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Football Team Rhabdomyolysis

The Pain Beats the Gain and the Coach Is to Blame

Eichner, E. Randy, MD, FACSM

Current Sports Medicine Reports: May 2018 - Volume 17 - Issue 5 - p 142–143
doi: 10.1249/JSR.0000000000000484
Pearls and Pitfalls
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College football continues to lead the nation in team exertional rhabdomyolysis (ER) that puts players in hospitals. The largest outbreak of team ER was in Iowa and the most recent in Nebraska, but Oregon and Maine also are on the list. The theme is the same, and the coaches are to blame. Similar themes occur in team ER in other sports. To explain, I will cover 17 outbreaks of team ER in recent years, starting with football.

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College Football Team Rhabdomyolysis

The most recent outbreak of college football team ER was at the University of Nebraska in January 2018, when two players were hospitalized the first week back after winter break. With no bowl practice for the first time since 2007, the players were on their own to work out during the break. The head coach, who was new on campus, said the cause was an intense weightlifting workout designed for 40 min but cut to 32 to 36 min. The strength and conditioning coach also was new, but the head coach backed him and blamed the victims instead. More on that below. Within 3 d, both players were out of the hospital and later rejoined the team.

The largest outbreak of college football team ER was at The University of Iowa in January 2011. Two days after a 3-wk break, the team endured what some called the toughest 1-d regimen in their playbook. The hardest task was 100 timed back squats at 50% top weight for one repetition. In the next few days, 13 players were hospitalized with ER. These 13 were more likely to have gone to muscle failure during the back squats, to think they could not finish the back-squat drill, and to do more squats, because some were not counted as full squats. The risk of major ER also increased with the number of sets and time needed to finish the 100 squats (1).

An outbreak of team ER occurred at The University of Maine in January 2012. It was presented in brief at a sports medicine meeting later that year. Implicated was a squat drill similar to that at The University of Iowa, along with other lower-body drills and a sprint workout, over the first 2 d back from winter break. On day 3, a player was hospitalized with ER and underwent bilateral fasciotomy for lateral thigh compartment syndrome. Soon after, three or four more players were hospitalized for milder cases of ER. All these athletes returned to football. It seems this outbreak got little media coverage.

The University of Oregon outbreak of team ER was in January 2017, after 3 d of grueling workouts that included a drill of up to an hour of continuous push-ups and up-downs. These workouts were directed by a new strength and conditioning coach, who came with a new head coach. This intense conditioning came right after the players returned from a winter break of over a month, after a 4-8 season the prior year. Three players were hospitalized with ER; two stayed in for a week. The strength coach was suspended for a month without pay and told to report to someone other than the head coach, and the head coach issued a formal apology. In December 2017, after a 7-6 season, the head coach left to coach in Florida and took the strength coach with him.

The theme is always the same. All four outbreaks occurred in January, after a winter break, when some deconditioning occurs. However, the prior season had been marked by losing key games. In two of the four outbreaks, so many games had been lost that the head coach and strength coach were new. It seems that, after “losing seasons,” football coaches conclude that losing is the fault of the players.

As soon as the players returned from winter break, the coaches enforced intense conditioning, to “teach them a lesson” or “toughen them up.” The Iowa strength coach told players that losing close games the prior year should concern everyone and that the drills ahead would determine “who wants to be here.” In all four cases, the workouts were novel overexertion, and the result was team ER. Then, the coaches blamed the victims.

The Nebraska head coach said that “all they were doing was lifting” and “two kids that exerted themselves too far” got rhabdomyolysis. The Oregon head coach said the team ER was a “bogus story” in the sense that the players could have “tapped out” at any time, but “some overworked themselves” to show “they are not quitters.” The Iowa head coach said he could find “no smoking gun” to explain the team ER. He gave his strength coach an award for being the “most valuable coach of the year,” raising the question: What attributes do football coaches value?

