Rachel Apa appeared to be in exceptional physical condition.
The 24-year-old runner and former college field hockey player had spent months preparing for the New York City Marathon. By the time she reached Mile 24 on Sunday, she was close to completing the race.
Then, just two miles from the finish, Rachel suddenly collapsed. She was taken to a Manhattan hospital, where she was pronounced dead later that evening.
Rachel’s father, Steve Apa, told The New York Times that his daughter died from rhabdomyolysis—a rare and potentially fatal condition in which muscles break down and release toxic substances into the bloodstream.
The resulting chemical overload can overwhelm the kidneys, causing organ failure and death within hours.
‘It’s unfathomable,’ Steve said. ‘Perfect health, perfect shape, 24 years old.’
Doctors say the intense training undertaken by elite athletes can sometimes trigger rhabdomyolysis, as extreme exertion damages muscle fibers faster than the body can repair them.
Its first warning signs can be easy to overlook, including swelling, weakness and dark urine. Athletes may mistake them for the ordinary effects of strenuous exercise.
Rachel Apa collapsed during the New York City Marathon and died from rhabdomyolysis, her father revealed
The Cleveland Clinic estimates that about 26,000 Americans develop rhabdomyolysis each year. The condition has a mortality rate of between 5 and 10 percent.
Doctors who were not involved in Rachel’s treatment told Our News Outlet that rhabdomyolysis begins when the muscle fibers responsible for movement rapidly deteriorate.
As those fibers break down, they release large quantities of electrolytes and substances including potassium and myoglobin into the bloodstream. They also release creatine kinase, an enzyme doctors use to assess the extent of muscle damage.
Although the kidneys usually filter these substances from the blood, the enormous quantities released during rhabdomyolysis can overwhelm and obstruct the organs.
‘Unfortunately, these large muscle proteins are incredibly thick and easily clog and damage that delicate filtration system,’ Dr Marc Levine, chair of orthopedic surgery at Jersey Shore University Medical Center, told Our News Outlet.
The chemicals can also affect the heart and trigger dangerous abnormal rhythms.
‘Damaged muscles release potassium into the blood, which can reach dangerous levels and cause sudden cardiac arrest,’ Dr Eric S Levy, an emergency medicine physician and director of simulation at Northwell’s Staten Island University Hospital, told Our News Outlet.
‘In severe cases, multiple organs can fail when damaged muscle tissue floods them and disrupts their function.’
Intense or prolonged exercise is among the condition’s principal risk factors. A normal workout, such as a short run or cycling session, produces tiny muscle tears that the body can repair and use to build stronger tissue.
Extremely demanding exercise, however, can place more stress on muscle-cell membranes than they can withstand.
Extreme exertion can also disrupt cellular signaling and cause calcium levels inside muscle cells to rise. That process can initiate cell breakdown and death.
Traumatic injuries, including car crashes that trap or compress muscle tissue, can also cause rhabdomyolysis.
Rhabdomyolysis may develop within hours or over several days, and its symptoms are not always dramatic at first. Typical signs include intense muscle pain, severe weakness and urine that is dark brown, resembling cola or strong tea.
‘It’s unfathomable… perfect health, perfect shape, 24 years old,’ Rachel’s father told The New York Times
Levine told Our News Outlet that dark urine may indicate severe dehydration, as the body attempts to conserve water. The symptoms often emerge gradually during the hours after an intense workout or race.
‘As swelling and muscle damage worsen, the weakness can become so severe that someone may struggle to stand, raise their arms or support their own body weight,’ he said.
Levine said ordinary post-exercise soreness generally causes stiffness and aching, while rhabdomyolysis is more likely to produce deep pain and difficulty moving the affected muscle.
‘If you experience that level of extreme weakness, notice unusual muscle swelling or see dark, tea-colored urine, you must go to an emergency room immediately rather than waiting at home,’ he said.
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Emergency physicians can diagnose rhabdomyolysis with blood tests that measure creatine kinase and urine tests that detect myoglobin. An electrocardiogram can identify heart-rhythm problems linked to elevated potassium levels.
