Let’s talk about physical therapy for CrossFit athletes. It is important to understand the difference between CrossFit physical therapy and regular physical therapy. The goal of any type of physical therapy is to take you from an injury back to your desired activity level. If you hurt your back and are unable to sit for your desk job, then the goal of physical therapy is to help you sit without pain. More activity is always better, but if your goal is only to sit at your computer without pain, then that is the end goal of physical therapy.
However, if you are a CrossFitter who wants to get back to powerful overhead lifting, then simply sitting without pain is not the end goal of physical therapy. Unfortunately, many physical therapists do not understand how to progress someone beyond sitting without pain, or they are unable to do so because they are limited by health insurance companies.
At Eclipse Wellness in Sterling, VA we specialize in working with high level athletes including CrossFit athletes who want to get back to doing what they love safely. That means rehabilitating the injury and decreasing pain as soon as possible while gradually building up tolerance to return to weightlifting and exercise. It also means looking at surrounding factors including workload, mobility, and strength to determine what could have caused the injury. Addressing these variables can hopefully prevent future injuries from occurring.
Before we get any further down the rabbit hole I have a confession to make: I thought CrossFit was a bad idea and an injury risk when it first started. I figured that giving inexperienced lifters access to technical movements was foolish. I maintain that poor coaching can, of course, be dangerous for novices, but not exercising at all is worse than imperfect form. Also, research from Alekseyev, et al. found that experienced lifters were more likely to be injured. CrossFitters who had trained for over 3 years were 3.3 times more likely to be injured than those who had trained for fewer than 2 years. The bigger issue that the general population is facing is not one of injuries from CrossFit, but rather the fear of injuries causing them to not exercise at all.
I grew up playing sports my entire life and I looked at CrossFit as being more dangerous than the average sport. Interestingly, a study by Klimek, et al. found that injury rates for CrossFit are comparable to contact sports like football and rugby as well as less violent sports such as distance running or soccer. I thought that “traditional” sports were safer and provided the same benefit as CrossFit. In reality, they had similar safety levels and CrossFit was getting people to exercise for the first time, which is a huge benefit.
I believe that the best exercise is the one that you will stick to. Most people dealing with chronic pain need to find an activity that they like and will continue, no matter if that activity is running or CrossFit. As a profession, physical therapists need to move away from discouraging a form of exercise that clearly motivates some people, has an equal injury risk as other activities, and is actually safer for novice participants. I have an immense respect for the benefits of CrossFit and my goal as a physical therapist is to get people back to working out as soon as possible!
Common CrossFit Injuries
According to Alekseyev, et al., the back and shoulder are the two most common areas of injury in CrossFit athletes. The exercises that caused the most injuries included squats and deadlifts. It is important to understand the causes of injuries, but that does not mean that we should abandon squats and deadlifts altogether. Too often, medical professionals react to an injury by stating that you should not perform the activity that caused the injury. I often see physicians tell patients with low back pain to never deadlift again.
While deadlifting and squatting can lead to low back pain, they are also the best way to prevent pain. Building your tolerance to an activity can help decrease risk and improve performance. If you can deadlift 300 pounds then you are less likely to get injured moving furniture compared to someone who can only deadlift 100 pounds.
Any activity can lead to injury, especially if you do it repetitively. If you are a baseball player throwing 100 pitches a game then you risk shoulder injury. If you are a basketball player jumping up and down you risk a knee injury. All sports are repetitive by nature and CrossFit is no different. Understanding the injury patterns in CrossFit helps us study the causes and ultimately how to prevent injuries.
Causes of CrossFit Injuries
As a physical therapist, I have three simple criteria to prevent injuries: can you move, how do you move, how often do you move? Let’s break each one down.
First, can you move? This is a simple concept and I want to see if your body can perform the necessary movement. If you lack the ability to bend your knee then you probably can’t squat. Movement limitations can be due to mobility or strength. If you are not strong enough to lower yourself into a squat then you won’t be able to squat. This is the most common stage that involves physical therapy and it is often overlooked. Many people do not even realize that they have an ankle or pelvic limitation that prevents them from performing a good squat. They keep trying to load more aggressively or work with different coaches, but they are missing the fundamental piece of actually being able to move.
Second, how do you move? This is where coaches and physical therapists need to communicate. If someone has great mobility and strength they are often discharged from physical therapy. Unfortunately, they might not know how to squat at all, but they look great laying on a table. At Eclipse Wellness, I want to see clients perform movements such as squatting and deadlifting before they are discharged to ensure they are safe to return to exercise. This also involves communication with a coach who may have a better grasp of the client and their movement capabilities.
Finally, how often do you move? You can be the best squatter in the world, but if you squat 1,000 times per day everyday then you are asking to get hurt. Similarly, if you only squat once a week you probably won’t get stronger. Working with a coach to maximize your benefit and health with exercise is crucial. This is why you need to have a plan with exercise to attain your long term goals.
