Rhabdomyolysis in runners: the warning signs every marathoner should know

Our hearts go out to the family and friends of Rachel Apa. The 24-year-old from Lewisberry, Pennsylvania, a former Bucknell field hockey player, was running her first marathon, the New York City Marathon, on Sunday, November 1, 2026, and raising money for the Parkinson’s Foundation in memory of her grandfather.^[7,8,9] She collapsed in Central Park near Mile 24. Bystanders, including people who said they were doctors, gave CPR, and she died that night at Mount Sinai after roughly six hours of efforts to save her.^[8,9,10] Her father told The New York Times (external site) that doctors attributed her death to rhabdomyolysis.^[7,9,10]

What is rhabdomyolysis, and can you get rhabdo from running?

Yes. Rhabdomyolysis is when damaged muscle breaks down and releases its contents, including myoglobin (a muscle protein), into the blood. That load can injure the kidneys.^[1] Severe exertion, such as marathon running, is one known cause.^[1]

The kind caused by exercise is called exertional rhabdomyolysis. A 2025 U.S. military guideline defines it as severe muscle pain, stiffness or weakness after hard exercise, plus a blood test showing heavy muscle damage.^[2] In a review of 772 athletes with it, more than half had been running, including marathons.^[11]

Rhabdomyolysis warning signs: when is it an emergency?

Soreness after a race is normal. These signs are not:^[2,1]

• Muscle pain out of proportion to the effort, or pain that gets worse instead of better after 5 to 7 days
• Swelling or tightness in a muscle
• Weakness, or trouble moving the muscle at all
• Dark urine: brown, red or the color of cola
• Less urine than usual

Often the signs are vague, so don’t wait for all of them.^[3]

Go to the emergency room now if you have dark urine with severe muscle pain or weakness after hard exercise. A systematic review urges checking anyone with muscle pain or cramps and dark urine after an endurance event.^[11]

Where does surgery fit? Compartment syndrome in the leg

Your lower-leg muscles sit in tight sleeves of tissue called fascia. When a muscle swells inside that sleeve, pressure can climb high enough to choke off blood flow to muscle and nerve. That is compartment syndrome.^[4]

The military guideline lists it as a complication of exertional rhabdomyolysis and tells doctors to call a surgeon early.^[2] Watch for:^[2,4]

• pain far worse than you’d expect, and worse when the muscle is stretched
• a tight, full or hard feeling in the leg
• tingling, burning or numbness
• trouble moving the foot or toes

Acute compartment syndrome has no effective treatment without surgery. A surgeon opens the skin and fascia so the muscle has room, a fasciotomy.^[4] Speed matters: numbness and paralysis are late signs that usually mean lasting damage.^[4] In one reported case, a healthy athlete had leg pain and a dropped foot the day after a hard workout. After IV fluids and emergency fasciotomies, then six months of therapy, he returned to sports and earned a college football scholarship.^[12]

Our practice does not run an emergency room, and rhabdo and acute compartment syndrome are treated in the hospital. But if leg pain, tightness or numbness keeps coming back with running, Dr. Efe Ozturk, a Foot and Ankle Surgeon and podiatrist, can evaluate it. One cause is chronic exertional compartment syndrome, a repeating form that is usually not an emergency.^[4] When non-surgical care fails, a planned fasciotomy has excellent results for the front and outer leg compartments.^[4] In a pooled analysis, it gave more pain relief than non-surgical care, and patients had about 3.5 times the odds of being satisfied.^[13]

How common is rhabdo in runners, and why haven’t you heard of it?

Because severe cases are rare. In one Minnesota county, exertional rhabdomyolysis was diagnosed about once per 100,000 people a year.^[5] It is far more common in military training, at about 40 per 100,000 service members a year.^[14]

Meanwhile, some muscle breakdown is a normal result of hard exercise.^[2] In 348 ultra-trail runners, the muscle enzyme creatine kinase (CK) typically rose more than 50-fold, yet only one runner was diagnosed with rhabdo.^[6] After endurance events, these levels usually return to baseline in about six days.^[15] So lab numbers alone can’t always separate harmless strain from real illness.^[16] Researchers still think rhabdo is underrecognized.^[11]

Heat raises the risk. The 2022 New York City Marathon was the hottest on record. Four city hospitals treated 24 runners for rhabdo after it, more than the other five marathons from 2017 to 2023 combined.^[17]

What causes exertional rhabdomyolysis?

