Management of suspected fluid balance issues in participants of wilderness endurance events
Abstract
Dehydration and exercise-associated hyponatremia (EAH) are both relatively common conditions during wilderness endurance events. Whereas dehydration is treated with fluids, EAH is appropriately managed with fluid restriction and a sodium bolus but can worsen with isotonic or hypotonic fluids. Therefore, caution is recommended in the provision of postevent rehydration in environments where EAH is a potential consideration because accurate field assessment of hydration status can be challenging, and measurement of blood sodium concentration is rarely possible in the wilderness. Dehydration management with oral rehydration is generally adequate and preferred to intravenous rehydration, which should be reserved for athletes with sustained orthostasis or inability to tolerate oral fluid ingestion after some rest. In situations where intravenous hydration is initiated without known blood sodium concentration or hydration status, an intravenous concentrated sodium solution should be available in the event of acute neurological deterioration consistent with the development of EAH encephalopathy.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In some environments overhydration is almost as frequent as dehydration and is a key stimulus for the development of symptomatic exercise-associated hyponatremia (EAH).
“However, it should be noted that in some environments overhydration is almost as frequent, being a key stimulus for the development of symptomatic hyponatremia associated with exercise (EAH) [11]”
From Nutrition-Related Adverse Outcomes in Endurance Sports Competitions: A Review of Incidence and Practical Recommendations (2020) · cites this paper as [11]
Cites
1 retracted
Marathon Runner with Acute Hyponatremia: A Neurological Disorder
Kormann, R., Philippart, F., Hubert, S., & Bruel, C. (2012) · Case Reports in Emergency Medicine · doi:10.1155/2012/342760 · Cited by 9 · see citing works
RetractedThomas, D. T., Erdman, K. A., & Burke, L. M. (2016) · Journal of the Academy of Nutrition and Dietetics · doi:10.1016/j.jand.2015.12.006 · Cited by 1,359 · see citing works
Running economy: Measurement, norms, and determining factors
Barnes, K. R., & Kilding, A. E. (2015) · Sports Medicine - Open · doi:10.1186/s40798-015-0007-y · Cited by 465 · see citing works
Noakes, T. D., Sharwood, K. A., Speedy, D. B., Hew, T. D., Reid, S., Dugas, J. P., Almond, C. S. D., WHARAM, P. C., & Weschler, L. B. (2005) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.0509096102 · Cited by 330 · see citing works
Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in Marathon Runners
Ayus, J. C., Varón, J., & Arieff, A. I. (2000) · Annals of Internal Medicine · doi:10.7326/0003-4819-132-9-200005020-00005 · Cited by 313 · see citing works
Antihypertensive Medication Adherence in the Department of Veterans Affairs
Siegel, D., Lopez, J., & Meier, J. L. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2006.06.028 · Cited by 227 · see citing works
Hew-Butler, T., Rosner, M. H., Fowkes-Godek, S., Dugas, J. P., Hoffman, M. D., Lewis, D. P., Maughan, R. J., Miller, K. C., Montain, S. J., Rehrer, N. J., et al. (2015) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000221 · Cited by 205 · see citing works
Exercise-associated hyponatremia in marathon runners: a two-year experience
Davis, D. P., Videen, J. S., Marino, A., Vilke, G. M., Dunford, J. V., Camp, S. P. V., & Maharam, L. G. (2001) · Journal of Emergency Medicine · doi:10.1016/s0736-4679(01)00320-1 · Cited by 182 · see citing works
Weight changes, medical complications, and performance during an Ironman triathlon
Sharwood, K. A., Collins, M., Goedecke, J. H., Wilson, G., & Noakes, T. D. (2004) · British Journal of Sports Medicine · doi:10.1136/bjsm.2003.007187 · Cited by 179 · see citing works
Hyponatremia in Marathon Runners due to Inappropriate Arginine Vasopressin Secretion
Siegel, A. J., Verbalis, J. G., Clement, S. C., Mendelson, J. H., Mello, N. K., Adner, M. M., Shirey, T., Glowacki, J., Lee-Lewandrowski, E., & Lewandrowski, K. B. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2006.10.027 · Cited by 157 · see citing works
Hyponatremia and Ultramarathon Running
Frizzell, R. T. (1986) · JAMA · doi:10.1001/jama.1986.03370060086025 · Cited by 149 · see citing works
