Medical Illness in the Endurance Running Athlete
Brian J. Krabak MD MBA FACSMClinical Professor
Rehabilitation, Orthopaedics and Sports MedicineUniversity of Washington & Seattle Children’s Sports Medicine
Medical Director, 4 Deserts Series Ultra-MarathonsMedical Director, Seattle Rock n Roll Marathon
National Team Physician, USA Swimming
Disclosure
Financial disclosures: Neither I, Brian Krabak, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.
Off-label use disclosures: None.
Learning Objectives
• Describe common medical injuries in the endurance running athlete
• Develop treatment strategies for managing these illnesses
Exercise Associated Collapse
Overall Injuries and Illness Rates
Krabak & Waite 2011
Hoffmann 2011Roberts 2000
Major1 Mild1
Diagnosis No. (%) No. (%) Skin Disorders Abrasion 0 43 (3.9) Blister 10 (16.2) 642 (57.8) Cellulitis 1 (1.6) 8 (0.7) Hematoma (Subungual) 1 (1.6) 106 (9.5) Other6 00 23 (2.1)Musculoskeletal Injuries Bursitis 1 (1.6) 11 (1.0) Sprain 2 (3.2) 25 (2.3) Strain 1 (1.6) 27 (2.4) Tendonitis 7 (11.3) 115 (10.3) Other5 3 (4.8) 29 (2.6)Medical Illnesses Exercise-Associated Collapse2 35 (56.5) 43 (3.9) Altitude Sickness 0 11 (1.0) Serious Medical Diagnosis3 1 (1.6) 1 (0.1) Other Medical Diagnosis4 0 27 (2.4)
Roberts 2000, Krabak & Waite 2011
Marathon (Twin Cities) Ultra-Marathon (Multistage)
Event Overall Medical (NF/F) MSK (NF/F) Skin (NF/F) Marathon (per 1000 runners) 18.9 – 25.5 10.1 – 13.7 3.35 4.1 UM multistage (per runner)* 3.8 0.38 (0.1/0.27) 0.71 (0.04/.67) 2.7 (0.04/2.7)
*UM runner = 95% were minor illnesses or injuries
Overall Injuries and Illness Rates
Exercise Associated Collapse
• Differential Diagnosis• Cardiovascular Illness (i.e. Cardiac Arrhythmia, Postural Hypotension,)• Electrolyte Abnormalities (i.e. Hyponatremia, Hypoglycemia, Exertional
Rhabdomyolysis, Drug Toxicity, Gastrointestinal)• Heat Related Illness (i.e. Hyperthermia, Hypothermia)• Altitude Sickness• Respiratory/ Immune (i.e. Asthma, Anaphylaxis)• Acute Musculoskeletal Injury (i.e. Cramps, Fracture, Tear of Tendon)• Neurologic (i.e. Seizures, Concussions)
Exercise Associated Hyponatremia
Exercise Associated HyponatremiaEtiology
Excessive Consumption“Too Much In”
Fluid overload“Dilution” HYPONATREMIA
Failure to Excrete“Not Enough out”
Inadequate intake
“Not Enough in”
Excessive loss sweat/urine
“Too much out”
Sodium deficit“Depletion”
Inappropriate AVP secretion (SIADH)Non-osmotic stimuli (exercise, stress, hypovolemia) Impaired mobilization of osmotically inactive sodium
storesInappropriate inactivation of osmotically active
sodium
Increased Access or Behavior
Impaired mobilization of osmotically inactive sodium stores
Inappropriate inactivation of osmotically active sodium*
Inactivation of Sodium
Exercise Associated HyponatremiaMarathon – Dilution Model
Noakes 2005Weight GAIN correlated with worsening hyponatremia and the most weight gain strongly
associated with the most symptomatic patients (N =2135)
Exercise Associated HyponatremiaSingle Stage Ultramarathons – Depletion Model
Hoffman 2013
Weight LOSS correlated with hyponatremia and more symptomatic people suffered greater biochemical alterations (N =669)
Exercise Associated HyponatremiaMulti-Stage Ultramarathons – Dilutional Model
Krabak
Weight GAIN correlated with worsening hyponatremia and the most weight gain strongly associated with the most symptomatic patients (N 124)
N=124 r=-0.21 p=0.02
• Documented Na level • No IV iso or hypotonic fluid• Restrict fluid till urination• Oral salty snacks • Observe 60 minutes (GI water)• Fluids
• Oral : Hypertonic (salty)• IV: 100ml IV bolus 3% HS; repeat x2 q
