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Rhabdomyolysis and Its Context within CrossFit StPete
For a bit now people have been forwarding this article and talking (often with alarm) about the dangers of the condition rhabdomyolysis (aka “rhabdo”) particularly associated with CrossFit. In simple terms rhabdo is the breakdown of muscle fibers that leads to the release of muscle fiber contents (myoglobin) into the bloodstream. Myoglobin is harmful to the kidney and often causes kidney damage. Things that can cause it:
· Alcoholism (with muscle tremors)
· Crush injuries
· Drugs, especially cocaine, amphetamines, statins, heroin, or PCP
· Genetic muscle diseases
· Heatstroke
· Ischemia or necrosis of the muscles (which may occur with arterial occlusion, deep venous thrombosis, or other conditions)
· Low phosphate levels
· Seizures
· Severe exertion, such as marathon running or calisthenics
· Shaking chills
· Trauma
· Symptoms:
· Abnormal urine color (dark, red, or cola colored)
· Decreased urine production
· General weakness
· Muscle stiffness or aching (myalgia)
· Muscle tenderness
· Weakness of the affected muscles
Now that we are through the basic knowledge of it, I will counter a bit of the article by Eric Robertson. First, I will say that the risk factor is there, but it is there with any other high intensity or high volume training program. His article fails to mention that there are mild cases and severe cases. Severe cases are very rare, even in CrossFit. On the other hand, mild cases are very common, not only in CrossFit, but in every type of fitness activity and sport. For example, after completion of a triathlon virtually every single competitor could be diagnosed with it from mild to severe, with severe being extremely rare. The truth is if you’ve ever played a physically demanding sport, or gotten pretty sore from a work out or just doing everyday tasks (a girl I knew from Europe got severely sore from walking around the mall, like unable to walk sore) you’ve probably had a mild case of rhabdo, if you would be checked for it.
After speaking with medical professionals involved with three cases of rhabdo outside CrossFit StPete, they acknowledge that the methods for determining if an incidence of rhabdo has occurred are pretty straight forward (checking the blood for the levels of an enzyme called creatine kinase). However, from there diagnosis and treatment of rhabdo varies considerably. The issue with diagnosis is that there is currently no clinically accepted standard for how much creatine kinase in the blood constitutes a rhabdo event. As a result, who has experienced rhabdo, how often, and how severely is up for debate and very relative depending on who makes the diagnosis. The apparent reality being that mild cases happen relatively frequently and are not dangerous at all. Check out this article for a more even handed explanation of Rhabdo… by someone who doesn’t have an axe to grind.
While no consistent measure is available for determining if rhabdo has happened to an Athlete, in our (limited and anecdotal) experience, it seems that workouts with a high volume of body-weight reps with a “negative” aspect can be a trigger for rhabdo. The WOD “Murphy” is a prime example: all body-weight, and high volume of pull-ups, push-ups, and squats. All those movements have a “negative” component during the eccentric phase. Those unprepared for “Murphy” or dehydrated prior to attempting this particular WOD are at risk.
Now let me get on to the next part of it as it relates to our gym, CrossFit StPete. Number one, we have never had a case of Rhabdo at our gym amongst the many, many (probably nearing 2000) people that have come through our doors since we opened in early 2008. We are one of the original 600 affiliates and we’ve taken measures from the outset to protect our people from all injury. In fact, our overall injury rate is low. This is because we have intelligent programming. If you read Robertson’s article, the workout described is hundreds of pushups and push presses. This doesn’t even make sense and I would never write something like that. Everything we do has a goal to accomplish. This is one reason why I don’t like people to change things around on our workouts. Everything I do is geared to make you better. I’m not out to exhaust everyone to death… any idiot can do that. I’m trying to hit the correct dose to make you better. This is why I don’t have a lot of long chippers in our training. I
think
know it is stupid. If you are someone from another gym who is constantly doing long chippers and little on the strength end, leave that place because your trainer is a buffoon. I do think there is a place for that sort of thing, but I train people up for things like “Murphy” when we PLAN to do it. I also adjust it for anyone I even think may not be able to do it safely. Bottom line, if I’m not sure, I don’t let them do it. That is why I start new people out EASIER THAN I THINK THEY NEED. I’m not worried about impressing them by how hard I can push them.
In regards to general injury (as well as Rhabdo), there are few things I look at when I design or choose workouts I look at what we are doing that day and basically build things that will help the main movement, which is always a basic lift: Snatch, Clean and Jerk, press, squat, deadlift, bench press. So on a snatch day we may do overhead squats, power snatches, or hang movements in the WOD combined with other movements that can help: Situps, toes to bar, etc; or general conditioning exercises: Running, rowing, double unders, wallball, box jumps. I then also try to make them as balanced as possible, in other words, not do hundreds of upper body pushing reps, but instead try to make a balanced body, much like body building strives for, this decreases the chances of imbalances and overuse injuries. I generally keep the reps under 100 for any give ‘type’ (upper body push, pull; lower body push, pull) and usually much less than 100. I also take into consideration the ‘danger’ level of the movement. Box jumps sometimes can cause Achilles tendons to snap (of course we teach them in a way they won’t, but imperfect things happen) so I don’t put them in more than once every few weeks and try to keep the repetitive reps at a lower level (can you do with 25 reps just as well as with 50? I think so). I also take into consideration what I’m planning to do for the rest of the week and month ahead. I’ve got it all planned out and I take a lot of time doing so. That is why I have hard weeks (red) medium weeks (orange) and easy weeks (yellow). Within those weeks I also have easy and hard days. So a red week won’t necessarily have a week’s worth of balls hard workouts. What this does allow you to hit hard workouts and recover and improve. I don’t throw “Murphy” in as a random workout. I plan ahead so people are prepared to hit it and what happens is they do well and never have a problem.
