J Med Cases
Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc
Journal website http://www.journalmc.org

Case Report

Volume 4, Number 1, January 2013, pages 12-14

Severe Rhabdomyolysis Associated With a Popular High-Intensity At-Home Exercise Program

Demetrios Paidoussisa, Robert J. Dachsb, c, d

aDepartment of Family Medicine, Ellis Hospital, Schenectady, NY 12308, USA
bDepartment of Emergency Medicine, Ellis Hospital, Schenectady, NY 12308, USA
cEllis Hospital Family Medicine Residency, Albany Medical College, USA
dCorresponding author: Robert J. Dachs, Department of Emergency Medicine, Ellis Hospital, 1011 Nott Street, Schenectady, New York 12304, USA

Manuscript accepted for publication September 24, 2012
Short title: Rhabdomyolysis and Home Exercise Program
doi: https://doi.org/10.4021/jmc875w


High-intensity exercise programs have become popular methods of unsupervised home exercise. We present a case of severe rhabdomyolysis that developed in a 23-year-old athlete, who after two sessions of the extreme workout known as the “P90X” developed rhabdomyolyis. His CK level peaked at 1,286,900 IU, the second highest CK level ever reported in the medical literature. After aggressive inpatient medical care, the patient sustained no long-term sequelae.

Keywords: Rhabdomyolysis; Exercise; High intensity


Many physicians are well aware of the potential risk of rhabdomyolysis in individuals participating in strenuous athletic endeavors, but may not consider the diagnosis in those participating in home exercise programs. Extreme physical workouts have become popular among athletes and non-athletes as a method of losing weight and gaining muscle strength. A particularly popular exercise and nutrition program, P90X (the Beachbody Company), has reported sales of almost three million copies [1]. P90X can be performed at home without supervision or prior medical evaluation. This case highlights a healthy athlete who developed severe rhabdomyolysis shortly after initiating this exercise regimen.

Case Report▴Top 

A 23-year-old African American male athlete presented to the Emergency Department (ED) of our community hospital seeking treatment for bilateral arm pain and swelling of 3 days duration. The swelling developed after the second day of using the P90X exercise program. In addition to experiencing diffuse muscular pain, which was most intense in the arms, he also reported having brown colored urine. His past medical history was significant for migraine headaches and a traumatic rupture of the tympanic membrane. There was no family history of muscle related disorders. He denied any medications, steroids, hormone replacements or dietary supplements. He did report the use of marijuana, but denied using cocaine or other stimulants. He also denied any additional athletic activities during the 2 days prior to presentation. The physical exam demonstrated tense, swollen upper extremities bilaterally, most notably in the biceps. No neurovascular compromise was noted in the upper extremities.

The initial laboratory evaluation revealed a serum creatinine kinase (CK) level of 170,300 IU/L (normal 0 - 195 IU/L). Myoglobinuria was present without hematuria or other abnormalities on microscopy. Intravenous fluids were initiated and the patient was admitted to the medical service with a diagnosis of rhabdomyolysis.

Approximately 10 hours after admission, a repeat CK value of 1,286,900 IU/L was recorded. Liver function studies revealed an AST of 1720 IU/L (Normal 10 - 41 IU/L), ALT of 364 IU/L (Normal 15 - 62 IU/L), and LDH of 5147 IU/L (Normal 60 - 190 IU/L). The compartment pressure in both posterior upper extremity compartments was 27 mmHg.

Hydration, urinary alkalinization and opiate analgesia were continued during the patient’s hospitalization. The patient’s pain and swelling gradually improved. His laboratory values also demonstrated gradual improvement (Table 1). The patient was discharged after 7 days of hospitalization.

Table 1.
Click to view
Table 1. Daily Laboratory Values

Rhabdomyolysis has been attributed to illicit drug use (for example, PCP), medications (for example, statins), trauma, and excessive muscular exertion. Approximately 26,000 cases of rhabdomyolysis are reported annually in the US [2]. However, the percentage of cases associated with exercise is unknown. A historical cohort study of 157 patients diagnosed with rhabdomyolysis noted only 9 cases due to “excess activity” [3]. Since then, exercise-induced rhabdomyolysis has been reported in small series and case reports but its association with proprietary exercise programs has not been previously reported [4-12].

P90X is a 90-day program utilizing a mix of exercises that include strength training, cardiovascular, yoga, plyometrics and stretching. Included is a nutrition guide, fitness plan, DVD series and calendar. Cost is $119.85. The routine consists of exercising six days per week, for 13 weeks. Each workout is usually less than 1 hour in duration. Workouts consist of pushups, pull ups, yoga exercises, and aerobic exercises. A Medline search using the term “P90X” resulted no reports of rhabdomyolysis. A Google search revealed only one self-report of rhabdomyolysis associated with P90X that did not require hospitalization.

Most ED physicians would consider rhabdomyolysis in patients at risk but might think home exercise would only be associated with delayed-onset muscle soreness (DOMS) [8]. Common risk factors associated with rhabdomyolysis are listed in Table 2. Interestingly, our patient had no known underlying risk factors for developing massive rhabdomyolysis, which suggests that even physically fit individuals should remain cautious when initiating at home workout regimens.

