Exertional Rhabdomyolysis – a Legal Analysis

By JoAnn M. Eickhoff-Shemek, PhD, FACSM

This article is an excerpt from the new, ground-breaking textbook — Law for Fitness Managers and Exercise Professionals by JoAnn M. Eickhoff-Shemek, PhD, Barbara J. Zabawa, JD, MPH, and Paul R. Fenaroli, JD. This excerpt, edited for this newsletter, is from Chapter 8. This chapter focuses on negligent instruction and supervision and describes many lawsuits that have occurred in fitness programs including (a) personal training, (b) group exercise, (c) youth exercise, (d) strength and conditioning, (e) clinical exercise, and (f) first responder/military. For more information about the textbook, educational courses, and authors’ bios, visit the Fitness Law Academy, LLC website (www.fitnesslawacademy.com). The textbook is sold on Amazon-Click Here.

Exertional rhabdomyolysis (ER) occurs from strenuous exercise that leads to a breakdown of skeletal muscle resulting in a protein (myoglobin) being released into the bloodstream (1). Excess myoglobin can lead to kidney damage and, in severe cases, kidney failure. Severe muscle damage can also lead to compartment syndrome – a swelling of the affected muscle tissue that can cause muscle necrosis (death). Early signs and symptoms include excessive muscle soreness and dark brown urine. To diagnose ER, a urine analysis is needed along with a blood test to determine levels of creatine phosphokinase (CPK) – an enzyme associated with muscle damage.

Exertional Rhabdomyolysis: A Historical Perspective

A 1989 case, Turner v. Rush Medical College (2),was one of the first negligence lawsuits involving an ER injury. A 23-year-old medical student suffered many serious injuries including “extreme exertional rhabdomyolysis” after he was required to run an 8-minute mile as a class experiment. Since 1989, additional lawsuits have occurred involving ER injuries in personal training, indoor cycling, collegiate strength and conditioning, and military fitness programs (3).  Cases involving student-athletes are described below. From these cases, it is evident that any type of exercise program (e.g., body weight/resistance activities, cardiovascular, or various combinations) that are high intensity may lead to ER.

In 2005, CrossFit expressly acknowledged the risk of ER associated with its high intensity exercise programs in two published articles (4). One of these articles described five reported cases of ER resulting from CrossFit workouts (5). A warning, confirming the link between CrossFit and ER, was included in the article about this potentially lethal risk. The rapid growth of CrossFit worldwide in the 2000s and beyond created a hot topic of debate among exercise professionals and the CrossFit community. Although this debate focused on safety concerns with CrossFit training, it also increased the awareness among exercise professionals and the lay public regarding the connection between extreme exercise programs and ER. During this time, CrossFit and other extreme conditioning programs (ECPs) such as P90X and Insanity became increasingly popular among military and athletic conditioning programs.                   

Given the rising popularity of ECPs in military and civilian communities, the authors of a 2011 article (6) stated injuries from ECPs including ER are reportedly occurring at increasing rates. They stated that these programs appear to violate accepted standards for safety and that solutions to reduce these injury risks are of paramount importance. One recommendation of the many listed in this article was to “introduce ECPs to new participants gradually with a specific progression (acclimation) to exercise intensity, duration, and advanced exercises” (6, p. 387). Regarding the increases in the frequency of ER among collegiate athletes, the authors of a 2012 article (7) stated that “workouts that are too novel, too much, too soon, or too intense (or a combination of these) have a strong connection to exertional rhabdomyolysis. Introducing full-intensity workouts too quickly is especially high risk” (p. 478). This article, prepared by authors representing 12 different organizations, provided a list of several recommendations. The first two recommendations focus on the prevention of ER: acclimatize progressively for utmost safety, and introduce new conditioning activities gradually (7).                                  

The major purpose of these two articles was to increase awareness of this potentially life-threatening condition and provide recommendations for exercise professionals on how to prevent the serious risks associated with high intensity or extreme conditioning programs (ECPs). Additional articles to increase the awareness of ER were also published in various journals between 2003 and 2013 such as Medicine & Science in Sports & Exercise (8), Strength and Conditioning Journal (9), Journal of Physical Education, Recreation & Dance (10), and IDEA Fitness Journal (11). This topic of ECPs has also been presented at various professional conferences. For example, the lead author of the 2011 paper (6), Dr. Michael Bergeron, gave a presentation titled: Extreme Conditioning Programs – Are They Worth the Risk? at the ACSM Health & Fitness Summit in 2013 (12).

