Author: Dr. Spencer Lindholm
“If your training and preparation is just as rigorous as every other athlete than it truly comes down to who can recover smarter, faster, and stay injury-free the longest.”
As a sports injury chiropractor specializing in soft tissue injuries I have had the opportunity to treat countless CrossFit athletes including close to a dozen regional or games level athletes and many member of the Dark Horse Performance team. The goal of this article is to provide information regarding the most common CrossFit injuries observed in practice and a brief analysis of causes, prevention strategies, and treatment options.
First off, let’s be clear regarding the stigma associated with CrossFit injury rates: There is no evidence to suggest that CrossFit or strength and conditioning as a whole provides an inherently increased risk of injury. CrossFit has gotten an extremely bad rap for causing a high number of injuries, especially in the “early” years of CrossFit. However, these claims are purely anecdotal with no supporting research to suggest that CrossFit is more dangerous than other common sports. Although studies of injury rates can vary widely, the average results of comprehensive studies show that around 20% of CrossFit athletes experience some form of injury throughout a single year. That percentage pales in comparison to the over 60% injury rate associated with running. Yes, you read that right. A largely single plane movement such as running has a 3x increased risk of injury compared to the constantly varied and multi-faceted sport of CrossFit. Furthermore, the vast majority of injuries are likely preventable with proper assessment, programming, coaching, and recovery strategies.
Regardless of whether CrossFit has higher or lower injury rates than other sports, it still appears that 1-in-5 athletes will sustain some type of injury throughout their training year. Injuries inevitably occur with any fitness regimen and the goal of every athlete and coach should be to minimize risk with proper prevention strategies and rehabilitation protocols. Not surprisingly, due to the highly repetitive nature of CrossFit training, many of the injuries that do occur are repetitive overuse injuries resulting in tendinopathies or strained muscles. In order to be able to understand how to prevent and treat injuries properly, let’s take a look at some of the most commonly observed injuries associated with CrossFit training.
- Rotator Cuff Tendinopathy/Impingement Syndrome
The rotator cuff is a group of tendons and muscles in the shoulder that help provide stability to the shoulder joint and assist in rotational movements of the humerus. Injuries to the rotator cuff group most commonly occur from repetitive overuse injuries or acute trauma. Since the rotator cuff is a primary stabilizer of the shoulder joint, especially with overhead movements, injury to this group of muscles may lead to impingement syndrome. Impingement syndrome is most often caused by injury or weakness of the rotator cuff musculature. The resulting inability of the rotator cuff to properly stabilize the head of the humerus in the shoulder socket when the arm is raised causes pain and weakness when a tendon is “pinched” or impinged. Shoulder injuries such as rotator cuff tendinitis are more common in CrossFit due to the high volume of olympic lifts, gymnastics, and other complex movements. More specifically, high repetition pull-ups and overhead pressing movements most often result in a strain of the rotator cuff musculature which leads to rotator cuff tendinopathy and resultant impingement syndrome. The best prevention strategies involve strengthening the muscles of the rotator cuff with exercises like crossover symmetry and focusing specifically on internal/external rotation exercises. Restricted shoulder range of motion (ROM), especially forward flexion and external rotation, can also place increased stress on the rotator cuff. Following a shoulder MobilityWOD program to address these restrictions can be a beneficial prevention strategy as well. As with all movements in the gym there should be a formal assessment of technique and mechanics as well as proper progression implemented to minimize the risk of injury.
- Medial Epicondylagia (Golfer’s Elbow)
Injury to the flexor tendons of the forearm which results in pain and discomfort at the medial (inside) elbow is referred to as medial epicondylagia, or more commonly, golfer’s elbow. The flexor tendons of the forearm, wrist and hand originate at the medial elbow and end in the hand. Their function is to flex the wrist, hand and fingers as well as function in gripping. This condition gets the name “golfer’s elbow” due to its prominence in golf from high repetition of flexion and gripping. CrossFit involves not only a lot of gripping various objects (barbells, kettlebells, rings, gymnastics bars, etc.), but also involves a lot of strength with pressing exercises which utilizes the strength and endurance of the forearm flexor muscles. This condition typically results in pain, weakness, tightness and dysfunction in the affected muscles. Repetitive overuse injuries such as medial epicondylagia typically occur when either there is a high amount of force utilized or a high amount of repetitions. In this case, CrossFit happens to demand a significant amount of both high repetitions and high force production, making injury to the forearm muscles particularly common. Avoidance of such injuries is best accomplished by not progressing too rapidly as the tendons need time to adapt and strengthen to the stimulus of increased force and time under tension. Focusing on wrist and elbow extension mobility can help greatly as these muscles tend to get reactively tight very quickly and extremely taut fibers do not have the same force production or ability to handle increased work capacity as mobile and relaxed tissues.
