CASE REPORT Severe localized scapular Editor’s key points With the rising popularity of ultra- pain after a strenuous distance endurance events, strength and conditioning programs, and obstacle course races, exertional weight-lifting session rhabdomyolysis (ER) has become increasingly common in sporting Rosamond E. Lougheed Simpson MD MSc CCFP(SEM) DipSportMed communities. Steven R. Joseph MD MA CCFP(SEM) DipSportMed Lisa Fischer MD CCFP(SEM) FCFP DipSportMed Exertional rhabdomyolysis is often characterized by the classic triad habdomyolysis is a medical condition whereby the intracellular con- of generalized weakness, myalgia, tents from damaged skeletal muscle tissues are released into the blood, and myoglobinuria; however, it is critical to recognize that many cases causing myriad clinical symptoms and outcomes. These can range will not present with all 3 of these Rfrom muscle pain to compartment syndrome, end-organ failure, and death.1-3 criteria. For the male patient in this While the triggers of rhabdomyolysis are numerous, physical exertion as a report, severe myalgia was his only presenting symptom from the triad. causal factor has been receiving increasing media attention recently.4-7 The incidence of exertional rhabdomyolysis (ER) has been challenging The ability to recognize ER, stratify 8 patients into low- and high-risk to estimate, as many cases are likely underrecognized. Current incidence categories, and understand how estimates range from 22.2 to 29.9 per 100 000 patients a year.9,10 As ultra- risk affects patients’ return to play distance endurance events, strength and conditioning programs (eg, CrossFit), can help family physicians make treatment, referral, and return- and obstacle course races have become wildly popular with the superfit to-play decisions with increased and weekend warriors alike, ER is being increasingly recognized as common confidence. This article offers an in sporting communities.1 It is paramount that family physicians be adept at algorithm that outlines appropriate ER management based on the most recognizing and managing ER, identifying those who warrant further labora- widely accepted practices. tory workup, and providing return-to-play (RTP) counseling (Figure 1).1,10,11 We report the case of a 29-year-old white man who presented to a Points de repère Canadian emergency department (ED) with severe localized scapular pain du rédacteur following an uncharacteristically strenuous weight-lifting workout. He was Compte tenu de la popularité diagnosed and treated for ER secondary to his workout. grandissante des épreuves d’endurance d’ultra-distances, des programmes de musculation et Case de conditionnement, de même A 29-year-old man (178 cm tall, weighing 99 kg) presented to the ED follow- que des courses à obstacles, la ing acute onset of right posterior shoulder pain the night before. Pain was rhabdomyolyse d’effort (RE) est devenue de plus en plus fréquente localized along the scapular spine and was severe, with the patient rating dans le monde des sportifs. it a 9 out of 10 on the pain intensity scale. The pain had started a few hours after an unusually strenuous workout, involving many bench press repeti- La rhabdomyolyse d’effort se reconnaît souvent par la tions with heavy weight. He did not experience an atypical amount of dis- traditionnelle triade de faiblesse comfort while performing these exercises, and did not have pain elsewhere généralisée, myalgie et myoglobinurie; worse than that expected postworkout. However, his scapular pain was par ailleurs, il est essentiel de reconnaître que de nombreux cas ne different and worse than any pain he had experienced previously, which se présenteront pas avec l’ensemble prompted him to go to the ED. des 3 critères. Dans le cas du patient He was a previously healthy former elite athlete, with no history of illicit drug dont il est question dans ce rapport, le seul symptôme de la triade présent use or personal or family history of metabolic myopathy. The patient treated était la myalgie sévère. himself with nonsteroidal anti-inflammatory drugs and ice, with little relief. L’habileté à reconnaître la RE, à His vital signs at triage were normal. Physical examination of his right shoul- stratifier les patients selon qu’ils der revealed range of motion and generalized pain equal to that of the unaf- sont à risque faible ou élevé, et à fected side. Palpation of the scapular spine was painful, and the area was mildly comprendre comment le degré de risque influe sur le retour au jeu des erythematous and swollen. He noted no change in urine colour or frequency patients peut aider les médecins de and had been fully ambulatory since his pain began. Findings of the remainder famille à prendre des décisions avec of the review of systems and physical examination were unremarkable. plus de confiance en ce qui concerne le traitement, une demande de Given the severity of the patient’s muscle pain, visible localized swell- consultation et le retour au jeu. Cet ing of the proximal upper