdown. Repeated episodes of exertional rhabdomyolysis should raise the suspicion of such an underlying disorder, in particular in individuals in whom the severity of the rhabdomyolysis episodes exceeds the expected response to the exercise performed. The present review aims to provide a practical guideline for the acute management and postepisode counselling of patients with exertional rhabdomyolysis, with a particular emphasis on when to suspect an underlying genetic disorder. The pathophysiology and its clinical features are reviewed, emphasising four main stepwise approaches: (1) the clinical significance of an acute episode, (2) risks of renal impairment, (3) clinical indicators of an underlying genetic disorders and (4) when and how to recommence sport activity following an acute episode of rhabdomyolysis. Genetic backgrounds that appear to be associated with both enhanced athletic performance and increased rhabdomyolysis risk are briefly reviewed.

  • Muscle damage/injuries
  • Exercise
  • Training
  • Neuromuscular

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