Here are some things you can do to avoid Rhabdo in our gym:
Be consistent. The most dangerous time for getting Rhabdo is when you’ve been in shape and take a lay off. When you come back you aren’t capable of doing what you did before muscularly, but mentally you
can and it is easy to overdo it. That is why I tell people to stay active on vacations. It doesn’t have to be at the same level, but you shouldn’t be sitting around doing nothing.
Don’t drink excessively. I don’t particularly drink. I’m armed wherever I go, so I don’t figure I need to be intoxicated at anytime. Plus I desire to be in top notch form all the time and it doesn’t correlate very well with my goals. Never know when zombies are going to come. But if you are going to do it, keep it moderate and don’t do it right before a hard workout.
Stay hydrated. I know for a fact that there are people in our gym who only drink water when they are at our gym. It’s time to grow up and make your main drink water. It’s really the only acceptable drink to have. Rizzo posted a paper showing levels of hydration determined by urine color on the walls of our bathrooms. Check them out, stay in the hydrated zone all the time. I have to drink about a liter of water to get rehydrated each morning. I doubt I’m an outlier in that.
Eat a good diet. Paleo is great. At a minimum you should be eating real non processed food mainly from meat, vegetables, and fruit. If your diet consists mainly of French fries and prepackaged food, you are doing yourself a disservice and have more dangerous and common things to worry about than rhabdo. But a shitty diet will put you in a good spot to have things going wrong.
Do the program. Don’t add extra workouts or exercises. Don’t go to the Globo Gym and try to do more (this is the number 1 cause of injury at our gym). Don’t do a different workout because you think one for the day is too easy. Don’t go out and try to run a marathon. Just do what I’ve got and strive for improvement. ALL of my best people just do the program. The ones who have the most problems are the ones to deviate from it.
My last soap box is on trainers. There are good and bad in the strength and conditioning field, coaching, personal training, nautilus training, jazzercize, cardio kickboxing, curves, and CrossFit. The bad thing is that the bad is more common than the good. I’ve been astounded at some of the idiots I’ve met coaching strength and conditioning at the college sports and professional sports level, and this isn’t on the sort of things that are merely opinion (you know like actually knowing that a clean is not a curl). But I’m not going to get on those, I’m going to get on CrossFit coaches because they are my peers. I want nothing but the best from this community because we are bringing something good to a generally shitty field. The problem is that there are some shitty people coaching in CrossFit, whether they think they will make a quick buck, or just aren’t competent enough to do it. Much of that is fixable, but it takes a level of desire most don’t have. Desire and passion is something I look for in potential trainers as well as a common outlook on what is important in training. I can teach the rest.
Long ago Greg Glassman said that the shortage isn’t in potential clients; the shortage is in competent, knowledgeable trainers. It was his aim to go out and change that. Sadly, to this day, the same is true. I think there are more good trainers, but the majority, in my experience, still sucks and a big problem is that the people who need help the most are the people who don’t know the good from the bad. My indicators for finding a good trainer:
-They understand programming and how it relates to physiology, strength and conditioning. As a result, they write their own program, not copy and paste Main Site or ‘do outlaw’ at their gym. They should be competent enough to write a well thought out program if they are teaching people.
- They can explain the reasons why they have you doing each exercise and in the amount they do them. They can (and frequently do) modify their basic program to fit an individual Member’s goals or limitations. This is more than just scaling the workout. Scaling is part of it, but other things should be taken into consideration than just the level of intensity and weight/reps used.
- They have a thorough knowledge of how to teach lifts and can explain the anatomy of the lift, what it does for your fitness, how to do the lift properly, and how to modify it for a specific Member so they can still get maximum benefit despite limitations. Or, they’re competent enough to have an individual avoid an exercise completely until the limitation is mitigated.
- They have some kind of foundations or on-ramp program to teach you the lifts and movements and make sure Members are safe and comfortable BEFORE throwing them into a general population/class format.
- The base of the program should be strength, if it isn’t, walk away. I’ve been doing strength based programs since about 2005, way before it was popular, before CrossFit Football, before strength biased program, and before Outlaw was around. I had been cussed out for it, told I’m an idiot, that I was doing CrossFit wrong, and other general nonsense. Now days it’s just considered doing CrossFit correctly. Don’t settle for METCON Junkies, it’s the best way to get hurt, whether it is general injuries, or Rhabdo.