What Every Marathon Runner Should Know About Rhabdomyolysis

I was in the best shape of my life . . . and I almost died. So listen up, you might learn something. Because what happened to me, could also happen to you.


Don't be alarmed, and don't stop running. The key is to be informed so you can avoid much of the pain and torture that I suffered, as did my family.


I've been an athlete all my life. Started with baseball at 7 years old. Added football at 9. Played some basketball here and there and was skiing 15 or more days every winter. I stuck with those sports until I graduated from high school. But during those years, I didn't really have an affinity for distance running -- in fact I dreaded doing any kind of running in practice.


That all changed in college. A buddy of mine who ran cross-country and track started torturing me at 6 a.m. to run 6 miles every single day. Every morning we ran. We ran in the rain. We ran through 3 foot high snow drifts and into 20 mph winds during white-out condition blizzards. Later we added other endurance sports, such as cycling and nordic skiing. We went on long arduous hikes on a mission to conquer the 46 highest peaks in the Adirondacks, including a famous 20 miler that ended with bloody and blistered feet, and a car that ran out of gas. He finally abandoned me to pursue his olympic dreams (in fact, despite competing in 2 olympics, that Jacked Up Old Man is still trying to do it again). Despite the torture, I was transformed forever. I was grateful for being forced to acquire the taste for running, and I continued to log miles out on the road and the trails.


I ran my first NYC Marathon during my third year of law school - I was 26 years old. My goal then was very simple . . . finish the race. As it turned out, that would be my best performance. I didn't train particularly hard, but I stuck to the recommended training for first time marathoners that came in a brochure from the NY Road Runners Club. I finished the race in 3:57:54 and, looking back on it, that was a very good first marathon. Back then, in 1992, the only time kept was "gun time". The race was so crowded that it probably took anywhere from 4 to 7 minutes just to reach the starting line. Nowadays, with the ChampionChip timing chip, the runner's time begins when the starting line is crossed, and not with the gun.


In 1996, I lucked out again and made it into the race off the lottery. Unfortunately though, I was working at a law firm, had a long commute, and my training was relegated to late nights at a dimly lit track. I didn't nearly train as hard as I did for my debut, and it showed in the results - a "gun time" of 4:08:15. Although my goal was to finish under 4 hours, I was satisfied with my result given the paltry amount of training I put in.


I vowed to run another marathon and finish in a time of 3 hrs and 40 minutes. But my motivation for doing so was purely for the health benefits of running. My training was more religious when I had the goal of completing a marathon. It gave me something to work toward. My daily runs had much more significance and it was no longer acceptable to skip a day if I didn't feel like it. Even in preparation for my second marathon, I didn't log the long runs I needed but the fear and embarassment of not finishing the race always motivated me to get my butt out the door to run at least 3-6 miles five days a week.


Unfortunately, over the next couple of years, I was closed out of the marathon. In or around 2003, I discovered that the NY Road Runners Club changed their marathon entry policy. Instead of simply applying and hoping to be randomly selected for a spot, they gave automatic entries to members who completed a certain number of qualifying races the previous year. I decided then that I would rejoin the Club, do as many qualifying races as I could, and enter the marathon in 2004.


Despite being 37-38 years old, 2003-04 turned out to be a time when I tremendously improved as a runner. I ran dozens of races. My average pace went from 8 min. per mile, down to 7. I took a 2nd place age group finish in a 5 mile race, and a few 3rd place finishes in some 5k races. Then the unthinkable - I ran two races at a 6:50 pace. I was now only a month away from the marathon and feeling great.


On the day of the big race, the weather was warmer than in previous years. I hydrated myself the same way I always did -- mostly water, one bottle of diluted gatorade and, in fact tried to drink a little more given the unseasonably warm temperature. I had signed up to run with a special pace group. The group had an experienced runner who would carry a sign for our target finish which was 3 hrs and 40 minutes. I decided I would start with the group, but I would largely run at whatever pace was comfortable for me. I could always fall back with the group and use their location as a good indication of where I stood in relation to my goal.


After the gun fired at the start, I felt incredibly strong and confident. Four times in the 3 months leading up to the race I had done hot weather training runs of 20-22 miles, and this would be just like another training run. I had left the pace group behind at mile 3, finding the pace to be just a little bit slower than the pace I wanted to run.


At the 10k mark, my time was 48:18--a pace of approx. 7:47 per mile. My adrenaline surged. I was exceedingly comfortable running at a pace that would carry me to accomplish my goal. The crowd was cheering, gently pushing me toward the finish. I wore a watch that calculated my pace and I knew I was going slightly faster than I had planned. I talked to myself. Could I sustain this pace for the entire 26.2 miles? I told myself I could. I reminded myself of the long training runs of 18, 20 and 22 miles I did. Surely, I could at least go those distances at my current pace and, even if I had to slow down for the last 5 or 6 miles, I would still make my goal.


