- Urine – abnormal color
- Red, brown, green: Urine colors and what they might mean
- Departures from the familiar yellow are often harmless but should be discussed with a doctor.
- Dark yellow
- Brown or black
- What the Color of Your Pee Says About Your Health
- If your pee is… Red or pink
- If your pee is… Orange
- If your pee is… Pale yellow
- If your pee is… Bright yellow
- If your pee is… Green or blue
- If your pee is… Brown
- If your pee is… Foamy or cloudy
- If your pee is… Clear
- 4 Things You Didn’t Know About Rhabdomyolysis (aka Rhabdo)
- 1. It’s not just from hardcore workouts.
- 2. Dehydration puts you at a higher risk.
- 3. You won’t pee blood.
- 4. It can take three days to set in.
- Rhabdomyolysis Treatment and Prevention
- The Takeaway
Rhabdo and CrossFit
- Why Should I Care About Rhabdo?
- What are the Symptoms of Rhabdo?
- Dude, I get extreme soreness and muscle pain after every workout…
- What type of workouts cause rhabdo?
- Who generally gets rhabdo?
- What movements cause rhabdo?
- Below is a case study that can help us learn about rhabdo.
- How do my coaches at CrossFit Impulse help me prevent rhabdo?
- What should I do to prevent rhabdo?
- What should I do if I think I have rhabdo?
- I have rhabdo. What now?
- Well now I’m scared of stepping into the gym and doing anything…
- Over-Exercising Linked to Life-Threatening Condition Called ‘Rhabdo’
Urine – abnormal color
Abnormal urine color may be caused by infection, disease, medicines, or food you eat.
Cloudy or milky urine is a sign of a urinary tract infection, which may also cause a bad smell. Milky urine may also be caused by bacteria, crystals, fat, white or red blood cells, or mucus in the urine.
Dark brown but clear urine is a sign of a liver disorder such as acute viral hepatitis or cirrhosis, which causes excess bilirubin in the urine.
Pink, red, or lighter brown urine can be caused by:
- Beets, blackberries, or certain food colorings
- Hemolytic anemia
- Injury to the kidneys or urinary tract
- Urinary tract disorders that cause bleeding
- Blood from vaginal bleeding
- Tumor in the bladder or kidneys
Dark yellow or orange urine can be caused by:
- B complex vitamins or carotene
- Medicines such as phenazopyridine (used to treat urinary tract infections), rifampin, and warfarin
- Recent laxative use
Green or blue urine is due to:
- Artificial colors in foods or drugs
- Medicines, including methylene blue
- Urinary tract infections
Red, brown, green: Urine colors and what they might mean
Departures from the familiar yellow are often harmless but should be discussed with a doctor.
Updated: October 23, 2018Published: March, 2012
Most of the time, urine is a pale yellow color because it contains urochrome, one of the substances produced when hemoglobin gets broken down. Hemoglobin is the protein in red blood cells that sticks to oxygen so it can be ferried around the body.
Occasionally, though, urine turns a very different color. Men may notice the change as their urine enters the toilet bowl or urinal. Women may be more likely to observe it after wiping. Seeing red or orange instead of the usual yellow can be alarming, especially if there are also symptoms like a burning sensation or pain with urination. The alarm may be justified: an abnormal urine color can be an early sign of a serious medical condition. To be on the safe side, it should be discussed with a doctor or another clinician.
But don’t push the panic button. Urine can also change color for harmless reasons having to do with the foods you’ve eaten or medications you’re taking. And colors other than red and orange are very unusual.
Following is a brief rundown of some of the color changes and what they might mean.
The urinary tract
Urine consists of water and waste products that your kidneys have filtered out of your blood. If your urine turns a dark yellow, it may contain less water and more waste products than usual, which can be an indication that you’ve gotten dehydrated from not drinking enough fluid.
The red of red urine can vary from pink to a very dark red. A simple test can tell if the red color is from hematuria, the medical term for blood in the urine. Urine can also turn red if it contains myoglobin, an oxygen-binding protein in muscle cells that is similar to the hemoglobin found in red blood cells.
Any number of problems affecting the urinary system (the two kidneys and ureters, the bladder, and the urethra) can allow blood to get into the urine. The long list includes kidney stones, bladder infections or bladder cancer, and, in men, enlargement of the prostate gland (benign prostatic hyperplasia).
Strenuous exercise can also result in urine turning red. Hemoglobin can come from red blood cells that leak into the urine or be caused by damaged cells in the blood stream. During strenuous exercise, muscle cells break down and in some people enough myoglobin is released to turn urine red.
