Medical Illness in the Endurance Running Athlete

1. Medical Illness in the Endurance Running Athlete Brian J. Krabak MD MBA FACSM Clinical Professor Rehabilitation, Orthopaedics and Sports Medicine University of Washington & Seattle Children’s Sports Medicine Medical Director, 4 Deserts Series Ultra-Marathons Medical Director, Seattle Rock n Roll Marathon National Team Physician, USA Swimming

2. 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.

3. Learning Objectives • Describe common medical injuries in the endurance running athlete • Develop treatment strategies for managing these illnesses

4. Exercise Associated Collapse

5. Overall Injuries and Illness Rates Krabak & Waite 2011 Hoffmann 2011 Roberts 2000

6. Overall Injuries and Illness Rates 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 Marathon (Twin Cities) Ultra-Marathon (Multistage) 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

7. 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)

8. Exercise Associated Hyponatremia

10. Exercise Associated Hyponatremia Etiology Increased Access or Behavior Excessive Consumption “Too Much In” Excessive loss sweat/urine “Too much out” Inadequate intake “Not Enough in” Fluid overload “Dilution” Sodium deficit “Depletion” HYPONATREMIA Failure to Excrete “Not Enough out” Inactivation of Sodium Inappropriate AVP secretion (SIADH) Non-osmotic stimuli (exercise, stress, hypovolemia) Impaired mobilization of osmotically inactive sodium stores Inappropriate inactivation of osmotically active sodium Impaired mobilization of osmotically inactive sodium stores Inappropriate inactivation of osmotically active sodium*

11. Exercise Associated HyponatremiaMarathon – Dilution Model Weight GAINcorrelated with worsening hyponatremia and the most weight gain strongly associated with the most symptomatic patients (N =2135) Noakes 2005

12. Exercise Associated HyponatremiaSingle Stage Ultramarathons – Depletion Model Weight LOSS correlated with hyponatremia and more symptomatic people suffered greater biochemical alterations (N =669) Hoffman 2013

13. Exercise Associated HyponatremiaMulti-Stage Ultramarathons – Dilutional Model N=124 r=-0.21 p=0.02 Weight GAIN correlated with worsening hyponatremia and the most weight gain strongly associated with the most symptomatic patients (N 124) Krabak

15. Exercise Associated Hyponatremia Field Treatment • 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 • 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

16. Heat Related Illness

17. Heat Related Illness Temperature Humidity / Sun Wind / Clothing Medical Illness Medication Nutrition Heat Production / Loss Heat Dissipation / Retention • Evaporation : liquid to gaseous phase** • Radiation : electromagnetic waves* • Convection : affected to wind velocity* • Conduction : direct physical contact • * Cutaneous Dilatation ** Sweat Exercise 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

18. Pryor 2015

20. Heat Exhaustion Inability 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 Stroke Collapse 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) Heat Related Illness

22. Adams 2015, Demartini 2010, Casa 2010

23. 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

24. Rhabdomyolysis • Incidence: Unknown; but high CPK in 66% ultramarathon • Pathophysiology: Muscle injury leading to disruption of the sarcolemma and release of intracellular myocytes into plasma Szczepanik 2015, Hoffman 2012

25. Rhabdomyolysis • 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 Szczepanik 2045

26. Rhabdomyolysis • 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

27. Gastrointestinal / Hygiene

28. 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 (ondanestronDT), GI protective (ie ranitidine), Abx (ie Ciprofloxacin) • Prevention: Education, Hand & Toilet Hygiene, appropriate caloric/hydration, hand sanitizer at aid stations Stuempfle 2015

29. Pryor 2015

30. Summary • Majority of non-cardiac Medical Illnesses can be managed during a race with conservative treatment • Hyponatremia: Drink To Thirst Hypervolemia vsHypovolemia Avoid Hypotonic IV / use Hypertonic IV • Hyperthermia: Cool 1st (30 min) & Transport 2nd • Organize medical team and care appropriately