Authors: Benjamin H. Gleason1, Katherine N. Alexander1,2, and M. Catherine Fontenot3

1Department of Kinesiology, Louisiana Tech University, Ruston, LA, USA
2Department of Human Development and Family Studies, Utah State University, Logan, UT, USA
3Department of Human Ecology, Louisiana Tech University, Ruston, LA, USA

Corresponding Author:
Benjamin H. Gleason, PhD, CSCS*D, RSCC, USAW-2
P.O. Box 3176
Ruston, LA, 71270
[email protected]
334-546-1872

Benjamin H. Gleason, PhD, CSCS*D, RSCC, USAW2 is an Assistant Professor of Kinesiology at Louisiana Tech University in Ruston, LA. His research interests focus on methods of enhancing sport performance, professional roles found within high performance sport, and athlete monitoring.

Katherine N. Alexander, BS, is a Human Development and Family Studies doctoral student at Utah State University in Logan, UT.  Her research interests include developmental impacts of early sport-specialization on athletes and social support systems associated with sport participation.

Mary Catherine Fontenot, PhD, RD, LDN, is an assistant professor of nutrition and dietetics in the Department of Human Ecology at Louisiana Tech University in Ruston, LA. Her research interests include food insecurity and its impact on health, nutrition, and aging.

Exertional Rhabdomyolysis in a Female Collegiate Powerlifter with Type-1 Diabetes

ABSTRACT

Purpose: Investigate a case of exertional rhabdomyolysis (ER) in an athlete with Type-1 diabetes. Methods: The athlete shared relevant details from her training notebook, food journal, and medical information from the event with the researchers in a series of in-person interviews and electronic communications. The athlete’s food journal data was evaluated by a Registered Dietitian Nutritionist using computerized nutritional analysis program. The training program was evaluated by a Certified Strength and Conditioning Specialist in collaboration with the athlete to determine the precipitating factors for the injury. Results: Insufficient preparatory training, insufficient recovery, insufficient protein, and insufficient caloric intake were likely contributors to this ER injury. High caffeine intake, training in hot weather, and mild dehydration are also potential factors to an unknown extent. Conclusions: A well-organized, progressive return to heavy training is necessary to avoid musculoskeletal injury. In addition, athletes require appropriate nutrition to support the demands of heavy training and post-exercise recovery. While difficult to assess the extent at this time, athletes with diabetes could be at a higher risk for injury because of their health condition. Therefore, careful attention should be given to details of training, diet, glucose monitoring, and medication regimen, with supervision and education provided by trained professionals. Applications in Sport: This case study identifies specific precipitating factors of a rare case of exertional rhabdomyolysis in an athlete with type-1 diabetes. Knowledge gained from this case may be used to help other athletes prevent injury.

Key Words: resistance training, return to training, sport nutrition

INTRODUCTION

Rhabdomyolysis is a dangerous medical condition that generally produces myalgia, muscle weakness, and myoglobinuria; it may lead to several conditions, such as acute kidney failure, compartment syndrome, and blood clotting issues (33). Exertional rhabdomyolysis (ER) is typically brought on by acute exposure to severe muscle trauma during physical activity (9, 18). While a wide variety of muscle-damaging causes of exertional and non-exertional rhabdomyolysis are well-documented in non-athletic populations, it is frequently attributed to acute increases in exercise volume paired with heavy density of intense exercise that the athlete was not properly prepared for by progressive conditioning practices (see 32). A host of possible complicating circumstances exist, including and not limited to: dehydration (16), hyperthermia and heat stroke (18), poor diet (3), extreme pre-competition weight cutting (28), medications (16), and genetic conditions such as sickle cell trait and several single nucleotide polymorphisms (10, 18). In addition to the above complications, metabolic diseases such as diabetes mellitus (DM) may work independently or in combination with the above variables to make individual athletes more susceptible to ER injury at certain times.

