Medical Illness in the Endurance Running Athlete

Brian J. Krabak MD MBA FACSMClinical Professor

Rehabilitation, Orthopaedics and Sports MedicineUniversity of Washington & Seattle Children’s Sports Medicine

Medical Director, 4 Deserts Series Ultra-MarathonsMedical Director, Seattle Rock n Roll Marathon

National Team Physician, USA Swimming

Disclosure

Financial disclosures: Neither I, Brian Krabak, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.

Off-label use disclosures: None.

Learning Objectives

• Describe common medical injuries in the endurance running athlete

• Develop treatment strategies for managing these illnesses

Exercise Associated Collapse

Overall Injuries and Illness Rates

Krabak & Waite 2011

Hoffmann 2011Roberts 2000

Major1 Mild1

Diagnosis No. (%) No. (%) Skin Disorders Abrasion 0 43 (3.9) Blister 10 (16.2) 642 (57.8) Cellulitis 1 (1.6) 8 (0.7) Hematoma (Subungual) 1 (1.6) 106 (9.5) Other6 00 23 (2.1)Musculoskeletal Injuries Bursitis 1 (1.6) 11 (1.0) Sprain 2 (3.2) 25 (2.3) Strain 1 (1.6) 27 (2.4) Tendonitis 7 (11.3) 115 (10.3) Other5 3 (4.8) 29 (2.6)Medical Illnesses Exercise-Associated Collapse2 35 (56.5) 43 (3.9) Altitude Sickness 0 11 (1.0) Serious Medical Diagnosis3 1 (1.6) 1 (0.1) Other Medical Diagnosis4 0 27 (2.4)

Roberts 2000, Krabak & Waite 2011

Marathon (Twin Cities) Ultra-Marathon (Multistage)

Event Overall Medical (NF/F) MSK (NF/F) Skin (NF/F) Marathon (per 1000 runners) 18.9 – 25.5 10.1 – 13.7 3.35 4.1 UM multistage (per runner)* 3.8 0.38 (0.1/0.27) 0.71 (0.04/.67) 2.7 (0.04/2.7)

*UM runner = 95% were minor illnesses or injuries

Overall Injuries and Illness Rates

Exercise Associated Collapse

• Differential Diagnosis• Cardiovascular Illness (i.e. Cardiac Arrhythmia, Postural Hypotension,)• Electrolyte Abnormalities (i.e. Hyponatremia, Hypoglycemia, Exertional

Rhabdomyolysis, Drug Toxicity, Gastrointestinal)• Heat Related Illness (i.e. Hyperthermia, Hypothermia)• Altitude Sickness• Respiratory/ Immune (i.e. Asthma, Anaphylaxis)• Acute Musculoskeletal Injury (i.e. Cramps, Fracture, Tear of Tendon)• Neurologic (i.e. Seizures, Concussions)

Exercise Associated Hyponatremia

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCMixi8eL2ccCFVIqiAodGIUN9g&url=http://jpp.krakow.pl/journal/archive/11_06_s11/articles/02_article.html&psig=AFQjCNFzCLGVmU3KW6VJ_3Kn8xGHwg3hoA&ust=1441308704932571

Exercise Associated HyponatremiaEtiology

Excessive Consumption“Too Much In”

Fluid overload“Dilution” HYPONATREMIA

Failure to Excrete“Not Enough out”

Inadequate intake

“Not Enough in”

Excessive loss sweat/urine

“Too much out”

Sodium deficit“Depletion”

Inappropriate AVP secretion (SIADH)Non-osmotic stimuli (exercise, stress, hypovolemia) Impaired mobilization of osmotically inactive sodium

storesInappropriate inactivation of osmotically active

sodium

Increased Access or Behavior

Impaired mobilization of osmotically inactive sodium stores

Inappropriate inactivation of osmotically active sodium*

Inactivation of Sodium

Exercise Associated HyponatremiaMarathon – Dilution Model

Noakes 2005Weight GAIN correlated with worsening hyponatremia and the most weight gain strongly

associated with the most symptomatic patients (N =2135)

Exercise Associated HyponatremiaSingle Stage Ultramarathons – Depletion Model

Hoffman 2013

Weight LOSS correlated with hyponatremia and more symptomatic people suffered greater biochemical alterations (N =669)

Exercise Associated HyponatremiaMulti-Stage Ultramarathons – Dilutional Model

Krabak

Weight GAIN correlated with worsening hyponatremia and the most weight gain strongly associated with the most symptomatic patients (N 124)