Inherited conditions that affect red blood cells and hemoglobin, like sickle-cell anemia and thalassemia, can cause hematuria. A rare set of conditions known collectively as porphyrias can also turn urine reddish or brown.
But there’s also a perfectly harmless cause of red urine called beeturia, which can occur after you eat beets. Some people, especially those with low stomach acid, won’t break down the pigment called betanin in beets. It gets absorbed in the intestine, enters the blood stream and gets excreted by the kidneys. Iron deficiency and eating beets with foods that contain a substance called oxalate make beeturia more likely to occur.
Brown or black
If the red of red urine is dark, it may look brown or even black. In such cases, the causes of brown or black urine may be the same as those of red urine.
But urine can turn truly brown. Bilirubin, another breakdown product of hemoglobin, sometimes builds up in the blood because of liver conditions, like hepatitis and cirrhosis, or a bile duct blocked by gallstones, a tumor, or some other obstacle. If some of that excess bilirubin gets into the urine, the urine can turn a brownish color. Hemolytic anemia, when too many red blood cells get broken down at the same time, also produces a bilirubin surplus that may taint urine.
Melanoma, the most serious type of skin cancer, can, in rare instances, put melanin, the pigment that darkens skin, in circulation, and some of that pigment may wind up in the urine. Foods that may turn urine brown include fava beans and rhubarb.
Several medications can turn urine orange, including isoniazid, the mainstay of tuberculosis (TB) treatment; rifampin, another TB drug; high doses of riboflavin, a B vitamin; and phenazopyridine (Pyridium), a drug used in the treatment of urinary tract infection to ease painful urination. Large amounts of carrots or carrot juice may also give urine an orange tinge.
Urinary tract infections sometimes turn urine a milky-white color because they provoke an immune response that unleashes a flood of white blood cells. Other causes of whitish urine include uric acid crystals from eating purine-rich foods, such as anchovies, herring, and red meat (lamb, beef, and pork), and phosphate crystals from excess parathyroid hormone.
Methylene blue, a dye used in various diagnostic tests, can turn urine blue. Methylene blue has antimicrobial properties, so it’s sometimes found in medications and home remedies. It’s also used by itself to treat some rare medical conditions. Inherited conditions like blue diaper syndrome and Hartnup disease can result in blue urine.
If blue pigment gets into urine, the color is often green because the blue mixes with the yellow urochrome that’s naturally present. It’s not an everyday occurrence, but there are case reports of many common medications causing green — or bluish-green — urine, including the anesthetic propofol, the stomach acid drug cimetidine (Tagamet), and the tricyclic antidepressant amitriptyline (Elavil). The discoloration is a harmless side effect. Asparagus sometimes adds a greenish tinge that’s also perfectly harmless. But green urine can be a sign of a urinary tract infection or a bacterial infection that has gotten into the blood (bacteremia).
Purple is the only urine color that has a syndrome named after it: purple urine bag syndrome. It occurs when someone has a urinary catheter. Bacteria colonizing the catheter, the collection bag, or both produce a substance called indirubin, which is red, and indigo, which is blue, and they combine to make a bright purple color.
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
What the Color of Your Pee Says About Your Health
Unless you’re stuck in a car 100 miles from the nearest gas station when you feel the urge to pee, you probably don’t spend too much time thinking about your urine. But just like paying attention to changes in the color and consistency of your poop can help you learn about your diet and your health, taking a peek in the bowl on your pee breaks can, too.
You might be surprised to learn that, aside from the basic yellow hue, pee can actually come in a rainbow of colors—some healthy, some not. Jonathan Harper, M.D., a urologist and UW Medicine’s Chief of Endourology and Minimally Invasive Surgery, explains what the spectrum of pee color can mean—and when the color of your pee might signal a serious health problem.
If your pee is… Red or pink
Red or pink urine can be a sign of a mild or serious health issue. The big concern with any sort of pink or red urine is bleeding, called hematuria. This could signal an easy-to-treat urinary tract infection (UTI) or kidney stone—or something more serious, such as urinary tract cancer. If there is obvious blood in the urine, you should contact a healthcare provider.
Before you get too alarmed with any change of urine color, take note of what you’ve eaten. Beets and berries, especially blackberries, can stain your pee a light pink to crimson shade.
If your pee is… Orange
It’s probably a safe side effect of a medication you’re taking. Phenazopyridine, a drug used to relieve symptoms of urinary pain and discomfort, contains a dye that could leave you thinking you drank too much orange fruit punch. Rifampin, which is used to treat tuberculosis, can also have this startling side effect. Carrots have been known to do the same.