Hoffman, M. D., Pasternak, A. V., Rogers, I. R., Khodaee, M., Hill, J. C., Townes, D. A., Scheer, B. V., Krabak, B. J., Basset, P., & Lipman, G. S. (2014) · Sports Medicine · doi:10.1007/s40279-014-0189-3 · Cited by 112 · see citing works
Exercise-associated hyponatremia and hydration status in 161-km ultramarathoners
HOFFMAN, M. D., HEW-BUTLER, T., & STUEMPFLE, K. J. (2013) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0b013e31827985a8 · Cited by 111 · see citing works
Lebus, D. K., Casazza, G. A., Hoffman, M. D., & Loan, M. D. V. (2010) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e3181da53ea · Cited by 79 · see citing works
Case Series: Hyponatremia Associated With Moderate Exercise
Zelingher, J., Putterman, C., Ilan, Y., Dann, E. J., Zveibil, F., Shvil, Y., & Galun, E. (1996) · The American Journal of the Medical Sciences · doi:10.1016/s0002-9629(15)41646-5 · Cited by 59 · see citing works
Exercise-Associated Collapse in Endurance Events: A Classification System
Roberts, W. O. (1989) · The Physician and Sportsmedicine · doi:10.1080/00913847.1989.11709782 · Cited by 56 · see citing works
Rogers, I. R., Brechtel, G., Stuempfle, K. J., Hoffman, M. D., & Hew‐Butler, T. (2011) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e31821a6450 · Cited by 54 · see citing works
Exercise-associated hyponatremia with exertional rhabdomyolysis: importance of proper treatment
Hoffman, M. D., Stuempfle, K. J., Sullivan, K., & Weiss, R. H. (2014) · Clinical Nephrology · doi:10.5414/cn108233 · Cited by 51 · see citing works
Hoffman, M. D., & Stuempfle, K. J. (2015) · Sports Medicine - Open · doi:10.1186/s40798-015-0019-7 · Cited by 48 · see citing works
Sensitivity and specificity of clinical signs for assessment of dehydration in endurance athletes
McGarvey, J., Thompson, J., Hanna, C., Noakes, T. D., STEWART, J. M., & Speedy, D. B. (2008) · British Journal of Sports Medicine · doi:10.1136/bjsm.2008.053249 · Cited by 40 · see citing works
Exercise-Associated Hyponatremia with Rhabdomyolysis during Endurance Exercise
Ellis, C., Cuthill, J. A., Hew‐Butler, T., George, S. M., & Rosner, M. H. (2009) · The Physician and Sportsmedicine · doi:10.3810/psm.2009.04.1693 · Cited by 39 · see citing works
Dysnatremia Predicts a Delayed Recovery in Collapsed Ultramarathon Runners
Hew‐Butler, T., Sharwood, K. A., Boulter, J., Collins, M., Tucker, R., Dugas, J. P., Shave, R., George, K., Cable, N. T., Verbalis, J. G., et al. (2007) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e31804c779b · Cited by 37 · see citing works
Exercise-Associated Hyponatraemia after a Marathon: Case Series
Goudie, A., Tunstall-Pedoe, D. S., Kerins, M., & Terris, J. (2006) · Journal of the Royal Society of Medicine · doi:10.1258/jrsm.99.7.363 · Cited by 37 · see citing works
Encephalopathy due to severe hyponatremia in an ultramarathon runner.
Clark, J. M., & Gennari, F. J. (1993) · PubMed Central · Cited by 36 · see citing works
Efficacy of oral versus intravenous hypertonic saline in runners with hyponatremia
Owen, B. E., Rogers, I. R., Hoffman, M. D., Stuempfle, K. J., Lewis, D. P., Fogard, K., Verbalis, J. G., & Hew‐Butler, T. (2013) · Journal of science and medicine in sport · doi:10.1016/j.jsams.2013.09.001 · Cited by 33 · see citing works
Agreement of Decision Analyses and Subsequent Clinical Studies in Infectious Diseases
Bress, J., Hulgan, T., Lyon, J. A., Johnston, C. P., Lehmann, H. P., & Sterling, T. R. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2006.08.032 · Cited by 31 · see citing works
Hyponatremia in Distance Athletes
Noakes, T. D. (2000) · The Physician and Sportsmedicine · doi:10.3810/psm.2000.09.1209 · Cited by 30 · see citing works
Managing Collapsed or Seriously Ill Participants of Ultra-Endurance Events in Remote Environments
Hoffman, M. D., Rogers, I. R., Joslin, J., Asplund, C. A., Roberts, W. O., & Levine, B. D. (2014) · Sports Medicine · doi:10.1007/s40279-014-0270-y · Cited by 28 · see citing works
Hoffman, M. D., Cotter, J. D., Goulet, E. D. B., & Laursen, P. B. (2016) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2016.03.003 · Cited by 26 · see citing works
Hoffman, M. D., & Myers, T. M. (2015) · International Journal of Sport Nutrition and Exercise Metabolism · doi:10.1123/ijsnem.2014-0241 · Cited by 25 · see citing works
Hyponatremia is Associated With Higher NT-proBNP Than Normonatremia After Prolonged Exercise