Table 2.
Click to view
Table 2. Common Risk Factors Associated With Rhabdomyolysis

Our patient’s CK level quickly surpassed one million IU. The only other reported case of a CK level greater than one million was also in a young male starting an exercise program [13]. The degree of CK elevation correlates with the severity of muscle injury and has been associated with the development of acute renal failure (ARF) [3]. However, neither case of exercise-induced rhabdomyolyis with CK values over one million developed ARF. In 1994, Sinert reported 35 cases of exercise-induced rhabdomyolysis in which none of the patients developed ARF [14]. No cases of ARF were noted in a larger series of 89 students with elevated CK values after repetitive exercise [15]. All of these cases involved young patients that were presumably in good health. We hypothesize that other factors, such as age, co-morbidities, hydration status and volume resuscitation may play a more significant role in the development of ARF than the absolute CK value [16].

Aggressive volume administration is often recommended to prevent heme-pigment induced acute renal injury. However data is lacking regarding the proper rate of administration [16]. Urinary alkalinization to prevent heme-protein precipitation is also often employed but a recent review demonstrated no clinical benefit [17]. This same review found mannitol-induced diuresis also provides no benefit.

In conclusion, medical providers should not categorically dismiss complaints of muscle pain after home exercise programs as simple muscle soreness. Attention to complaints of exquisite muscle pain, swelling and/or dark colored urine should trigger further investigation.

Grant Support

This work was not supported by any external grant or funding.

Conflicts of Interest

The authors declare no conflicts of interest.

  1. Deprez, Esme (18 November 2010). "Beachbody: Thinking Beyond the Infomercial". Bloomberg. http://www.bloomberg.com/news/2010-11-18/beachbody-thinking-beyond-the-infomercial.html. Retrieved 3 December 2010.
  2. Sauret JM, Marinides G, Wang GK. Rhabdomyolysis. Am Fam Physician. 2002;65(5):907-912.
  3. Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med. 1988;148(7):1553-1557.
    pubmed doi
  4. Moeckel-Cole SA, Clarkson PM. Rhabdomyolysis in a collegiate football player. J Strength Cond Res. 2009;23(4):1055-1059.
    pubmed doi
  5. Moghtader J, Brady WJ, Jr., Bonadio W. Exertional rhabdomyolysis in an adolescent athlete. Pediatr Emerg Care. 1997;13(6):382-385.
    pubmed doi
  6. Line RL, Rust GS. Acute exertional rhabdomyolysis. Am Fam Physician. 1995;52(2):502-506.
  7. Ehlers GG, Ball TE, Liston L. Creatine Kinase Levels are Elevated During 2-A-Day Practices in Collegiate Football Players. J Athl Train. 2002;37(2):151-156.
  8. Inklebarger J, Galanis N, Kirkos J, Kapetanos G. Exercise-induced rhabdomyolysis from stationary biking: a case report. Hippokratia. 2010;14(4):279-280.
  9. Sevketoglu E, Kural B, Beskardes AE, Hatipoglu S. Exertional rhabdomyolysis after influenza A (H3N2) infection in a basketball player boy. Ann Trop Paediatr. 2011;31(1):93-96.
    pubmed doi
  10. Thoenes M. Rhabdomyolysis: when exercising becomes a risk. J Pediatr Health Care. 2010;24(3):189-193.
    pubmed doi
  11. Dekeyser B, Schwagten V, Beaucourt L. Severe rhabdomyolysis after recreational training. Emerg Med J. 2009;26(5):382-383.
    pubmed doi
  12. Gagliano M, Corona D, Giuffrida G, Giaquinta A, Tallarita T, Zerbo D, Sorbello M, et al. Low-intensity body building exercise induced rhabdomyolysis: a case report. Cases J. 2009;2(1):7.
  13. Casares P, Marull J. Over a millon Creatine Kinase due to a heavy work-out: A case report. Cases J. 2008;1(1):173.
  14. Sinert R, Kohl L, Rainone T, Scalea T. Exercise-induced rhabdomyolysis. Ann Emerg Med. 1994;23(6):1301-1306.
    pubmed doi
  15. Lin AC, Lin CM, Wang TL, Leu JG. Rhabdomyolysis in 119 students after repetitive exercise. Br J Sports Med. 2005;39(1):e3.
    pubmed doi
  16. Zager RA. Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int. 1996;49(2):314-326.
    pubmed doi
  17. Thomas R. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Bet 1. Rhabdomyolysis and the use of sodium bicarbonate and/or mannitol. Emerg Med J. 2010;27(4):305-308.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Journal of Medical Cases is published by Elmer Press Inc.


Browse  Journals  


Journal of Clinical Medicine Research

Journal of Endocrinology and Metabolism

Journal of Clinical Gynecology and Obstetrics


World Journal of Oncology

Gastroenterology Research

Journal of Hematology


Journal of Medical Cases

Journal of Current Surgery

Clinical Infection and Immunity


Cardiology Research

World Journal of Nephrology and Urology

Cellular and Molecular Medicine Research


Journal of Neurology Research

International Journal of Clinical Pediatrics



Journal of Medical Cases, monthly, ISSN 1923-4155 (print), 1923-4163 (online), published by Elmer Press Inc.                     
The content of this site is intended for health care professionals.
This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)

This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website: www.journalmc.org   editorial contact: editor@journalmc.org
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada

© Elmer Press Inc. All Rights Reserved.

Disclaimer: The views and opinions expressed in the published articles are those of the authors and do not necessarily reflect the views or opinions of the editors and Elmer Press Inc. This website is provided for medical research and informational purposes only and does not constitute any medical advice or professional services. The information provided in this journal should not be used for diagnosis and treatment, those seeking medical advice should always consult with a licensed physician.