Shoulder Injuries in CrossFit
In order to diagnose and direct management of a CrossFit athlete with a shoulder injury, the clinician must have an understanding of typical CrossFit movements. CrossFit include numerous exercises that involve the shoulder joint. Overhead squats, snatches, push presses, thrusters, and push jerks are common movements that place load on the shoulder. The shoulder, not typically a weight-bearing joint, is also used as a weight-bearing joint during gymnastic maneuvers such as handstand pushups and handstand walks. Finally, to the range of motion and power needed for kipping and butterfly pullups and muscle-ups, the shoulder is often stressed and challenged in CrossFit.
This is me doing “JJ”-modified with 135# and Regular HSPU
Additionally, a thorough history, knowledge of the anatomy and physiology of the shoulder complex, and understanding risk factors of shoulder injury are critical in making a correct diagnosis. First let’s look at some basic anatomy.
Basic Anatomy /Physiology
The shoulder is a complex joint consisting of three bony articulations—the acromioclavicular, the sternoclavicular and the glenohumoral joint.
Its complexity is compounded by the biceps tendon and labrum. The long head of the biceps starts outside of the true glenohumeral joint but traverses inside the true joint itself. Adding to the confusion that the “shoulder” to the layperson could mean the back of the neck and trapezius area, make determining the diagnosis of the injury challenging.
Finally layer on top of the joints and articulation all the muscles surrounding the shoulder– including rotator cuff muscles, deltoids, trapezius, serratus anterior, rhomboids, scalenes– and you can see why the diagnosis and subsequent treatment can be complex, even for the astute clinician.
What do the studies say?
While there are limited studies looking at CrossFit injuries and the pattern of injuries, we can learn a lot by delving into the available literature. The studies show that shoulder injuries are common in reported CrossFit injuries, so the clinician taking care of CrossFit athletes should be aware of these movements, the load it places on the shoulder and query the athlete on which movements that causes shoulder pain.
For example, cleans, jerks and snatches are pulling movements that puts high load on the biceps and its attachment into the labrum. Similarly overhead squats can put the shoulder in abduction and external rotation, which also loads the biceps and labrum. In addition gymnastics maneuvers such as handstand push-ups, kipping pull-ups and butterfly pullups can put both eccentric and concentric loads on the biceps. Kipping pull-ups also puts the shoulder in abduction and maximal external rotation, while butterfly pull-ups allows the athlete to quickly cycle pullups using forceful eccentric and concentric contractions of the biceps, lattisimus dorsi and serratus anterior.
Watch Chris Spealler perform and breakdown the butterfly pullup.
In the studies out in the literature, there are no studies that look at specific diagnosis of shoulder injuries. Labral tears, with the pull on the biceps and the use of the shoulder as a weight bearing joint, can be a common injury related to CrossFit. The history should ask CrossFitters which movements hurt the shoulder. Anything associated with overhead squats, snatches, thrusters, push presses/jerks should make the clinician consider labral tears in the differential. While the most common shoulder injury overall tends to be rotator cuff tendinopathies, this blog will focus on the labrum. Clinicians should still ensure they do a complete exam.
Diagnostic shoulder exams for the labrum can be challenging. Common symptoms include anterior shoulder pain, specifically where the biceps tendon enters the joint space and becomes the labrum. Rotator cuff strength is generally preserved. However, the subscapularis, which layers over the biceps tendon and provides stability for the biceps tendon, can be involved with labral tears. Clues to subscapularis involvement is the “lag sign,” where the patient cannot keep the wrist straight while performing a “belly press.” This is also called a “belly press test-modified.” (BJSM)
There are two special tests that are useful for testing the labrum—Speed’s test and the dynamic shear test. While there are many other tests, these are simple and easily done.
Speeds test is a commonly performed test and if positive, it suggests biceps/labrum involvement. Positive testing includes pain in the bicipital groove area and/or weakness compared to the other side. Speed’s has a likelihood ratio of 2.77 and is more sensitive but less specific and cannot rule in a labral tear, but may help rule it out. (BJSM Hegedus)
Dynamic labral shear test
This test has been described as putting the affected arm at 120 degrees of abduction with maximal external rotation. Then the examiner moves the shoulder from 120 degrees to 60 degrees of abduction while maintaining external rotation. This places shear on the biceps tendon and labrum and may cause pain and or painful click/pops in the anterior or posterior shoulder. (BJSM) I find this test very useful to rule in a labral tear (as it is more specific than sensitive). (Negative Likelihood ratio of 1.54)-BJSM Hegedus.
