This is a follow up to Bob’s introduction to rhabdomyolysis as it relates to martial artists.

Rhabdomyolysis is the destruction of skeletal muscle leading to the release of the muscular tissue components  creatine kinease (CK) and myoglobin into the bloodstream (Huerta-Alardin, Varon & Marik, 2004). These components can pose a potential serious risk to the kidneys as they are cleared from the blood stream. Rhabdo can be caused by numerous factors, and can cause symptoms ranging in severity from mild to life threatening. Classic symtpoms include muscle pain, weakness and darkened urine (ranging from pinkto cola colored). Blood tests reveal elevated serum CK and myoglobin levels. More severe cases may present symptoms such as malaise, fever, tachycardia, nausea and vomiting (Huerta-Alardin et al., 2004). In severe cases acute renal failure can result, requiring medical attention.

Drugs such as statins and antipsychotics, antidepressants, sedatives, antihistamines, amphetamines and alcohol can also cause rhabdo via abnormal muscular action (or inaction). For fighting arts and sports coaches, students or athletes taking these drugs present a possibly higher risk of rhabdo, particularly in higher risk environments, such as prolonged heat or muscular injury. Overuse of diuretics or cathartics can contribute to this in high heat and humidity environments (Huerta-Alardin et al., 2004). Careful review of a client’s PAR-Q (physical activity readiness questionnaire which teachers of fighting arts would do well to adopt when accepting new students) or an athlete’s medical history are valuable sources of preventative information.

Strenuous exercise is also a common cause of rhabdo (Huerta-Alardin et al., 2004).  Excess strenuous muscular activity in general can pose a risk, and neurological conditions such as dystonia or tonic-clonic contractions Exertion in high temperatures poses an increased risk, as muscle may be damaged by thermal or traumatic factors (Huerta-Aladin et al., 2004). Trainers and coaches can mediate this risk by maintaining a sensible level of exertion and providing adequate recovery and hydration. Crush injuries and general muscle injuries also account for many cases of rhabdo (Huerta-Alardin et al., 2004). For activities that involve high amounts of contact, such as American football, pugilistic arts/sports or high-impact sports like Judo, the risk of muscular trauma is higher, indicating that participants may be more likely to suffer rhabdo by this cause. An athlete who has sustained such an impact(s) should be monitored closely for signs and
symptoms of serious complications.

Interestingly, anecdotal stories of “hard training” in martial arts circles often mention “pissing blood” or dark colored urine in the days following significant trauma. In consideration of rhabdo’s causes and physiological mechanisms, I wonder if the majority of practitioners who recount such training are actually describing rhabdo, as opposed to the results of direct kidney trauma per se. Tales of forced, extreme stretching or hard forced sparring “slaughter lines” of fresh opponents for long durations are often equated with some honorable or admirable aspect of training, but such practices are usually a sign of questionable instruction. Considering the risks posed by such significant muscular trauma such practices have no place in a responsible school or club.

Among the causes of rhabdomyolysis impact trauma is of particular interest to practitioners and coaches of the fighting arts and sports. Although literature on rhabdo as a specific result of physical violence (in the form of beatings or participation in a combat sport or recreational martial art) are relatively few, the role of direct muscular trauma as a causal factor is associated with the condition (Huerta-Alardin, Varon & Marik, 2004).

By their nature, pugilistic arts such as boxing, kick boxing, Muay Thai, MMA and the many forms of “knockdown” full-contact fighting exposure athletes to impact trauma from strikes of varying intensities. Wrestling and grappling arts, such as Greco-Roman wrestling or Judo, expose athletes to regular impacts with the floor from various heights and angles and at various intensities. And among the various so-called traditional and modern martial arts, practitioners may engage in any of the practices above, as well as “impact conditioning” of various body surfaces. The latter may take place in each class, or may be irregularly practiced in a given duration (it’s worth noting that such “hardening” is particularly common in many branches of Chinese martial arts and the Naha schools of Okinawan karate and it’s offshoots; many of these schools feature it as a specialty).

Given that specific information regarding rhabdo and the fighting arts and sports is harder to come by, useful information can be drawn from case studies of rhabdo as a result of violent assault, although the examples may be more extreme than the physical violence typical to martial arts training in general and most competition. A review of two case studies of punitive beatings in South Africa by Bowley & colleagues (Bowley, Buchan, Khulu & Boffard, 2002) describes two men who received severe, prolonged beatings from both punches and kicks and from a whip-like weapon. In both cases, extensive soft-tissue damage resulted, leading to the classic physiological signs and symptoms of rhabdo (Huerta et al., 2004), including acute renal failure. One of these individuals survived ARF due to aggressive haemodialisis treatment , eventually regaining normal renal function within several months (Bowley et al., 2002). The second of these individuals did not receive medical attention until two days after a severe beating, and died before haemodialysis could be started. In the latter case the delay in presentation seems to have led to a fatality that may have otherwise been avoidable with prompt initiation of treatment.

Although the cases presented by Bowley & colleagues (Bowley, et al., 2002) are not an exact match for the conditions that a fight athlete or recreational martial artist will likely face, they are instructive as reminders that fighting arts and sports carry a higher risk of direct musculoskeletal injury. A review of boxing, wrestling and “martial arts” injuries presenting in emergency rooms in the US (out of 7290 cases of visits attributed to one of the three activities) (Pappas, 2007) found that contusions and fractures were among the most common injuries. Contusions were reported at 27% of total injuries from boxing, 16% in wrestling, and 23% in martial arts (Pappas, 2007). Given that the probability of a musculoskeletal injury is high in these sports and arts, coaches, athletes and participants need to be knowledgeable of the causes and the early signs and symptoms. Fight athletes competing in high-contact activities or training should be advised as to the necessity of rapid medical attention and treatment in suspected cases. Recreational martial artists participating in vigorous, high contact training should be similarly informed, and the need for such intensity should be carefully determined and placed in a training program that allows adequate recovery between such intense practices. Participating in abusive training is to be discouraged, and seeking treatment for suspected cases of rhabdo should be encouraged and supported by the instructor(s) and culture of the group.

Students who have sustained muscular impact trauma from various forms of conditioning (“kitae”, etc.) should be monitored for the signs and symptoms listed earlier in this article. In extreme cases, 24 hours is the window of opportunity to begin aggressive hydration and dialysis before kidney damage or failure sets in. “Extreme” workouts or stretching, especially with unconditioned or under prepared students are to be avoided, and students should be advised to maintain adequate hydration and recovery rates between training session following intense training or in predisposing conditions (heat, prolonged heavy impact, use of certain drugs, etc.). If you regularly practice impact conditioning, consider programming it into a training schedule that allows for  a few days to a week of recovery between sessions, and that separates it from intense weight training or impact from falls and strikes by days or weeks.


Bowley, D.M.G., Buchan, C.,  Khulu, L.,  Boffard, K.D. (2002). Journal of the Royal Society of Medicine 95, 300-301.

Huerta-Alardin, A.L., Varon, J, & Marik, P.E. (2004). Bench to bedside review: Rhabdomyolysis- an overview for clinicians. Critical Care, 9 (2), 158-169.

Pappas, E. (2007). Boxing, wrestling and martial arts related injuries treated in emergency departments in the United States, 2002-2005. Journal of Sports Science and Medicine, 6 (CSSI 2), 58-61.