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High School Football Team Rhabdomyolysis

The theme continues in three outbreaks in high school football. The most famous was in McMinnville, Oregon, in August 2010, when a new coach came to town and began a “football camp.” Day 1 featured an intense, triceps-focused drill, “supersets” (chair dips and push-ups), 5 bouts, fast repetitions to failure, with competitive motivation. In the next few days, 12 of the 43 players were hospitalized for ER of the upper arms, and three had fasciotomy for triceps compartment syndrome (2).

The “triceps theme” continued in a Maryland high school in 2011, when a new coach conjured up a novel drill, “triangulated push-ups on chairs.” Soon after spring break, his players did this drill, 125 push-ups. Three were hospitalized with ER; one got fasciotomies for triceps compartment syndrome. Finally, in January 2016, in a Texas high school, three to five football players went to the hospital with ER after coaches made them do hundreds of squat jumps for 2 or 3 d in a row, as punishment for leaving the locker room dirty. The head coach resigned (3).

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Team Rhabdomyolysis in Other Sports

College swimming has seen two outbreaks of team ER. In the first, on day 1 after a summer break, 41 swimmers met a new coach and a new drill before their usual 2 h of swimming. The drill was as many push-ups as possible in a minute, then as many squats as possible in a minute, with the sequence repeated 10 times. Other novel drills continued on days 2 to 3, along with swim practice. Beginning on day 2 and continuing for a few days, seven swimmers, men and women, were hospitalized with ER of the triceps and pectoral muscles. All returned to college swimming (4). In the second outbreak, after a novel “arm competition” drill on day 10 of off-season training, six college swimmers, men and women, were hospitalized for ER. Within 6 wk of discharge, all returned to normal swim training (5).

College lacrosse also has seen two outbreaks. On day 1 after a 3-month hiatus, a women’s team did three sets of 20 biceps curls with weights. The next day, several had ER of the biceps. In 3 wk, they were back to full participation (6). Then, at The Ohio State University in 2012, a lacrosse outbreak put six women in the hospital with ER. This was from an intense, ad hoc, upper-body workout after the team lost a big game. The athlete who tried the hardest to meet the demands, and did the most exercise in the drill, suffered the most severe case of ER (3).

Team outbreaks also have occurred in college women’s soccer and track in Ohio. Three soccer players were hospitalized for ER in 2011 after 2 d of pull-ups, chin-ups, push-ups, and bench presses with dumbbells. In 2014, six women on a track team were sent to a hospital (and one admitted for a few days) for ER after a novel workout.

At a Mississippi middle school in 2013, three 13-year-old boys spent 1 to 2 wk in the hospital after a grueling tryout for the basketball team that involved bear crawls, lunges, and frog jumps. One boy said that, late in the drill, “If I tried to bend over or squat, my legs would give out and I would fall over.” Also, for a college softball team in Kansas, a new coach devised a strange new drill. On day 1 of team training, he took 21 players to a steep incline, the grassy face of a dam, and had them jog up and walk down backward, four times. Six players ended up in the hospital with ER of the calves (7).

Team ER occurred in volleyball at Texas Woman’s University in August 2016. After an “annual fitness test,” eight players — mainly freshmen — were hospitalized for ER. One clue to the outbreak is that the testing scheme was new. Instead of each player doing as many repetitions as she could in a given time — as in past years — the entire team was urged to do a given number of repetitions in a given time. This unwise demand likely hit freshmen the hardest (8).

Finally, team ER occurred in college women’s golf in Oklahoma in 2017. A novel, strenuous workout led to arm pain in all players and to hospital admission of one player for upper-extremity rhabdomyolysis. Maybe better just to practice and play golf.

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Concluding Pearl

I cover 17 outbreaks of team ER in sports: seven in football, two in swimming, two in lacrosse, and one each in soccer, track, basketball, softball, volleyball, and even golf. In each case, the cause was novel overexertion: too much, too soon, too fast. In all cases, to a greater or lesser degree, the culprits were the coaches.

The author declares no conflict of interest and does not have any financial disclosures.

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