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DISABLEMENT MODEL CASE STUDY 

 

37 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 
 

Rhabdomyolysis and Hypothyroidism in a Collegiate Hammer 
Thrower: A Disablement Model Case Study 
S. Andrew Cage, EDd., LAT, ATC*; Robert Michael Galbraith, DO, CCFP (SEM)†‡, Rebecca Peebles, DO, CAQSM, FAAFP†‡; 
Payton Williams, MS, LAT, ATC*; Brandon Warner, M.Ed., LAT, ATC§ 
*The University of Texas at Tyler, Tyler, TX; †The University of Texas Health Science Center at Tyler, Tyler, TX; ‡UT Health East 
Texas, Tyler, TX §Grand Canyon University, Phoenix, AZ   

 
ABSTRACT 
The purpose of this disablement model case report was to detail the case of a patient suffering from rhabdomyolysis and 
hypothyroidism. Despite swelling, cramping, and loss of range of motion at the wrists, hands, and fingers, the patient did not seek 
physician evaluation until their athletic trainer encouraged them. While hypothyroidism is a relatively common condition, there has 
been little literature published that associate hypothyroidism with rhabdomyolysis. In this case, the patient reported to the athletic 
training staff reporting swelling, cramping, and loss of range of motion at the wrists, hands, and fingers. After evaluation by the 
team physician and subsequent testing, the patient was diagnosed with hypothyroidism and rhabdomyolysis. The patient was 
hospitalized and treated with intravenous hydration and oral levothyroxine. After a 10-day hospitalization, the patient had 
improved enough to be discharged. As the patient remained adherent with his levothyroxine prescription, the patient continued to 
improve to the point of being able to resume sport-specific activities. When evaluating a patient with swelling, cramping, and loss 
of range of motion after intense physical activity or muscular trauma, the clinician should consider rhabdomyolysis as a potential 
factor. Patients presenting with these symptoms should be referred for emergency care. 
Content Focus: Health Care Competency  
 
Correspondence 
S. Andrew Cage, The University of Texas at Tyler, 11325 Preakness Drive, Flint, TX 75762. 
Email: sacage@uncg.edu.  
 
Full Citation 
Cage SA, Galbraith RM, Peebles R, Williams P, Warner B. Rhabdomyolysis and hypothyroidism in a collegiate hammer 
thrower: A disablement model case study. Clin Pract Athl Train. 2023;6(2): 37-42. 
https://doi.org/10.31622/2023/0006.02.6.  
 

 
INTRODUCTION 

Hypothyroidism is a relatively common pathology related to thyroid hormone deficiency.1 Hypothyroidism is 
classified based on the biochemical characteristics of the patient.1 Subclinical hypothyroidism describes 
patients with thyroid stimulating hormone (TSH) slightly above normal limits. Clinical primary hypothyroidism 
describes patients whose TSH concentrations are above normal limits and free thyroxine levels are below 
normal limits.1 Diagnosing hypothyroidism is often relatively simple, with blood draws confirming TSH and 
free thyroxine levels.1,2 Common signs and symptoms indicating the need for this blood work include cold 
intolerance, unexplained weight gain, constipation, dry skin, bradycardia, and slow mental processing.2 
More rare signs and symptoms of hypothyroidism include hypothermia, congestive heart failure, blood 
clotting issues, depression, seizures, and pseudo-obstructions of the intestinal tract.2 Once diagnosed, treating 
hypothyroidism is relatively straightforward, consisting of oral levothyroxine sodium.1,2 To ensure the patient 
receives the proper dose, follow-up blood work is usually required to ensure that TSH and free thyroxine 
levels respond appropriately.1,2 

While hypothyroidism is a treatable condition, unchecked hypothyroidism can lead to various complications, 
including life-threatening diseases such as myxedema coma.1,2 In rare cases, hypothyroidism can be a 
comorbidity of rhabdomyolysis.3-5 Rhabdomyolysis is a severe and potentially fatal condition characterized 
by damage to the myocyte membrane.6 This damage can lead to increased intracellular calcium and muscle 
and organ tissue destruction.6 To date, the available research on this correlation between hypothyroidism 
and rhabdomyolysis has been reported in case reports. This appears to indicate that this combination of 
pathologies is, in fact, rare.7 Therefore, the purpose of this case report is to describe a case of 

mailto:sacage@uncg.edu
https://doi.org/10.31622/2023/0006.02.6


Rhabdomyolysis and Hypothyroidism in a Collegiate Hammer Thrower: A Disablement Model Case Study 

 

38 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

rhabdomyolysis in a collegiate hammer thrower who was also suffering from hypothyroidism. This case report 
will detail the pathological presentation, diagnosis, treatment, patient-reported disablements, and outcomes. 