10 min;
• Transport to hospital
Exercise Associated HyponatremiaField Treatment
• Unknown Na level*• Restrict IV iso and hypotonic fluid• Restrict fluid till urination• Oral salty snacks • Observe 60 minutes (GI water)• Fluids
• Oral : Hypertonic (salty)• IV: 100ml IV bolus 3% HS; repeat x2 q
10 min;
• Transport to hospital
*Weigh risks of EAH vs dehydration or rhabdomyolysis + AKI
Hew Butler 2015, Rogers 2015, Hoffman 2015, Krabak 2013
Heat Related Illness
Heat Related Illness
HeatProduction / Loss
TemperatureHumidity / SunWind / ClothingMedical Illness
MedicationNutrition
HeatDissipation / Retention
Exercise Evaporation : liquid to gaseous phase** Radiation : electromagnetic waves*Convection : affected to wind velocity*Conduction : direct physical contact * Cutaneous Dilatation ** Sweat
Compromise of the thermoregulatory center (hypothalamus) due to excessive heat gain (hyperthermia) or heat loss (hypothermia)
Pryor 2015, Casa 2013, Casa 2012, O’Connor 2010
Pryor 2015
Heat Related Illness
Heat ExhaustionInability to continue exercise or collapse, weakness, fatigue, muscle cramps, nausea, irritability, agitation, mild confusion
Normal to slightly elevated rectal temperature( 102-104O F), skin still moist
Heat StrokeCollapse after strenuous activity, Mental status changes
Cardiovascular collapse, Elevated rectal temperature(>104O F) skin may be hot and dry
Complications: Thrombocytopenia, Hemolysis, Rhabdomyolysis, ATN, Fatality (proportional to length of time core temp elevated)
Adams 2015, Demartini 2010, Casa 2010
Heat Related Illness• Treatment
• Removal of excessive equipment• Rectal Temperature• Cold Water Immersion (Cool First, Transport Second)• Oral fluids vs IV fluids (CHECK NA)
• Return to Activity
O’Connor 2010, Casa 2012, Pryor 2015
• Incidence: Unknown; but high CPK in 66% ultramarathon
• Pathophysiology:
Rhabdomyolysis
Szczepanik 2015, Hoffman 2012
Muscle injury leading to disruption of the
sarcolemma and release of intracellular myocytes into
plasma
• Symptoms/Signs• Myalgia, weakness, dark urine 24-72 hr after exercise
• Testing• Urine dipstick 1+ pr, 3+ blood, Sp Gr >1.025; • CK 5X normal (>10,000)
• Complications: • Acute kidney injury (17-35%), electrolyte abnormalities (HyperP,
HyperK, HypoCa (early), Hyper Ca (late), compartment syndrome, arrhythmia
Rhabdomyolysis
Szczepanik 2045
• Treatment• Rest, Hydration (oral vs IV*), Education• Confirmed increase CK =Transport to hospital for monitoring
and aggressive hydration BUT RULE OUT EAH
• Return to Play: • Phase 1: Rest 72 hr + hydration + check CK/UA• Phase 2 (if peak CK < 5x Nl) : Light activities over 1 week • Phase 3 (no symptoms) : Gradual return to sport
Rhabdomyolysis
Gastrointestinal / Hygiene
Gastrointestinal / Hygiene• Epidemiology: Prevalent (up to 96%), may impact performance, typically
benign• Etiology: Multifactorial, exercise-induced gastroparesis, dehydration and
suboptimal caloric intake, quality and quantity of fluid intake• Presentation: Nausea, vomiting, cramping• Treatment: Reduce exercise intensity, anti-emetics (ondanestron DT), GI
protective (ie ranitidine), Abx (ie Ciprofloxacin)
• Prevention: Education, Hand & Toilet Hygiene, appropriate caloric/hydration, hand sanitizer at aid stations
Stuempfle 2015
Pryor 2015
Summary• Majority of non-cardiac Medical Illnesses can be managed during a
race with conservative treatment• Hyponatremia: Drink To Thirst
Hypervolemia vs Hypovolemia
Avoid Hypotonic IV / use Hypertonic IV• Hyperthermia: Cool 1st (30 min) & Transport 2nd
• Organize medical team and care appropriately