Athletes with type-1 diabetes mellitus (T1DM) must practice good blood glucose control by daily monitoring of their values and eating a well-balanced diet. Given the nature of their health condition and the impact eating, training, and competition can have on blood glucose levels (35), they are potentially at greater risk for developing injuries of all types, but particularly, ER. To date, a direct relationship between risk of ER for T1DM sufferers has not been well established, and case reports of athletes with diabetes who experience ER are uncommon. Only three reports exist to the authors’ knowledge, with multiple risk factors presented in each case. One report involves a 23-year old male with T1DM who reported to the emergency department with symptoms of ER one week after resuming a weight training regimen, of which the specific training details were not reported (34). The attending physicians identified a mitochondrial disorder in the patient based upon a mutation to A3243G mitochondrial DNA, to which they associated the cause of injury. Another report involved a 27-year old male with T1DM who was transferred to the emergency department after experiencing severe hypoglycemia and seizure activity while racing in a marathon (14). The patient had experienced a severe episode of nocturnal hypoglycemia the night before the race and complained of severe myalgia within a day of being admitted to the hospital. The attending physicians identified hypoglycemia-induced seizures and intense physical activity as the primary factors leading to ER. Similarly, another report involved a 22-year old male with T1DM who reported worsening symptoms of rhabdomyolysis after severe caloric restriction and high volumes of exercise (31). The attending physicians identified uncontrolled brittle diabetes, caloric restriction, and intensive exercise as the potential factors contributing to the injury but did not classify the event as exercise-induced.

Though these ER events may appear to be unusual, previous research suggests that complications of T1DM may cause some degree of exercise intolerance. For instance, diabetic ketoacidosis (DKA) and other complications of poorly controlled diabetes mellitus such as abnormal blood glucose and hyperosmolarity can be directly responsible for muscle tissue damage and non-exertional rhabdomyolysis (1, 5, 24). Damage may be exacerbated during intense exercise due to dehydration and glucose metabolism. Furthermore, diabetic myopathy causes physiological changes that create bioenergetic inefficiencies within muscle tissue and impaired recovery ability (11, 30). Investigating the circumstances of ER injuries observed in DM sufferers may provide valuable information about how the complications of DM may possibly lead to exercise intolerance and a greater risk of ER injury. In addition, establishing a more complete understanding of circumstances surrounding ER events may aid the coach, athlete, and clinician to implement effective training, injury prevention, and injury management strategies. Accordingly, the purpose of this rare case report (27) is to present details of a case of ER in a 19-year-old female athlete with T1DM.

METHODS

Participant

The athlete in this case study was a 19-year-old female collegiate powerlifter with T1DM (height: 1.6 m, body mass at time of injury: 61.2 kg) who experienced an ER injury returning to training following a period of inactivity. The athlete had a 16-year history of T1DM and reported no known complications from the disease. She had previously been a competitive soccer player and had a 3-year resistance training history, but she was fairly new to competitive powerlifting (10 months experience, totals: squat—132.5 kg, bench press—47.5 kg, deadlift—110 kg). Her medication regimen is listed in Table 1. She used insulin pens to manage her diabetes and had a history of elevated blood glucose levels (HbA1C ranges: 7.0-8.5 %).

TABLE 1: Medication Regimen

MedicationDosageFrequency
Lansoprazole20 mgonce daily, evenings
Montenuklast10 mgonce daily, evenings
Norethindrone-E.Estradiol-Iron1 mg / 0.02 mgonce daily, evenings
Toujeo/ insulin glargine12-13 unitsonce daily, evenings
Humalog/ insulin lisproup to 15 units, as needed based on insulin to carbohydrate ratiosat least three to five times daily, given before meals and as needed
Bio E with selenium400 IU vitamin E 100 mcg seleniumonce daily, evenings
Electrolyte pills400 mg calcium 2 mg iron 150 mcg iodine 290 mg magnesium 1,370 mg chloride 270 mg sodium 570 mg potassium 88 mg sulfate 2 mg lithium 1 mg borononce daily, evenings

Data Collection and Analysis

The Institutional Review Board at Louisiana Tech University approved the methods of this case report. The athlete was recruited by the investigators and provided informed consent to participate in the study. The athlete had maintained a detailed training notebook and food journal using the online tool myfitnesspal.com. Through interviews and electronic communication, the athlete provided the researchers with specific details of activities leading up to the injury and medical diagnosis of ER. A Certified Strength and Conditioning Specialist (CSCS) and Registered Dietitian Nutritionist (RDN) evaluated the details of training and diet, respectively, and made professional assessments of the likely precipitating factors for developing ER.

The ER injury was localized to the abdomen; therefore, the total volume of abdominal exercises was calculated using Microsoft Excel (Excel for Mac Version 16, Microsoft, Redmond, WA) to assist with visual interpretation of progression of training (Figure 1). Historical food journal entries of meals, snacks, and beverages recorded by the athlete were given to the RDN to analyze the athlete’s nutritional intake.

