Disclosures: Alpha Anders, MD: No financial relationships or conflicts of interest

Case Diagnosis: Exertional rhabdomyolysis in an elite high school athlete with a Ryanodine Receptor Type 1 mutation genetic predisposition.

Case Description: A 17-year-old male division 1 football prospect presented to PM&R clinic for return to play (RTP) evaluation. History was significant for exertional rhabdomyolysis (ER) that once required admission and IV resuscitation due to an acute kidney injury (AKI) and critically elevated Creatinine Phosphokinase (CPK). Historical labs demonstrated a persistently elevated CPK. Genetic work up after his admission revealed a monoallelic mutation of the Ryanodine Receptor Type 1 (RYR1) gene.

Setting: ClinicAssessment/

Results: In addition to standard behavior, hydration, and exertion recommendations, the athlete’s parents and athletic staff were leveraged. They all received education on the signs and symptoms of rhabdomyolysis, prevention strategies, and symptom contingency planning. Weekly labs with telemedicine follow up during the football season enabled close quantitative trending and performance monitoring. He completed the football season without a repeat incident of ER.

Discussion: The life-threatening complications associated with exertional rhabdomyolysis complicate RTP management. Patients with a history of ER can be stratified into high-risk and low-risk categories that denote the probability of recurrence and deleterious sequalae. This patient’s RYR1 mutation, the gene that regulates sarcoplasmic reticulum calcium release, predisposes him to ER. His RYR1 mutation, persistently elevated CPK, and history of AKI with ER places him in the high-risk category. While low-risk athletes can follow a well-defined return to play protocol, high-risk athletes require a more individualized RTP plan.

Conclusion: High-risk college and professional athletes’ access to regular medical supervision enables individualized exertional rhabdomyolysis RTP management via vigilant monitoring. Without access to the same level of institutional monitoring, an elite high-risk high school athlete with ER presents a greater RTP challenge. With clear prevention measures, close outpatient surveillance, and strong partnerships, a high school athlete can successfully return to competition without adverse events.

Level of Evidence: Level IV

« Back to AAPM&R Annual Assembly 2021

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/return-to-play-management-of-high-risk-exertional-rhabdomyolysis-a-case-report-of-an-elite-high-school-athlete-with-a-ryanodine-receptor-type-1-mutation/