Harris, G., Reid, S., Sikaris, K. A., & McCrory, P. R. (2012) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e3182580ce8 · Cited by 23 · see citing works
Hyponatremia in an 85-Year-Old Hiker: When Depletion Plus Dilution Produces Delirium
Coler, C., Hoffman, M. D., Towle, G., & Hew‐Butler, T. (2012) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2012.02.013 · Cited by 22 · see citing works
A near-fatal case of exercise-associated hyponatremia
Severac, M., Orban, J., Leplatois, T., & Ichaï, C. (2014) · The American Journal of Emergency Medicine · doi:10.1016/j.ajem.2013.12.041 · Cited by 21 · see citing works
Intravenous versus Oral Rehydration in Athletes
van Rosendal, S. P., Osborne, M. A., Fassett, R. G., Lancashire, B., & Coombes, J. S. (2010) · Sports Medicine · doi:10.2165/11319810-000000000-00000 · Cited by 21 · see citing works
Elsaesser, T. F., Pang, P. S., Malik, S., & Chiampas, G. (2013) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2012.11.048 · Cited by 19 · see citing works
Exercise associated hyponatraemia leading to tonic-clonic seizure
Reynolds, C., Cleaver, B., & Finlay, S. E. (2012) · BMJ Case Reports · doi:10.1136/bcr.08.2012.4625 · Cited by 19 · see citing works
Exercise-Associated Hyponatremia in a Lactating Female
Bailowitz, Z., Grams, R., Teeple, D., & Hew‐Butler, T. (2016) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000344 · Cited by 18 · see citing works
Seizure Disorder in a Professional American Football Player
Dimeff, R. J. (2006) · Current Sports Medicine Reports · doi:10.1097/01.csmr.0000306502.32987.57 · Cited by 16 · see citing works
In Reply to Clinical Practice Guidelines for Treatment of Exercise-Associated Hyponatremia
Bennett, B. L., Hew‐Butler, T., Hoffman, M. D., Rogers, I. R., & Rosner, M. H. (2013) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2013.06.004 · Cited by 16 · see citing works
Exercise-Associated Hyponatremic Encephalopathy in an Endurance Open Water Swimmer
Rogers, I. R., Grainger, S., & Nagree, Y. (2014) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2014.07.010 · Cited by 15 · see citing works
Symptomatic Hypotonic Hyponatremia Presenting at High Altitude
Spano, S. J., Reagle, Z., & Evans, T. (2014) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2013.09.014 · Cited by 15 · see citing works
Hiker fatality from severe hyponatremia in Grand Canyon National Park
Myers, T. M., & Hoffman, M. D. (2015) · Wilderness & Environmental Medicine · doi:10.1016/j.wem.2015.03.001 · Cited by 15 · see citing works
Avoid adding insult to injury - correct management of sick female endurance athletes
Hew‐Butler, T., Boulter, J., Bhorat, R., & Noakes, T. D. (2012) · South African Medical Journal · doi:10.7196/samj.6156 · Cited by 15 · see citing works
Three Cases of Severe Hyponatremia During a River Run in Grand Canyon National Park
Pearce, E. A., Myers, T. M., & Hoffman, M. D. (2015) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2014.08.007 · Cited by 13 · see citing works
Exercise-Associated Hyponatremia in an Ultra-Endurance Mountain Biker
Khodaee, M., Luyten, D., & Hew‐Butler, T. (2013) · Sports Health A Multidisciplinary Approach · doi:10.1177/1941738113480928 · Cited by 13 · see citing works
Hoffman, M. D., Cotter, J. D., Goulet, E. D. B., & Laursen, P. B. (2016) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2016.04.004 · Cited by 9 · see citing works
Hoffman, M. D., & Myers, T. M. (2015) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2014.12.024 · Cited by 7 · see citing works
Is Postevent Intravenous Hydration an Appropriate Service at Endurance Competitions?
Hoffman, M. D., Hew‐Butler, T., Roberts, W. O., Rogers, I. R., & Rosner, M. H. (2016) · Wilderness and Environmental Medicine · doi:10.1016/j.wem.2015.12.014 · Cited by 5 · see citing works
Tseng, C.-H., & Chiu, W. (2014) · The American Journal of Emergency Medicine · doi:10.1016/j.ajem.2013.12.039 · Cited by 4 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Role of Functional Beverages on Sport Performance and Recovery
Orrù, S., Imperlini, E., Nigro, E., Alfieri, A., Cevenini, A., Polito, R., Daniele, A., Buono, P., & Mancini, A. (2018) · Nutrients · doi:10.3390/nu10101470 · Cited by 100 · see citing works
“What experts do agree on is that for most people just drinking water is sufficient to rehydrate [6,12].”
