A young and otherwise healthy New York City marathoner died hours after completing the race due to a dangerous condition that can develop from exercise.
Rachel Apa was running her first marathon when she collapsed in Central Park, just two miles from the finish line.
The 24-year-old was rushed to Mount Sinai and died at 9:40 p.m. from a condition called rhabdomyolysis, her father, Steve Apa, told the New York Times.
This is when muscles break down, flooding the blood with proteins and electrolytes, damaging critical organs.
How could this happen to someone in “perfect health, perfect shape,” as her dad described?
Apa had been training for months for the race, he said. But that’s exactly why she was at heightened risk for the life-threatening disease.
Here’s what to know about rhabdomyolysis, aka “rhabdo.”
What is exertional rhabdomyolysis?
Rhabdomyolysis is the rapid breakdown of skeletal muscles — those attached to bones, as opposed to muscles in the heart and other organs.
That releases a deluge of compounds into the blood that the body isn’t equipped to process, the most notable of which are the protein myoglobin and the electrolyte potassium.
The kidneys try to filter myoglobin out, but the large molecules clog it up, poisoning the kidney tissue and leading to renal failure.
Damaged muscle cells burst and dump potassium into the blood, disrupting signals in the heart. This can cause fatal cardiac arrhythmias and cardiac arrest.
Any muscle injury, like a car crash, burns, electrical shocks, and even medications, can cause rhabdomyolysis.
Exertional rhabdomyolysis is specifically from high-intensity exercise or a prolonged, extreme workout.
Who is at risk?
Rhabdo is relatively uncommon, with about 26,000 people in the US developing it every year.
Endurance athletes like marathon runners are at higher risk, as are those who do similarly intense activities, like spin classes or CrossFit.
Authors of a 2021 study on exertional rhabdo noted that the condition predominantly strikes young, healthy women — and wanting to keep up with others in a fitness class could be increase their risk.
“While participants in a class are allowed to tailor the level of intensity, cadence and resistance to their fitness level, it is easy to succumb to peer pressure and overexert during the activity,” they wrote.
Those undergoing military training or who work in hot environments while also doing a lot of physical work (firefighters, foundry workers) are also at risk of developing rhabdo.
Dehydration doesn’t cause rhabdo, but it can make it much worse and increases the risk of deadly complications.
The key is that occasional endurance activities don’t cause rhabdomyolysis. Your risk increases if you push yourself too hard without resting, according to the Cleveland Clinic.
The authors of the 2021 study recommend that if you do spin class, make sure to properly hydrate, avoid any medications or supplements that can increase your risk, and gradually build up exercise volume and intensity.
While it’s associated with extreme exercise, most cases are seen in people who’ve had major injuries.
Rhabdo can also happen if you don’t move for a long time, cutting off normal blood flow and causing cell death. People over 65 are at increased risk of this.
What are the symptoms of rhabdo?
Symptoms usually appear a few days after the muscle injury, and some people may not even notice muscle soreness, according to Cleveland Clinic.
Top symptoms to look out for are the “classic triad” of muscle pain, muscle weakness and dark urine the color of tea or cola.
But a vast majority of people will not get all three symptoms — in fact, only about 10% of people experience all three, according to the American Academy of Physical Medicine and Rehabilitation. More than 50% of patients do not report muscle pain or weakness, but that’s still the most common symptom.
Other potential symptoms include fever, nausea, vomiting, malaise, dehydration, infrequent urination, confusion and loss of consciousness.
What is the treatment for rhabdo?
If you suspect you might have rhabdo, it’s important to seek medical attention immediately.
Treatment involves IV fluids, which can stop the condition from progressing to severe kidney damage. When that happens, patients might need to go on dialysis. In up to 50% of cases, damage to the kidneys require continuing dialysis for an extended time.
Many people totally recover after treatment, but most people have lingering muscle weakness that lasts for weeks.
And while patients might feel better at that time, it’s important to listen to your doctor before going back to exercise. They may advise several weeks or months off before returning, Cleveland Clinic said.
