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Pearls and Pitfalls

Updates on Team Rhabdomyolysis, Caffeine Fatalities, and Heat Cramping

Eichner, E. Randy MD, FACSM

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doi: 10.1249/JSR.0000000000000207
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Rhabdomyolysis continues to rear its ugly head. I cover a seventh recent outbreak of team rhabdomyolysis, this time in softball. All seven outbreaks have a common denominator: a coach with a novel notion that does more harm than good. I also cover updates on fatal overdose from caffeine powder and debates on the causes and cures of muscle cramping in athletes. I close with a caveat emptor for alpha humans who experience cramping.

Team Rhabdomyolysis

It has happened again: another outbreak of team rhabdomyolysis. This time, it was on the softball team at Butler Community College in El Dorado, KS. On August 10, 2015, the first day of team training, all 21 players gathered at 6 a.m. at a nearby dam for a novel drill. Coaches had them jog up the face of the dam, an 80-yd grassy incline, and walk down on it backwards. They did this four times, amounting to a total of 320 yd of downhill, backwards walking. Then, they had an intrasquad scrimmage that evening. The next morning, three players had unusual calf soreness. They scrimmaged again that evening, and the next day, two players were hospitalized with sore calves and creatine kinase (CK) values consistent with exertional rhabdomyolysis (ER). Four of seven other players with sore calves were tested for CK and then admitted. Thus, six softball players were hospitalized for ER.

The long-time Butler softball head coach told the media he had never heard of rhabdomyolysis. The athletic director said that in 29 years in sports medicine, including 16 years as an athletic trainer, he had never seen a clear-cut case of rhabdomyolysis. It was a mystery to them, and they wondered what the young women had done wrong. The school statement to the media on the outbreak described the team jogging up the hill but not walking down it backwards. For parents, this is like dropping your kids off at a swimming pool with no lifeguards.

The young women did nothing wrong. These team outbreaks of ER are from novel overexertion at the hands of coaches set on building Rome in a day. We cover six recent outbreaks of team ER in the NCAA Sports Medicine Handbook: three in football, two in lacrosse, and one in swimming. Like the Butler team softball outbreak, all six prior team outbreaks of ER were from novel overexertion in unphysiologic drills designed and enforced by coaches (2,32,3).

Fortunately, the clinical course of ER was mild for the six Butler softball players. Only one had a CK level over 50,000 U·L−1, and three were admitted with CK values under 10,000 U·L−1. None had a compartment syndrome; all were home in a few days and were soon back training with the team. To their credit, the head coach said the downhill backwards walking “put too much force on their calves” and the athletic director said that the drill would never be repeated. It turned out that the dam drill was designed by a new strength and conditioning coach who had worked with Major League Baseball. The Butler softball team has great athletes and a winning heritage, but you cannot turn them overnight into the Cincinnati Reds. I am told that the strength coach is no longer with the Butler softball team.

Caffeine Fatalities

Last year, I wrote about an accidental fatal overdose from caffeine powder bought through the Internet. Logan Steiner, 18, a star wrestler, top student, and senior prom king in Ohio, left school for lunch at home, where he collapsed and died from caffeine powder that he apparently took as a preworkout supplement. A similar overdose death occurred in Georgia, where a man, 39, a fitness buff, was fired from his job because of aggression and 2 h later was found dead at his front door, with dried white fluid on his shirt, a bag of caffeine powder in his truck, and a sky-high blood level of caffeine found at autopsy (4).

Deaths have occurred from caffeine tablets, too; for example, in 2006 in Connecticut, James Stone, 19, collapsed and died at home after taking about 25–30 No-Doz pills (each with 200 mg of caffeine). He had a high blood level of caffeine, and the medical examiner called it an accidental overdose. But at least, caffeine tablets are labeled as to dose. In stark contrast, anyone who digs into a bag of caffeine powder with a kitchen spoon to gauge the dose may soon end up dead. I called caffeine powder a public health menace (4).