If your pee is… Pale yellow
Congrats, your pee is normal! Typically, if you’re well-hydrated, your urine will be a pale yellow hue. If it’s not on the pale side of yellow, it’s not something to be concerned about, it just means you might want to drink a little more water throughout the day.
On the other hand, if you’re dehydrated, your urine will be more concentrated and will be a darker shade of yellow. That’s a sign that you might want to chug some H2O, especially if you are prone to kidney stones.
If your pee is… Bright yellow
Does your morning regimen include popping handfuls of vitamins and supplements? High-dose vitamins can turn your pee a bright, almost neon yellow color. The most common culprit is vitamin B2, also known as riboflavin, which is found in most multivitamins. The neon color in pee is just a harmless sign that you’re taking more than your body needs, and the excess is mixing with your pee.
If your pee is… Green or blue
Pseudomonas, bacteria that can cause UTIs, can turn your urine a deep shade of bluish green. It’s pretty unusual, and most often happens in people with catheters, but it’s something to be aware of.
Eating asparagus, which is known to make your pee smell weird, can also tint your pee light green.
If your pee is… Brown
If your pee is ever cola colored, call your healthcare provider ASAP. It could be a pigment from something you ate, but it could also be a side effect of liver disease. Rhabdomyolysis, which is a release of protein into the bloodstream that’s toxic to the kidneys, is a side effect of extreme exercise or trauma that can turn your pee brown, too.
Brown-looking pee can also be from blood. Blood in the urinary tract may form a clot and turn the urine a very dark color if not peed out quickly. It takes a while for urine to travel from the kidneys, where it is produced, down to your bladder, and not everyone completely empties their bladder every time they pee. If this is the case, you may not have bleeding in your kidneys or bladder right now, but because you did at some point, you should have the issue addressed.
If your pee is… Foamy or cloudy
Maybe you’ve jumped on the ketogenic diet bandwagon or you just love steak. Either way, eating a very high-protein diet can occasionally result in protein in the urine and cause it to appear foamy. This can happen in people with kidney disease, too. In some cases, cloudy or milky-looking urine can also be a sign of infection.
If your pee is… Clear
You get a gold star for hydration, but you might actually be overdoing your water intake. People who get recurring kidney stones should aim to have urine that’s close to clear, but for everyone else, there’s no shame in the yellow pee game.
It’s a new year, the gyms are unusually busy, and many of us started a new physical activity. Several health clubs are offering fun, interactive, and dynamic exercises such as whole-body workouts, functional training, CrossFit, high-intensity interval training, spinning, etc.
Some of these classes are incorporating intense workouts, which was a hot topic in exercise physiology in 2017. There is significant enthusiasm around these programs among my friends, family, and patients. Some of these classes have loud music, lights, and trainers whose job is to push you to a new level. Increasing the intensity of a workout may bring significant health benefits for some; however, lately we are starting to see cases of a potentially life-threatening disease as a result of these activities. It’s called rhabdo.
The other day I saw someone wearing a shirt that said “Pushing until Rhabdo.” That made me cringe. And I realized that, although rare, some people do not understand how serious rhabdo can be.
What is rhabdo?
Rhabdo is short for rhabdomyolysis. This rare condition occurs when muscle cells burst and leak their contents into the bloodstream. This can cause an array of problems including weakness, muscle soreness, and dark or brown urine. The damage can be so severe that it may lead to kidney injury. Intense physical activity is just one of the causes. Others include medication side effects, alcohol use, drug overdose, infections, and trauma/crush injury. Fortunately, most people who have rhabdo do not get sick enough to require hospitalization. But if you develop any of these symptoms after a hard workout, it’s a good idea to set up an appointment with your doctor. A simple blood and urine test could help establish the diagnosis.
How to avoid rhabdo
I know you are probably excited about your new exercise program, and you want to excel. And that’s great. But take it easy, especially if this is a new exercise routine. You want to challenge your body, but avoid extremes. If you are working with a trainer, make sure you tell him/her where you stand in terms of fitness level and health concerns. In addition:
- Drink lots of water. That will help prevent problems and help flush your kidneys.
- Avoid using anti-inflammatory medications such as ibuprofen and naproxen. These drugs may worsen kidney function.
- Avoid drinking alcohol. Alcohol is a diuretic, which means it will make you more dehydrated. You need more fluids in your system, not the opposite.
If you experience intense pain and fatigue after your workout, you should call your doctor. Most cases of rhabdo are treated at home simply by increasing fluid intake. If muscle enzyme levels are high, or if there are signs of kidney problems, IV fluids may be needed. In some cases, we have to admit patients to the hospital and even to the ICU for close monitoring and further treatment.