The athlete documented her meals, snacks and beverages starting on May 1 through June 20, 2018 with the intent to closely monitor her intake to assist her move to a lighter weight class. The RDN transferred the athlete’s food journal entries from MyFitnessPal into ESHA Food Processor software (ESHA, Salem, OR) to more accurately analyze the subject’s nutritional intake. The recorded meals, snacks and beverages were reviewed, and a qualitative approach was used to determine the number days that would accurately reflect the subject’s consumption over the 6.5 weeks her food and beverages were recorded. Day 1 through Day 10 represented 20 % of the total days documented and were used to obtain an average of total calories and grams of macronutrients consumed during the 45-day period. Over this time, the athlete displayed a very disciplined food and beverage meal pattern with little deviation. In a discussion with the RDN, the athlete indicated that the slightest deviation from the foods typically consumed often negatively affected her blood glucose levels. After Day 10, the subject’s meal combinations and types of snacks and beverages began to consistently repeat through the remaining 35 days of the food journal documentation. Therefore, it was determined that it was unnecessary to analyze all 45 days provided for review due to the consistency of her eating habits.

The average of the total calories consumed per day as well as the macronutrients were determined and then compared to the athlete’s estimated nutritional needs. As a reference point, the athlete’s resting energy expenditure (REE) was calculated using her body mass at the time of injury (61.2 kg). The estimated total daily calorie range was determined using the Mifflin St. Jeor resting metabolic rate (RMR) formula (25), and REE was calculated using the 1985 World Health Organization technical report; this figure was then multiplied by the activity factor (2.0) for strength athletes undergoing vigorous training (13). In addition, the recommended macronutrient distribution for strength-power athletes performing combined training (13) was applied (see Table 6). To complete caloric intake recommendations, 500 kilocalories per day were subtracted from the total to target a 1-2 lb weight loss per week, which was aligned with the athlete’s weight class goals. A conservative approach was used to calculate the athlete’s caloric needs because she had restricted her intake for an extended period of time. No laboratory values were available to validate malnutrition, so the RDN remained conservative in estimating nutritional needs, maintaining careful consideration of the athlete’s medical history, daily glucose levels, food and beverage intake, and physical activity.

In addition to training and nutritional details above, historical blood glucose readings were obtained from the athlete’s continuous glucose monitor (Dexcom G6, DexCom, Inc., San Diego, CA). To investigate the potential of heat stress as a factor in injury, specific historical environmental conditions were obtained from the local weather station’s online records.

RESULTS

Recent Training Overview and Analysis

In order to meet competitive goals, the athlete had successfully reduced her body mass from 64.9 kg to 53.6 kg over a 3-month period prior to the ER injury. Over that time period, she was participating in a training regimen involving frequent maximal loading to prepare for a national-level collegiate powerlifting competition. After the powerlifting competition on April 19, she took a break from training and was sedentary for 35 days. Her body mass increased from 53.6 kg to 61.2 kg in this time frame. She participated in a reconditioning training regimen (for cardiovascular training see Table 2) featuring lighter loads (up to 70% of 1-repetition maximum (1RM)) and training volume from May 24 to June 2 (Table 3), then transitioned to a higher volume of training on June 4 (Tables 4 and 5).

TABLE 2: Cardiovascular Training

DateExercise/machineSetsReps/DurationIntensity
24-Mayelliptical11 hrmoderate
28-Maybike120 minlight
29-Mayelliptical140 minlight
30-Mayelliptical130 minmoderate
 bike130 minlight
31-Mayrun1100mmoderate
 1200mmoderate
 1300mmoderate
 1400mmoderate
 5-Junbike150 Calhigh
 7-Junhill run8200 mhigh
 sled drags1400 m90 lb
 9-Junrun125 minlight
 striders8100 ydmoderate
run125 minlight

Beginning on June 4, she started powerlifting training 3 times per week, with individualized CrossFit training sessions 3 times per week. She did intermittent cardiovascular training including various high-intensity interval training (HIIT) workouts twice a week and ran longer distances twice per week. From June 4 through June 9, she worked out every day. She began experiencing extreme fatigue and soreness on June 10, so she performed only two workouts that week.