Just before the halfway mark, it happened. Just what happened, I didn't know or understand at the time. All of a sudden I felt sick. I felt like I had a bad fever. I didn't understand it. I became insatiably hungry and thirsty. I pulled out a "Gu" packet and sucked it down. It didn't help -- in fact it made me feel nauseous. I continued to run but eased up a bit. I began drinking water and gatorade, literally chugging 2 cups at every station where it was being handed out. Yet I felt more and more sick as I continued.


As I crossed the Kosciuszko Bridge, the landmark signature of the halfway point of the race connecting the boroughs of Brooklyn and Queens, I started to change my game plan. No longer was it important for me to finish in 3:40--I just wanted to finish. I hit 13.1 miles at 1:46:46. My average pace had slowed to 8 minutes. I could still finish respectably.


In hindsight, it was incredibly stupid for me to continue the race. I should have stopped running right then and there. Call it ego, fear of embarassment, or whatever you want -- the thought of not finishing the race was never even a consideration for me. Not once did the thought enter my mind. I had trained hard, made incredible advances in my running over the past year, all for this one race.


Over that last year, I had taught myself how to psychologically push through pain. I almost welcomed it, as a challenge, and mastered the art of convincing myself that pain was all in my mind. Now it was up to the ultimate test.


After crossing the bridge, I decided that I would take a minute to compose myself before pushing on. I located another water station, drank more, ate a chunk of a banana, and dodged into a port-a-potty to relieve myself.


For those in the know, one of the telltale signs of kidney failure is when a cola or syrup looking color is discharged in the urine. Not only did I not know this, but I also wasn't really paying attention. I think this may have happened right there in the race. I noticed out of the corner of my eye that my urine wasn't clear, but didn't think anything of it because it is often discolored after consuming vitamins and certain other things. I had so much gatorade and "Gu" at that point, I thought nothing of it.


Soon enough, I was back in the race, only now I was running a more leisurely pace. I continued to feel sick, however. Did I have a virus? What horrible timing. Still I pushed on. At the Queensboro Bridge, the trek is long and windy over the East River as the race heads into Manhattan. I knew that there was a long uphill on First Avenue waiting for me, but that the cheering crowd there would help get me through it. I stopped and walked for a few minutes on the bridge to prepare for what lay ahead.


The plan seemed to work. I was able to run up First Avenue at a decent pace all the way to the next bridge crossing to the Bronx. However, by then, I was in severe pain. I alternated running and walking all the way through the Bronx and back into Manhattan. Once back in Manhattan, I knew I was nearing the finish, but I was feeling sick, nauseous and even a little delirious.


As I inched my way toward Central Park, my pace group went running by! It was demoralizing to see how close I was to attaining my goal, but I was not able to keep up with the pace group for the last few miles. I continued to push through the pain.


I finally entered Central Park. I decided I would run slow but steady and not stop for anything. I was intensely focused on the finish, which was still a couple of miles away. Friends of mine cheered me on, but I did not even notice.


I finished with a "chip time" of 4:08:15. I managed a quick smile for the cameras, took my solar blanket and walked through the corrals until I found a spot near a small fence. I sat down, shut my eyes and held back the urge to vomit.


After I got my breathing under control, I limped slowly to find my belongings and to get dressed. I managed to find the subway where I rode out to my in-laws apartment to meet my family. I napped for a few hours there before we went home.

The trip to hell and back began around 3 a.m. I never wake in the middle of the night, but woke up and promptly threw up. I began having chills. I was sure I had a virus of some sort.

I stayed in bed that day. I put on several layers of clothes to stay warm and slept. I woke only to vomit - and I vomited several times. At my wife's urging, I called the doctor and made an appointment for the next day. That evening I bent over before getting into bed, and lifted one knee toward my stomach - a strange but excruciating pain shot through my core like I have never experienced before. What in the world was that all about?

At the doctor's office, I saw a physician's assistant who determined that I had a rotovirus that was making its way through the area. He said the virus takes up residence in the stomach and was causing the nausea I was experiencing. It sounded reasonable to me. I was prescribed some medicine. Of course, I had described everything that happened to me. I told him about my experience in the marathon, and told him about the shooting pain when I bent over to get into bed.

The medicine made me more nauseous and, in fact my vomiting increased. I started losing weight dramatically, and the chills got worse and worse. All I wanted to do was sleep. I tried going to work. I carried plastic bags in my car in case I needed to pull over and vomit - which happened twice. I would leave work because I was so cold, sit in my car with the heat on, and fall asleep for an hour or so, then go back inside to the office.

Now, five days after the marathon, my weight had dropped from 165 lbs to 150. My situation had not improved one bit, and my sister - a doctor - was questioning the competency of the medical advice I was given. She said there were certain conditions that were common among those who ran marathons, and that she could not believe I was not given a blood test. She told me to insist upon it.