By 2013, there was ample published scientific evidence that high intensity exercise programs or ECPs can lead to ER. Although numerous efforts have been made to help ensure that exercise professionals were well-informed of this clearly “foreseeable” risk, individuals are still being diagnosed with ER after participation in various high intensity exercise programs led by exercise professionals. Why? There may be several reasons, but the likely ones are: (a) some exercise professionals leading these programs lack adequate knowledge and skills to design/deliver a program incorporating important safety principles of exercise such as progression, and (b) some fitness/athletic managers are not making a concerted effort to help ensure their employees possess the necessary knowledge and practical skills to properly teach, train, and/or coach. Exercise professionals that instruct a low-fit person, a beginner, or even an elite athlete to perform a high intensity workout on their first day of exercise or training are, clearly, failing to meet the standard of care of a reasonable, prudent, exercise professional.

Exertional Rhabdomyolysis Cases – Student Athletes

Even well after the 2012 publication (7) regarding collegiate conditioning programs, student-athletes continue to be diagnosed with ER. For example, in 2019, 12 collegiate women soccer players were diagnosed with ER after participation in an extreme conditioning program led by the strength and conditioning coach, Minor Bowens, at the University of Houston (13). Bowens was fired following the incident (13). Additional ER cases include:

1. University of Iowa – 13 football players, 2011 (14)
2. Ohio State University – 6 women’s lacrosse players, 2013 (15)
3. University of Oregon – 3 football players, 2017 (16)
4. University of Nebraska – 2 football players, 2018 (17)

When serious, preventable injuries or deaths occur, there is often an investigation conducted by the university/college. These unfortunate events create a great deal of media attention and reflect negatively upon the athletic program and the institution. The investigations and policy changes that are made, based on the investigative reports, are costly. For example, the policy changes established at the University of Houston are expected to exceed $1 million (18). But the costs do not end there. Although most student-athletes fully recover from ER, some do not and, thus, have filed negligence lawsuits, such as one of the 13 football players at the University of Iowa and two of three players at the University of Oregon.

Football player William Lowe at the University of Iowa filed a lawsuit that was eventually settled (19). He claimed he suffered acute renal failure and elevated creatine levels due to his ER diagnosis and continued to experience various mental and physical problems and mounting medical expenses. Interesting in this case were the findings in an internal, official report submitted to the Iowa State Board of Regents. It stated that the strength and conditioning coaches had no knowledge of ER (14). The report cleared all coaches, physicians, and trainers of any wrongdoing and provided recommendations including discontinuing the intense, high-volume squat-lifting workout (14). Several questions arise regarding the knowledge/skills of the strength and conditioning coaches in this case. It is likely, in a Division I football program such as the University of Iowa, the strength and conditioning coaches possessed degrees and professional certifications in strength and conditioning. By 2011, they should all have known about ER and how to prevent it. At a minimum, they should have known about the signs and symptoms of overexertion through their educational and certification preparation programs. So why did they have the players perform another mandatory intense workout the day after the first intense workout? After the first workout, many players complained of substantial leg pain and stiffness and dark urine prior to the workout on the second day. Why did they not have the players seek medical care given their signs and symptoms?

University of Oregon football players, Doug Brenner and Sam Poutasi, filed lawsuits in 2019 (two years after their ER injuries) against the University, head coach Willie Taggart, and former strength coach Irele Oderinde seeking $11.5 million and $5 million in damages, respectively (16, 20). In his lawsuit, Brenner claimed the individual defendants imposed and carried out the workouts in a negligent manner and the institutional defendants were negligent in failing to regulate and supervise the individuals leading the workouts (16). In the other lawsuit, Poutasi claimed he suffered injuries in addition to ER such as muscle aches, kidney damage and the loss of use of his arms (20). These lawsuits are pending. Oderinde was suspended for one month without pay, but a year later left Oregon for Florida State University (13).

NCAA Response to Help Prevent Exertional Rhabdomyolysis

In 2018, the NCAA Chief Medical Officer prepared an exertional rhabdomyolysis message that included five guiding principles regarding the prevention of ER (21). The fifth guiding principle specified that all strength and conditioning workouts should (a) “be documented in writing, (b) reflect the progression, technique, and intentional increases in volume, intensity, mode, and duration of the physical activity, and (c) be available for review by athletic departments” (21, p. 2). This message is available at: NCAA Addresses Exertional Rhabdomyolysis | NATA.

JoAnn Eickhoff-Shemek (Professor Emeritus, Exercise Science at the University of South Florida and President of the Fitness Law Academy, LLC), has served as an expert witness in two ER cases. The plaintiffs suffered permanent injuries resulting from high intensity exercise after their first workouts, one involving an indoor cycling class and the other, a personal training session. 

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2. Turner v. Rush Medical College, 537 N.E.2d 890 (Ill. App. Ct., 1989).
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Sitzler B. NCAA Addresses Exertional Rhabdomyolysis, NATA Now, February 1, 2018. Available at: https://www.nata.org/blog/beth-sitzler/ncaa-addresses-exertional-rhabdomyolysis. Accessed June 19, 2019.