Yes, the title sounds pretty terminal, but I really wanted to grab your attention as this is potentially one of the most important pieces of information you may read this year. As the organisers of the Montane Lakeland 50/100 and other endurance events, we take our safety and medical care very seriously. As events become longer and people push themselves harder, we are starting to see a small number of life threatening cases and the more we can publicise these cases and educate athletes, the safer we'll all be.
There are lots of people who drop out of events with common issues such as dehydration, low blood sugar and low body temperature. This can occur either because they haven't eaten enough, drank enough, worn enough clothing or done enough training. The reality is, these conditions will very rarely require more than a little medical help, a can of coke and a warm blanket. Aside from the odd case, they very rarely become life threatening.
Over the last 5 years, the subject of 'over hydration' has been discussed more frequently, leading to a condition known as hyponatremia. Drinking too much can dilute your body salts and can potentially be fatal. This is a critical point to understand that dehydration is far less likely to put you in hospital compared to over-hydration. Hyponatremia has become more common and amongst endurance athletes, it is now more widely recognised. At the Montane Lakeland 50/100 we weigh people before the event, this is due to the fact that dehydration leads to weight loss, whilst over-hydration doesn't and can often cause weight gain. Common symptoms are bloated stomach and vomiting water. Hyponatremia is one to watch, as it can be fatal.
However, whilst hyponatremia is a serious condition, that's not what's prompted us to write this article. It's the subject of Rhabdomyolysis which has caused more serious concern in the last 6 months. Here's 2 examples of people we know:
1. A local triathlete who races under The Endurance Store team name completed Ironman Lanzarote May 2016 (he's also done multiple Lakeland 50 and other IM events). Upon reaching the finish line, he presented as being ok (obviously looked tired as he'd done an Ironman) but over the next 24 hours his condition deteriorated. He was taken to hospital and his condition was described as 'critical' for several days. He was told that his blood creatine kinase (CK) levels (normally 100) had increased to 100,000. After several days in hospital he fortunately recovered and was allowed to travel home.
2. A Montane Lakeland 100 runner and regular checkpoint helper competed at UTMB 2016 and reached the finish line in a bad way but was cleared by medics. He traveled home but his condition deteriorated and he was admitted to hospital with kidney failure. His condition was life threatening for a significant period of time and was lucky to pull through. He has now regained partial kidney function and is fortunately starting a very long and slow journey towards recovery.
These are not the only 2 cases that I personally know of in the last 6 months, which is why all endurance athletes need to know about Rhabdomyolysis. You need to understand the symptoms in case it happens to you or one of your friends. Spotting it quickly could help to save someone's life.
What is it?
We talked in last week's blog about muscle damage causing DOMS. Rhabdomyolysis is the effects of muscle tissue damage and the contents of muscle fibres leaking out into the blood. Our first example above mentions blood CK levels rising from 100 to 100,000. Creatine Kinase is an enzyme involved in the breakdown of Creatine. That's not really important... what is important is that it should be in your muscles, not your blood. When muscles become damaged, it leaks out into the blood and medics use it as a way of measuring how much damage there actually is.
CK isn't the only thing to leak out. Myoglobin is found in muscles and carries oxygen (myoglobin is in the muscles, haemoglobin in the blood). Myoglobin leaks out of damaged muscle into the blood stream and one of the more common symptoms of rhabdomyolysis is dark red/brown urine. Don't confuse this with dark yellow urine caused by dehydration. One of the bigger issues is that to pass substances such as myoglobin in your urine, it has to pass through the kidneys in such quantities, along with other substances, that it can lead to kidney failure.
Let's be very clear on this subject. If you race an ultra distance event or Ironman triathlon, you will have rhabdomyolysis on some level. The likelihood is that it will not be severe enough to cause problems, but for the minority, it could be very dangerous. It's at it's worst when doing activities which are extremely excessive or those which you are not accustomed to (running downhill in particular if you're not accustomed to descending causes significant damage).
How do you diagnose?
1. It's VERY IMPORTANT to understand that there is generally a delay. An athlete can present themselves at the finish looking tired but healthy. The symptoms develop over the next 24 hours. You may appear fine when checked by a medic at the finish, which is a real issue for medics and event organisers. You must be very wary in the 24-48 hours post-event, even if you feel fine when you are at the finish.
2. Dark red/brown urine is a key sign.
3. You will have a general feeling of illness/sickness, similar to the feeling when you have an infection.
4. You'll have swelling / DOMS.
5. If you use pain killers or anti inflammatory drugs during racing or training, you need to stop that for multiple reasons. You are a high risk runner.
If in doubt, you should always seek medical advice and explain to them that you have completed an ultra endurance event and why you are worried. More importantly, you should always look out for friends and family who have completed a challenge as they are often too tired to recognise or react to these symptoms themselves. By making friends and family aware, it might just save an athlete's life.
Please share this article with other athletes and friends. We have already had a small number of critical cases and we're fortunate that these athletes are now recovering. Understanding the symptoms and dangers of rhabdomyolysis can go a long way to reducing future risks.
The Endurance Store