Ouch—bad mechanics and the reason for astronomical injury rates in runners.

In January, we asked about your interest in a town hall-style dialogue—any question-and-answer session(s) that would better your experience as an MPH athlete. We received many comments, both on the website and via email. From Ryan D.: what are typical CrossFit over-training injuries, and what are their preliminary signs?

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Town Hall
Question Three: Origins of “Overuse” Injuries

The complex system of nerves, muscles, and connective and structural tissues that allow us to move throughout enormous area, functions best when it is functioning—that is, when joints are in normal alignment and have complete range-of-motion, when nerves are signaling muscles properly, and when those muscles are at their correct, useful length (not short and tight, or elongated and weak). This organization requires motor control and sensory coordination (proprioception), and coordinated motion and awareness of body position (kinesthetic awareness) in order to optimize itself and preserve dynamic alignment through movement.

Overuse injuries are not very well named. These stress-related outcomes should be termed improper-use injuries, and they occur in sport for two reasons. The first is from repetitive, uncommon movement patterns executed on an otherwise sound athletic base—heel-strike running, for example. But, we can also see this in well-moving athletes who are asked to incessantly revisit the same action, such as a baseball pitcher’s throw or a tennis player’s serve. Every time either of these movements occurs, the shoulder is inundated with extreme external rotation and flexion, and the trunk with extension and unidirectional rotational force—even with fluid, qualified mechanics. Without parity in exercise or function, these athletes can eventually begin to break down. In compensation, shoulder flexibility can adapt to the loaded position of the throw and can become limited in internal rotation, the scapula may begin to wing, and the torso can become hypermobile in the lumbar spine, and hypomobile in the thoracic spine. A balanced training protocol, then, would include counter drills like shoulder internal rotation and extension, and hip mobilization and unilateral strengthening, with movement selection that promotes stabilization at the trunk and at each working joint.

Otherwise, improper-use injuries typically occur—notoriously so in CrossFit—from natural movement patterns performed on an unsound base. CrossFit is a highly equitable strength and conditioning protocol. In using it, we train through broad ranges of motion, and utilize functional movement patterns, with focus on core-to-extremity strength and activity. Capacity is developed within all 10 general physical skills, and all energy pathways are addressed. However, many athletes coming to CrossFit are ill-suited to begin this training regimen, as prescribed, from the start. They must first correct muscular imbalances, regain full transit at each joint, fix poor postural habits, and begin to learn how to control their body weight in space before being loaded, or before executing powerful and ballistic movements. Simply put, there must be correction and progression, and the body must be given a chance to adapt—most athletes must learn how to move.

The classic CrossFit overuse injury case occurs in athletes who begin training after an extended time off (where natural movement patterns and flexibility have been lost), or after executing the same fitness routine for months or years (where tightness and movement imbalances have developed). These athletes are loaded beyond their capabilities, with exercises beyond their physical competence. After a few months of this abuse, they invariably develop pain and problems—a nagging shoulder, or tightness in the lower back, or knee swelling that just won’t go away, to name a few. The typical medical prescription: rest the area until the pain subsides, pop some anti-inflammatories or painkillers to speed that process—then return to training, or just remove CrossFit completely. But, reactionary medicine is just that—no solution, just elimination of pain or symptoms that are signals from the body, not of the problem itself.

The actual problem is solved by addressing joint motility, body control and strength. Athletes must first have normal, balanced range-of-motion throughout the movement being trained. In overhead exercises, for example, this means having shoulder and spinal mobility such that a stable position can be achieved with good, external rotation at the shoulder and concomitant scapular movement, and not hyperextension at the lower back and cervical spine, and breakage at the hip. Then, body control or awareness, the ability to move through a pattern with the correct musculature, is trained. In the squat and deadlift, for example, this occurs by learning and demanding rigid spinal and pelvic structures. By bracing and creating tension in these regions while achieving spinal neutrality from hip to head, athletes are able to utilize their legs and hips to move, and not their spinal erectors, which burdens the spine itself. Body control can also be trained by giving mulit-directional training stimuli. Lower extremity concerns can often be mitigated not only by embracing minimalist footwear, but also by training hip and ankle stabilizers via unilateral, balance-rich methods.

Finally, athletes must be strong enough to complete the intended movement. Tissue overloaded beyond its strength capacity can create stress-related injury, if not avoid obvious, acute implications. This also transfers force to secondary muscle or connective tissue and causes problems or pain there—it’s most easily illustrated by how we avoid it. For example, athletes should first execute legitimate pushups, then static dips, before progressing to ring stabilization work, and finally to ring dips. Only fully-developed movement patterns should ever be loaded—athletes should not perform thrusters until they can front squat, for example.

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It is our job to identify each athlete’s deficiencies and give him or her the tools to correct them, and it is our responsibility to teach proper mechanics, and to enforce these mechanics, even when it means unloading the bar (or ego). We do this from the first interaction with a prospective athlete, as we catalog his or her fitness, health and injury history. The process continues during the introductory program, and then in the regular classes. Every single executed motion, and ache or pain along the way, is meaningful, and part of developing a holistic approach to a training program designed to keep athletes safe and injury-free, while moving toward optimal wellness. Yet, each athlete has a different history and level of commitment, and will consequently progress at a different rate. It is not possible, for example, to undo the bike accident that shattered a femur and caused global, dynamic compensations, or to eliminate 20 years of sitting hunched over at a desk. But, everyone can work on minimizing future injuries by fixing flexibility issues stemming from these situations, by being aware of posture and movement each day in life and in the gym, and by committing to coaching and instruction, and their demands for accuracy and efficiency.

Rest today.

–Melody and John