Ramping up safely
Be smart and train your muscles to adapt to new activity. Exercise is better if it is enjoyable and entertaining, and I have to say that some of these classes are incredibly fun. But make sure that you listen to your body. Watch out for trainers who may push you too hard to the point of exhaustion. That should not be your goal when you are first starting a brand-new routine, especially if you haven’t been active for a while. A good trainer should get to know you and will tailor the exercise routine to your level of fitness. Adding a new workout to your day is probably one of the healthiest habits you can incorporate in 2018, but don’t “push until rhabdo.” Instead push slowly but consistently, challenging your body toward wellness and better function.
4 Things You Didn’t Know About Rhabdomyolysis (aka Rhabdo)
A few years ago, a weird-sounding condition called rhabdomyolysis got a lot of attention as a scary—and possibly lethal—side effect of very intense workouts, like CrossFit. If you were into this kind of thing, you may have gotten a little nervous. If not, you probably moved on with your life.
But in July, The New York Times reported on an increase in cases of rhabdomyolysis from spin class, bringing it back into the limelight. What was once a condition reserved in people’s minds for the most hardcore has now left us all wondering: “Could it happen to me?”
Rhabdomyolysis, also known as rhabdo, is essentially muscle breakdown. When you exercise, some muscle breakdown is normal, and part of the process of getting stronger, explains Nayan Arora, M.D., a nephrology fellow at the University of Washington.
When people overstress their muscles, they are at risk for the muscle tissue breaking down so much that it releases the protein myoglobin into the bloodstream. Myoglobin is toxic to the kidneys, which is why rhabdo can lead to kidney damage or complete kidney failure if left untreated, Arora explains.
While rhabdo is serious—and seriously terrifying—it’s still pretty rare, he says. That means you shouldn’t let it stop you from exercising—but you should have it on your radar. Here are four things that you need to know about rhabdomyolysis.
1. It’s not just from hardcore workouts.
Arora says there has been a slight uptick in cases of exercise-related rhabdo, likely as a result of the rise in popularity of grueling workouts, from high-intensity interval training to spinning and ultrarunning. But muscle exertion isn’t the only cause. The condition can also be a result of alcohol abuse, medications including statins and prednisone, illicit drug use, muscle diseases, trauma, certain health conditions and genetic issues, seizures and immobility, research shows.
Rhabdomyolysis was studied extensively for the first time during World War II, when researchers examined soldiers with crush injuries from the 1940 London Blitz, says Arora.
“Interestingly, rhabdo-like symptoms are mentioned in the Bible. When the Jews were crossing the desert they were eating large amounts of quail,” he says. Researchers believe the birds may have eaten hemlock, resulting in rhabdomyolysis from accidental hemlock poisoning.
Exercising in hot, humid conditions or while taking creatine supplements, ephedra diet pills, or energy drinks with high doses of caffeine also increases your risk, says Arora.
2. Dehydration puts you at a higher risk.
Usually, doing a tough workout alone won’t land you in the hospital, says Arora. Most people who get rhabdo from exercise were doing something really intense and didn’t drink enough water before and during whatever activity they were doing.
“Going all the way back to 1940 with victims of crush injuries, it was people who didn’t have access to water who had the highest risk,” says Arora.
That’s why IV fluid is the No. 1 rhabdomyolysis treatment to prevent kidney damage, he says. To protect yourself from getting rhabdo in the first place, make sure you hydrate, hydrate, hydrate.
How much water you should drink depends on a lot of factors, including your weight, fitness level and the foods you eat during the day, says Arora. But a good rule of thumb during exercise is to drink some water every time you take a break—and to give yourself those breaks even if you’re in a class that doesn’t encourage rest.
3. You won’t pee blood.
One rhabdomyolysis symptom is red or brown urine, which patients often mistake for blood, says Arora. What looks like blood is actually myoglobin, that toxin that can lead to kidney damage. When this happens, your condition has gotten serious, and it’s important to seek medical help right away, he says.
4. It can take three days to set in.
You might expect to know shortly after, or even during, a workout that something is wrong. But rhabdo usually peaks at 24 to 72 hours after a workout or injury, says Arora. Delayed-onset muscle soreness, or DOMS, is normal after a tough workout, and it can sometimes be hard to differentiate between DOMS and rhabdomyolysis, he says.
If you experience muscle pain or weakness in one muscle group that seems out of proportion to the workout, it could be rhabdo, says Arora. Swelling or a cramp-like sensation that won’t go away, especially in one muscle group, are other possible signs. If you’re sore all over, you’re probably OK, but it’s always better to err on the side of caution if you’re concerned, he says.