- Low Back Pain
Due to the amount of Olympic and powerlifting present in CrossFit there is a large amount of compressive load being placed on the spine. This can result in simple mechanical low back pain or slightly more complicated disc injuries. Additionally, CrossFit involves a lot of exercises which place the spine in flexion under load or high tension. Performing these exercises such as deadlifts and toes-to-bar at heavy weights or high repetitions can take a toll on the back and sometimes result in injury. Most back injuries occur from poor technique and lifting mechanics as well as a lack of core stability. Low back pain is not as simple as some of the tendinopathies discussed in this article and could be caused by a plethora of different injured tissues including muscles, joints, discs, nerves, or even biomechanical abnormalities such as abnormally tight/weak hip flexors or glutes. Spending the proper amount of time assessing and correcting technique and mechanics can hold irreplaceable dividends in both injury prevention and performance enhancement moving forward.
- Achilles Tendinitis
As previously discussed, tendinitis is most commonly caused from repetitive overuse with high amounts of repetitions and high load placed on the muscle. The achilles tendon is what attaches your calf muscle at the base of the heal and its function is to plantarflex or push the foot downward. CrossFit involves many exercises that involve this motion with either high repetition or force such as box jumps, double-unders, running, sled pushes, wall balls and many other exercises. Extremely tight calves are often a culprit of achilles tendinitis along with repetitive overuse and high volume with CrossFit. If left untreated this type of injury can lead to other issues like plantar fasciitis. Focusing on calf stretching coupled with ankle flexion/extension mobility exercises can help greatly with injury prevention.
- Patellar Tendinitis (Runner’s knee)
The patellar tendon is what attaches your quadriceps muscles at the knee joint just below your knee cap and the primary function involves knee extension. This means that the quadriceps muscles are being used and the patellar tendon is being placed under stress almost every time a CrossFit athlete performs a squat, deadlift, box jump, wall ball, kettlebell swing, burpee, or almost any other movement you can name within the CrossFit or strength and conditioning. Due to the need to use this muscle with the majority of exercises it may be heavily overworked and result in a repetitive overuse injury. A common pattern identified involves over-recruitment of the vastus lateralis (outside quad muscle) which can result in abnormal tracking or pulling of the patellar tendon. Spending the proper amount of time stretching and mobilizing the quads as well as putting increased focus on the lateral quad can be an extremely effective prevention strategy.
Many of these injuries can be avoided by sticking to CrossFit’s mantra of “mechanics, consistency, intensity” as well as avoiding overtraining and spending time on recovery. All aspects of prevention and recovery need to be analyzed and given attention including proper injury treatment, mobility, hydration, sleep and nutrition. The majority of injuries, especially repetitive overuse injuries, can be avoided by practicing proper lifting mechanics, warming up properly, performing the necessary stability/strengthening exercises, and listening to your body when the signs and symptoms of an injury begin to rear their ugly head. I’m sure that it is very evident that the majority of injuries with CrossFit or strength and conditioning involve tendinopathies or repetitive overuse injuries. Finding the right coach for your goals with appropriate programming is crucial for injury prevention and to avoid simple overuse injuries. Assessing mobility and stability to determine which area you’re deficient is necessary for developing a proper prevention strategy as well as finding the right treatment option.
In the unfortunate circumstance that an injury does happen, there are lots of great treatment options available to most people. Many athletes express discontent with finding the right treatment option and even just knowing who to see or where to go. If it is an emergency or life-threatening injury, 911 should be called immediately. However, the vast majority of injuries are not emergencies and require rehab or therapy to properly treat the injury. The best providers to see for the types of injuries discussed in this article are a sports injury chiropractor, physical therapist, or acupuncturist. A referral for orthopedic assessment may be a necessary option as well. As far as the type of treatment modalities, there are some great options available. Injuries to muscles, tendons, and joints can be treated with evidence-based protocols such as Active Release Technique (ART), chiropractic manipulation, instrument assisted soft tissue mobilization (IASTM), Muscle Activation Technique (MAT), dry needling/acupuncture, kinesiology taping, and specific physical therapy stretching and exercise protocols. There are also some great preventative or recovery options that I recommend such as Whole Body Cryotherapy (WBC), LED therapy, compex stim units, normatec recovery boots, float therapy, and sports massage.
Have questions or concerns regarding injury prevention or treatment? Feel free to contact me at [email protected]. Stay tuned for future athletic injury content regarding in-depth analysis, prevention, and treatment strategies for different regions of the body. Want more information on finding a great coach and appropriate programming to meet your athletic goals and recovery? Follow the link below.