Page 18 - JSOM Summer 2018

A Case of Rhabdomyolysis Caused by
Blood Flow–Restricted Resistance Training

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Joshua Krieger, MD *; Donald Sims, ATC ; Cameron Wolterstorff, MD 3
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ABSTRACT
Blood flow–restricted resistance (BFRR) training is effective as circulation. 9,10 This leads to an increase in, among others, ex-
a means to improve muscle strength and size while enduring tracellular potassium, creatine kinase (CK), and myoglobin.
less mechanical stress. It is generally safe but can have adverse The increase in circulating myoglobin can obstruct the renal
effects. We present a case of an active duty Soldier who devel- tubules and cause direct nephrotoxicity, leading to acute renal
oped rhabdomyolysis as a result of a single course of BFRR failure. Presenting symptoms often include muscle pain out of
training. He was presented to the emergency department with proportion to examination findings, weakness, and darkening
bilateral lower extremity pain, was admitted for electrolyte of urine. Laboratory abnormalities include elevated CK and
monitoring and rehydration, and had an uncomplicated hos- myoglobinuria, often manifesting on urinalysis as blood on
pital course and full recovery. This is an increasingly common a urine dipstick without red blood cells on urine microscopy.
mode of rehabilitation in the military, and practitioners and These patients are optimally treated with hydration and elec-
providers should be aware of it and its possible adverse effects. trolyte and kidney function monitoring.

Keywords: rhabdomyolysis; blood flow restricted training; Presentations of rhabdomyolysis can range from subclinical
ischemic training to severe, and the quantity of elevation of serum CK does not
indicate prognosis. Rhabdomyolysis can be characterized as
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mild, moderate, or severe based on the elevation in CK. Mild
Introduction generally corresponds to CK less than 10 times the upper limit
of normal, moderate to elevations from 10 to 50 times the
BFRR training, or ischemic conditioning, has been shown to upper limit of normal, and severe to greater than 50 times
be an effective alternative to conventional weight training for the upper limit of normal (roughly 15,000 IU/L, depending
improving muscle strength and hypertrophy. The low resis- on the calculating laboratory). Exertional rhabdomyolysis,
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tances involved lead to decreased mechanical stresses across compared with other causes, is much less likely to lead to renal
joints, making the procedure beneficial in rehabilitating ath- failure and has a very low recurrence rate. 12,13
letes. BFRR training is gaining popularity among the lay pub-
lic as well as among strength, conditioning, and rehabilitation Two previous cases of rhabdomyolysis resulting from ischemic
professionals. A Google search reveals articles published in conditioning are published in the kinesiology and strength
Men’s Health, on bodybuilding.com, on muscleandfitness. and conditioning literature. To our knowledge, we present the
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com, a YouTube video reviewing the research, and an occlu- third case, and the first case to be published outside the sports
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sion training band sold at Walmart. medicine literature.
This procedure has recently gained followers in the US mil-
itary and is now commonly performed on service members. Case Report
The procedure is generally safe, but there are documented ad- A 37-year-old active duty man presented to our emergency
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verse events, to include mechanical injury to skin and under- department (ED) with the chief complaint of bilateral
lying structures, venous thrombosis, and ischemia–reperfusion cramping calf pain. He had sprained his left ankle 6 days
injury. There are also two published cases of rhabdomyolysis earlier and had been performing physical therapy, with part
resulting from first-time BFRR. 7,8 of his rehabilitation consisting of ischemic conditioning of
his legs. The goals of this ischemic conditioning were to de-
Rhabdomyolysis is a condition often resulting from prolonged crease edema, control pain, and improve ankle strength and
or heavy exertion but also caused by a variety of other con- proprioception.
ditions. It is characterized by injury to muscle cells leading to
leakage of their contents into the bloodstream. Regardless of He underwent ischemic conditioning with a 34-in tourni-
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the cause of muscle damage, there is a final common pathway quet placed around his thigh and inflated to 80% of his
leading to an increase in intracellular calcium, which causes lower extremity loss of pulse pressure (i.e., if he lost pulses at
muscle cell necrosis and the leakage of its contents into the 200mmHg, the cuff would be deflated to 160mmHg).
*Correspondence to 4915 39th Ave S, Seattle, WA 98118; or jakrieger@gmail.com.
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1 CPT Krieger is at the Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA. Mr Sims is with 1st Special Forces
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Group at JBLM, WA. MAJ Wolterstorff is at Department of Emergency Medicine, Madigan Army Medical Center.
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