TABLE 3: Week 1 Resistance Training & CrossFit Workouts

DateExerciseSetsRepsIntensity (%1RM)Weight (lb)
24-Mayunrecorded workout – – – –
      
28-Mayclose stance high bar squat41067155
 high bar Olympic squat3860145
 leg press320 –
 walking lunges312 20
 lateral lunges310 25
 leg curls310 10
 kettlebell side bends420 20
 forearm band rolls3xfront & back25 
 air squats1100  
      
29-Mayair squats1100 –
      
30-Mayair squats1100 –
 close grip bench press2875-7775
 close grip bench press2870-7365
 spoto press367575
 cable chest flys312 10
 lat pulls510 40
 cable low row410 50
 front deltoid raises410 6
 tricep kickbacks415 5
 tricep 1-arm complex415 5, 3.5
 tricep diamonds415 12.5
 tricep rope pulldowns415 15
 bicep curls415 8
 crunches160 –
  165 –
 6 inches360s –
 toe-touches340 –
 reverse crunches335 –
 crunches170 –
      
1-Junfront squat3665125
 deficit deadlifts4670175
 rack pulls3488245
 hip abduction-adduction312 80, 95
 banded hip thrusts325 –
 leg extension412 85
 leg curls310 10
 air squats1100 –
 fat grip curls310 15
 hammer curls310 15
      
2-Junpause bench press457575
 close grip bench press287065
 single arm lat pulls310 30
 cable chest flys510 15
 front deltoid raises310 6
 tricep 1-arm complex412 7.5, 3
 tricep diamonds412 15
 tricep rope pulldowns412 12.5
 bicep curls412 8

The athlete trained in two different indoor facilities. She did powerlifting workouts in an air-conditioned gym (» 22 °C) and did CrossFit training in a warehouse (» 27 °C). When she did HIIT workouts, they were performed outside during the middle of the day (31-32 °C, 51-52 % humidity). When she ran longer distances, she ran in the morning (20-27 °C, 79-100 % humidity).

The most demanding abdominal exercise was performed on June 7. This was 3 sets of 10 repetitions of weighted (20-lb dumbbell held with arms overhead) sit ups on a glute-ham developer rack (GHD sit ups), in which the bottom of the range of motion involved a back-hyperextended position at hip extension with the weight brought down to the floor, and the top of the range of motion involved hip flexion. Though it was preceded by several other exercises (3 sets of 10 seated leg raises and 3 sets of 40 flutter kicks), the athlete perceived the GHD sit ups to be the specific exercise that induced the most muscle damage leading to ER. This is a reasonable conclusion due to the loaded eccentric component, which is a substantial stressor in this exercise. Within 24 hours following the workout on June 7 (Table 4), the athlete experienced pain and cramps in her anterior abdomen, specifically in the rectus abdominus musculature, but did not immediately seek treatment. She sought medical intervention on June 14.

TABLE 4: Week 2 Resistance Training & CrossFit Workouts

DateExerciseSetsRepsIntensity (%1RM)Weight (lb)
4-Junclose stance high bar squat41070165
 high bar Olympic squat3865155
 leg press320 –
 walking lunges312 20 (fat grip)
 lateral lunges310 25
 kettlebell side bends420 25
 air squats1100  
 1-legged squat125 ea. leg  
 crunches160  
  165  
 6 inches360s  
 toe touches340  
 reverse crunches120  
      
5-Junring rows515-20  
 Arnold press115, 12, 10, 8, 8 5 (10 for last set)
 jumping eccentric pullups55  
 kettlebell rotations520 15
 GHD sit ups150AFAP# 
 back extensions 50AFAP 
 iron scap crossover115 2.5
      
6-Junair squats150  
 close grip bench press168575
  367565
 spoto press367575
 cable chest flies312 15
 lat pulls510 40
 cable low row410 50
 front deltoid raises410 7
 tricep kickbacks315 5
      
7-Junkettlebell overhead carry4100m unknown
 kettlebell suitcase carry4100m unknown
 bent over barbell rows48 35
 sitting leg raises*310  
 flutterkicks*340  
 GHD sit ups*310 20
      
8-Junbarbell press max  10055
 snatch max  10090
 clean & jerk max  10075
 front squat3665125
 paused deadlifts4670205
 leg press36 75
 hip abduction-adduction320 95, 105
 banded hip thrusts325  
 leg curls310 10
 air squats1100  
 dumbbell forearm holds420-30sec 15

Note. Bold* indicates the exercise that was thought to primarily induce rhabdomyolysis;
*possible contributor to severity of injury; #AFAP: as fast as possible.

