Rhabdomyolysis After Crawling Military Training

• Published in: Military medicine 2017-07, Vol.182 (7), p.e1948-e1952
• Main Authors: Atias-Varon, Danit, Sherman, Haggai, Yanovich, Ran, Heled, Yuval
• Format: Article
• Language: English
• Subjects: Adolescent; Breakdowns; Education - methods; Education - standards; Exercise; Gangrene; Humans; Hydration; Injuries; Laboratories; Male; Medical screening; Metabolism; Military personnel; Military Personnel - statistics & numerical data; Military recruitment; Military training; Physical Exertion - physiology; Physical fitness; Physiology; Prevention; Professional relationships; Rhabdomyolysis; Rhabdomyolysis - diagnosis; Rhabdomyolysis - epidemiology; Rhabdomyolysis - etiology; Young Adult
• ISSN: 0026-4075; 1930-613X
• DOI: 10.7205/MILMED-D-16-00373

Rhabdomyolysis is a syndrome characterized by muscle necrosis followed by release of intracellular muscle contents into the circulation. Exertional rhabdomyolysis (ER) occurs in response to nonfamiliar and/or excessive, prolonged, or repetitive exercises, with eccentric characteristics. In military populations, due to the type of intense, all out physical loads, ER is a significant threat, particularly when training under heat stress. However, many other etiologies exist, and clinical presentations vary greatly. This heterogeneity may result in difficulty in prevention, diagnosis, and return-to-duty decision. The purpose of this report is to point to a new potential risk factor to an extreme muscle breakdown and ER. In this article, we describe three cases of ER in army recruits after strenuous acts of crawling over hard surfaces during an intense military selection process. The soldiers' creatine phosphokinase levels were markedly raised (44,000, 123,500, and 176,599 IU/L), but none of them developed any significant medical complication. There are two major mechanisms leading to ER: the mechanical pathway which is associated with muscle tension, and the metabolic pathway which is associated with cellular energy depletion. During this military selection process, the intensity of the exercises, and cycles of work and rest are highly controlled, and so are the timings of meals and fluids consumption. Moreover, the soldiers were all at least moderately fit and had participated in strenuous exercise events before. According to years of experience with this military selection process, under similar conditions (exercise volumes and loads) we have experienced along the years minimal medical events. At the same time, and this was the unique part in these case, all patients suffered significantly from mechanical injuries caused by crawling on hard surface which were not a part of the planned selection program. Thus, we suggest that the significant muscle breakdown in the presented cases occurred mostly due to crush injury and was not solely a result of the metabolic strain. Thus, we suggest that the extreme creatine phosphokinase levels may be attributed to a synergistic interaction between low-energy trauma, caused by crawling on hard soil and stones, and exertion. We also emphasize the fact that proper physiological support such as proper hydration may assist in prevention of ER complication such as acute renal failure.