Journal of Strength and Conditioning Research Publish Ahead of Print DOI: 10.1519/JSC.

0000000000000318

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Title Page The nature and prevalence of injury during CrossFit training

Mr. Paul Taro Hak MBChB, MRC . pecialist Registrar, !ll "ales Trau#a and $rthopaedic Training Progra#, Cardiff, %&. 'r. (#il Hod)ovic MBChB. Foundation Trainee, !ll "ales Training Progra#, Cardiff, %&. Mr. Ben Hickey, MBChB, MRC . pecialist Registrar, !ll "ales Trau#a and $rthopaedic Training Progra#, Cardiff, %&. Corresponding !uthor* Mr. Paul Taro Hak

5o industry or other funding has .een accepted for this pu.lication. The authors also disclose no conflicts of interest. The results of the present study do not constitute

endorse#ent of any product .y the authors or the 5 C!.

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Page 2 of 14 The nature and prevalence of injury during CrossFit training

ABSTRACT CrossFit is a constantly varied, high intensity, functional movement strength and conditioning program which has seen a huge growth in popularity around the world since its inception twelve years ago There has !een much criticism as to the potential injuries associated with CrossFit training including rha!domyolysis and musculos"eletal injuries

purpose of this study was to determine the injury rates and profiles of CrossFit athletes

international CrossFit online forums &ata collected included general demographics, training programs, injury profiles and supplement use A total of '() responses were

injuries were reported with * ,+ 2./ re%uiring surgical intervention An injury rate of ( ' per '222 hours trained was calculated No incidences of rha!domyolysis were reported 3njury rates with CrossFit training are similar to that reported in the literature for sports such as 4lympic weight5lifting, power5lifting and gymnastics and lower than competitive contact sports such as rug!y union and rug!y league Shoulder and spine injuries predominate with no incidences of rha!domyolysis o!tained To our "nowledge this is the first paper in the

literature detailing the injury rates and profiles with CrossFit participation 6ey 7ords8 Crossfit, 3njury, weight5lifting,

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collected with *+ ,+( -./ having sustained an injury during CrossFit training A total of '01

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sustained during routine CrossFit training An online %uestionnaire was distri!uted amongst

#owever to date no evidence e$ists in the literature to the injures and rates sustained The

Page 3 of 14 The nature and prevalence of injury during CrossFit training

3NTR4&9CT34N CrossFit descri!es itself as a :constantly varied, high intensity, functional movement; strength and conditioning program !ased around functional movements with the !asis of :moving large loads, over long distances, and to do so %uic"ly;,</ 4ver the past twelve years since its inception it has grown to include almost (-22 affiliated gyms worldwide and

The program ta"es the form of 7or"outs 4f the &ay ,74&s/ which typically last around twenty minutes and include a variety of !odyweight e$ercises, gymnastics, 4lympic style weightlifting, running, rowing, s"ipping and using a various !ar!ells, "ettle !ells and other odd shape o!jects =ach 74& is scala!le to allow participation !y a variety of different strengths and fitness levels and are typically scored and often involves a competitive element !oth !etween participators and !y the individual participant themselves This has lead to CrossFit !eing descri!ed as the :Sport of Fitness; and there are annual CrossFit

!efore the world games with the most recent games attracting a total pri?e purse of @',222,222

&escri!ed as :constantly varied;, criticism has !een made with regard the apparently

random e$ercise regimes and lac" of individualisation for participants of these programs 7hilst there has !een widespread support of the CrossFit method for improvements in general health and fitness as an efficient e$ercise program that can !e used safely for a variety of starting fitness and strength levels, %uestions have arisen with regards its safety due to the high intensity and competitive nature Reports of rha!domyolysis have !een documented and damages were award to one participant in )220,'-,'+/ Concerns have

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>ames which include initial %ualifying 74&s nationally, then regional %ualifying events

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a recent ten5year sponsorship with Ree!o"