Rhabdomyolysis Treatment and Prevention
If you think you may have rhabdomyolysis, get yourself to an emergency room right away. Rhabdo can be fatal if left untreated, says Arora.
“Basically, the whole point of treatment is to prevent you from getting kidney damage, and the way to do it is with huge doses of fluids,” he says.
Depending on the extent of toxins released, IV fluids are usually given for two to five days. At that point, most people will have recovered. A provider will recommend patients take an exercise break. This could be a couple of weeks to a couple of months, but will depend on many factors, including the severity of the condition and a person’s fitness level. Easing back in with a provider’s guidance is always recommended, Arora says.
At the end of the day, no workout is worth dying over. Listen to your body, ease into new workouts, pay attention to hydration, take regular breaks and seek help right away if something feels wrong after a workout, says Arora.
Rhabdo and CrossFit
Why Should I Care About Rhabdo?
Because it can kill you. Rhabdomyolysis (rhabdo) is a rare but serious health condition sometimes caused by working out at very high intensity. CrossFit workouts, just like all high intensity workouts, have the potential to cause rhabdo under the right circumstances. Rhabdo is very, very rare. You’re more likely to spot a Bigfoot playing cards with Elvis than to ever cross paths with rhabdo. But even though it’s very rare, it’s also very serious. So reading this article is an important step towards keeping you safe while still experiencing all the great things CrossFit has to offer.
If you feel terrible after a workout, then the next day extreme swelling and soreness starts, and then you start peeing brown urine—you have rhabdo. Go to the ER immediately. This is no joke. It can be fatal if not treated. Rhabdo happens when your muscles break down to the point that muscle tissue enters your bloodstream. Your kidneys can’t handle this. They freak out and eventually shut down. This is how rhabdo can be fatal—kidney failure. The most important thing you can learn fom this entire article is this: If you experience dark urine after a grueling workout, then go to the ER immediately.
What are the Symptoms of Rhabdo?
- extreme muscle pain and soreness
- difficulty moving the affected muscles
- weakness in the affected muscles
- dark urine (brown, cola-colored)
Dude, I get extreme soreness and muscle pain after every workout…
I understand, believe me. Some muscle soreness is simply a part of exercise. But if you have rhabdo, the soreness will reach a whole new level. You’ll be almost unable to move the affected area, and you’ll feel like you got hit by a truck. But yes, we’re all a little sore after most workouts. That’s not rhabdo. Be on the lookout for dark urine. That’s the tell-tale sign you actually have rhabdo, and not the usual muscle soreness.
What type of workouts cause rhabdo?
Using light loads for many, many repetitions in a long workout is the usual culprit. Performing many reps of one movement in a row without changing movements or resting can also be a factor. However, heavy lifting generally does not cause rhabdo. Lifting heavy loads forces you to stop before severe muscle breakdown occurs. For example: performing 5 sets of 5 squats at a heavy load is not a workout that carries a rhabdo risk. However, performing 1 set of 100 squats as quickly as possible with a light load would carry a rhabdo risk.
Who generally gets rhabdo?
Not many people at all. Rhabdo is very rare. It’s like the opposite of winning the lottery. It’s highly unlikely, but if it does happen, the consequences are severe. Classic literature often tells us that men have higher risk of rhabdo than women. While this is historically true, I think this may be rooted in past social norms, and not biology. As CrossFit continues to build strong, determined women, they too need to be cognizant of rhabdo. Next, rhabdo usually strikes someone who has been away from intense exercise for a while and then jumps back in with too much volume and intensity. Someone who has been very fit in the past and has taken six months off must ramp up volume slowly as he returns to intense exercise. This type of athlete has the mind and the determination to push himself beyond his body’s capabilities—where rhabdo lives.
What movements cause rhabdo?
Well, there’s no magic movement that always causes rhabdo. But some movements are higher risk than others when performed by new athletes or when performed to excess repetition. These are usually movements with a demanding eccentric motion. Stay with me. This really isn’t too complicated. Most movements have two parts: an eccentric part and a concentric part. Eccentric means that muscles are stretched under load. As you lower into the bottom of a squat, you are performing the eccentric portion of the squat. Your hamstrings are lengthening under load. Concentric means that muscles contract under load. As you drive out of the bottom of the squat you are performing the concentric portion. After being stretched, your hamstrings are now contracting and driving the load upwards. Eccentric motion is very demanding on muscles. Stretching muscles under a load with lots of repetition can cause the muscle breakdown that triggers rhabdo. Here are a few examples of movements with a strong eccentric portion: jumping pullups, GHD situps, walking lunges. Now these are all excellent movements that have their uses in building a strong and healthy body. Just don’t jump into doing hundreds of them, unless you’re a strong and experienced athlete that has worked up to that level of ability.
