Into the Unknown: Recurrent Exercise-Induced Rhabdomyolysis in a Pediatric Soccer Player

Case Diagnosis: Recurrent exercise-induced rhabdomyolysis in a 17-year-old male soccer player.

Case Description or Program Description: The patient presented to sports medicine reporting recurrent abdominal pain following physical exertion. After particularly intense matches, he would develop calf cramping. His symptoms would resolve with rest.

Setting: Sports medicine clinic.

Assessment/Results: Patient was found to have an elevated creatine kinase (CK) (up to 6 times normal) after each game that would decrease with rest and hydration. After a long game when he was poorly hydrated, he was also found to have an elevated serum myoglobin and serum creatinine indicative of muscle breakdown and an acute kidney injury. Extensive testing revealed a possible genetic variant predisposing him to exertional rhabdomyolysis. The patient gradually improved after evaluation to assess the length of time, duration in various exercise zones, and types of exercise tolerated (futsal vs soccer) before experiencing an elevation in his CK. A treatment plan was developed to allow him to play soccer and prevent severe elevations in his CK.

Discussion (relevance): Recurrent exercise-induced rhabdomyolysis is a rare condition that, if not recognized and treated quickly, can lead to kidney injury, electrolyte abnormalities, liver injury, compartment syndrome, and in severe cases disseminated intravascular coagulation and possibly death. As of now, no clear guidelines for management of chronic exertional rhabdomyolysis and return to play exist in the literature. Most evidence and case reports regarding the treatment of recurrent exercise-induced rhabdomyolysis are seen in the military population, particularly adult males. Very little literature has been published regarding the management of this condition in pediatric athletes.

Conclusions: Here we outline a possible treatment plan for a pediatric soccer player experiencing recurrent exercise-induced rhabdomyolysis. Being active and playing sports is very important to the well-being, overall health, and sense of identity in pediatric athletes. There is a need for clearer guidelines to better manage and support this patient population.