Page 4 of 14 The nature and prevalence of injury during CrossFit training

also !een raised with regard the loss of good and proper form during timed wor"outs which may predispose to injury A recent colla!orative wor"shop !y the Consortium for #ealth and Ailitary Berformance ,C#AAB/, other mem!ers of the &epartment of &efense ,&o&/, and representatives of the American College of Sports Aedicine ,ACSA/, suggested potential !enefits !ut also highlighted significant ris" of injury in those involved in e$treme conditioning programs such as crossfit,'/ Recommendations include further research into the potential injury ris" involved in these e$ercise programs

that e$ist in CrossFit despite the high profile anecdotal ris"s that have !een proposed This study aims to define the ris" of injury during CrossFit wor"out participation and also define

design This will ena!le an evidence5!ased approach to the understanding of the ris" of injury during CrossFit participation To our "nowledge this is the first study of its "ind in the pu!lished literature

A=T#4&S

This o!servational study design was !ased on an online %uestionnaire to allow collection of cross5sectional data from active participants of all levels of CrossFit training An anonymous online %uestionnaire was designed and lin"s were distri!uted amongst national and international CrossFit online forums Following an 3nternet search using :CrossFit forums; as a search tag, the top ten ran"ed forums were chosen and a lin" to the anonymous

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the pattern of sustained injuries !y using a cross sectional o!servational e$perimental

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7ithin the literature there is a lac" of o!jective evidence to the safety and injury profiles

Page 5 of 14 The nature and prevalence of injury during CrossFit training

%uestionnaire was posted All readers, including those who had not sustained any injuries, were as"ed to complete The %uestionnaire included patient and health demographics including age, se$, smo"ing status and alcohol consumption And performance enhancing drug use Training !ehaviours included total period training CrossFit as well as wee"ly training participation Barticipants were as"ed if they had sustained an injury during training CrossFit and to list the num!er and nature of all these injuries from their starting CrossFit Specifically only injuries sustained during CrossFit training were included 3njury was defined as any injury sustained during training which prevented the participant training, wor"ing or competing in any way and for any period of time 3njuries re%uiring surgery were also recorded &ata was collected anonymously !etween Fe!ruary to Aay )2') &ata was collected and compiled using Aicrosoft =$cel and injuries were grouped according to !ody part injured and analysed

4ur study does include certain limitations The retrospective nature of the study has inherent limitations in terms of respondent recall and medical personnel did not document injuries Also due to the nature of self5selection of respondentCs !ias may have !een

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introduced, with athletes who have had an injury !eing more li"ely to participate #owever, we did note a num!er of respondents who did participate !ut had no injuries to document and these athletes were encouraged to respond &espite these limitation we !elieve this study provides valua!le insight into this e$tremely popular and fast e$panding training method and provides the first o!jective evidence into the ris"s and nature of injuries

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Page 6 of 14 The nature and prevalence of injury during CrossFit training

R=S9DTS 4ver the collection period there were '() responses with no responses discarded due to incomplete completion of the %uestionnaire *( ,+2 -./ respondents were male and (* ,)* -./ were female with a mean age of () ( years ,range '* E -+ years/ There was a smo"ing prevalence of ( 0. and ')1 respondents ,*- -./ consumed fourteen or less units

enhancing drug use with a prevalence of ) ). Aean total period of training CrossFit was

7ithin the group *+ ,+( -./ participants had sustained an injury that had prevented them from wor"ing, training or competing A total of '01 injuries were reported in our cohort Nine participants ,+ 2./ had sustained an injury that re%uired surgical intervention No reports of rha!domyolysis were reported The most common injury locations ,Figure )/ were shoulder, spine followed !y armFel!ow

The total duration of training and wee"ly participation were used to identify the at ris" period for those participating in CrossFit training 9sing this data and the total injuries sustained an injury rate per '222 hours trained was calculated This would allow comparisons with other sports injury rates already pu!lished 3n our sample an injury rate

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was ( ' injuries per '222 hours trained

4ur study is the first to report the type and incidence of injury in CrossFit athletes The most commonly injured area was the shoulder followed !y spine 4verall rate of injuries