Below is a case study that can help us learn about rhabdo.
In January 2011 the University of Iowa football team returned to training from a three week winter break. On Thursday about 85 players performed a workout that involved 100 back squats at 50% of 1-rep max followed by a series of sled pushes, all done as quickly as possible. This same workout had been performed by the team in previous years with no ill-effects–once during late spring training and once during the fall after a one-week break. Later Thursday evening many of the players felt extreme soreness. On Friday they performed another workout focusing on the upper body, with a similar rep scheme. They then had the weekend off before returning for another light workout on Monday that involved calisthenics and stretching. By Monday night 13 of the 85 players were admitted to the hospital suffering rhabdomyolysis. What can we learn from this? By the way, I’m not interested in finding blame or criticizing anyone in hindsight. I’m interested in learning how to prevent future rhabdo injuries, so shelve the judgment and focus on learning.
- Warning Sign: Athletic, strong, mentally-determined men who just took three weeks off from training
- Warning Sign: Light load performed for high repetitions (100 squats at 50% 1RM)
- Warning Sign: Team atmosphere where each player would push himself to his limits
Let’s also look at some of the details of how the situation unfolded:
- Delayed onset: Players experienced extreme soreness the same night of the workout, but many did not realize hospitalization was necessary until four days later.
- You can have rhabdo and still workout: Many players performed more workouts between the rhabdo-inducing workout on Thursday and hospitalization on Monday.
- Stretching and calisthenics were the last straw: Rhabdo often is not fully realized until immediate swelling subsides and myoglobin from the affected muscles begins to flood the blood stream. Stretching can make this release of myoglobin even worse. Many of the players were not hospitalized until after the light workout on Monday that involved stretching.
How do my coaches at CrossFit Impulse help me prevent rhabdo?
First, they provide you a program that limits the risk of rhabdo. Every workout we perform has been evaluated for rhabdo risk. Next, they know how to identify at-risk athletes and prevent rhabdo before the workout begins. Scaling workouts to your ability level is also important in preventing rhabdo. Your coaches will provide you several suggested scaled versions of the workout and help you select one that is right for you. Your coaches may modify the workout on the fly or simply tell you to stop working if your movement patterns display a high risk of rhabdo during the workout. Finally, time cutoffs are used judiciously during high intensity work to ensure you are not under stress for too long. All of these measures limit the risk of rhabdo, but they cannot eliminate it. Each athlete must still take her own preventative measures.
What should I do to prevent rhabdo?
- Gradually build up volume and intensity in your workouts, especially after a long break from exercise. Your first workout after a break in training should get your heart rate up and allow you to do some work, but it shouldn’t be crushing. You should leave the gym feeling better than when you arrived. Note that there is a time and a place for workouts that push your limits. Your first day back after a cruise to the Bahamas is not that time and place.
- Even if you have been exercising regularly, jumping to a much higher intensity too suddenly can be dangerous. This doesn’t mean that you should not work out at high intensity. This means that you should ramp up your intensity slowly, over several weeks or even months.
- Don’t fear putting weight on the bar. Lifting heavy weight forces you to stop and prevents rhabdo. Rhabdo comes from performing way too many reps at a light to medium load.
- Listen to your coach. Your coach is your co-pilot for training. When you press the gas pedal to the floor with reckless abandon, your coach is there to prevent a catastrophic crash. He can’t ultimately control the vehicle. You’re the pilot. But he will exert as much influence as you will allow, so trust him and allow him to guide you.
- Give your coach information. Your coach doesn’t live in your shirt pocket. He doesn’t know that you drank a thimble of water over the past two days and ran a half-marathon for fun after yesterday’s deadlifts. Be honest with your coach about how you feel that day. You’ll get thoughtful concern in return—not scolding—I promise.
- Hydrate before, during, and after your workout. Does that mean you should visit the water fountain during short metcons? Sometimes. If you hydrate adequately before your workout, then you probably don’t have to visit the water fountain during a 10-minute effort. If you didn’t hydrate well prior to beginning your workout, then you should indeed visit the water fountain as much as needed. But this isn’t always necessary if you drink water throughout the day. For a 20-minute workout or more, get some water during strategic rest breaks. And after the workout is over, drink copious amounts of water–always.
- Even if you and your coach does everything right, sometimes the perfect storm of circumstances can conspire against you. That’s why it’s important that you know the warning signs, symptoms, and what to do if you think you have rhabdo.
What should I do if I think I have rhabdo?
