Key Insights On Managing CrossFit Injuries

Given that the CrossFit program can be more intense than a regular workout, are participants at a greater risk for injury? These authors provide a look at the workouts the athletes experience, the CrossFit culture and the literature on injuries.

CrossFit high intensity and highly technical workouts have exploded in popularity in the last three years with thousands of facilities in the United States. The sport consists of constantly varied functional movements performed at relatively high intensity, usually in a group setting. These workouts are short, intense and constantly changing. CrossFit pushes athletes to go as hard and as fast as possible, stressing the body to its limits.

CrossFit is a specific type of workout based on Workout of the Day routines (WODs). These WODs typically fall into two categories: complete the prescribed workout in as little time as possible or complete as many repetitions of the prescribed exercises as you can in a given amount of time. The Workouts of the Day typically take advantage of a concept known as muscle confusion, which is a form of training that employs several variations in exercise intensity during a single session with the goal of stressing different metabolic pathways. It is a form of high intensity interval training that in theory offers improvements in aerobic fitness with minimal time commitment in comparison to traditional aerobic training.

The typical CrossFit participant is unique, intense, dedicated, skeptical and superstitious. This participant is also knowledgeable about his or her health, well being and nutrition. This participant does not want to stop his or her workouts. This attitude definitely plays into the treatment course, recovery and rehabilitation of the injury.

Accordingly, one should consider these patients’ use of the theory of “relative rest.” The treating podiatrist must help patients modify certain types of their CrossFit workouts. This is the basis for the treatment of all injuries whether acute or chronic, especially in this population of the injured CrossFit athlete. Treatment is all about the cause and not the symptom.

Initially, one should perform a “functional screen,” which is a series of simple parameters to evaluate the injury itself, muscle and joint imbalance, weakness and compensation associated with the injury. Clinicians then establish a diagnosis and can initiate a specific treatment plan. Magnetic resonance images, X-ray, dynamic ultrasound are adjunctive diagnostic tools to assist in this functional screen.

CrossFit training is based on the following:

1. Major lifts (i.e. deadlift, clean, squat, press, clean and jerk, and snatch)
2. Basic gymnastics (pull-ups, pushups, sit-ups, handstands)
3. Biking, running, rowing and swimming
4. Five to six days of work per week in varying combinations

These workouts are not typical of anything athletes have experienced in the past. The typical CrossFit gym or box does not have the typical machines to isolate muscles, stationary bikes, power bars or cases of powders to make you build muscle. The gyms have different equipment, rubber mats, barbells, plates, kettlebells, medicine balls, jumping rope and rowing machines. Specifically, the workouts include constantly varied functional movements modified to meet the individual capacities of the participant. The participant is timed when performing specific exercise at or near maximum physical exertion. Many police academies, tactical operations, professional sports teams as well as laypeople have adapted this type of workout.

CrossFit specifically utilizes three different standards or models for evaluating and guiding fitness. Collectively, these three standards define the level of fitness through the eyes of a CrossFit viewpoint only. The first is based on 10 general physical skills widely recognized by an exercise physiologist. These 10 skills are cardiovascular endurance, stamina, strength, power, flexibility, speed, coordination, agility, balance and accuracy. The second standard is based on performance of the athletic tasks. The third standard is based on energy systems that drive the human body.

The CrossFit methodology also leans heavily on the “zone diet” with its recommended intake of 40 percent carbohydrates, 30 percent protein and 30 percent fat. In interviews with CrossFit affiliates, this is a cornerstone of the lifestyle.

Who Is The Typical CrossFit Patient?

CrossFit athletes tend to be extremely competitive. These patients are commonly former college and professional athletes, fitness enthusiasts, current and ex-military personnel as well as law enforcement officers. One of our biggest challenges is getting these patients to remain inactive to allow their bodies to recover. This is typically not in their nature.

Earlier this summer, the senior author treated a CrossFit athlete who suffered a fifth metatarsal shaft fracture while jumping during one of her workouts. In sitting down with the patient, he reviewed her X-rays, explained the nature of her injury and discussed the need for immobilization. The senior author spent the next 15 minutes of the office visit shooting down every possible scenario as to how she could continue to participate in CrossFit workouts while in her cast. She was compliant for about the first month until the senior author transitioned her to a controlled ankle motion (CAM) boot.

At each subsequent visit, she would let it slip that even though she remained on crutches the majority of time, she was gradually starting to work out including swimming and cycling out of her boot. As one would expect, she noticed increased pain levels during these activities but she pushed through the pain and completed her workouts. This is the mindset of a typical CrossFit patient.

How Intense Is CrossFit?