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'0 1 months Aean wee"ly participation in CrossFit training was - ( hours per wee"

of alcohol per wee" ,figure '/ Three respondents admitted to use of performance

Page 7 of 14 The nature and prevalence of injury during CrossFit training

sustained during training are !roadly similar to that reported in the literature for sports including weightlifting, powerlifting,),-,+,'*,)2/ and gymnastics,''/ and lower than that reported in competitive contact sports such as Rug!y Deague,0/ and Rug!y 9nion,'2/ #owever all these sports could !e classed as pushing the envelop of physical e$ertion or competitiveness Comparing adult fitness activities,)'/, including general gymFfitness clu! trainingG and long, middle and sprint distance running,'</ and triathlon training ,')/ The injury rates are also !roadly similar to CrossFit training

higher than those previously reported for elite and competitive 4lympic weightlifters,)/ 3n 4lympic weight lifting the placement of the shoulder in an at5ris" position of e$treme

injury,1,'0/ &uring CrossFit wor"outs 4lympic style overhead movements are performed at high repetition range and at high intensity often with heavy weights This may lead to poor form and placing the shoulder at e$tremes of motion in the at ris" position and predispose to injury An e$ample of this is the technical low s%uat snatch position ,figure (/ 7ith good form ,figure (/ fle$ion at the shoulder is noted and no a!normal forces are generated #owever with the poor form ,figure </ the shoulder can !e seen to !e placed in

a position of hyperfle$ion, internal rotation and a!duction, the at ris" position Also the addition of a :"ipping; motion, using !ody momentum and the lower !ody to generate e$plosive force to complete the repetition, on e$ercises such as pull up also places the shoulder in e$tremes of hyperfle$ion and internal rotation and the soft tissue structures at ris" of injury At the !ottom position of a traditional pull up ,figure -/ the shoulders remain in a comforta!le range of forward fle$ion and no a!normal force is loaded through

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fle$ion, a!duction and internal rotation place the tissues of the shoulder at ris" of

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The high prevalence of shoulder injuries ,(' 0./ accounting for )- 0. of total injuries is

Page 8 of 14 The nature and prevalence of injury during CrossFit training

the shoulder Conversely at the !ottom of a H"ippingC pull up ,figure 1/ the shoulder is placed in an e$treme position of hyperfle$ion, internal rotation and a!duction with significant force !eing generated at the !ottom of the movement to spring the athlete !ac" up into the ne$t repetition Both these movements are particularly prevalent in 74& programming with nine out of the

may lead to the unusually high prevalence of shoulder injury and the popularly termed

The incidence of low !ac" pain and injuries are well documented in the athletic as well as general population,*,'(/ The high prevalence of spinal injuries, in particular low !ac" injuries, mirrors that seen in powerlifting and weight lifting,),)2/ Again the use of high intensity, high repetition and heavy weight in e$ercises re%uiring strict form may e$plain the high num!er of low !ac" injuries in our sample Doss of form at e$tremes of fatigue during

forces and stresses throughout the thoracic and lum!ar spine leading to injury &uring 4lympic style weightlifting the focus is placed on performing only one repetition of the movement, however during CrossFit wor"outs these movements are often performed with

high num!er of repetitions with an emphasis on speed and this may lead to poor form and injury The dead lift progression with strict form ,figure +/ emphasises holding the lum!ar and thoracic spine inline and in neutral to prevent injury 7ith fatigue this can !e lost with forward fle$ion of the thoracic and lum!ar spine ,figure 0/ This may contri!ute to the high prevalence of injury

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e$ercises including variations of weighted s%uat, deadlift, clean and snatch, place a!normal

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injury amongst participants of :CrossFit shoulder;

fifteen !enchmar" or core wor"outs involving pull5ups or a overhead pressing motion This