Start drinking water and go to an emergency room– immediately. Rhabdo can be fatal. This is very simple: If you have dark urine then go to the ER, because if you don’t then you could die. I’m not trying to be dramatic. I’m just being blunt.
I have rhabdo. What now?
The fact you’re able to ask that question is a good sign. It means you’ve identified your condition, and presumably have sought help from a hospital. The good news is that almost all rhabdo victims that seek treatment make a 100% recovery. You’ll be in the hospital a few days sucking down fluids while your kidneys flush the toxins. After that you’ll get released and take a little break from working out. After your doctor clears you, then you can start working out again at very low intensity. You can eventually ramp up your intensity (slowly) until you’re training at full intensity again.
Well now I’m scared of stepping into the gym and doing anything…
Is it possible for us to be part of a horrible car accident that puts us in the hospital? Absolutely. Every day we drive, we take that risk. But we all drive. Because we know that if we do our part to keep ourselves safe, and we work with others who have our safety in mind, then we can avoid most catastrophic crashes. So we drive and we usually avoid calamity. Such is the case with exercise and rhabdo. Rhabdo is extremely rare. Yes, if we get behind the wheel and act like a maniac and ignore the advice of professionals, we can create the rhabdo car crash. And unfortunately, even if we do our part and do everything right, if the odds strike us just right, then we could end up in a crash. But when executed properly, the odds of catastrophe are far outweighed by the positive effects we get from training. So there’s no need to be scared of rhabdo. You and your coaches are actively working every day to give you a well-coached program that keeps you safe while responsibly pushing your limits and achieving your goals. But part of that safety mechanism is educating you. So if the worst happens now you know how to identify rhabdo, and you know what to do. I hope this education has helped you feel more comfortable about exercising at high intensity. You are now empowered with knowledge. You are working with coaches who are also empowered with knowledge, and they are actively working to protect you at every turn. I hope that is liberating. See you in the gym.
Over-Exercising Linked to Life-Threatening Condition Called ‘Rhabdo’
TUESDAY, March 12, 2013 — When it comes to exercise, most people think the harder you train, the better results you’ll get. But athletes who overexert themselves can end up with a life-threatening condition called rhabdomyolysis, known in fitness circles as “rhabdo.”
Steve Hanson, a 31-year-old former Corporal in the Army rangers who is stationed in Afghanistan and works for the federal government as diplomatic security, developed rhabdomyolysis it when he overworked his body while training for races that lasted up to 12 hours.
“I was concurrently training for endurance races that involved biking, kayaking and running,” Hanson said via email. “I was training six days a week, and the one day off apparently wasn’t enough.”
The pain from the rhabdo was so excruciating that he initially thought he had broken his back.
“I was in terrible pain,” he said. “I was convinced my spine was fractured at the very least. I didn’t know at the time that it was my kidneys shutting down. On top of that, my feeling of well-being was at an all-time low. I felt extremely depressed, which only amplified the pain.”
Rhabdomyolysis occurs when skeletal muscle tissue breaks down quickly and the damaged cells enter the bloodstream and disrupt kidney function, which can cause sometimes-fatal kidney failure. Rhabdo symptoms include muscle pain, weakness and swelling of the affected muscles, and dark, tea-colored urine, caused by presence of the protein myoglobin.
While overexertion — as in Hanson’s case — is a major trigger for rhabdomyolysis, the condition can also be caused by hyper- or hypothermia; infections such as the flu, malaria and salmonella; and crush injuries, which is why rhabdomyolysis is common after earthquakes, in which survivors can be trapped under rubble, according to the U.S. Centers for Disease Control and Prevention.
A University of Iowa ‘Mini Epidemic’ of Rhabdo
Student athletes, often pressured by coaches, frequently develop rhabdomyolysis, according to a statement by the National Collegiate Athletic Association. In January 2011, 13 University of Iowa football student-athletes reported the telltale tea-colored urine after a strenuous workout, the NCAA reported. The athletes, who had just returned from a three-week break and were required to do 100 back squats at half of their last recorded maximum weight, all required hospitalization.
“It’s always the same thing in these epidemics − and there are a lot more of them than people think − too much, too soon, of an exercise that’s too novel for them,” former University of Oklahoma team physician Randy Eichner said in the statement. “A lot of people don’t think about rhabdo.”
The University of Iowa released an 18-page report on the incident, outlining measures that need to be taken to prevent the school’s athletes from developing rhabdo again, such as better player and coach education, and stopping exercise when players complain of worse than normal soreness. In addition, the report found that the players who developed rhabdomyolysis were all dehydrated, and encouraged coaches to ensure than all athletes stayed properly hydrated.