CrossFit takes high intensity interval training to another level. In a typical high intensity interval training regimen, participants perform the exercises with their own body weight. CrossFit incorporates high intensity interval training principles with additional weight and often times complex full body Olympic lifts and other various activities. The goal of CrossFit is unique in that the regimen is designed to achieve functional fitness. Unlike bodybuilding in which pure size and definition are the goals or endurance training in which distance and time are the goals, CrossFit is designed to prepare individuals for any type of fitness task put in front of them.

The high intensity nature of CrossFit training may improve overall fitness, particularly in people of moderate fitness capacity. Traditional CrossFit workouts may not be for older individuals or those who have had previous injuries. It is critical to scale each workout to the individual’s fitness levels and abilities. The overall CrossFit program must be targeted and have exercise appropriate to the participant’s physical ability. Otherwise, injuries may occur.

It is well known that many CrossFit participants have suffered from spine problems, torn rotator cuff injuries and overuse injuries with tendons.¹ We blame the actual nature of CrossFit training. These type of functional training/body weight exercise movements can aggravate old injuries. It is well documented in studies that working the CrossFit program will increase overall work capacity by an average of 20.3 percent. Work capacity may increase by as much as 24 percent with a six-week program.² Overall, though, there have been very limited studies with the CrossFit movement and the reporting of injury.

The lead author has found that many patients who practice CrossFit training state that practicing good technique, working around your weaknesses and staying within your limits will allow you to progress to a higher level of fitness without injury. This includes different cycles of increased workloads and periods of rest and recovery as well as an offseason and participation in other sports throughout the year. Athletes must establish consistency at a certain level of intensity before turning up the next level of intensity. If patients do not specifically address this, mental or physical burnout or injury can occur. Overdoing it with the amount of repetitions, the difficulty of the workout and/or the intensity of the workout can cause injury or decline in the potential progressive functional fitness level.

What Are The Benefits Of CrossFit?

CrossFit can be fun for athletes. Traditionally, exercise has been solo proposition. Slugging it out alone in the gym or doing mile after mile on the road can become tedious. CrossFit has done a fabulous job of creating a team atmosphere in its gyms or boxes. It can be a very warm and welcoming environment for people, even those who have never stepped foot in a gym.

CrossFit has helped to bring hard work back into training. For years, exercise was, for many, limited to seated exercise stations and leisurely strolls on a treadmill. Accordingly, most exercisers got very little benefit. CrossFit, along with products like P90X, reintroduced the importance of giving effort in the gym. As a result, CrossFit participants like the results they get. Tools like barbells, pull-up bars and heavy ropes are now some of the most popular items in the gym.

For many, CrossFit works. Anecdotal studies are everywhere. Clinically, a 2012 study at the University of Wisconsin-Eau Claire found that a four-week CrossFit training program resulted in “statistically significant” improvements in endurance, strength and agility.³ A study at Ohio State University found that a 10 week CrossFit-based program improved maximal aerobic fitness and body composition.⁴

A Closer Look At The Potential Injury Risks

Despite its staggering growth and popularity worldwide, not everyone buys into the CrossFit hype. Many of the world’s top strength coaches and personal trainers are not only skeptical of the CrossFit product, but are absolutely hostile toward it. They cite evidence, both clinical and anecdotal, of high injury rates, overtraining and lack of functional carryover to sport.¹

CrossFit is a very demanding, technical skill-based activity that requires excellent instruction and practice to perfect. CrossFit participants depend upon their certified trainers to teach them the skills required to execute highly technical lifts such as the deadlift and clean jerk. CrossFit trainers vary in knowledge and teaching skill so trainees must do their due diligence in assessing the competence of a trainer.

While there are no published studies of CrossFit injury rates, associations between injury potential with certain lifts and exercises performed frequently by CrossFitters are clear. Is participating in CrossFit any more dangerous than other activities? Until further study occurs, we can draw no conclusions.

There seems to be no standardized screening process, such as the Functional Movement System (FMS) or the Selective Functional Movement Assessment (SFMA), to determine a prospective CrossFitter’s capabilities to perform the required movements. As a result, the athletes may face undue risk of injury caused by facing challenges for which they are not prepared.

The demands of CrossFit yield a wealth of foot and ankle pathology. As the popularity of the sport continues to grow, we will all see these patients in our office more frequently. Since CrossFit is an intense activity, the concept of recovery is critical. Since there is a random nature to the workouts, there may not be adequate recovery periods. Patients go through workouts that involve technically complex lifts during a fatigue state. In this situation, athletes often sacrifice proper form in order to push through those last couple of reps before time runs out. When form breaks down, injuries occur.