So, I returned to the doctor's office. I had to insist on the blood test, and I was given information to go to a Quest Diagnostics lab where I had it done.

The call came in late the next afternoon. I was working on a brief in my office that had to go out. I still felt like crap, but was learning to manage my condition as best as I could. There were definitely times when I felt a little better, and times when I felt like I would pass out. The physician's assistant asked how I was doing. I replied that nothing had changed.

He then asked me where the nearest hospital was to my home. That threw me for a loop. "Why?" I asked. "Because we got your blood test back and it seems perhaps your kidneys aren't working exactly the way they should. We think you should have it checked out." Now, I'm thinking at least we are getting to the bottom of this mysterious illness. So I told him the name of the nearest hospital.

"Okay, well I will fax them the blood test results and inform them you will be coming in within the next hour." Next hour? What is this guy talking about? "Well, I'm working on something really important at work. Can I go there tomorrow morning? Or after dinner? I have to finish this brief, get my kids from school, then pick up my wife at the train station."

"No. You have to go right now," he replied. I was stunned.

I called my wife, and she left work right away to come home. She was as confused as me. We got the kids and left for the emergency room. We checked in, and a nurse came to take my vital signs. She had not seen the fax with my blood results yet. I gave her this description:

"I ran the marathon on Sunday and felt sick halfway through. I began vomiting the next day. I had this shooting pain in my lower back when I bent over to . . ."

Without hesitation, she interrupted, "You have renal failure."

How was it this emergency room nurse knew what my doctor's office didn't? I was amazed.

I waited for the ER doctor to arrive. He had received the blood test results. He told me my creatinine level was high and there would be a nephrologist coming in shortly who he wanted to consult with. He confirmed that the blood test meant I was experiencing problems with kidney function.

We knew a thing or two about dialysis. My mother-in-law was suffering from acute renal failure for the past year or two, and had her own peritoneal dialysis machine in her apartment. My wife was becoming an expert on it. Now, the prospect of me having to go through the same thing was about to push her over the edge.

When the nephrologist arrived, he explained the blood test results. My creatine level was off the charts and, quite frankly, the mortality rate for people whose creatinine was that high was 50%. Fifty-freakin-percent! There was a 50% chance I would die. Those were not good odds. He also said it was likely I would require dialysis. Another blow.

The nephrologist also explained that it was likely I was suffering from rhabdomyolysis. He explained that marathon running is a classic activity that can result in a breakdown of skeletal muscle - usually in the legs. The broken down muscle fiber contents travel in the bloodstream to the kidneys where they would be filtered out, but instead can block the kidney's structures shutting them down and damaging them.

Because my kidneys had been "shut off" for the past week, the toxicity level in my blood was rising to dangerous levels. I was being poisoned by my own blood.

The game plan was to first have an ultrasound performed to see if the kidneys were damaged. If so, I would need dialysis. But if they were not damaged, we could try something else.

The ultrasound revealed that my kidneys were in decent enough shape that they could be nursed back to health. The plan was simple. I had to pee . . . alot. I had to keep drinking water, take fluids intravenously, and urinate as much as possible. By doing that, kidney function might be restored.

For the next few days, I sat in a hospital room hooked up to an I.V., watched college football, drank gallons of water and peed like a race horse. I missed my son's birthday party. But I was lucky. My creatine level was so greatly reduced that I was able to go home. My kidneys would need a few months to rebuild, and I would still have to drink tons of water, but it appeared I would be fine.

Over the next few months I made several visits to the nephrologist to have my blood checked.

I'm on direct orders from both my wife and my doctor to stop running marathons. I still run several times a week, mix in a good dose of cycling, and have ran some 5k races and competed in one duathlon.

I don't think anybody really knows how or why rhabdo strikes marathoners when it does. My nephrologist mentioned the names of several elite marathoners that have suffered from rhabdomyolysis. Why rhabdo struck during the race and not during one of my long training runs is a still a mystery to me. After all, I had run in excess of 18 miles several times in the six months leading up to the race, yet on this day I felt sick at only 12.

Some people insist on telling me that I was dehydrated. Some say I was overhydrated. Others blame sports drinks.

Severe exertion is a classic risk factor that can lead to rhabdomyolysis. There are many documented case studies of rhabdo resulting from physical exertion, and nearly all of the victims were marathon runners or going through military conditioning. Yet, as I can attest firsthand, not all medical care professionals are going to quickly make a proper diagnosis.

By understanding that rhabdo is one possible risk of marathon running, you will already be a step ahead of where I was. Listen to your body, seek medical attention if you suffer any of the same symptoms and, most importantly, make sure you insist on having a blood test.

Rhabo can affect the well-trained athlete in addition to those who are not so well-trained. I had been active in sports since the age of 7, and running on a regular basis -- 3 to 4 times per week -- since 1984. That's twenty (20) years of running, including two other marathons and numerous long distance runs, and rhabdo got me.