There are of course other reasons for injury, but I find these to be the core reasons that I see as a physical therapist. Now I want to talk about some specific exercises that I like to use with CrossFit athletes to assess and prevent injuries.
How to Prevent CrossFit Injuries
Before assigning corrective exercises, it is important to perform a detailed assessment to determine what individual exercises are needed. Let’s look at some basic movements that I assess with my CrossFit athletes.
First I like to study how they move through their low back or lumbar spine. The first two movements I study, flexion and extension, are shown below:
The important thing to remember with lumbar testing is to actually look at the lumbar spine. People will often cheat and move their hips or other parts of their body to compensate for decreased mobility in their spine. Additionally, you will often see “hinges” where there is excessive movement, particularly with extension. If someone is having pain in a specific location and they are actually moving too much in that area then they need to work on mobility of the surrounding joints and stability at the injured joint. Blindly stretching the area will often make the problem worse. If possible, I will have clients take their shirt off so that I can better observe how they are moving.
Sidebending is another important movement of the lumbar spine. As human beings, we do most of our motion in the sagittal plane (moving forwards and backwards) and we often neglect sidebending and rotation. I am primarily looking for asymmetries in sidebending which can be caused by muscle tightness on one side or limited joint movement. Limited sidebending can also cause decreased flexion and extension, and simply working on side stretches for the obliques or quadratus lumborum can help with flexion and extension.
The final movements I evaluate for the lumbar spine are rotation to both sides. The lumbar spine plays a minimal role in rotation, but it is still good to evaluate for significant asymmetries. More often, limited rotation is caused by poor thoracic or hip mobility, but the lumbar spine and surrounding muscles can play a role as well.
The next area I want to focus on with CrossFit athletes is the shoulder. Many movements and lifts involve an overhead position and I want to see how well your shoulder can move. I will have clients lie on their back with their knees bent. Next I will cue them to push their low back into the table gently to posteriorly tilt their pelvis. Finally, keep your arms straight and reach back as far as possible without your low back coming off the table. If you are unable to bring your arm to the table then there is tightness that is preventing you from going overhead. If you are able to perform the movement with your back off the table then your latissimus dorsi (or “lat”) is usually the problem.
The lat runs from your low back to your shoulder and allowing your back to come off the table shortens the muscle. This allows you more movement to reach overhead, but it compromises your form. Imagine performing an overhead press and you are unable to avoid arching your back. Your lower back would become the fulcrum for the weight and you would limit your lifting potential as well as expose your low back to injury. This is just one example of why a thorough evaluation is needed because limitations in one area can cause injury or decrease performance in another area.
The next shoulder movement I like to evaluate is external rotation. The easiest way to examine this is to have someone lying down with their knees bent. I will once again cue pushing your low back gently into the table to minimize compensation. For this test, you want to keep your elbow bent and in line with your shoulder. You will then rotate your arm to a position similar to throwing a ball. You should imagine that your elbow is in a fixed position and your arm is rotating around it. This evaluates external rotation, which is crucial for overhead positioning as well. Limitations in external rotation mean that you will not be able to achieve a clean overhead position. Imagine if my hand did not make it past my head in this position. How am I going to keep a barbell straight over my body to press overhead? External rotation is an often overlooked component of good overhead mobility.
The final movement that I want to discuss is the squat. Squats are a great way to evaluate lower body mobility, but I want to focus on the pelvis. We often neglect pelvic mobility in physical therapy, but it is something I see many people struggle to achieve.
A squat is fundamentally the vertical movement of the pelvis. A hip hinge or deadlift pattern is the horizontal movement of it. If you watch someone squat and they immediately shoot their hips straight back, then they are simply hinging and not squatting. This is a common cue from coaches (“sit back”, “keep your weight on your heels”, etc.) that often limits the effectiveness of a squat. These athletes have lost the ability to translate their pelvis vertically and effectively load their quadriceps in a squat pattern.
If someone has a tendency to hinge when squatting, then I will place a small wedge under their heels. Small dumbbells or weight plates can be effective in a gym setting. If the athlete is then able to execute a better squat, then the pelvis is usually the issue. Shifting weight forward to someone’s toes allows them to keep a more neutral pelvis and move vertically instead of horizontally. I will often have these athletes perform their warm up squats with something under their heels to build mobility and teach the movement pattern.
Exercises to Prevent CrossFit Injuries
Now you have an overview of some tests and techniques I use to evaluate my patients who are CrossFit athletes. Based on the results of these tests, I will give patients corrective exercises to address their individual findings. If you are interested in the corresponding exercises for these assessments, then send me an email at danny@eclipsewellnessnova.com and I will send you the exact techniques I use with my clients. If you are a CrossFit athlete in the Northern Virginia area feel free to reach out for an individual evaluation to address your limitations!