extremity around the scapula, and his history of article présente un algorithme qui weight lifting the previous day (which was in excess of his normal num- explique la prise en charge appropriée de la RE en se fondant sur les ber of repetitions), bloodwork was ordered to investigate possible meta- pratiques les plus largement acceptées. bolic myopathy. Initial bloodwork revealed a creatine kinase (CK) level of 32 290 U/L. The extended electrolyte panel results, complete blood count, Vol 65: OCTOBER | OCTOBRE 2019 | Canadian Family Physician | Le Médecin de famille canadien 719 CASE REPORT Figure 1. Treatment and risk stratification algorithm for appropriate ER management and RTP decisions, based on the most widely accepted practices Conduct initial patient assessment • History taking • Physical examination • Laboratory work, as appropriate Diagnosis of ER • Rule out complications of ER • Investigate and treat as required Stratify based on risk Low risk if ... High risk if ... • Rapid clinical recovery and normalization of CK • Delayed recovery (> 1 wk) levels following exercise restriction • Persistent elevation of CK levels despite resting for 2 wk • Reasonably fit or well trained athlete with a history • Peak serum CK level > 100 000 U/L of intense training • AKI to any degree • No personal or family history of rhabdomyolysis • Personal or family history of recurrent muscle cramps, • Existence of ER cases among other group or team sickle cell trait, or malignant hyperthermia members participating in the same exercise sessions • Muscle injury following low-moderate workout activity • Suspected or documented concomitant viral illness • Personal history of serious heat injury • Ingestion of drug or supplement that might contribute to development of ER RTP phase 1 • Rest for 72 h • Maintain oral or IV hydration • Encourage 8 h of sleep nightly • Remain in thermally controlled environment if ER is related to heat illness Repeat serum CK and UA tests after 72 h Remain in phase 1; reassess in 72 h Have CK levels dropped below 5 times If CK levels remain the ULN, and are UA results negative? No elevated or UA results remain abnormal for 2 wk Yes RTP phase 2 Consult with a neuromuscular specialist • Begin light activities; no strenuous activity • For appropriate additional workup, • Engage in physical activity at own pace or intervention, and RTP as able, based on distance customized risk mitigation strategies • Follow up with care provider in 1 wk Have symptoms returned? Yes Remain in phase 2 Is persistent muscle No and reassess in 1 wk pain present for > 4 wk? Yes RTP phase 3 • Gradual return to regular sport or No physical training • Follow-up as needed AKI—acute kidney injury, CK—creatine kinase, ER—exertional rhabdomyolysis, IV—intravenous, RTP—return to play, UA—urinalysis, ULN—upper limit of normal. Data from Szczepanik et al,1 Tietze and Borchers,10 and O’Connor et al.11 720 Canadian Family Physician | Le Médecin de famille canadien Vol 65: OCTOBER | OCTOBRE 2019 CASE REPORT and bicarbonate, creatinine, and troponin levels which might occur in cases of rhabdomyolysis.15 Acute were normal. Urinalysis results were positive for kidney injury is assumed in those patients who are trace of blood. anuric or oliguric despite fluid resuscitation, and this can He was admitted to hospital for ER. He was moni- occur in 13% to 50% of cases of rhabdomyolysis from tored for acute kidney injury and treated with intrave- all causes.16 In these patients, hemodialysis or continu- nous normal saline, targeting a urine output of 100 to ous renal replacement therapy might be indicated, the 200 mL/h. His CK level peaked at 62 350 U/L 4 days details of which are beyond the scope of this article, but after hospital admission. which are explained elsewhere.16 Seven days after admission he was discharged, with a CK level of 9635 U/L and otherwise normal Algorithm bloodwork results. His scapular swelling was noted to Figure 11,10,11 helps to outline the management of ER dissipate with dropping CK values. He was instructed and to identify patients who should be referred for addi- to consume more than 2 L of water daily, and to tional laboratory workup. It incorporates criteria recom- avoid strenuous exercise over the next week. He mended by Szczepanik et al1 for stratifying patients into returned to activity gradually without complications. high- and low-risk categories. This stratification identi- fies who should be referred for consultation and inves- Discussion tigation of potential underlying conditions. The figure A PubMed search was completed using the MeSH terms also integrates guidelines for RTP, as proposed by the rhabdomyolysis, exertion, and creatine kinase. Articles Consortium for Health and Military Performance, with that were published in languages other than English, the goal of increasing clarity and confidence among that were published more than 5 years ago, or that health care providers regarding management decisions included patients younger than age 16 were excluded.