Marathoner Dies of Rhabdomyolysis: What to Know About Rare Condition

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When you think about athletes, you tend to think about stamina, strength and being in peak physical condition.

But anyone pushing his or her body to its limits also has to beware of overdoing it. The tragic death of Rachel Apa, a former college athlete who collapsed two miles from the finish line of the New York City Marathon, is an extreme case of a body fatally breaking down within a few hours, but a reminder that it can happen.

According to her father Steve Apa, Rachel died of rhabdomyolysis, a condition in which damaged muscle tissue breaks down and sends harmful proteins into the bloodstream.

“It’s unfathomable,” he told the New York Times. “Perfect health, perfect shape, 24 years old.”

Rachel, running her first marathon, had texted her dad after passing the 9-mile mark of the 26.2-mile route, which starts on Staten Island and finishes in Central Park, "I feel amazing. I've never felt this good."

Steve texted back from the family's home in Lewisberry, Penn., per NBC News, "Great, don’t overdo it. First marathon. This is a learning run. Don’t overdo it.”

Rachel had played field hockey for Bucknell University, was a regular exerciser and had trained for months ahead of the event.

“She was always on the go, always go," Steve said, "and it doesn’t matter if it’s school or sports or whatever it is. She was go."

So, how the heck does something like this happen?

Here is what to know about rhabdomyolysis, who is most at risk and more:

What is rhabdomyolysis?

If you had never heard of rhabdomyolysis (or "rhabdo," as it's often abbreviated) you're hardly alone, as it's considered relatively rare, with about 26,000 cases reported in the United States each year, meaning it affects .0076 percent of the country's population.

According to the National Institutes of Health, rhabdomyolysis is a condition in which skeletal muscles break down and release intracellular components such as myoglobin, creatine phosphokinase (CPK), electrolytes and sarcoplasmic proteins into the bloodstream. 

When toxic components of your muscle fibers enter your circulation system and kidneys, it can lead to acute kidney injury (AKI), electrolyte disturbances, and disseminated intravascular coagulation (a blood clotting disorder), per the NIH.

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What causes rhabdomyolysis? 

A "crushing injury" is the most common cause of rhabdomyolysis, according to the Cleveland Clinic, while overexertion (too much exercise without rest) and severe dehydration and overheating can also cause rapid muscle breakdown.

Cited causes of rhabdomyolysis also include certain medications, such as antipsychotic, antidepressant and antiviral medications, as well as statins; long periods of inactivity and physical conditions such as muscular dystrophy.

Who gets rhabdomyolysis?

Endurance athletes and members of the military—i.e. those who engage in high-intensity physical activity—are considered more at risk, per the Cleveland Clinic, as are firefighters and others who work in hot environments and people over 65, as they're considered more prone to falls that could lead to injuries and prolonged immobility.

“Exertional rhabdomyolysis can occur after strenuous exercise and from high-intensity workouts during which the muscles are overused,” Niloofar Nobakht, MD, associate clinical professor of nephrology, told UCLA Health in 2023. “You can also get rhabdo from direct trauma, such as a crushing injury from a motor vehicle accident or a fall.”

But almost any intense activity can cause rhabdo, most commonly among people who are trying something new, according to Eric Rawson, chair of the department of health, nutrition and exercise science at Messiah College in Pennsylvania.

"You can be fit, and I can come up with a workout that you are unaccustomed to, and that could be what causes rhabdo," he told the NY Times in 2017, explaining why it's so important to start out at a beginner's level of a new activity before notching up the intensity.

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What are the symptoms of rhabdomyolysis?

Experiencing sore or weak muscles a few days after exercising, muscle swelling and abnormally dark or otherwise off-color urine can be signs of the condition.

The Cleveland Clinic notes that symptoms usually develop one to three days after a muscle injury, and persistent soreness doesn't always register as a potential life-threatening complication.

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Is rhabdomyolysis always fatal?

Rhabdomyolysis is survivable but requires prompt treatment, according to medical experts. Usually the condition is treated with fluids and electrolytes administered intravenously, while extreme kidney damage could require dialysis.

“We might start with an IV fluid and closely monitor electrolytes such as potassium, phosphorus and calcium," UCLA's Nobakht said. "Potassium and calcium are the two main electrolytes that play a significant role in recovering muscle function."

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What happened to NYC marathoner Rachel Apa?

Witnesses said that Rachel Apa collapsed around the 24-mile mark of the New York City Marathon in Central Park. Three people, two of whom said they were doctors, took turns administering CPR, spectator Michaela Nicholas told the NY Times. New York Road Runners, which organizes the marathon, said event medical staff used a defibrillator on the fallen athlete before paramedics arrived and transported her to Mount Sinai Medical Center, where she was pronounced dead after six hours of attempted life-saving measures.

University of Michigan Health emergency medicine physician Dr. Bradley Uren told the publication that, for Rachel, "that worst case scenario happened just very, very quickly."