CrossFit is a popular high intensity training program combining weightlifting, gymnastics and aerobic training. Concerns about high intensity conditioning such as CrossFit involve the perception that there is an increased risk of musculoskeletal injury from these demanding programs. A recent review in the Journal of Sport Rehabilitation reported that incidences of injuries associated with CrossFit training programs were comparable or lower than rates of injury in Olympic weightlifting, distance running, track and field, rugby, or gymnastics.
Whilst acute injuries do occur in CrossFit, particularly at the elite level during competition, as with any other sport, chronic, insidious overuse injuries are far more common, especially in people who use CrossFit as a recreational training method rather than a competitive sport.
Studies looking at injury patterns among CrossFit athletes have found the most common upper body part injured in CrossFit is the shoulder. The majority of injuries are caused by overuse.
Most CrossFit workouts are in the anterior (front) or overhead plane and shoulder problems may stem from a muscle imbalance between muscles at the front of the shoulder that are heavily used and muscles at the back of the shoulder that are used far less often.
People who experience shoulder pain when kipping (such as kipping pull ups or handstand push ups) but are pain-free when performing the same strict movement, are more likely to have pain from shoulder impingement. Internal impingement develops due to humeral head malpositioning in the glenoid (the ball of the shoulder joint doesn’t sit in the centre of the socket) with poor scapulohumeral rhythm secondary to muscle bulk imbalance.
The shoulder joint
The shoulder joint complex relies on correct positioning of both the shoulder blade on the chest wall and the shoulder joint itself, as well as coordinated contraction of the muscles stabilising both the scapula (shoulder blade) and the shoulder joint. Strong, tight anterior muscles pulling against weaker scapular stabilisers can lead to the pain of functional impingement, which might be the athlete’s problem rather than a structural injury to the shoulder joint.
Avoidance of aggravating activities in the short term and assessment by a physiotherapist or Sport and Exercise Physician, ideally one familiar with CrossFit, for a structured rehabilitation program with targeted soft tissue strengthening and stretching are warranted for any pain lasting longer than 1-2 weeks.
More often than not in CrossFit injuries, chronic activity related pain stems from a dysfunction within the kinetic chain and management needs to address all possible deficiencies in the chain, not just the area of pain. Shoulder pain may be related to scapular dyskinesis, cervical and thoracic spine dysfunction and restriction, and poor core stability.
The important thing to note is that any CrossFit enthusiast presenting with pain during movement does need to have their injury assessed and managed but concurrently there are still many things they will be able to continue to do in the meantime, so that they can still fulfill their activity goals whilst addressing their problem.
Shoulder pain case study
- A recreational CrossFitter who enjoys participating in CrossFit classes 6 days a week presents with shoulder pain during overhead activities
- A thorough history and examination is performed to assess for common causes of shoulder pain such as glenohumeral instability (subluxing or dislocating shoulder), rotator cuff dysfunction or tear, AC joint injury or frozen shoulder (see shoulder injuries for more details on these conditions)
- Further investigations such as x-rays or MRI may be indicated to rule in or out specific structural pathology after considering the clinical information from the history and physical examination but are not always needed
- Often a clearly identified injured structure is NOT found in people presenting with pain during CrossFit movements (which is a good thing), but this is also when many are mistakenly told to rest until the pain goes away
- The problem with resting to fix a pain is that it never really goes away and when the person returns to the same activity that caused their pain, the pain returns too
In order for something to change, you need to change something!
- Specific to the shoulder, factors such as altered scapular muscle recruitment patterns and muscle endurance and performance as well as flexibility deficits in the surrounding soft tissues may restrict normal scapular movement and lead to shoulder or neck pain with certain overhead activities
- In the initial stages of pain, there is a redistribution of activity within and between muscles – this may have the short term benefit of protection from further pain and injury but if the activity continues, the long term problem of adverse mechanical consequences to pain sensitive tissues develops
- Unfortunately athletes often don’t present in the initial stages of injury and wait until their pain impacts their ability to continue to train before seeking help
- At this later stage, the athlete is likely to need to refrain from overhead activities such as snatch, overhead press and jerk movements as well as pull ups and hanging from the rings, but may easily be able to substitute these movements with squats, deadlifts, sit ups and rowing (a favourable movement for most anterior shoulder pain) to continue their training while their pain is being investigated and managed
- The art in managing these conditions is to work out what muscles are weak and need strengthening, which ones are short and need lengthening and what accessory exercises are needed initially to re-establish correct neuromuscular activation and coordinated movement patterns
- This requires skill from the assessor and diligence from the athlete but the athlete should be able to return to full pain free movements if they put the work in and are guided through a graduated and progressive, CrossFit specific rehabilitation program – at the end of the day, exercise is medicine!