PATIENT INFORMATION 

Patient 

The patient was a 20-year-old male, a collegiate hammer thrower. The patient reported a history of 
hypothyroidism, specifically his mother, maternal grandmother, and paternal aunt. The patient sought 
medical care from the team physician with reports of swelling, cramping, and tightness in his forearms, hands, 
and fingers. Approximately one month before seeking medical care, the patient moved into a new 
apartment. The patient reported minimal fluid intake while carrying heavy objects into his apartment. The 
patient noted that he initially felt muscle cramping in his legs, back, latissimus region, forearms, hands, and 
fingers about two days after the move. The cramping in the patient’s legs and back improved, but swelling 
and cramping persisted in the patient’s forearms, hands, and fingers. 

Differential Diagnosis and Evaluation 

Initial evaluation revealed strength within normal limits, mild loss of motion in all directions within the wrist 
and fingers, mild paresthesia extending into the right thumb, and visible swelling in the hands and fingers 
(Figures 1 & 2). Intake screening also revealed the patient’s blood pressure was 140/70 Mm Hg. Although 
the patient did not report any muscular weakness, he did state that he had to alter his upper body exercises 
in the weight room due to loss of motion in his wrist and fingers. Despite needing to make these modifications, 
the patient did not seek medical care from the sports medicine staff until the swelling in his wrists, hands, and 
fingers worsened. The differential diagnosis included rhabdomyolysis, exertional compartment syndrome, 
forearm muscle tendinopathy, and radial nerve compression. Because symptoms did not resolve with rest or 
have pain, exertional compartment syndrome, forearm muscle tendinopathy, and radial nerve compression 
were quickly removed from the differential diagnosis list. 

       

Figure 1 & 2. Images of the patient’s swollen right hand. 

Given the patient’s symptoms, the team physician ordered blood and urine analysis to assess for 
rhabdomyolysis. These lab results revealed several abnormal findings, which are presented in Table 1. After 
reviewing the results, the team physician immediately referred the patient to the emergency department at 
the local hospital for admittance.  



Rhabdomyolysis and Hypothyroidism in a Collegiate Hammer Thrower: A Disablement Model Case Study 

 

39 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

Table 1. Blood Testing Results 
Value Reading Normal Range 
WBC 
RBC 
Hemoglobin 
MCV 
MCH 
MCHC 
RDW 
Mean Platelet Volume 

7.1 
4.51 
14.5 
91.1 
32.2 
35.3 
13.2 
12.8 

4.5-13.5 10*3/uL 
3.90-5.90 10*6/uL 
14.0-18.0 g/dL 
80.0-95.0 fL 
30.0-37.0 pg 
33.0-37.0 g/dL 
11.5-14.5% 
7.4-10.4 fL* 

Neutrophils 46.5 42.4-72.6% 
Lymphocytes 38.9 20.5-51.1% 
Monocytes 8.5 1.7-11.7% 
Eosinophils 4.9 0.0-6.3% 
Basophils 0.8 0.0-1.2% 
Glucose 68 74-106 mg/dL* 
Creatinine 1.9 0.5-1.2 mg/dL* 
Aspartate 
Aminotransferace 

282 0-41 U/L* 

Alanine 
Aminotransferace 

134 0-41 U/L* 

Creatine Kinase 15,049 80-1083 U/L* 
TSH 148.1 0.27-3.20 ulU/mL* 
Free Thyroxine < 0.10 0.93-1.70 ng/dL* 
*Abnormal result   

 

Body Structure and Function 

Given the patient’s symptoms, the primary diagnostic techniques used to determine the need for blood and 
urine analysis were comprehensive patient history, family history, and strength and range of motion tests. At 
the time of presentation, the patient presented with limited wrist and finger motion and full strength in all 
motions when compared bilaterally. Throughout the presentation of symptoms, the patient did not exhibit 
any signs or symptoms of kidney, liver, or other systemic dysfunction. 

