Exercise-associated hyponatremia (EAH) has been well described in the literature, and its pathogenesis has been elucidated. The most common presenting symptoms of EAH are confusion or severe alterations in mental status. Although rhabdomyolysis in association with hyponatremia has been described in other settings, only 1 case of EAH associated with rhabdomyolysis at presentation has been previously described. In this article, we report on the occurrence of EAH with rhabdomyolysis in 4 athletes participating in the West Highland Way Race, a 95-mile endurance foot race. The pathogenesis of this association is described with implications for therapy.