A young, otherwise healthy New York City marathon runner died hours after completing the race from a dangerous condition linked to intense physical exertion.
Rachel Apa was competing in her first marathon when she collapsed in Central Park, about two miles from the finish line.
The 24-year-old was taken to Mount Sinai Hospital and died at 9:40 p.m. from a condition known as rhabdomyolysis, her father, Steve Apa, told The New York Times.
Rhabdomyolysis occurs when muscles rapidly break down, releasing proteins and electrolytes into the bloodstream that can damage vital organs.
How could this happen to someone in “perfect health, perfect shape,” as her father described her?
Apa had trained for the marathon for months, he said. But that intense preparation may also have increased her risk of developing the potentially fatal condition.
Here’s what to know about rhabdomyolysis, often called “rhabdo.”
What is exertional rhabdomyolysis?
Rhabdomyolysis is the rapid breakdown of skeletal muscle — the muscles attached to bones, rather than those found in the heart and other organs.
The process releases a surge of substances into the bloodstream that the body may struggle to handle, particularly the protein myoglobin and the electrolyte potassium.
The kidneys attempt to filter out myoglobin, but the large molecules can obstruct the organs, damage kidney tissue and lead to renal failure.
When injured muscle cells rupture, they also release potassium into the bloodstream. This can interfere with the heart’s electrical signals, potentially causing dangerous arrhythmias or cardiac arrest.
Rhabdomyolysis can result from many types of muscle injury, including car crashes, burns, electrical shocks and certain medications.
Exertional rhabdomyolysis specifically develops after high-intensity exercise or prolonged, extreme physical activity.
Who is at risk?
Rhabdomyolysis is relatively uncommon, affecting about 26,000 people in the US each year.
Endurance athletes, including marathon runners, face a higher risk. The condition can also affect people who take part in similarly strenuous activities, such as spin classes and CrossFit.
Authors of a 2021 study on exertional rhabdomyolysis noted that it disproportionately affects young, healthy women. Trying to match the pace or intensity of others in a fitness class may further raise the risk.
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“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,” the researchers wrote.
People undergoing military training, as well as those who perform demanding physical labor in hot environments — including firefighters and foundry workers — are also vulnerable to rhabdomyolysis.
Dehydration does not directly cause rhabdomyolysis, but it can worsen the condition and increase the risk of life-threatening complications.
Occasional endurance exercise does not typically cause rhabdomyolysis. According to the Cleveland Clinic, the risk rises when someone pushes too hard without allowing enough time for rest and recovery.
The authors of the 2021 study recommend staying properly hydrated during spin classes, avoiding medications or supplements that may increase the risk and gradually building exercise volume and intensity.
Although rhabdomyolysis is associated with extreme exercise, most cases occur after major injuries.
The condition can also develop when a person remains immobile for an extended period, reducing normal blood flow and causing muscle-cell death. Adults over 65 face a higher risk in these circumstances.
What are the symptoms of rhabdo?
Symptoms often emerge several days after the muscle injury, and some people may not notice significant muscle soreness, according to the Cleveland Clinic.
The condition’s “classic triad” consists of muscle pain, muscle weakness and dark urine that may resemble tea or cola.
However, most people do not experience all three symptoms. In fact, only about 10% of patients develop the full triad, according to the American Academy of Physical Medicine and Rehabilitation. More than 50% of patients do not report muscle pain or weakness, though muscle symptoms remain among the most common signs.
Other possible symptoms include fever, nausea, vomiting, malaise, dehydration, infrequent urination, confusion and loss of consciousness.
What is the treatment for rhabdo?
Anyone who suspects they may have rhabdomyolysis should seek medical care immediately.
Treatment typically includes intravenous fluids, which can help prevent the condition from progressing to severe kidney damage. If kidney failure develops, dialysis may be necessary. In up to 50% of cases, kidney damage requires patients to continue dialysis for an extended period.
Many people make a full recovery with treatment, although muscle weakness can persist for weeks.
Even if symptoms improve, patients should follow their doctor’s guidance before returning to exercise. The Cleveland Clinic notes that some people may be advised to take several weeks or months off before resuming physical activity.