In July 2014, the U.S. Food and Drug Administration (FDA) warned about the chancy dosing and health hazards of caffeine powder. Now, another tragic death from overdose has occurred, and the FDA is cracking down further. James Sweat, 24, from Alabama, was newly married, had a great job, and was health conscious. He thought he had found a healthier way to get going in the morning. Instead of drinking coffee or cola, he bought caffeine powder through the Internet and mixed some with milk or water. But the first time James tried it, his father said, in a few minutes his heart began beating out of control, and a few minutes later, his heart stopped. Health workers got his heart going again, his father said, but it kept stopping and James eventually fell into a coma and died (7).

Now, the FDA has sent warning letters to five producers of caffeine powder. The Center for Science in the Public Interest applauds this move but said that it hopes this is the first step toward a ban and “not a substitute for one.” Apparently, one or more (some say four) of the producers have already stopped selling caffeine powder on the Internet (8). We can hope.

Heat or Sweat Cramping

If hope springs eternal, so does the debate on the causes of exercise-associated muscle cramping (EAMC). Recently, a group of team physicians debated online about how to cope with heat (sweat) cramping in football, a debate that recurs every summer. The winner again for prevention was salt. Dehydration and muscle fatigue also are invoked in EAMC in summer football. The same case is made for tennis (1).

You also can read in this journal on the opposing “altered neuromuscular control theory” of EAMC (6). This hypothesis is based partly on a model in which the tibial nerve is hit percutaneously with low-frequency trains of electrical stimuli until the flexor hallucis brevis muscle cramps. In simple terms, the big toe is shocked until it cramps. I doubt this model applies to heat (sweat) cramping in tennis or football, but one “shocking” finding in this model is that pickle juice “works” fast (in about 85 s) to alleviate the cramp. The hypothesis is that pickle juice sparks a neural reflex that originates from the oropharynx and inhibits the firing of the alpha motor neurons of the cramping muscle (5).

Setting aside problems of interpretation, practice effect, and placebo response in this big-toe model — and along the lines of “only in America” — a venture-backed Boston startup, Flex Pharma, Inc., is touting a new “sports drink” for EAMC that springs from the same big-toe model and follows the same hypothesis. It contains not pickle juice but a crafty blend of ginger, cinnamon bark, and chili pepper. It is meant to be quaffed in 2-oz shots, whereupon it will annoy or stimulate the oropharynx to signal the brain to signal the spinal cord to signal the alpha motor neurons to signal the cramping muscle to cut it out. So far, they are low on science but high on enthusiasm. Their draw is a Nobel-winning cofounder, Rod MacKinnon, whom they call an “Alpha Achiever.” In their bold brand positioning, they proclaim that their target is “Alpha Humans for whom EAMC can mean a humiliating loss of power, achievement, and control.” Who knew EAMC was that monumental? They hope to hit the market in 2016.

To which I say, “Caveat emptor.” You can save money by not buying the Flex Pharma drink and using instead another older form of distraction, the tried-and-true cramp therapy of old-timer football coaches: pinch their upper lip so hard they forget their cramp.


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2. Eichner ER. Rhabdo redux: “Don’t know much about history”. Curr. Sports Med. Rep. 2011; 10: 174–5.
3. Eichner ER. Rhabdomyolysis on teams, stimulated spleens, and postoperative compartment syndromes. Curr. Sports Med. Rep. 2014; 13: 3–4.
4. Eichner ER. Fatal caffeine overdose and other risks from dietary supplements. Curr. Sports Med. Rep. 2014; 13: 353–4.
5. Miller KC, Mack GW, Knight KL, et al. Reflex inhibition of electrically induced muscle cramps in hypohydrated humans. Med. Sci. Sports Exerc. 2010; 42: 953–61.
6. Miller KC. Rethinking the cause of exercise-associated muscle cramping: moving beyond dehydration and electrolyte losses. Curr. Sports Med. Rep. 2015; 14: 353–4.
7. Stein R. Potent powdered caffeine raises safety worries. Available from: Accessed 2015 Sep 20.
8. Tavernise S. FDA warns 5 producers of powdered caffeine. Available from: Accessed 2015 Sep 20.
Copyright © 2015 by the American College of Sports Medicine.