Treatment may include intravenous fluids and medication to correct electrolyte imbalances. In the most serious cases, dialysis may temporarily perform the kidneys’ filtering work while they recover.
Dr Alina Mitina, an emergency medicine expert at Hackensack Meridian Health, said rhabdomyolysis does not automatically end an athlete’s career, and most patients have a strong chance of making a full recovery.
‘The treatment is pretty straightforward,’ she told Our News Outlet. ‘Apa’s tragic case is exceptional. Rhabdomyolysis does not usually progress this quickly.’
‘If we catch it in time, there is a really good and easy way to treat it. How fast someone improves depends on the individual, but recovery is generally good.’
Doctors told Our News Outlet that casual athletes are generally not at increased risk of rhabdomyolysis, but should build activity gradually and take regular breaks
Mitina said most people who go for a casual jog, take a weekend bike ride or follow a normal gym routine are not at heightened risk of rhabdomyolysis.
‘A lot of the time, this happens after very rapid exertion,’ Mitina said, describing situations in which someone remains inactive, skips a warm-up and then goes ‘from zero to 100.’
However, she emphasized that strenuous exercise is not the only cause. The condition can occur after someone lies on the floor for an extended period, suffers a traumatic accident or takes a cholesterol-lowering medication that causes muscle breakdown.
Several professional athletes in different sports have developed rhabdomyolysis and later returned to competition.
Former NFL defensive lineman Albert Haynesworth, now 45, was diagnosed with rhabdomyolysis during preseason training camp in August 2010, according to The Washington Post at the time.
The Washington Redskins, his team then, initially characterized the issue as a ‘headache.’ It later emerged that Haynesworth had experienced dizziness, nausea, vomiting and muscle swelling. Team doctors treated him, and he returned to the field in a preseason game several days later.
Last year, Indiana Fever player and Caitlin Clark teammate Kelsey Mitchell, 30, faced a serious health scare during the WNBA semifinals after developing severe leg cramps and numbness.
Former NFL defensive lineman Albert Haynesworth, now 45, recovered from rhabdomyolysis
Mitchell later said she had briefly experienced paralysis in her lower body and had been treated for rhabdomyolysis. She made a full recovery and returned to play for the Fever this season.
In 2024, 12 members of the Tufts University men’s lacrosse team were hospitalized with the condition after a workout led by a Navy SEAL trainee. More than a dozen Iowa Hawkeyes football players were also hospitalized with rhabdomyolysis after an intense workout in 2011.
Levy told Our News Outlet that prevention depends on avoiding sudden overexertion and allowing the body enough time to rest. Athletes should increase intensity gradually, remain hydrated and take regular breaks.
‘The bottom line is that exercise-related muscle pain should not always be dismissed as normal soreness,’ he said. Severe pain, unusual weakness or dark urine after exercise are warning signs that should never be ignored.
‘Early treatment can prevent life-threatening complications.’
For Rachel, however, treatment came too late. The runner collapsed in Central Park as she neared the end of Manhattan’s iconic race.
‘Rhabdomyolysis is a very, very dangerous condition, and it can go from being very simple and not dangerous to becoming dangerous pretty quickly,’ Mitina said.
Rachel was an accomplished athlete. She earned letters in field hockey and lacrosse in high school before playing Division I field hockey for four years at Bucknell University.
WNBA player Kelsey Mitchell experienced a rhabdomyolysis scare during last year’s semifinals
She had trained for months for Sunday’s marathon. It remains unclear whether she experienced any of the warning signs described by Levine before beginning or during the race.
A social worker and physicians in the crowd rushed to help after she collapsed, followed by marathon medical staff carrying a defibrillator, according to a statement from race organizer New York Road Runners (NYRR).
Paramedics arrived soon afterward and transported Rachel by ambulance to Mount Sinai Medical Center. Doctors attempted to save her for six hours before pronouncing her dead at 9:40 p.m.
After Rachel’s death, NYRR confirmed that she was the first runner to die during the New York City Marathon since 2024. In 2007, five-time U.S. national champion Ryan Shay died in Central Park during the Olympic marathon trials, which NYRR held the day before that year’s New York City Marathon.
