Summary:
The Uniformed Services University and Department of Defense collaborators have released an updated 2025 Clinical Practice Guideline for Exertional Rhabdomyolysis, providing standardized, evidence-based strategies to improve recognition, management, and safe return-to-activity decisions for military and civilian populations engaged in intense physical activity.

Key Takeaways:

  • Early Detection & Risk Stratification: The guideline emphasizes prompt recognition and use of tools like the McMahon Score to identify patients at risk for severe complications such as acute kidney injury.
  • Standardized Management Pathways: It outlines clear inpatient and outpatient care protocols, including hydration, activity restriction, and follow-up within 24–72 hours for lower-risk cases.
  • Guided Return-to-Activity Process: A staged reconditioning approach supports safe and gradual return to duty or sport, with specialist input for high-risk or recurrent cases—principles that can be applied in athletic and rehabilitation settings.

The Uniformed Services University (USU), in partnership with the U.S. Army Heat Center and other Department of Defense collaborators, has released the recently updated standardized Clinical Practice Guideline (CPG) for the Management of Exertional Rhabdomyolysis (ER) in Warfighters. Developed through USU’s Consortium for Health and Military Performance (CHAMP) and the Warfighter Heat- and Exertion-Related Events Collaborative (WHEC), this guideline provides military clinicians with a critical, evidence-based framework to identify, manage, and return Service Members to duty following this potentially dangerous condition.

Exertional rhabdomyolysis—muscle breakdown caused by strenuous activity—can escalate quickly to serious complications, including acute kidney injury (AKI). The updated guideline standardizes recognition, risk stratification, treatment, and return-to-duty (RTD) decisions across the Military Health System, ensuring timely and consistent care while protecting Service Members and strengthening operational readiness. Importantly, while designed with Warfighters in mind, the principles outlined in the guideline also have broad application for civilian populations—including athletes, first responders, and others who engage in intense physical activity.

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“We are very pleased to release this 2025 Rhabdomyolysis CPG update, which presents multiple significant changes and additions from our 2020 product,” said Dr Francis O’Connor, professor of Military and Emergency Medicine and medical director of CHAMP. “Our joint service team of DoD providers, representing hundreds of years of military relevant experience, has worked very hard to share the most current evidence-based information to our military colleagues to optimize the diagnosis and initial management of warfighters impacted by exertional rhabdomyolysis, and importantly, facilitate return to duty decisions.”

The extensively updated guideline sets a clear standard for diagnosing exertional rhabdomyolysis, helping doctors recognize the condition earlier and with greater accuracy. It also gives medical teams a way to quickly sort patients into low-, or high-risk categories to assist in both initial management and return to duty decisions. High-risk warning signs include significantly elevated muscle enzyme levels, signs of dangerous muscle pressure inside the muscles (compartment syndrome), lab results that show kidney damage, very dark urine, serious chemical imbalances in the blood, or having the sickle cell trait. Another important tool introduced in this update is the McMahon Score, which combines lab results and patient information to help predict the chance of severe kidney injury or the need for dialysis. Patients are also considered higher risk if their situation makes it hard to ensure close medical follow-up.

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For patients who need to be admitted to the hospital, the guideline recommends treatments that protect the kidneys and close monitoring for those at moderate to high risk of complications. For patients who can be managed outside the hospital, it provides a clear step-by-step approach focused on staying well-hydrated, limiting activity, and coming back for a check-up within 24–72 hours. This outpatient pathway is especially important for lower-risk cases or when exertional rhabdomyolysis is suspected but not yet confirmed.

Decisions about returning to duty are guided by a gradual, staged process. Low-risk patients start with rest, fluids, and careful monitoring, then slowly move through reconditioning phases until they can safely return to full activity if symptoms don’t return. Patients at higher risk, or those who experience the condition more than once, require a tailored plan that involves input from medical specialists. To support clinicians in these decisions, the guideline includes practical tools such as step-by-step flow charts, a glossary of terms, and appendices that address duty profiles, return-to-duty guidance, and medical coding.

“At the Army Heat Center, we frequently see cases of exertional rhabdomyolysis, either secondary to heat illness or on its own. Unlike exertional heat stroke, prior to the development of this CPG, return-to-duty guidance was lacking,” said Army Lt. Col. (Dr) David DeGroot, director of the Army Heat Center. “Now, providers have a resource to help as they work to return the injured warfighter to duty as quickly as possible but without jeopardizing their health or increasing risk of reoccurrence.”

The CPG is designed for use by military primary care, emergency medicine, sports medicine, and operational clinicians, as well as command medical leaders overseeing training, selection, and deployment cycles. Civilian clinicians may also find it a valuable reference when treating exertional rhabdomyolysis in athletic or occupational settings.

The Clinical Practice Guideline: Management of Exertional Rhabdomyolysis in Warfighters (September 2025) is now available online in 508-compliant PDF format at:  https://www.hprc-online.org/resources-partners/whec/clinical-care/clinical-practice.  For more information on CHAMP, the Army Heat Center, and the Warfighter Heat- and Exertion-Related Events Center, visit the following links:

For more information about the Uniformed Services University and its programs, visit www.usuhs.edu.

Featured image: The Uniformed Services University, in partnership with the U.S. Army Heat Center and other Department of Defense collaborators, has released the recently updated standardized Clinical Practice Guideline for the Management of Exertional Rhabdomyolysis in Warfighters. Photo: Uniformed Services University