Activity and Participation 

Despite experiencing symptoms for over a month, the patient did not report to the sports medicine staff until 
he began altering his activities. The patient stated that he had to modify how he lifted weights with his upper 
extremities due to his loss of range of motion. The patient had not noticed a perceived change in his ability 
to perform the hammer throw at that time. Additionally, the patient’s measured performance had not 
diminished despite his decreased range of motion. After conversations with his primary athletic trainer, the 
patient finally agreed to seek evaluation by the team physician. 

Environmental and Personal Factors 

Outside of hammer-throwing-related activities, the patient stated that his swelling and decreased range of 
motion affected his daily living activities. Specifically, the patient expressed having to alter how he 
completed grooming tasks. The patient also reported that when his fingers swelled, he had difficulty typing 



Rhabdomyolysis and Hypothyroidism in a Collegiate Hammer Thrower: A Disablement Model Case Study 

 

40 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

for school assignments. The swelling was so significant at one point that the patient said he could not use a 
keyboard without touching four keys at a time. This difficulty led to the patient expressing concern about 
completing the required schoolwork on time. 

INTERVENTIONS 

Upon admittance to the hospital, the patient’s treatment began with intravenous hydration and oral 
levothyroxine 150 mcg once a day. While the patient was hospitalized, the athletic training staff worked 
with the institution’s faculty athletics representative to communicate with the patient’s professors to ensure 
reasonable accommodations for assignment due dates were provided. Over the next ten days, the team 
physician collaborated with the treating hospitalist and nephrologist to ensure optimal patient care. His blood 
and urine analyses improved as the patient continued his course of intravenous fluids and levothyroxine. 
When discharged ten days after admittance, the patient’s blood pressure had improved to 104/56 Mm Hg. 
The patient’s creatine kinase levels had also improved to 4,050 U/L. At discharge, the nephrologist instructed 
the patient to follow up with the team physician and an endocrinologist for further treatment. Upon 
consultation with the endocrinologist, it was concluded that the patient did not require any further 
pharmacological intervention to resolve his condition. 

OUTCOMES 

Body Structure and Function 

Two weeks after being admitted to the hospital, the team physician reevaluated the patient. At this time, the 
patient reported feeling better overall. While the patient continued swelling in his hands and upper 
extremities, the swelling had visibly improved, and the patient reported feeling like he had more energy. 

Nineteen days after being admitted to the hospital, the patient had a follow-up appointment with an 
endocrinologist. During this visit, the patient reported feeling much better. He noted he had gained a 
significant amount of weight after beginning to experience symptoms. During preparticipation physical 
examinations, the patient weighed 272 pounds. At one point, the patient had weighed over 300 pounds. 
Since the patient had begun taking levothyroxine, the patient’s weight had decreased to 291 pounds. After 
evaluation, the endocrinologist recommended that the patient gradually increase physical activity and 
schedule a follow-up appointment for two months from that date. 

Forty-five days after the patient had been admitted to the hospital, the patient had another follow-up 
appointment with the team physician. The patient’s weight had decreased to 274 pounds, and he reported 
feeling continually improving energy levels and no recurrence of swelling in his upper extremities. The patient 
had begun to participate in moderate physical activity, and the team physician recommended increasing the 
frequency, intensity, and volume of activity provided blood work and urine analysis levels continued to 
improve. The blood and urine analysis revealed a creatine kinase level of 237 U/L and a TSH level of 31.87 
ulU/dL. At this time, the team physician stated that he saw no reason why the patient would not be able to 
resume complete activities upon completion of a gradual return to activity and continued compliance with 
the prescribed course of levothyroxine. 

Activity and Participation 

After the patient’s follow-up evaluation with the endocrinologist, physical activity gradually increased. 
Exercise began with resistance training at 50% of maximum effort. The patient started with a light 
cardiovascular workout on the stationary bike before progressing to short sprint drills of less than 40 yards 



Rhabdomyolysis and Hypothyroidism in a Collegiate Hammer Thrower: A Disablement Model Case Study 

 

41 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

and ladder drills for activity. Given that hammer throwing did not exacerbate his symptoms and the 
anaerobic nature of the sport, the patient was then able to return to practice at this time as well. The patient’s 
athletic trainer scheduled regular meetings with the strength and conditioning coaching staff to ensure the 
weightlifting restrictions were followed.  