In our practice, we commonly see Achilles and peroneal tendinopathy, stress fractures, acute fractures and plantar fasciitis in our CrossFit patients. In addition, we see compensatory injuries as these athletes are often pushing through other chronic injuries. The majority of these injuries are rarely surgical in nature but typically require some form of immobilization, rest and sometimes aggressive physical therapy. As physicians, especially those of us who specialize in sports medicine, we often try to find ways to keep athletes playing through injuries.

The Risks Of Rhabdomyolysis: What You Should Know

More concerning is the risk of rhabdomyolysis. The very nature of CrossFit and its culture places these athletes at risk, so much so that CrossFit enthusiasts have even created a cartoon character called “Uncle Rhabdo.”⁵ As the sport gains popularity, there are reports of more and more cases of this life-threatening condition.5 It can occur after athletes overexert themselves to the point of muscle death.

Rhabdomyolysis literally means striated muscle dissolution or disintegration. As a result, dead muscle proteins such as myoglobin leak into blood circulation with potentially serious effects. Initially, patients can experience extreme hyperkalemia, resulting in arrhythmia and cardiac arrest. These dead muscle proteins can subsequently result in acute renal failure and ultimately kidney death. The condition can be fatal. In some cases, patients can also develop compartment syndrome. As physicians, we should ensure that our patients are aware of this potentially serious complication and educate them accordingly.

One major challenge is that the local symptoms of rhabdomyolysis include muscle pain, tenderness, swelling, bruising and weakness. These symptoms commonly occur after any type of strenuous workout, especially CrossFit, so most patients with exercise-induced rhabdomyolysis do not even know something is wrong until they are in serious trouble.

What Do The Studies Say Regarding CrossFit Injuries?

It is also important to emphasize that all sports, not just CrossFit, have serious risks. There is now emerging data on the long-term effects of traumatic brain injuries in contact sports such as football and hockey. Basketball players are plagued with shoulder, knee and ankle injuries. We are also seeing a dramatic increase in the year-round, single-sport athlete, especially in youth sports. These athletes are also more prone to injury.

One advantage of CrossFit is that it constantly varies the fitness activity, preparing the body for any fitness challenge thrown its way. Common sense would dictate that CrossFit patients are at a higher risk for injury but are these athletes at a higher risk than those in other sports? This has yet to be studied. 

Currently, literature specific to the CrossFit athlete is scarce. There are no prospective randomized controlled trials specific to the sport. Does CrossFit increase endurance and improve overall fitness in comparison to a more traditional fitness regimen? Do the risks of CrossFit outweigh the benefits? These questions have yet to be answered.

In 2012, Beilke and colleagues examined the effects CrossFit training on overall power, agility, speed, muscular endurance, strength and body composition in young athletes.³ They examined 19 patients between the ages of 19 and 25 over the course of a four-week period. Each of their CrossFit sessions consisted of a combination of plyometrics, gymnastics, functional movements, anaerobic intervals, sprinting, weightlifting and Olympic lifting. They found that a four-week Crossfit training program substantially improved sport performance, aerobic capacity, muscle endurance and muscle strength. This study, while showing overall improvement in fitness utilizing a CrossFit regimen, did not compare CrossFit to a more traditional fitness regimen.

Smith and coworkers examined the effects of a CrossFit-based high intensity program on aerobic fitness and body composition.⁶ They examined 43 people who represented all levels of aerobic fitness and body composition. They found that after a 10-week CrossFit regimen, there were significant improvements in VO₂ max (maximal aerobic capacity) as well as a decrease in body fat percentage. Again, this study only examined a CrossFit regimen and did not compare CrossFit to a more traditional fitness regimen.

Barfield and colleagues also studied the effects that a CrossFit-style workout had on overall fitness in college students.⁴ They compared fitness gains between a basic instruction lifting program in which participants performed a traditional lifting regimen after instruction on proper technique to a CrossFit lifting program. They examined 87 participants in four specific areas of fitness: body composition (body mass index), muscular strength, muscular endurance and muscular power. They found that while a CrossFit workout does increase overall fitness in comparison to unsupervised lifting programs, it may not yield the same benefits as a traditional supervised basic instruction lifting program. Although both regimens demonstrated trends in fitness improvement, the traditional basic instruction program outperformed the CrossFit group in each category.

Pertinent Pearls On Effective Shoes And Orthoses

Start with the shoe evaluation and make sure the athlete’s shoes are in excellent condition. Many times, CrossFit participants do not wear the appropriate shoe for the appropriate activity. Their shoes are extremely broken down since they favor one particular shoe that they have overused. The participant should have three different types of shoes: one pair for lifting, one pair for jumping and one pair for cardiovascular fitness. Due to the demands of CrossFit, all shoe gear must be secure and tied tightly. It is very common during the typical CrossFit workout that the laces of shoe gear become loose, contributing to potential injury. Athletes must check and retie the laces throughout the workout.