BackgroundConsiderations for ultra-endurance activities: part 2 – hydration
Hoffman, M. D., Stellingwerff, T., & Costa, R. J. S. (2018) · Research in Sports Medicine · doi:10.1080/15438627.2018.1502189 · Cited by 83 · see citing works
Martínez-Sanz, J. M., Fernández Nuñez, A., Sospedra, I., Martínez-Rodríguez, A., Domínguez, R., González-Jurado, J. A., & Sánchez-Oliver, A. J. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17114082 · Cited by 25 · see citing works
“However, it should be noted that in some environments overhydration is almost as frequent, being a key stimulus for the development of symptomatic hyponatremia associated with exercise (EAH) [11], which in some endurance and ultra-endurance competitions has affected as many as 30% of the participants [12].”
BackgroundCurrent Trends in Ultramarathon Running
Spittler, J., & Oberle, L. (2019) · Current Sports Medicine Reports · doi:10.1249/jsr.0000000000000654 · Cited by 26 · see citing works
Running economy and energy cost of running with backpacks
Scheer, V., Cramer, L., & Heitkamp, H. (2019) · The Journal of Sports Medicine and Physical Fitness · doi:10.23736/s0022-4707.18.08407-4 · Cited by 15 · see citing works
Masodsai, K., Sahaschot, T., & chaunchaiyakul, R. C. (2022) · Sports · doi:10.3390/sports11010004 · Cited by 7 · see citing works
“The formulas can be designed according to the sports context: for example, to hydrate athletes, to restore energy, to improve circulation, and more recently, to improve mental focus and/or to prevent post-exercise muscle and joint pain [32,33].”
BackgroundComparison of Natural Mineral Water From Agrı Province With Sports Drinks
Çağıran, İ. H., YILMAZ, D. A., Atay, M. E., & Dege, G. (2023) · Akdeniz Spor Bilimleri Dergisi · doi:10.38021/asbid.1161264 · Cited by 5 · see citing works
Hoffman, M. D. (2018) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2018.10.026 · Cited by 4 · see citing works
Die belastungsassoziierte Hyponatriämie im Ausdauersport
Knechtle, B., Chlíbková, D., & Nikolaidis, P. Τ. (2019) · Praxis · doi:10.1024/1661-8157/a003261 · Cited by 4 · see citing works
Importance of Sports Drinks as a Performance Prerequisites
Halder, S., & Daw, S. (2021) · Senhri Journal of Multidisciplinary Studies · doi:10.36110/sjms.2020.05.02.002 · Cited by 5 · see citing works
“Therefore these sports beverages are processed to encourage our energy systems, mental focus, immune system and reduces joint pain (Hoffman et al., 2017).”
BackgroundPapaoikonomou, G., Kandyliari, A., Vlassopoulos, A., Malisova, O., & Koutelidakis, A. Ε. (2025) · Nutrients · doi:10.3390/nu17061078 · Cited by 3 · see citing works
“Thus, whether functional foods act by promoting a faster recovery through anti-inflammatory properties or bolstering endurance with energy-dense components, their strategic incorporation into an athlete’s diet can have a profound impact on their overall performance [28].”
Functional Nutritional Strategies for Peak Athletic Performance
Can, S., & Can, H. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-8699-6.ch001 · Cited by 1 · see citing works
Comment on “Drinking Strategies: Planned Drinking Versus Drinking to Thirst”
Hoffman, M. D. (2018) · Sports Medicine · doi:10.1007/s40279-018-1026-x · Cited by 1 · see citing works
Commercialised portable intravenous fluids in sports: placing vulnerable athletes at risk
Khodaee, M., Changstrom, B. G., & Hoffman, M. D. (2018) · British Journal of Sports Medicine · doi:10.1136/bjsports-2018-099855
- Authors
- Hoffman, M. D., Joslin, J., & Rogers, I. R.
- Affiliations
- SUNY Upstate Medical University (US)
- Corresponding author
- Hoffman, Martin D.
- Venue
- Current Sports Medicine Reports
- Published
- 2017-03
- Volume
- 16
- Issue
- 2
- Pages
- 98-102
- ISSN
- 1537-890X (ISSN-L)
- 1537-8918
- OpenAlex
- W2593446608
- Cited by
- 14
- References
- 49
- Citations by year
- 2025: 2 · 2023: 1 · 2022: 1 · 2021: 1 · 2020: 1 · 2019: 3 · 2018: 5
- FWCI
- 0.30
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Current Sports Medicine Reports (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Physiology › Thermoregulation and physiological responses
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Electrolyte and hormonal disorders
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › High Altitude and Hypoxia
- Keywords
- exercise-associated hyponatremia, dehydration, fluid balance, oral rehydration therapy, intravenous rehydration, fluid restriction, orthostatic intolerance, hyponatremic encephalopathy, hydration assessment
- MeSH terms
- Dehydration, Fluid Therapy, Humans, Isotonic Solutions, Saline Solution, Hypertonic, Water-Electrolyte Balance, Wilderness Medicine, Wilderness, Athletes
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
