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Rhabdomyolysis problem is real, and not unique to Haynesworth


Question: What do Redskins defensive tackle Albert Haynesworth and nearly two dozen football players from McMinnville High School in McMinnville, Ore., have in common?

Answer: If you said they're all acting like they're in high school, well, that's not the answer I was looking for. The correct response is that they all have rhabdomyolysis, which has kept them off the field.

This week, the sports viewing world was introduced to the tortuously named affliction, but it actually has deep roots in preseason football practice. In a nutshell, rhabdomyolysis, or "rhabdo," as some physiologists affectionately call it, is the massive breakdown of muscle cells.

A degree of muscle damage during exercise is completely normal, and in fact required for muscle building. When muscles are used, they are damaged and then rebuilt by the body to adapt to a greater workload. Think of the last time you did squats or bench presses at the gym after a long layoff. A day or two later, you were probably pretty sore. That's the calling card of muscle damage. But it's good muscle damage. It means that the muscles will be rebuilt bigger and better in an attempt to adapt to the stress to which you just subjected them.

The problem is that if the muscle damage is too extensive, as can happen in extreme rhabdomyolysis, it can be dangerous. When the muscle cells are broken, a protein called myoglobin leaks out from inside. Myoglobin takes oxygen out of blood as it passes through so that it can be used in the muscles for work. (In short: You breathe oxygen into your lungs... hemoglobin in the blood that's passing through the lungs snags the oxygen molecules.. the blood hurtles throughout the body to various muscles... as the blood goes by, myoglobin in the muscles snags oxygen from the blood... the blood then returns to the heart to be pumped back to the lungs, ad infinitum, until you die.) The massive amounts of myoglobin that are dumped into the bloodstream in extreme rhabdo are headed for the kidneys, which are not well-equipped to process the huge influx of protein. In potentially lethal cases of rhabdo, the myoglobin barrage can actually shut the kidneys down. Such severe cases generally come from, say, car accident victims who spontaneously undergo tremendous muscle damage.

But for all those times when announcers hyperbolically compare football collisions to car accidents, this is actually one where it's not terribly unreasonable. Football collisions can be considered mini-car-wrecks in which everyone involved ends up with some muscle damage, and some myoglobin headed toward their kidneys. And then add some additional stresses to that, like a heavy body and a hot workout environment, and the muscle breakdown can quickly go beyond the healthy range. Additionally, energy drinks that contain stimulants (caffeine included) can raise the body's core temperature and compound the heat stress. In fact, when football players die of heatstroke during preseason training, the actual cause of death can be kidney failure from rhabdomyolysis that is brought on or accentuated by an elevated temperature.

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So rhabdo is a very serious condition. But with no knowledge about the extent of Haynesworth's rhabdo, it's hard to say how valid a reason it is for having kept him off the field. In fact, some degree of rhabdo seems to be ubiquitous in NFL training camps. Sandra Fowkes Godek, director of the HEAT Institute at West Chester University in Pennsylvania, began studying Eagles players in the 2003 preseason. I saw some of the results of her work at the American College of Sports Medicine conference in New Orleans in 2007. The most striking part of her presentation were the photographs of urine samples collected from Eagles players. Some of the samples were so dark they could have been mistaken for Coca-Cola. That dark color probably comes from the myoglobin (perhaps from iron contained in myoglobin) as the kidneys work to get rid of it. The fact that there was enough myoglobin in the players' urine to turn it mahogany means that the kidneys were being overloaded.

"That color is a real clinical marker of rhabdomyolysis," Fowkes Godek said when I talked to her last year about heat illness, "which we know happens in professional football players in preseason in the heat." She added that she sees rhabdo "not just in the big guys, you see it in guys that are taking the most reps. They're either working really hard or hitting other players or getting hit. I'll see it to a higher degree in running backs, linebackers, defensive ends and safeties, guys that are physically mauling people or getting hit."

So chances are that Haynesworth is just one of scads of NFL players who have some degree of rhabdo. Whether or not it should be keeping him on the sideline is a matter of degree. In one sense, it's a tricky issue: Guy comes into preseason possibly overweight and in less-than-ideal shape, so the conditioning and game play that would get him into shape exposes him to the danger of more extreme rhabdo.

In the case of the McMinnville High School rhabdo cluster, players actually found themselves in a hazardous situation. If those athletes are like many high school football players, they probably had a relatively relaxing summer only to come in to preseason (perhaps a little heavy and out of shape) and start going all out and hitting in extreme heat.

A doctor in McMinnville has said that the players had spent some time working out in a wrestling room that was 115 degrees. Nineteen of the players subsequently tested for extremely high levels of the enzyme creatine kinase, which, like myoglobin, leaks out of damaged muscle cells in rhabdo. Three of the players were diagnosed with compartment syndrome, which is very rare in high school athletes, so three cases on one team in one week should (and did) raise eyebrows. Compartment syndrome is an illness in which extreme pressure builds up inside of an enclosed space (or compartment) in the body, such as an area where muscles are encased. In this instance, the syndrome, which squeezes nerves and impedes blood flow, caused swelling in the arms of the three players that had to be relieved by emergency surgery. And, to tie the medical story together, rhabdomyolysis can cause compartment syndrome.

It would seem that McMinnville High, which made national headlines with its compartment syndrome cluster, probably won't be hitting the 115-degree wrestling room again anytime soon. (Still, the exact causes of the medical problems faced by the players remain under investigation.)

Fowkes Godek told me that high school coaches should be especially aware that players who come into preseason training in poor shape or who are very heavy are at particularly high risk of rhabdo, and that the risk is compounded by high temperatures and the use of energy drinks or weight-loss supplements that contain stimulants that can raise body temperature. Of course, most cases of rhabdo, as evidenced by the Eagles players whom Fowkes Godek has studied for years, do not cause players to miss time. But the potential long-term effects of repetitive rhabdo are unknown. "I wonder whether there could be long-term kidney or even cardiac damage," Fowkes Godek said when we spoke last year. "It's one thing if [players] do it once or twice, and don't do it again, but I wonder about players who play in the Southeast, in Florida or Georgia, who play for years. Could that possibly have a long-term effect on major organs? That's something we don't know."