TABLE 5: Week 3 Resistance Training & CrossFit Workouts

DateExerciseSetsRepsIntensity (%1RM)Weight (lb)
11-Junclose stance high bar squat410, 10,9,875175
 high bar Olympic squat3665155
 leg press320 last rep with 25
 walking lunges312 20
 lateral lunges310 35
 air squats1100  
 dumbbell grip320-30 sec 15
      
12-Junring rows412 ––
 Arnold press115, 12, 10, 8, 8 –5 (10 for last 2 sets)
 jumping eccentric pullups54 ––
 KB rotations125 ea leg –25
 situps*315  

Note. Training halted due to hospital admission (June 14);
*possible contributor to severity of injury

Nutritional Analysis

The food journal information indicated that the athlete routinely consumed insufficient energy and macronutrients to support her needs, especially following training (Tables 6 and 7). Insufficient calorie intake may have prevented optimal glycogen store repletion and impaired muscle repair and growth. Repeated pairing of insufficient energy consumption and vigorous physical activity potentially contributed to muscle tissue being used for energy to support her training demands. Because of the possibility that protein from her muscle tissue was used for energy in lieu of adequate calorie intake, a larger risk of rhabdomyolysis may have been present.

TABLE 6: Sample Diet from June 7, 2018

Food ItemServing SizeEnergy (kcal)
Breakfast277
Blueberries0.5 cup 
Jif unsweetened peanut powder1 Tbsp 
Red Mill oats0.38 cup, dry 
Starbucks doubleshot espresso192 mL 
Lunch516
Chocolate Premier Protein325 mL 
Libby’s peas and carrots1 cup 
John Soules chicken breast with rib meat85 g 
Minute brown rice1 cup 
Snacks603
Anderson peanut butter pretzels16 pieces 
Dried mushroom pieces10 pieces 
Starbucks doubleshot espresso192 mL 
Luna chocolate chip cookie granola bar1 bar 
Total daily energy intake 1,396

TABLE 7: Estimated Nutritional Needs vs. Actual Consumption

 Kcal/dayCarbohydrateProteinFat
Estimated Needs2,400 ± 2006-10 g/kg1.4-2.0 g/kg0.87-1.32 g/kg
Target Macronutrient Distribution 50 %30 %20 %
Minimum Recommended Intake2,200367 g86 g53 g
Average Daily Intake (% of Minimum)1,048 (47 %)150 g (41 %)60 g (70 %)24 g (45 %)

The athlete also consistently consumed at least five cups of black coffee each day in order to boost her metabolism. She also drank 2 L of water per day habitually and increased up to 3 L of water per day according to thirst. She had trained for 3 consecutive days prior to the training session in which the injury likely occurred (June 7th), and the resistance training session was preceded by a series of outdoor hill sprints. Insufficient information is available to determine actual hydration status over this time frame. Because her sweat rate and data indicating a specific body mass change on the day of injury were not available, dehydration remains a potential influence in this case to an unknown degree.

Hyperglycemia

From May 1st, 2018 to June 20th, 2018, the athlete’s time in range (TIR) was 41 %, her time above glucose target range (TAR) was 58 %, and her time below target glucose range (TBR) was 1 %. Current recommendations suggest at least 70 % TIR (2), therefore the athlete spent more TAR than is recommended for health reasons. Further suggesting hyperglycemia, her most recent HbA1C directly after the incident was 8.5 % (obtained on June 21st).

Medical Diagnosis of ER

Upon admission to the emergency room on June 14th, she reported nausea, stomach swelling, and a sharp pain in her abdomen. Her blood pressure was 113/77, and her pulse was 62. Initial differential diagnosis included non-specific abdomen pain, peritonitis, pyelonephritis, and ureterolithiasis. Ketones were not present in the urine, and all other values were normal. A CT scan and blood tests were ordered (see Table 8). The CT scan was normal; however, CK was 2,302 U/L, exceeding the ER diagnostic threshold of 1,000 U/L (23). She was diagnosed with ER by the attending physician and started on a saline drip. Her CK dropped to 447 U/Lby June 17th, and her blood glucose remained somewhat elevated. Her renal function remained stable, and she was discharged on June 17th. Her CK continued to decrease over the next several days (225 U/L on June 19th and 57 U/L on July 3rd).

