Medical experts have outlined the warning signs of a potentially life-threatening condition after a 24-year-old woman died following her collapse during the New York City Marathon.
Rachel Apa was taking part in the annual race on Sunday, November 1, when she collapsed in Central Park during the 24th mile of the 26.2-mile course.
Despite efforts to save her life, including CPR reportedly administered by a hospital worker who had been watching the race, Rachel was pronounced dead at approximately 9:40pm.
Her father, Steve Apa, described the loss as unfathomable, explaining that his daughter had appeared to be in excellent health before the event.
The family has since identified a medical condition they believe caused her death, prompting renewed attention to its symptoms and the circumstances in which it can develop.
What is rhabdomyolysis?
According to Rachel's father, she died from rhabdomyolysis, a serious condition involving the rapid breakdown of skeletal muscle tissue.
Commonly referred to as 'rhabdo', the condition occurs when damaged muscle cells release substances into the bloodstream.
These include myoglobin, creatine kinase, potassium and phosphate, which can cause serious complications when released in excessive amounts.
Myoglobin, a protein normally found inside muscle cells, can contribute to kidney damage when large quantities enter the bloodstream.
Elevated potassium levels can also interfere with the heart's electrical activity, potentially causing dangerous heart rhythms.
In severe cases, rhabdomyolysis can lead to acute kidney injury, organ complications and death.
Although Rachel's family has attributed her death to the condition, the available reporting does not establish whether a final medical examiner's determination has been publicly released.
What are the warning signs of rhabdomyolysis?
According to the Cleveland Clinic, rhabdomyolysis can cause a range of symptoms, some of which may initially resemble ordinary discomfort following exercise.
Potential warning signs include:
Symptoms may begin within hours of muscle injury or develop over the following one to three days.
Importantly, not everyone experiences the same symptoms, and some people may have significant muscle damage without obvious muscle pain.
One warning sign can be mistaken for something less serious
Muscle soreness is common after exercise, especially following an unusually demanding workout or endurance event.
However, doctors warn that severe or unexpected pain should not automatically be dismissed as normal post-exercise discomfort.
One particularly important warning sign is a noticeable change in urine colour.
Urine that becomes dark brown, reddish or tea-coloured can indicate the presence of myoglobin released from damaged muscle tissue.
However, dark urine is not present in every case, and its absence does not rule out rhabdomyolysis.
Anyone experiencing severe or unusual muscle pain, weakness, swelling or dark urine after exercise should seek urgent medical assessment.
Early diagnosis is important because treatment can help reduce the risk of potentially dangerous complications.
Why can the condition affect otherwise healthy people?
Although rhabdomyolysis is relatively uncommon, it can affect people who are young, physically active and otherwise healthy.
According to the Cleveland Clinic, particularly strenuous physical activity can sometimes cause muscle damage severe enough to trigger the condition.
Endurance athletes, including marathon runners, may face an increased risk under certain circumstances.
Other activities associated with exertional rhabdomyolysis include high-intensity interval training, demanding cycling sessions and intensive military training.
However, exercising regularly does not mean someone is likely to develop the condition.
Most people who participate in marathons or demanding workouts will never experience rhabdomyolysis.
The risk may increase when people push themselves significantly beyond their usual level of conditioning, particularly without adequate recovery.
What else can cause rhabdomyolysis?
Exercise is not the only potential trigger.
The condition can also develop following serious injuries, prolonged immobility, heat-related illness, certain infections and reactions to some medications.
People working in physically demanding environments with high temperatures may also face an increased risk.
Examples include firefighters, foundry workers and people performing heavy labour in extreme heat.
Older adults may develop rhabdomyolysis after prolonged periods of immobility, particularly following a fall or illness.
Although rhabdomyolysis itself is not generally considered a hereditary disease, certain inherited muscle disorders can increase susceptibility.
Rachel had complained of pain during the marathon
Rachel had reportedly been communicating with her parents by text message during the race.
According to reporting from The New York Times, she sent messages expressing pain while still several miles from the finish line.
Her father later sent her an encouraging message as she approached the final stages of the marathon.
Tragically, she did not respond.
Rachel collapsed near mile 24 in Central Park and was later pronounced dead.
While the messages suggest she had experienced discomfort during the race, they do not establish when rhabdomyolysis developed or whether any particular symptom was caused by the condition.
How is rhabdomyolysis diagnosed?
Doctors typically assess a patient's symptoms, recent physical activity, medical history and potential risk factors.
Blood tests are particularly important in diagnosing the condition.
One of the main measurements is creatine kinase, commonly abbreviated to CK, an enzyme released into the bloodstream when muscle cells are damaged.
Significantly elevated CK levels can indicate substantial muscle injury.
Doctors may also assess kidney function, electrolyte levels and urine samples to identify possible complications.
The severity of rhabdomyolysis can vary considerably, meaning treatment depends on the patient's condition and test results.
Can rhabdomyolysis be treated?
Yes. Many people recover from rhabdomyolysis when it is recognised and treated promptly.
Treatment often involves intravenous fluids to support circulation and kidney function, alongside careful monitoring of electrolytes and urine output.
Doctors will also address the underlying cause of the muscle damage.
In severe cases involving significant kidney injury, dialysis may be required.
Recovery can take several weeks, particularly when muscle damage has been extensive.
However, serious cases can become life-threatening, making early medical intervention especially important.
How can people reduce their risk?
Medical professionals recommend gradually increasing exercise intensity rather than suddenly attempting extremely demanding workouts.
Allowing adequate recovery time, avoiding excessive exertion and taking precautions during hot weather can also help reduce risk.
Staying appropriately hydrated is important, although drinking water alone cannot guarantee prevention.
People should also avoid pushing through severe or unusual symptoms during physical activity.
Those experiencing concerning symptoms should stop exercising and seek medical assessment rather than assuming the discomfort will resolve on its own.
Rachel was running in memory of her grandfather
Rachel had entered the New York City Marathon to raise money for the Parkinson's Foundation in honour of her grandfather, who died in 2022.
She had spoken about the influence he had on her love of sport and physical activity.
The 24-year-old was a former college athlete who had taken on the challenge of completing her first marathon while supporting a cause close to her family's heart.
Her death has prompted an outpouring of sympathy from the running community.
For health professionals, the tragedy is a reminder that serious medical conditions can sometimes affect people who appear otherwise fit and healthy.
Although rhabdomyolysis is uncommon, recognising unusual symptoms and seeking prompt treatment can be crucial in preventing severe complications.