N=124 r=-0.21 p=0.02

• Documented Na level • No IV iso or hypotonic fluid• Restrict fluid till urination• Oral salty snacks • Observe 60 minutes (GI water)• Fluids

• Oral : Hypertonic (salty)• IV: 100ml IV bolus 3% HS; repeat x2 q

10 min;

• Transport to hospital

Exercise Associated HyponatremiaField Treatment

• Unknown Na level*• Restrict IV iso and hypotonic fluid• Restrict fluid till urination• Oral salty snacks • Observe 60 minutes (GI water)• Fluids

• Oral : Hypertonic (salty)• IV: 100ml IV bolus 3% HS; repeat x2 q

10 min;

• Transport to hospital

*Weigh risks of EAH vs dehydration or rhabdomyolysis + AKI

Hew Butler 2015, Rogers 2015, Hoffman 2015, Krabak 2013

Heat Related Illness

Heat Related Illness

HeatProduction / Loss

TemperatureHumidity / SunWind / ClothingMedical Illness

MedicationNutrition

HeatDissipation / Retention

Exercise Evaporation : liquid to gaseous phase** Radiation : electromagnetic waves*Convection : affected to wind velocity*Conduction : direct physical contact * Cutaneous Dilatation ** Sweat

Compromise of the thermoregulatory center (hypothalamus) due to excessive heat gain (hyperthermia) or heat loss (hypothermia)

Pryor 2015, Casa 2013, Casa 2012, O’Connor 2010

Pryor 2015

Heat Related Illness

Heat ExhaustionInability to continue exercise or collapse, weakness, fatigue, muscle cramps, nausea, irritability, agitation, mild confusion

Normal to slightly elevated rectal temperature( 102-104O F), skin still moist

Heat StrokeCollapse after strenuous activity, Mental status changes

Cardiovascular collapse, Elevated rectal temperature(>104O F) skin may be hot and dry

Complications: Thrombocytopenia, Hemolysis, Rhabdomyolysis, ATN, Fatality (proportional to length of time core temp elevated)

Adams 2015, Demartini 2010, Casa 2010

Heat Related Illness• Treatment

• Removal of excessive equipment• Rectal Temperature• Cold Water Immersion (Cool First, Transport Second)• Oral fluids vs IV fluids (CHECK NA)

• Return to Activity

O’Connor 2010, Casa 2012, Pryor 2015

• Incidence: Unknown; but high CPK in 66% ultramarathon

• Pathophysiology:

Rhabdomyolysis

Szczepanik 2015, Hoffman 2012

Muscle injury leading to disruption of the

sarcolemma and release of intracellular myocytes into

plasma

• Symptoms/Signs• Myalgia, weakness, dark urine 24-72 hr after exercise

• Testing• Urine dipstick 1+ pr, 3+ blood, Sp Gr >1.025; • CK 5X normal (>10,000)

• Complications: • Acute kidney injury (17-35%), electrolyte abnormalities (HyperP,

HyperK, HypoCa (early), Hyper Ca (late), compartment syndrome, arrhythmia

Rhabdomyolysis

Szczepanik 2045

• Treatment• Rest, Hydration (oral vs IV*), Education• Confirmed increase CK =Transport to hospital for monitoring

and aggressive hydration BUT RULE OUT EAH

• Return to Play: • Phase 1: Rest 72 hr + hydration + check CK/UA• Phase 2 (if peak CK < 5x Nl) : Light activities over 1 week • Phase 3 (no symptoms) : Gradual return to sport

Rhabdomyolysis

Gastrointestinal / Hygiene

Gastrointestinal / Hygiene• Epidemiology: Prevalent (up to 96%), may impact performance, typically

benign• Etiology: Multifactorial, exercise-induced gastroparesis, dehydration and

suboptimal caloric intake, quality and quantity of fluid intake• Presentation: Nausea, vomiting, cramping• Treatment: Reduce exercise intensity, anti-emetics (ondanestron DT), GI

protective (ie ranitidine), Abx (ie Ciprofloxacin)

• Prevention: Education, Hand & Toilet Hygiene, appropriate caloric/hydration, hand sanitizer at aid stations

Stuempfle 2015

Pryor 2015

Summary• Majority of non-cardiac Medical Illnesses can be managed during a

race with conservative treatment• Hyponatremia: Drink To Thirst

Hypervolemia vs Hypovolemia

Avoid Hypotonic IV / use Hypertonic IV• Hyperthermia: Cool 1st (30 min) & Transport 2nd

• Organize medical team and care appropriately