TABLE 8: Laboratory Test Results Following Injury

Blood Chemistry14-Jun15-Jun16-Jun17-JunNormal Ranges
CK (U/L)2302↑1242↑697↑447↑26-192
Non-fasted Glucose (mg/dL)209↑234↑224↑298↑74-106
BUN (mg/dL)118997-18
Creatinine (mg/dL)0.70.70.71.00.4-1.7
BUN to Creatinine Ratio1611↓139↓12-20
Sodium (mmol/L)139139140137136-145
Potassium (mmol/L)4.04.24.24.03.5-5.1
Chloride (mmol/L)104108↑10510498-107
Carbon Dioxide (mmol/L)27.926.328.722.821-32
Anion Gap7.14.7↓6.3↓10.27-13
Calcium (mg/dL)8.98↓8.68.4↓8.5-10.1
Total Protein (g/dL)7.05.6↓6.7 6.4-8.2
Albumin (g/dL)3.3↓2.5↓3.0↓ 3.4-5.0
AGRT111 1
Aspartate aminotransferase (U/L)77↑46↑40↑ 15-37
Alanine aminotransferase (U/L)93↑7174 12-78
Alkaline phosphatase (U/L)41↓35↓39↓ 46-116
Bilirubin total (mg/dL)0.20.20.3 0.2-1.0

Note. ↓ indicates a result lower than normal; ↑ indicates a test value higher than normal

DISCUSSION

Several cases of ER localized to the abdomen have been reported in apparently healthy individuals. For example, Boyle and colleagues (4) reported two cases of female adult patients who had experienced ER in the rectus abdominus musculature after performing 100 sit ups at home in one case (CK levels 6 days after = 15,000 U/L), and an unknown number of sit ups in a “boot camp” fitness class in the other (CK levels 6 days after = 38,000 U/L). Another case of abdominal ER was reported by Haas and Bohnker (15), featuring details of a 23-year old active duty sailor who had resumed a weight training regimen and performed an unknown number of abdominal exercises. During his emergency room visit a diagnosis of right upper wall ER was made (CK 4 days after = 53,000 U/L). In addition, a case of abdominal ER was reported by Kao and colleagues (20) following performance of 30-40 sit ups for 5 successive days by a 29-year old previously sedentary man prior to the hospital visit (CK levels 1 day after = 12,586 U/L).

Although little research has explored the relationship between DM and ER, current insights into the complications of DM support the idea that diabetes may cause some unknown amount of exercise intolerance that could increase the potential for ER compared to an individual with normal pancreatic function. It is possible that intense exercise outside normal physiological conditions amplifies the effects of muscle damage that occurs during intense exercise. Long and colleagues (23) suggested that “exercise/overexertion” constitute a significant number of ER cases in the United States and noted that acquired causes comprise around 75 % of rhabdomyolysis cases.

The relationship between non-exertional rhabdomyolysis and a variety of ailments have already been established within the medical community (18, 23). The presence of complications such as diabetes necrosis suggests that poorly controlled blood glucose—specifically hyperglycemia—can directly cause severe muscular damage in animal studies (22). Other complications that seem to occur regardless of HbA1C status include vascular dysfunction and diabetic myopathy (11), which in combination with bioenergetic changes have the potential to cause exercise intolerance within DM sufferers and undermine recovery (30). Poorly controlled diabetes may increase risk of developing ER, for instance due to development of diabetic ketoacidosis (DKA). Some evidence exists of athletes with DM intentionally maintaining high blood glucose in order to prevent hypoglycemia, which may be a source of higher HbA1C and challenge long-term health (17). Our data suggest that our athlete may have also intentionally maintained high blood glucose levels, as she spent 58 % of her time above recommended blood glucose levels (TAR) during this period and demonstrated an HbA1C reading of 8.5 %.

Dietary analysis clearly demonstrates that the athlete did not properly transition to a normal caloric intake from her pre-competition weight cutting phase, and she continued to follow a similar low-calorie diet plan during her time off and into her return to training. While laboratory values were not available to definitively determine if the athlete was specifically protein-calorie malnourished, self-reported food journal entries indicate that she routinely consumed insufficient energy to support her overall nutritional needs, especially during recovery (Table 6). Of particular concern was her low protein consumption, which was only 70 % of the recommended minimum recommended for a strength-power athlete in a heavy training phase (13). Over time, this would have impaired her muscle tissue repair and growth (19). In addition, she consumed only 41 % of her minimum carbohydrate needs, restricting her ability to train at maximum effort and support glycogen repletion during recovery (19). Over time, food restriction over time alters energy metabolism (26), and as such, the athlete’s metabolic processes may have adapted. The cortisol response tends to increase in the underfed state, and an increase in cortisol shunts metabolism from carbohydrate to other energy sources, including stored fat and protein (from muscle tissue) for energy (21). Of note, poor nutrition was a factor in one other ER injury, in which a swimmer followed a poorly controlled vegetarian diet that was protein-insufficient (3).

