Just Ran a Marathon? Watch Out For These Red Flags.

The worst Martin Hehir ever felt at the end of a race came after finishing his first marathon, California International in 2018. He was nauseated, couldn’t eat for a couple of hours, and barely had the strength to walk. He was concerned. But this physical state, as it does for most runners, corrected itself once Hehir drank enough fluids to fix electrolyte imbalances and replenished his body with calories. (1.2 grams of carbs per kilogram of bodyweight, 16-27 ounces of fluids, and 1000-1,500mg of electrolytes.)

Hehir, now 31, is experienced enough both on and off the roads to know these symptoms could quickly worsen if not addressed. He was a Reebok-sponsored pro for five years, taking sixth at the 2020 U.S. Olympic Trials Marathon in Atlanta and running 2:08:59 to win the The Marathon Project later that year. He went on to earn his MD in 2021 and is about to start his fourth and final year of anesthesiology residency at the University of Virginia  Medical Center in Charlottesville.

But less experienced runners might not know what to do when these symptoms don’t go away, or that they could be indications of serious health issues. It’s essential to be clued into your body and know the difference between typical post-race symptoms and woes, and when something is wrong.

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What is Rhabdomyolysis—and How Do You Treat it?

A major (and highly) serious thing that can go wrong during a race is when your muscles go into rhabdomyolysis. In fact, rhabdomyolysis (often referred to as “rhabdo”) is one of the main conditions running coaches Mark Cucuzzella, M.D. and Rochelle Basil, CPT, advise their athletes to watch out for post-marathon. Rhabdomyolysis is a condition in which damaged skeletal muscle breaks down rapidly, often due to high intensity exercise over a short period of time or heat stroke. With prompt treatment, you can fully recover from this, but the key is addressing it early.

Cucuzzella, also a competitive masters runner, a physician with the Department of Veterans Affairs, and a professor at the West Virginia University School of Medicine, says identifying rhabdomyolysis is fairly easy, as it initially presents as very dark urine with fairly severe muscle cramping and pain. Left untreated, it can escalate dangerously.

“This can rapidly progress into renal failure as the myoglobin from the broken-down muscles can clog the renal tubules,” he explains, adding “and lead to a serious condition which could result in hospitalization and kidney failure.”

If you suspect you’re suffering from rhabdomyolysis, Cucuzzella advises that the key to reversing this condition early is, “hydration hydration hydration.” And if that doesn’t clear up the dark urine and relieve cramping, it’s essential to get to a hospital.

Basil is a New Zealand-born coach and runner who three times represented her native country on the international stage. She came to the U.S. in 2008 on a running scholarship at George Mason University, and holds a master’s degree in cognitive behavioral neuroscience. She echoes Cucuzzella’s thoughts on rhabdomyolysis, adding that those who have experienced it are at a higher risk of a repeat event because it usually means you participate in activities that commonly trigger it (endurance feats), are genetically predisposed (glycolysis or metabolic disorders), or never properly recovered.

The key to recovery from rhabdomyolysis is to drink water and electrolytes until your urine is clear, Cucuzzella says. If issues persist or are extreme, head to the emergency room to get treated and to rule out any issues with your kidneys.

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Pay Attention to the Weather

Cucuzzella says the weather dictates what immediate risks might be waiting for runners heading towards the finish line. Heat stroke often goes undetected or ignored until it’s too late and symptoms have become dangerous.

“The most lethal and sometimes undetected consequence on a warm day is heat stroke,” he says. “The initial symptoms can be subtle—just some mild disorientation.”

Another symptom of heat stroke includes a body temperature over 100 degrees, though runners might not feel “hot”, and instead get the chills with goosebumps. This happens because your body is overheating and can’t effectively dissipate the heat, so your thermoregulation system overcorrects itself, constricts blood vessels, and reduces blood volume, which impairs your ability to sweat. You might also feel a throbbing headache, nausea, and rapid, shallow breathing.

Runners at risk of heat stroke need to immediately lower their body temperature. That means getting to a medical tent that’s, ideally, equipped with a cooling tub. Cucuzzella stresses the importance of asking for help, especially if you haven’t already been identified as someone experiencing symptoms.

