Return to physical activity after exertional rhabdomyolysis

Exertional rhabdomyolysis (ER) is a condition characterized by muscle pain, swelling, and weakness following some exertional stress, with or without concomitant heat stress. Athletes who experience ER often present to the emergency department, the training room, or the physician's office seeking guidance and care for this condition, often feeling it is simply normal delayed onset muscle soreness. The astute clinician must perform a thorough history and focused exam, in addition to ordering a serum creatine kinase (CK) and urinalysis. In this clinical setting, a CK equal to or greater than five times normal or a urine dipstick testing positive for blood with no demonstrable red blood cells upon microscopic assessment confirms the diagnosis. A urine or serum myoglobin is more definitive when expeditiously available. After treatment for ER, the provider must risk-stratify the athlete for risk of recurrence, consider further testing, and make the difficult decision on when, if, and under what conditions the athlete can safely return to play.