The guideline sums it up as “too much, too fast, and too soon.”^[2] Risk factors include:^[2]

• hard, long or repeated exercise you aren’t trained for
• eccentric work, where a muscle lengthens under load, as in running downhill^[6]
• hot, humid weather and heat illness^[18]
• starting the effort low on fluids
• a recent viral illness, or short sleep
• supplements, especially stimulants, and some drugs, including statins (cholesterol pills) and alcohol
• sickle cell trait, which raised the risk by about half in a large Army study^[19]
• inherited muscle conditions, such as McArdle disease^[16]

In that Army study, recent statin use nearly tripled the risk.^[19] Never stop a prescribed medicine on your own; talk with your doctor before a big race.

How do doctors diagnose rhabdomyolysis?

• CK blood test. Most studies define rhabdo as a CK at least five times the upper limit of normal.^[20] The military guideline uses 5,000 IU/L or more, plus symptoms.^[2]
• Urine test. A dipstick that shows “blood” when the microscope finds no red blood cells may point to myoglobin.^[2]
• Potassium and kidney tests. Broken-down muscle releases potassium, which can disturb the heart’s rhythm, and the kidneys may start to fail.^[3,2]

How is rhabdomyolysis treated?

• Early, aggressive IV fluids to flush the kidneys and keep urine flowing.^[3,2]
• Correcting potassium and other blood salts, with heart monitoring when needed.^[2]
• Dialysis if the kidneys fail.^[3] After the 2022 New York race, only 1 of the 24 runners treated needed it.^[17]
• Emergency fasciotomy if compartment syndrome develops.^[2]

Caught early, the outlook is good. In the Minnesota study, most patients were hospitalized, for a median of two days, and all went home without lasting problems.^[5]

How to lower your risk and get back to running

• Build mileage gradually, and practice downhill running before a hilly course.^[2,6]
• Respect the heat. In New York, rhabdo cases rose with the race-day heat index.^[17]
• A recent viral illness and short sleep both add risk, so get well and rested before race day.^[2]
• Drink fluids after a hard effort.^[1] But more is not better. Drinking too much during long exercise can drop your blood sodium to a dangerous level (hyponatremia), so drink when you’re thirsty instead of forcing extra water.^[21]
• Go easy on anti-inflammatory pain pills (NSAIDs, such as ibuprofen). High doses can harm the kidneys, a risk that may be higher after major muscle breakdown.^[2]

Coming back. For lower-risk cases, the guideline uses three phases: about 72 hours of rest with fluids and repeat labs, then light activity with no all-out or timed efforts for roughly 3 to 4 weeks, then full training. Move up only when pain is gone, strength is close to normal, CK is falling and urine is normal.^[2] Repeat episodes, rhabdo after light exercise, CK that stays high after 1 to 2 weeks of rest, or a family history call for a specialist workup.^[2]

The limits. No return-to-running plan for rhabdo is backed by published data.^[2] For chronic exertional compartment syndrome, the studies are mostly look-back reviews, and a 2020 review found too little evidence to favor surgery or non-surgical care. Satisfaction after fasciotomy ranged from 48% to 94%, and risks include a collection of blood under the skin and nerve injury.^[22] Results are less predictable for the back of the leg.^[4]

Common questions

What color is your urine with rhabdo?

Dark: red, brown or cola-colored, and often less of it.^[1]

Is it rhabdo or normal soreness after a marathon?

Normal soreness peaks within about three days and keeps improving. Rhabdo pain is severe, can come with swelling, weakness or dark urine, and doesn’t settle after 5 to 7 days.^[2]

How long does rhabdo take to recover?

Milder cases may get back to normal activities in a few weeks to a month, though some people stay tired or sore longer.^[1]

Can drinking water prevent rhabdo?

Not by itself. Starting a hard effort low on fluids is one risk factor, but the main trigger is effort beyond your training.^[2] And extra water is not safer: drinking too much can cause dangerously low blood sodium, so drink when you’re thirsty.^[21]

When to see a Foot and Ankle Surgeon

For running injuries, see our sports medicine page and our guide to stress fractures in runners. Numbness on top of the foot that builds with running can also come from a pinched nerve; see our Lower Extremity Nerve Institute (external site). When a procedure makes sense, learn about foot and ankle surgery.

We see patients in Lyndhurst, Paramus and Millburn; find an office on our locations page. Please call our office at 908-215-5953 to inquire about your insurance.