“If there’s any good that came out of our deal,” Iowa football coach Kirk Ferentz told the Columbus Dispatch, “it’s that people learned a lot about it.”
When rhabdo is caught early, the prognosis is generally good, with athletes returning to normal activities in a few weeks, according to the National Institutes of Health. However, because rhabdo can lead to potentially deadline kidney failure, the NIH recommends that athletes prevent the condition by staying hydrated.
“Drink plenty of fluids after strenuous exercise to dilute your urine and flush any myoglobin that is released from your muscles out of your kidneys,” the NIH says on its website.
Hanson developed rhabdomyolysis twice more, once from kayaking and once from mixed martial arts, and he’s learned that in addition to checking the color of his urine after a workout, staying hydrated is one of the best ways to prevent rhabdo.
Experts also say to avoid supplements such as creatine, which can put you at a higher risk of developing rhabdo, according to a 2000 study published in the Journal of the American Board of Family Medicine.
“Supplements that lead to further dehydration should be avoided if you’re exercising a lot,” Hanson has learned from his doctors. “Stay away from fat burners or over-caffeinated drinks, especially during summer months. You’re already draining your body of everything if you exercise a lot. These supplements make it harder to recover.”
Ultimately, athletes have to work their way up to strenuous exercise slowly, especially after an extended break, Eichner said in the statement. The important thing for athletes to remember, he said: “You don’t have to build Rome in a day.”
What is it?
Exercise-induced hematuria is a benign condition in which blood is present in the urine (hematuria) following exercise. This has also been called runners bladder, marathoners hematuria, and stress hematuria.
Exercise-induced hematuria may have various causes, ranging from relatively harmless ones to more worrisome ones. In general, if the urine clears 72 hours after exercise, there is no need to further investigate. However, some causes do need to be investigated, particularly if the blood in the urine keeps appearing, or does not clear after 72 hours. Sometimes, the breakdown products of red blood cells and muscles may appear in urine, making the urine appear much darker, and this may be mistaken for actual blood. Some foods may color the urine reddish, and some medications, such as blood thinners, may lead to actual blood in the urine. For most cases of exercise-induced hematuria, the causes are related to the intensity and duration of activity, as well as the hydration status of the athlete. Longer and more intense events have been known to more likely cause hematuria. It is most common in runners, especially those running more than 10,000 meters. Sometimes, hematuria is related to a traumatic injury, such as a direct blow or a fall.
Risks of developing hematuria after exercise include long endurance events, very intense events, and/or poor hydration. Weight-bearing, intense activities appear to place an athlete at higher risk than other, less weight-bearing, forms of exercise. Any of these factors alone or any combination of them may result in hematuria. Any direct impact to the kidneys, bladder or urethra could potentially cause traumatic hematuria as well. Hematuria in itself can be caused by other factors apart from exercise, such as urinary tract infections, the presence of a stone in the urinary tract, kidney disease, among others; athletes with such conditions may be at higher risk of exhibiting blood in their urine after exercise. As above, taking some medications may predispose an athlete to exhibiting blood in his/her urine.
Apart from having blood in the urine, athletes with exercise-induced hematuria usually have no other symptoms. Occasionally, athletes will have pain just above the front region of the hip. If the hematuria is related to direct trauma, then pain at the site of impact is expected.
Sports Medicine Evaluation
The sports medicine physician will perform a thorough history and physical exam of the athlete, often focusing on the genitourinary and gastrointestinal systems of the patient. Evaluation of a urine sample is needed to investigate hematuria. This will be done with both a urinalysis (which looks for abnormal urine contents) and with a microscope, for a more detailed look at the urine. Further investigation may be needed depending on the results of these tests. Athletes may require repeat urinalysis testing until their hematuria has resolved. In cases where trauma is involved, imaging such as a computed tomography (CT) scan or ultrasound may be needed.
In cases where there is no trauma, exercise-induced hematuria usually resolves within 24-72 hours of rest after the athletic event. In these cases, no specific treatment is necessary. If hematuria persists longer than 72 hours or continues to occur with strenuous exercise, further investigation may be needed. In cases where trauma is involved, treatment will depend on the severity of the trauma.
Recommendations for preventing hematuria include staying well hydrated and running with a bladder that is not completely empty. In contact sports, wearing the proper protective equipment is necessary.
Return to Play
In cases where there are no symptoms, athletes may return to play if the hematuria has resolved within 72 hours. If not, medical clearance from health care personnel is advised. In cases where trauma is involved, returning to play may take longer and will depend on the severity of the injury.
AMSSM Member Authors
Matthew Hilton, DO and George Pujalte, MD