Of potential concern, the athlete habitually consumed at least five cups of black coffee each day. As an adenosine receptor antagonist, caffeine present in coffee is a stimulant, which increases metabolism and lipolysis (7). Currently, long-term health effects of a high intake of caffeine are unknown (7). Stimulants (specifically amphetamines) have been implicated in prior rhabdomyolysis cases (18), however caffeine is common recommended ergogenic aid (7) and to our understanding it has not yet been specifically implicated in any rhabdomyolysis cases.

Environmental stressors such heat and humidity can influence the rate of dehydration and result in training injury. Numerous cases of dehydration associated with high volume exercise and hot weather conditions are reported every year. One of these featured a 16-year old high school football player who experienced heat cramps at the end of a second sequential two-a-day football practice session (30.4 °C, 70.4 % humidity) (8). The athlete was diagnosed with ER following admission to the hospital (CK peaked at 3,363 U/L later that day). The athlete in the present study did not report experiencing heat cramps, however some amount of dehydration was likely due to training in hot environmental conditions. Predisposition to muscle damage brought on by dehydration has been proposed in several reviews (18, 23, 29), and it is likely associated with rhabdomyolysis due to decreased fluid available to assist the kidneys in clearing myoglobin in the dehydrated state.

The athlete in this case study only performed one week of low-intensity preparatory training (Table 3), therefore her training program would not be considered appropriately progressive for a return to heavy training from a sedentary period based upon contemporary strength and conditioning standards for collegiate athletes (6). Figure 1 shows the volume of abdominal exercises per session, which appears random. June 7th was the first time in the training program that the athlete had performed loaded glute-ham sit ups; a gradual progression of volume and intensity was not apparent for this particular exercise. Previous study has demonstrated that regular exposure (2-3 sessions per week for 16 weeks) to eccentric-enhanced resistance exercise is effective in reducing muscle damage induced by training sessions in novice resistance-trained college students (12). This point highlights the importance of progressive exposure to loading that is considered a best-practice in strength and conditioning (6). Taking a more progressive approach may have been injury preventive in this situation.

Figure 1: Abdominal Exercise Volume Per Workout

Figure 1

CONCLUSIONS

Evaluation of the factors leading to the occurrence of ER in this athlete has presented a complex interaction of inadequate preparatory training and insufficient post-exercise recovery due to poor nutrition. Possible contributors to an unknown level include the following: mild dehydration, high caffeine intake, and mild hyperglycemia. Further research should be performed to investigate exercise intolerance in athletes with diabetes in order to explore the possibility of increased risk of ER in this population. In addition, athletes with T1DM should be cautious with exercise intensity and duration and are advised to work with a support team of well-qualified professionals, including a strength & conditioning coach, RDN who specializes in sports nutrition, and their physician to establish an organized training program, diet, and medication regimen that are in sync. Further, because of hypersensitivity to abnormal blood glucose levels that may accompany extreme nutritional tactics often employed by weight class athletes, athletes with T1DM should carefully control blood glucose and seek to maintain a stable body weight year-round. The athlete should remain in close contact with their support team so that adjustments may be made in accordance with the environmental conditions and training goal adjustments.

APPLICATIONS IN SPORT

At least one return to training framework has been developed for advanced-level athletes and is freely available (6). Coaches and athletes are strongly recommended to follow a progressive return to heavy offseason training that involves cautious and gradual progression of training over several weeks following extended periods without training. Adding additional concern, certain athletes may require additional attention from coaches and sport support personnel to ensure their safety. The complexities of managing T1DM may present additional challenges for affected athletes (35) that could impair recovery and reduce preparedness at times. In addition, athletes seeking to reduce body mass should do so under consultation of a qualified dietitian with training in sport nutrition. It is recommended that nutrition education and training theory be shared with athletes regularly so that safe methods of return to training are employed. Further research may explore susceptibility of athletes with T1DM to muscular injury.

ACKNOWLEDGEMENTS

The authors report no conflicts of interest associated with this research project.

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