The appropriate choice of orthotic type is paramount. The orthotic device must address the functional aspects, structural aspects and needs of the individual as well as accommodating the shoes in use for all aspects of CrossFit training. The device must match perfectly in the arch. The orthotic must also address the injury. Athletes must be able to use the orthotic in all types of CrossFit training with lifting, jumping and cardio.

Other Keys To Treatment And Post-Injury Recovery For CrossFit Athletes

In our experience, the typical CrossFit athletes do not like oral medications such as anti-inflammatories, muscle relaxants or pain medications. At times, they prefer homeopathic or naturopathic medications. Many times, athletes use topicals such as diclofenac in the form of Solaraze (PharmaDerm), a Flector Patch (Pfizer) and Voltaren Gel (Endo Pharmaceuticals). These athletes commonly use custom compounded products that have a combination of muscle relaxant, analgesic, anesthesia and medications that increase blood flow. Athletes use these compounds three to five times per day and rub them in for 90 seconds per application for deep penetration. The physician can vary the percentage of components in these compounded products depending on the needs and response of the recovery in the post-injury period.

Physical therapy becomes a critical factor to augment the post-injury recovery. Active release technique (ART) and the Graston technique are in common use. Deep friction massage with topicals is common with range of motion exercises. Manual therapy, resistance exercises, foam roller use and the use of "The Stick" are common to mobilize the muscle and fascia structures that have been injured or have played a role in the injury. Acupuncture can also assist in the recovery and return to the CrossFit box.

CrossFit participants can’t wait to get back to unrestricted CrossFit activity. Strict adherence to the parameters established between the patient and the podiatrist must occur, and one must maintain and constantly reevaluate these parameters throughout the post-injury treatment period. These participants have a tendency to veer off the treatment plan, going up too quickly in the amount of workout activity and too intensely, causing setbacks. Due to the CrossFit workout routine(s) and the dedication of the participant, recurrence of the injury or setbacks are common. Again, keep in mind that we should treat the weakness and address the cause as opposed to treating symptoms.

In Conclusion

CrossFit can also be a dangerous proposition if one comes into training being significantly deconditioned, having significant movement dysfunctions and asymmetries, or having a lack of self-awareness that results in pushing oneself far beyond safe parameters.

CrossFit training and trainer quality vary significantly from box to box. We must counsel prospective trainees to do their due diligence before committing to a program.

Further research is needed regarding the safety and methodology of CrossFit. Any athletic activity entails a certain amount of risk and other recreational activities have very high rates of injury. Anecdotal evidence suggests that CrossFit does expose athletes to higher risk.

Dr. Romansky is a Fellow of the American College of Foot and Ankle Surgeons, and is a Diplomate of the American Board of Podiatric Surgery. He is the team podiatrist for the United States Olympic and World Cup Men's and Women's soccer teams. Dr. Romansky is in private practice in Media and Phoenixville, Pa.

Dr. Flannery is in private practice in Media and Phoenixville, Pa. He specializes in reconstructive surgery of the foot and ankle, diabetic limb salvage, foot and ankle trauma, and sports medicine.

Mr. Sayer is a certified personal trainer and performance enhancement specialist with Fitness Trainers Incorporated in Malvern, Pa.

References

1. Hashish R. Injury by CrossFit. Huffington Post. Available at https://www.huffingtonpost.com/rami-hashish/crossfit-debate_b_3181435.html . Published May 7, 2013. Accessed Jan. 7, 2014.

2. Paine J, Upgraft J, Wylie R. CrossFit study. Available at https://www.crossfitpraha.com/wp-content/uploads/2010/10/US-Army-Study.pdf . Published May 2010. Accessed Feb. 26, 2015.

3. Beilke C, Hetzel L, Kreft B, Pan L, Schroeder J. The effects of a Crossfit training program on sport performance and body composition in young healthy adults. J Undergrad Kenesiol Res. 2012; 7:21-31.

4. Barfield JP, Channell B, Pugh C, Tuck M, Pendel D. Format of basic instruction program resistance training classes: effect on fitness change in college students. Physical Educator. 2012; 69(4):325-341.

5. Robertson E. CrossFit’s dirty little secret. Huffington Post. Available at https://www.huffingtonpost.com/eric-robertson/crossfit-rhabdomyolysis_b_3977598.html . Published Sept. 24, 2013. Accessed Jan. 7, 2014.

6. Smith MM, Sommer AJ, Starkoff BE, Devor ST. CrossFit-based high-intensity power training improves maximal aerobic fitness and body composition. J Strength Cond Res. 2013; 27(11):3159-72.