*Exercise, in general, is good for you!
As a shoulder and sports medicine orthopaedic surgeon who does Crossfit four days a week, I am frequently asked if I feel like a hypocrite for doing something on a regular basis that commonly causes the very injuries I treat at work. I tend to answer something to the effect of “Yes, a little.” But then I expound on that admission by noting that I firmly believe that exercise is way better than no exercise and that anything can be dangerous if you don’t know what you’re doing, you’re not prepared for your task, or you are fatigued mentally and/or physically and you end up making poor choices as a result.
Dr. Jurek working hard outside of work
With those caveats in mind, there are certain injuries that tend to occur in Crossfit athletes. Here’s some general injury information and additional specific information on how to spot them.
When I see a patient in my clinic, I take his or her history, perform a physical exam, and frequently get imaging of the injured body part. I am first and foremost looking for what I think of as “red flag findings” – components of the history, imaging, or physical exam that cue me in to the possibility that a serious injury has occurred. Injuries with red flag findings typically present as sudden injuries where the athlete was completely fine and then suddenly wasn’t. A “pop” may have been heard and/or felt. At the time of the injury, there was a sudden inability to move or use the affected body part without extreme discomfort. Swelling typically occurs quickly. I frequently see patients with these stories who have persistent symptoms a couple of weeks out from their injury; I especially worry if their severe pain and disability has persisted despite rest and elevation and if they are having a hard time sleeping because of the pain. If you fall into this category after an injury, I highly recommend you see your health care provider to get checked out.
The most frequent injuries in Crossfit fall into the category of “overuse injuries.” These, too, can cause significant pain and disability, but they usually occur gradually over time. Typically, no one specific event or injury stands out to the patient; the pain and weakness just showed up and have not improved. Based upon my personal observation, the most frequently injured body part in terms of overuse Crossfit injury is the shoulder by far. Back pain/injury and knee injuries are next on the list.
Most Crossfit shoulder injuries involve irritation due to repetitive stress of the rotator cuff tendons, the biceps tendon, and the supportive ligaments of the shoulder. The shoulder joint is the most complex (and best :)) joint in the body with a lot of important structures that must all function perfectly together to work well without pain. If there is irritation or inflammation in the shoulder, this tends to set off a cascade of trouble that can result in persistent symptoms. Commonly, repetitive overhead lifting activities result in irritation and inflammation of the rotator cuff tendons (rotator cuff tendinitis or tendinopathy), irritation and inflammation of the bursa overlying the rotator cuff (subacromial bursitis), or a combination of the two. The biceps tendon is a structure separate from the rotator cuff that loves getting irritated with exercises common in Crossfit. Pull-ups, especially kipping ones, overhead squats, snatches, and shoulder-to-overhead moves like push presses can all irritate this tendon and cause persistent pain in the front of the shoulder. When any one of these conditions occur, the small muscles of the shoulder who have the responsibility of making the ball move perfectly within the socket sometimes fail to do so and even more pain occurs; this is termed “impingement syndrome.”
Sometimes the shoulder injury goes further than inflammation and is a tear of one of the structures. The rotator cuff tendons can tear away from their insertions into the bone (rotator cuff tear) and the labrum, which is a ring of cartilage that deepens the cup of the shoulder and helps provide stability can detach from the cup (labral tear or SLAP tear). These tears can occur suddenly with a major injury or gradually over time as an accumulation of repetitive trauma.
Sometimes the inflammation is associated with structural changes of the shoulder joint, resulting in wearing away of the cartilage over each surface of the bone, the formation of bone spurs, and eventually even reshaping or wearing away of the bony surfaces of the joint. Both the ball and socket joint of the shoulder (glenohumeral osteoarthritis) or the smaller joint between the collarbone and the lateral edge of the shoulder (AC joint arthritis) can be affected. This is usually determined by looking at an X-ray.
Back pain or injury in Crossfit is also typically an overuse problem but the sudden onset of severe back pain can occur and needs to be assessed by your health care provider. Muscle strain, inflammation of the supporting ligaments of the spine, irritation of the discs between the vertebrae, and inflammation surrounding the small nerves exiting the spinal cord are all sources of back discomfort. Typically icing, active rest, and physical therapy/directed home exercise are the initial treatments of choice for pain that has come on gradually without a sudden severe injury.
Crossfit knee injuries generally fall into the overuse category and respond well to activity modification (going lighter on squats, modifying or avoiding lunges or one-legged exercises such as pistols), ice, elevation, and compression. Although Crossfit does not generally involve a lot of agility movements (lateral, pivoting, or cutting motions), common Crossfit exercises like running, box jumps, double-unders, and squatting can all result in an injury to the cartilage of the knee most commonly seen in agility movements called a meniscus tear. This typically manifests as a focal, sharp pain in either the inside or outside part of the knee that occurs most frequently with twisting or flexion movements of the knee. Taking a break from exacerbating activities for a week or two is reasonable, but if these symptoms persist, it is best to seek evaluation with your health care provider.
There are a few other injuries that, while rare in general, tend to occur in the Crossfit population a little more frequently. Achilles tendon ruptures present suddenly and usually with a loud pop and a sharp pain in the back of the ankle. The history usually includes a variant of “I thought someone hit me in the back of the ankle with a baseball bat.” Bounding box jumps are the most common cause of this injury and modifying box jump technique to include pausing at the bottom before jumping back on top of the box will reduce the risk of this injury. Distal biceps tendon ruptures at the elbow where the tendon tears from its insertion into the upper forearm occur when a sudden and sometimes unexpected force is applied to a flexed elbow, causing the elbow to extend against resistance. Again, a pop is typically felt and/or heard in the elbow and the contour of the biceps muscle appears different than the unaffected side. Both Achilles and distal biceps tendon ruptures are typically treated with surgery, especially in active patients, and if you suspect you may have one of these injury, seek medical evaluation sooner rather than later.
My parting thoughts on Crossfit are these: Crossfit is neither safer nor more dangerous than any other fitness or workout option as long as you make safe choices. Loading up the barbell before you are well-versed in lifting technique, trying to keep up with your friend who has been doing Crossfit for five years and you just started three weeks ago, ignoring pain or limitations in your range of motion for the sake of completing a workout “as prescribed/Rx” all set you up for the likelihood of sustaining an injury. My advice: build up slowly and work within your abilities while striving to get a little better each day. Enjoy the endorphins and happiness that accompany getting sweaty and elevating your heart rate, developing your strength and endurance, and growing healthier with each workout. Injury is not a foregone conclusion with Crossfitting as long as you make smart workout decisions.
About Dr. Jurek:
Dr. Jurek is a board-certified orthopaedic surgeon who specializes in shoulder surgery and sports medicine surgery. In the OR, she enjoys repairing torn rotator cuff tendons (and all other tendons really), performing shoulder replacements, and fixing broken bones. She loves Crossfit but also enjoys dabbling in running, mountain unicycling, slacklining, surfing, and snowboarding. You can find her starting most of her mornings with a 5am workout at Rocket Crossfit in Seattle. Currently she is injury-free :).
Sara Jurek, MD