Page 123 - Journal of Special Operations Medicine - Fall 2015

Because the frequency (hours per week) and length 20% more weight); in two cases, subjects reported per-
of training (months) were obtained, the authors were forming exercises that involved rapid twisting move-
able to estimate that the injury rate was 3.1 injuries per ments with heavy weights, which could have led to the
1,000 hours of training. The authors asserted that the cervical vascular dissections. Traumatic carotid artery
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injury rate was similar to that “. . . reported in the litera- dissections can involve (1) a partial blockage and nar-
ture for sports including weightlifting, powerlifting and rowing of the carotid artery due to an uncomplicated
gymnastics, and lower than that reported in competitive rupture of the vessel wall (intimal dissection); (2) a par-
contact sports like rugby . . .” Limitations to this study tial tear, resulting in a hematoma forming in the vessel
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included the self-reporting of injuries and self-selection wall (intramural hematoma), or (3) a total rupture of
of participants. the vessel wall, leading to an aneurysm. Patients pres-
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ent with neck or facial pain and with constant, non-
Besides these investigations, there have been several throbbing headaches, although the headache can have
cases reported in the medical literature of rhabdomy- a sudden onset or throb severely. The dissection can af-
olysis, carotid artery dissections, and a retinal detach- fect the sympathetic nerves that ascend near the carotid
ment among individuals performing CrossFit training. artery, resulting in Horner syndrome. Horner syndrome
The retinal detachment case was unusual, involving the involves drooping eyelids (ptosis), sinking of the eyeball
failure of an elastic band a young man had tied to his into the face, and constructed pupils (miosis). Cranial
waist and a pull-up bar to assist him in performing pull- nerve palsies present in about 12% of patients because
ups during a CrossFit workout. The exertional rhab- of compression of cranial nerve XII (hypoglossal nerve)
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domyolysis cases 16,20–22 generally involved participants and manifest as impairments of taste and tongue weak-
who were new to CrossFit training or had performed an ness. Ischemic symptoms are reported in many patients
unusually intense workout compared with their previ- because of the release of clotting factors and the forma-
ous workouts. Low levels of physical activity prior to tion of blood clots (thrombi) caused by vessel damage.
an intense exercise bout has been associated with higher Diagnosis involves imaging with magnetic resonance
risk for rhabdomyolysis ; other cases of exertional angiography or computed tomography angiography.
23
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rhabdomyolysis have been reported in trained athletes Most carotid artery dissections heal spontaneously, so
performing unaccustomed or unusually intense exer- the goal of treatment is to limit neurologic deficits and
cise. 24–27 Exertional rhabdomyolysis involves damage to reduce complications due to thrombosis or reduced
skeletal muscles induced by excessive physical activity blood flow. Treatment includes use of thrombolysis
in otherwise healthy individuals. Exercisers presum- regimens (e.g., intravenous plasminogen activator or
ably perform so much activity that they deplete local urokinase), anticoagulants, (e.g., heparin, warfarin), or
muscle energy stores. As a result of energy depletion, antiplatelet therapy (e.g., aspirin). 35
muscle cells (myocytes) are unable to maintain cellular
integrity, resulting in cellular damage and the release of Recommendations
cellular contents into the circulation. Cellular contents
released include (but are not limited to) creatine kinase Until more data on ECPs emerge, we recommend that
(CK), myoglobin, calcium, potassium, organic acids, Soldiers follow guidance from the Army Institute of
and proteases. Acute renal failure is the most serious Public Health. Unit physical training programs should
36
complication of rhabdomyolysis and is thought to be generally be aligned with Army physical training doc-
due to free myoglobin, which causes renal vasoconstric- trine. If leaders and Soldiers choose to incorporate
37
tion and nephrotoxic effects and/or precipitate to pro- ECPs into their physical training programs, they should
duce renal tubular obstructions (pigmented “casts”). 28–30 follow these recommendations:
Rhabdomyolysis symptoms begin with localized muscle
soreness that progresses to swelling, stiffness, weakness, 1. Require that all authorized physical fitness trainers
and dark urine. Diagnosis involves a serum CK level five are certified by a nationally recognized, nonprofit
times higher than the upper limit of normal and/or a certifying organization (such as the American Col-
urine dipstick positive for blood (due to the presence lege of Sports Medicine certified health fitness spe-
of myoglobin) but lacking red blood cells under micro- cialist and/or National Strength and Conditioning
scopic urinalysis. Medical management of exertional Association certified strength and conditioning spe-
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rhabdomyolysis involves aggressive hydration with sa- cialist), as well as the respective ECP (e.g., CrossFit
line solution. 28,30 level 1 coach certification).
2. Inspect designated exercise areas regularly to make
Four cases of carotid artery dissections have been re- certain that they are safe, particularly in areas where
ported in association with CrossFit training. 32,33 In two improvised exercise equipment is in use.
of the four cases, subjects were performing workouts 3. Introduce ECPs to new participants gradually. Pro-
more intensely than usual (one case involved lifting vide a specific, stepwise approach to increase exercise

Extreme Conditioning Programs 111