Heat isn’t the only potentially dangerous weather condition for runners. In wet and cold weather, a runner’s body might naturally respond to cooler temperatures by shivering. This, coupled with conductive heat loss from wet clothing, can lead to fairly rapid hypothermia, which itself can cause cardiac dysrhythmia. In addition to aggressive shivering, early signs of hypothermia include drowsiness, lack of coordination, slurred speech, and a weak pulse.

“Preparation for this scenario is critical from both the participant and the race medical team,” Cucuzzella emphasizes. “Many runners do not have a drop bag or dry warm clothes at the finish and they leave it to chance. The medical team needs to have a place that is very warm and dry to reverse the hypothermia.”

Warm fluids and a survival emergency space blanket can also help bring body temperature back to homeostasis.

The answer to preventing and managing any of these potential ailments is preparation and knowledge. Be aware of the conditions that could present themselves during a race and know the procedures to take care of yourself.

Have a hot race coming up? Find out where you might be able to rapidly cool down, such as cold water immersion at a medical tent. Running in the wet and cold? Make sure to have a change of dry clothes as well as access to a warm, indoor space where you can dry off and change. And if possible, keep moving. That’s precisely what Cucuzzella did at the 2018 Boston Marathon, one of the coldest, wettest days in the history of the race.

“My strategy was to keep moving after the finish line to my friend’s nearby hotel which had a sauna,” he recalls. “Without this option, I probably would have ended up in the medical tent next to one of the French fry heaters.”

Above all, Cucuzzella advises runners to “stay within yourself.” In other words, don’t stubbornly hold onto your pace when conditions demand adapting your strategy to stay safe.

“Always be willing to dial down the pace and mix in walking before you head into areas of deep discomfort,” he says.

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Post-Marathon Blues

Less acute but more insidious are the post-marathon blues—something Basil sees all the time with her athletes.

“I like to plan something ‘fun’ for post goal races—be it a trip, a fun celebration with friends or family,” she shares. “The downtime is crucial to allow the brain and body to recover from the demands of training so that you can regroup and do it all again, but this time with a higher baseline.”

Ultimately, runners need to consider their long-term health and not put their life on the line for one race. Of course, as Hehir hints, this is easier said than done with runners.

“Marathoners are a special group of folks who train for months all to perform their best on one day,” he says. “But one thing to remind them is that life is unpredictable and the race plan needs to be flexible. A poorly timed race-week cold from one of your kids, unprecedented heat or cold conditions on race day, a nagging injury that has hindered training—all of these circumstances are out of our control, and though we may feel compelled to power through the race as planned. Being smart and adaptable on the day will result in healthier results.”

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The Pros of Proactive Prevention 

Heat stroke, hypothermia, rhabdomyolysis—these are some pretty terrifying conditions.  But Basil says one of the most common post-marathon issues is coming down with a common cold or flu.

“Running a marathon is a lot and a huge strain on every system on the body,” she says. “Hydration, nutrition, and rest post race should all be able to kick this. Obviously if symptoms are worsening or you are having difficulty respirating or if you have an elevated temperature, then seek medical attention.”

Basil echoes Cucuzzella’s advice and tells runners to pay attention to dehydration and electrolyte imbalance, something that can make or break athletes on race day, depending on the conditions.

“It is crucial to dial-in your fueling and hydration strategies pre-race,” she says. “I would recommend working with a registered sports dietitian for this, not only to ensure that you are taking in the adequate number of carbohydrates per hour, but it’s also crucial to ensure that you are crossing off all the crucial electrolytes, too.”

That might sound like a lot, but as Basil jokes, “who said running was simple?” before adding that runners also ought to be aware of their sodium levels. Dehydration can cause hyponatremia, which refers to dangerously low sodium levels alongside too much water.

“Mild symptoms can be treated with oral sodium,” she says before warning, “But this can indeed be fatal.”

Bottom line, whatever the issue, runners must not be shy about seeking medical attention at the first sign of any red flag symptoms, like persistent nausea, vomiting, and confusion after the race. Hehir sums it up:

“The best treatment for these scary outcomes is proactive prevention, which in the marathoner’s case, means being diligent about fluid and calorie consumption both during and immediately after the race,” he says. “The body is amazing and can compensate for quite a long time, but minimizing that fluctuation from homeostasis by replacing electrolytes and overall fluids is paramount in ensuring a speedy recovery.”

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