Page 9 of 14 The nature and prevalence of injury during CrossFit training

Although previously cited as a ris" during CrossFit participation,'-,'+/, rha!domyolysis was not reported in our sample This may !e due to the inclusion of all levels of fitness and participation, as rha!domyolysis would !e e$pected in those participating at the very e$treme level of intensity Although due to the nature of CrossFit 74&s rha!domyolysis remains a ris" we !elieve this ris" to remain remote and li"ely to !e similar to that e$perienced in other high intensity and competitive sports,1,'1/

BRACT3CAD ABBD3CAT34NS

The injury patterns seen in our sample of CrossFit athletes are the first to !e pu!lished in the sporting and scientific literature They are similar to those seen in other high intensity and technically demanding sports such as 4lympic weight lifting and power lifting as well as general fitness training The rates of injury are also lower than those seen in competitive contact sports The high prevalence of shoulder and low !ac" injuries however, due to the high intensity, high repetition and heavy weight movements, needs to !e considered and ta"en into account when programming 74&s to reduce these injuries and change the perception of injury in CrossFit

7e !elieve an increased focus, especially during the initial introduction to training, of proper lifting techni%ue and focus upon maintaining this throughout wor"outs rather than the speed and total num!er of repetitions performed is needed Also a more !alanced programing of wor"outs should !e !orne in mind, specifically reducing the rate certain movements such as pull5ups and overhead motions are included into wee"ly wor"outs 7e !elieve these measures would not impact on the overall health and fitness !enefits of

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Page 10 of 14 The nature and prevalence of injury during CrossFit training

participation !ut would lead to a reduction to the num!er and rate of injuries sustained during training The large focus upon meta!olic conditioning and apparently random wor"outs, with a lac" of focus upon strength wor"outs may have a !earing on injury rates and patterns Certainly ta"ing the wor"outs form the central CrossFit #I we!site for the month of April in the past

nineteen, si$teen and nineteen to meta!olic conditioning 7ithout a firm strength !asis we

ris"s injury

A lac" of individualisation has also !een proposed as a potential negative aspect of CrossFit 3ndeed those following the main CrossFit #I we!site programming with have no tailored programming performed #owever a majority of CrossFit participants do so in an affiliated gym where coaches are availa!le to tailor wor"outs and also provide individualised

un"nowa!le and therefore individualisation is not necessary 7hile this may !e true in certain circumstances, a degree of individualisation may help define more achieva!le goals and reduce injury rates 7e !elieve participation under the supervision of a dedicated

CrossFit gym and coach provides this compromise

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programing The ethos of CrossFit !elieves in training to !e prepared for the un"nown and

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!elieve performing the heavy weight, high rep meta!olic conditioning wor"outs so regularly

three years only three, five and three days over the month were allocated to strength with

Page 11 of 14 The nature and prevalence of injury during CrossFit training

R=F=R=NC=S ' Bergeron AF, Nindl BC, &euster BA, Baumgartner N, 6ane SF, 6raemer 7J, Se$auer DR, Thompson 7R, 4CConnor F> Consortium for #ealth and Ailitary Berformance and American College of Sports Aedicine Consensus Baper on =$treme Conditioning Brograms in Ailitary Bersonnel Current Sports Aedicine

) Calhoon >, Fry A 3njury Rates and Brofiles in =lite Competitive 7eightlifters

( >eorge A, &elgaudio A, Salhanic" S&. =$ertional rha!domyolysis 5 when should we start worryingK Case reports and literature review Bediatr =merg

< >lassman > 9nderstanding CrossFit The CrossFit Journal, )22+8 -1G'5) - >oert?en, L , et al , Aedical history associated with !ody !uilding and power lifting Sportverlet?ung Sportschaden, '*0* (8 p ()5(1 1 >ross AD, Brenner SD, =sformes 3, Son?ogni JJ Anterior shoulder insta!ility in weight lifters Am J Sports Aed '**(G)'8-**512(

+ #ay"ows"y, A J , & = R 7ar!urton, and # A Iuinney Bain and injury associated

0 #os"ins 7, Bollard #, #ough 6, Tully C 3njury in rug!y league Journal of Science and Aedicine in Sport, )221G *8 <15-1 * #oy &, Broo"s B, Blyth F, Buch!inder R The =pidemiology of low !ac" pain Best Bract Res Clin Rheumatol )2'2G)<,1/8+1*50'

