13 Iowa Football Players with Rhabdomyolysis: A Case of Coaching Incompetence

Thirteen University of Iowa football players were recently hospitalized for rhabdomyolysis caused by extreme physical exertion. Symptoms of the ailment include dark-colored urine, fatigue, muscle weakness, and muscle tenderness. Although the athletes have since been released from the hospital, information has not been released as to whether any permanent injury has resulted.

Rhabdomyolysis is a serious medical problem. It occurs when myoglobin leaks out of muscle cells due alcoholism, crush injuries, heatstroke, extreme physical exertion and other causes. Just as hemoglobin in red blood cells carries oxygen to the muscles and other body tissue to provide energy through oxidation of carbohydrates and fats, myoglobin carries oxygen within the muscle cells to the mitochondria, which are the oxidative energy-production units within the cells. Myoglobin is a large molecule and, when it leaks into the blood stream, it travels to the kidneys for removal. However, the myoglobin molecules are too large for the kidneys to readily clear, and can easily block the kidney’s filtration system. In addition, myoglobin breaks down into potentially harmful compounds. Permanent kidney damage or even kidney failure may result, which may require lifelong dialysis or a kidney transplant. See the National Institutes of Health for further information on rhabdomyolysis.

Extreme muscle soreness brings with it with a significant risk for rhabdomyolysis. Virtually all muscle soreness is attributable to the eccentric phase of exercise, which occurs when the muscle is lengthened while resisting. This occurs in the lowering phase of every weightlifting or calisthenic repetition, and also in the initial ground-contact phase of running, particularly downhill running. It also occurs during the deceleration phase of sports activities, as in braking for directional change and bringing a moving limb to a halt.

There is no excuse for any strength and conditioning coach to induce rhabdomyolysis. The press has reported that the workouts of the Iowa football players were extremely severe and may have been used as a punishment. One athlete said, “I had to squat 240 pounds 100 times and it was timed. I can’t walk and I fell down the stairs.” Another one said, “Hands Down the hardest workout I’ve ever had in my life!”. In addition, the severe workout occurred just after the athletes returned from winter break, during which most of them had not engaged in heavy resistance exercise. That made them particularly vulnerable to extreme muscle soreness and rhabdomyolysis.

Such an approach is totally unnecessary. Firstly, exercise should never be used as a punishment. Secondly, any knowledgeable and competent coach has to be aware that any exercise regimen that induces extreme muscle soreness presents a significant risk for rhabdomyolysis. Muscle soreness is not a prerequisite for muscle strengthening! The most effective way to increase strength is to start with light resistance and gradually increase the weight lifted over a period of time as the muscles strengthen. High repetitions are totally unnecessary for strength and power athletes like football players. Muscle fatigue following a workout is expected and desirable within limits, but muscle soreness is unnecessary and can actually slow down progress in strength development.

An extensive article and interview of coaches, doctors, and a parent of one of the players is available on the Internet.

How to Avoid Weightlifting-Related Shoulder Injuries

Terms used in this article:

• Rotator cuff: Muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the shoulder joint and rotate the arm at the shoulder
• Internal shoulder rotation: Standing with your upper arm against your torso with your elbow at a right angle, rotate your upper arm inward until your hand touches your abdomen.
• External shoulder rotation: From the position you just attained by internally rotating your shoulder, rotate your upper arm outward so that your hand moves away from your abdomen, as you would when throwing a Frisbee.
• Trapezius muscle: Extends from the back of your head and neck down your central upper back and serves to raise the shoulders and draw them backwards.
• Range of motion: The number of degrees through which a joint can be rotated.

A recent article by Kolber et al. in the Journal of Strength and Conditioning Research (Vol 24, no 6, pp. 1696-1704, 2010) reviewed existing scientific research articles on shoulder injuries brought on by weightlifting. It noted that 25-35% of people who engage in resistance training sustain an injury severe enough to require medical attention and that 36% of such injuries are to the shoulder. The vulnerability of the shoulder is related to the high number of exercises that involve the shoulder, the great stresses the exercises place on the shoulder, and the unfavorable positions in which some exercises place the shoulder. In addition, many lifters do not warm up properly, select a balanced set of exercises, use proper lifting technique, or modify/eliminate exercises that cause pain. Major muscles are frequently worked to the exclusion of minor ones, leading to muscle imbalances. Shoulder muscles commonly injured include the pectoralis major, biceps, deltoid and rotator cuff group.

The Most Common Signs of Shoulder-Dysfunction Among Weightlifters:

• Reduced internal shoulder rotation range of motion
• Excessive external shoulder rotation range of motion
• Underdeveloped external rotation strength relative to internal rotation strength
• Underdeveloped external rotation strength relative to arm abduction (raising) strength
• Underdeveloped lower trapezius strength relative to upper trapezius strength
• Instability of the anterior (front) shoulder
• Tightness of the posterior (rear) shoulder

Common Pain-Producing Exercises
The following exercises in which the upper arm is raised to the side and parallel to the floor while the forearm is vertical put the shoulder in a fully externally rotated position and are considered hazardous:

• Behind the neck pull-down
• Behind the neck overhead press
• Overhead stack machine press in which the hands move rearward as the weight is lifted

Other exercises, although generally safe, also associated with shoulder pain:

• Bench press
• Incline chest fly
• Supine chest fly
• Dip
• Biceps curl

The following may help to prevent weightlifting-related shoulder injury:

• Discontinue any exercise that causes pain.
• If an exercise hurts, try variations that do not hurt (e.g. bench press with rolled up towel on chest to limit movement).
• Balance every push exercise with a pull exercise in the opposite direction.
• Balance exercises involving major body movements (e.g. bench press, pull-down) with those that stabilize and rotate the shoulder.
• Exercises that strengthen external shoulder rotation are particularly important (e.g. do the external rotation movement described above, resisted by weight stack cable or elastic band).
• Do strength exercises for the lower trapezius (e.g. rowing motions with elbows high and shoulders drawn fully back).
• Do flexibility exercises to increase internal shoulder rotation.
• Do flexibility exercises to stretch the rear shoulder (e.g. Stand with upper arm parallel to the ground. Grip elbow with other hand and pull arm horizontally across the chest).