Aside from training for the hammer throw, the patient reported that his activities of daily living became 
easier when his swelling and range of motion improved. Had the patient not sought medical treatment, these 
issues would likely have continued to worsen and have an increasing effect on his activities of daily living. 
Fortunately, the patient has remained compliant with his levothyroxine prescription and continues to improve. 

Environmental and Personal Factors 

Given the patient’s concern about being able to complete coursework with his limitations, the sports medicine 
staff and faculty athletics representative worked closely with the institution's faculty. While hospitalized, the 
patient’s professors extended deadlines, allowing him to complete his coursework once his symptoms had 
resolved. Because the medical staff could work with the faculty athletics representative, institutional policies 
and procedures for accommodating students with temporary disabilities could be used. 

DISCUSSION 

This case details the diagnosis and management of a patient suffering from rhabdomyolysis exacerbated 
by undiagnosed hypothyroidism. While hypothyroidism is a relatively common condition, it has rarely been 
associated with rhabdomyolysis.3-5 Furthermore, in this case, the patient’s hypothyroidism was discovered due 
to his rhabdomyolysis. The patient’s family history of hypothyroidism gave the physician cause for suspicion. 
However, the signs and symptoms of hypothyroidism at the time might have been mild enough that the patient 
would not have noticed them if he had not experienced rhabdomyolysis. 

Overall, the patient’s willingness to be evaluated by the team physician led to an appropriate course of 
treatment that led to good outcomes. Had the patient chosen to forego physician evaluation, it is possible 
that his symptoms would have continued to worsen. With unchecked rhabdomyolysis and hypothyroidism, the 
patient may have been at risk for worse conditions. 

CLINICAL BOTTOM LINE  

Within the scope of clinical practice, clinicians may encounter patients with undiagnosed conditions. These 
conditions may be well reported in the literature but may have mild symptoms that are not relatively 
apparent. Sometimes, these conditions can predispose patients to other conditions with more obvious signs 
and symptoms. Collaboration between healthcare providers is crucial for delivering optimal patient care. 
When there are academic concerns at an institution of higher learning, clinicians should explore available 
resources for patient support, including faculty athletics representatives. Clinicians should always prioritize 
their patient’s safety and personal concerns when determining their course of treatment. Based on these 
values, clinicians may need to employ available resources to advocate for their patient population. 

REFERENCES 

1. Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet. 2017;390:1550-1562. 
http://dx.doi.org/10.1016/S0140-6736(17)30703-1  

2. Roberts CG, Landenson PW. Hypothyroidism. Lancet. 2004;363:793-803. 
https://doi.org/10.1016/S0140-6736(04)15696-1  

http://dx.doi.org/10.1016/S0140-6736(17)30703-1
https://doi.org/10.1016/S0140-6736(04)15696-1


Rhabdomyolysis and Hypothyroidism in a Collegiate Hammer Thrower: A Disablement Model Case Study 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

3. Boryushkina V, Ahmed S, Quadri K, Ramdass A. Recurrent rhabdomyolysis induced by severe 
hypothyroidism. Cureus. 2019;11(6). https://doi.org/10.7759/cureus.4818.  

4. Gurula D, Rajdey K, Acharya R, Idiculla PS, Habib S, Kryzak M. Rhabdomyolysis in a young patient due 
to hypothyroidism without any precipitating factor. Case Rep Endocrinol. 2019. 
https://doi.org/10.1155/2019/4210431  

5. Salehi N, Agoston E, Munir I, Thompson GJ. Rhabdomyolysis in a patient with severe hypothyroidism. Am 
J Case Rep. 2017;18:912-918. https://doi.org/10.12659%2FAJCR.904691.  

6. Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013;144(3):1058-1065. 
https://doi.org/10.1378/chest.12-2016.  

7. Chang ZY, Boo AY, Tulsidas H. Rhabdomyolysis: A rare complication of hypothyroidism. Proc Singap 
Healthc. 2015;24(3):188-190. https://doi.org/10.1177/201005815598456.  

https://doi.org/10.7759/cureus.4818
https://doi.org/10.1155/2019/4210431
https://doi.org/10.12659%2FAJCR.904691
https://doi.org/10.1378/chest.12-2016
https://doi.org/10.1177/201005815598456

	ABSTRACT