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with power lifting training in visually impaired athletes Journal of Lisual 3mpairment and Blindness, '*** *(,</8 p )(15)<'

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Care )2'2G)1,''/801<51

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Journal of Athletic Training, '***G (<,(/8)()5)(0

Reports, )2''G '2 ,1/8 (0(5(0*

Page 12 of 14 The nature and prevalence of injury during CrossFit training

'2 6err #A, Curtis C, Aicheli DJ, 6ocher AS, Mura"ows"i &, 6emp SBT, Broo"s J#A Collegiate rug!y union injury patterns in New =ngland8 a prospective cohort study Br J Sports Aed )220G<)8-*-E12( '' 6olt, > S and R J 6ir"!y, =pidemiology of injury in elite and su!5elite female gymnasts8 comparison of retrospective and prospective findings British Journal of Sports Aedicine, '***G((8(')5('0 ') 6ortia B6, Tunstall5Bedoe BS, Aaffulli N An epidemiological investigation of training and injury patterns in British triathletes British Journal of Sports Aedicine '**<G)08'*'5'*1

'( Doney BD, Stratford B7 The prevalence of low !ac" pain in adults8 a methodological review of the literature Bhys Ther '***G+*,</8(0<5*1 '< Dysholm J, 7i"lander J 3njuries in Runners The American Journal of Sports Aedicine, '*0+G'-,)/8'105'+'

'- Aitchell B Dawsuit alleges CrossFit wor"out damaging Aarine Corps Times

'1 Aoec"el5Cole SA, Clar"son BA Rha!domyolysis in a collegiate foot!all player Journal of Strength N Conditioning Research, )22*G)(,</8'2--5'2-*

'+ Aummolo J, &avenport C >ymOs #igh53ntensity 7or"out Deft Ae &isa!led, Aan

'0 Neviaser TJ 7eight lifting8 ris"s and injuries to the shoulder Clin Sports Aed '**'G'281'-51)'

'* Iuinney, # A , et al , Bowerlifting injuries associated with elite powerlifting training Canadian Journal of Applied Bhysiology, '**+G)2,- Suppl '/8<*

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August '1, )221

Testifies The 7ashington Bost 4cto!er +, )220

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Page 13 of 14 The nature and prevalence of injury during CrossFit training

)2 Ras"e, A and R Norlin 3njury incidence and prevalence among elite weight and powerlifters American Journal of Sports Aedicine, )22)G(2,)/8)<05)-1 )' Re%ua R6, &eAvilla DN, >arric" J> 3njuries in recreational adult fitness activities The American journal of Sports Aedicine, '**(G)',(/8<1'5<1+

AC6N47D=&=A=NTS No industry or other funding has !een accepted for this pu!lication The authors also disclose no conflicts of interest The results of the present study do not constitute endorsement of any product !y the authors or the NSCA Corresponding Author8 Ar Baul Taro #a"

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Page 14 of 14 The nature and prevalence of injury during CrossFit training

F3>9R= D=>=N&S Figure ' Alcohol consumption Figure ) Num!er of 3njuries and location

Figure ( S%uat snatch low position with good form Shoulders show no hyperfle$ion with good thoracic mo!ility allowing overhead position

Figure < S%uat Snatch low position poor form #yperfle$ion of shoulders to allow weight to !e loaded overhead, placing shoulders in the :at ris"; position /

fle$ion overhead with no stress !eing placed on joint Figure 1 Bottom of H"ippingC pull5up Forced hyperfle$ion of shoulders to gain momentum

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spine

to spring athlete !ac" to top of movement to get chin over !ar Figure + &ead lift progression with good form Dum!ar and thoracic spine "ept in neutral alignment throughout range of motion Figure 0 &ead lift progression with poor form Forward fle$ion of the lum!ar and thoracic

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Figure - Bottom position traditional pull5up Shoulders comforta!ly at range of forward

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