For the CrossFit athlete, the dynamic labral shear test can be useful test. Thrusters can place shear load on the labrum as the athlete pushes a barbell from a front squat position to overhead with explosive hip extension, forcing the barbell vertical. As the athlete brings the barbell back down to the front squat position, the shoulder position places a dynamic shear on the labrum; similar to the dynamic shear test. Painful clicks and pops during the thruster and similar overhead movements (push press, push jerks) can be a diagnostic clue to labral tears.
If the diagnosis is not clear, but suspicious for a labral pathology, a diagnostic injection of lidocaine into the bicepital sheath at the level of the biceps pulley can help confirm your diagnosis. More than 50-75% relief 10-15 minutes after lidocaine is diagnostic.
Differential Diagnosis-the Acromioclavicular Joint
A key differential is acromioclavicular (AC) pathology, especially in an older athlete. Most have some tenderness over the AC joint and can be simple to differentiate between labrum and AC joint. However, if the diagnosis is not clear, a simple diagnostic and or therapeutic injection into the AC joint can help differentiate pain generating from the AC joint versus labral pathology.
How about the rotator cuff?
While rotator cuff tendinopathy and tears are common shoulder injuries it is not clear if the CrossFit athlete are at increased risk. CrossFit programming with its “constantly varied” movements may help limit the constant focus on the pectoralis minor/major and internal rotation of other recreational weight lifters. Pulling exercises such as rowing, pullups, deadlifts may provide scapular and rhomboid balance which lowers the risk for cuff failure and impingement. Nevertheless, clinicians should keep rotator cuff tendinopathy and tears in the differential but not be surprised if the cuff appears strong and healthy on examination. A subacromial injection may help ascertain diagnosis.
Any patient who has a shoulder injury should be started in a physical therapy program for rehabilitation even if the labrum is considered the primary disorder. Ideally this should be a therapist with familiarity with CrossFit movements and how to return the CrossFit athlete back to CrossFit. The therapy should focus on strengthening of the dynamic stabilizers of the shoulder, the rotator cuff and the scapular stabilizers. Proprioceptive exercises can also facilitate return to sport and should be included in the rehabilitation. Sleeper stretches can also help with posterior capsule tightness and mobility issues.
Strengthening of the dynamic stabilizers of the shoulder, specifically the external rotators should be emphasized and can be continued during warm ups or cool downs using light resistance bands. All overhead movements should be pain-free. If pain free without load, the clinician can encourage the athlete to work on mechanics and consistency of technique and limit the load to pain free loads. Working on movement with the PVC pipe or light weight can keep the athlete active and engaged. Other pulling movements, such as rowing, light deadlifts, and ring rows can help strengthen the scapular stabilizers and should be encouraged if pain free. Shoulder proprioception exercises such as those emphasized in the “Turkish Get-ups” may help improve core stability and shoulder stability. Russian kettlebell swings can also be included as long as the athlete remains pain free during the range of motion. Athletes should be encouraged to work on front and back squats, box jumps, and even running.
Keeping the athlete and modifying the WODs can keep the athlete an active participant in their rehabilitation.
After 6-12 weeks of modification of exercise and rehabilitation, the athlete should be re-assessed for any improvement in pain. If the athlete continues to complain about pain with overhead movements, then continued evaluation to ensure the diagnosis is correct is warranted. An MRI is useful but may need contrast to see labral injuries and its use should be considered judiciously and always be used in conjunction with your clinical suspicion. Further modification of exercises with continued rehabilitation may be considered if the athlete is making improvement.
Finally, surgical consultation may help give the athlete full options in returning back into CrossFit. A labral tear will generally not heal, but the body may modulate the pain response where people can return to doing most activities. There is a paucity of literature available on long term effects of labral tears but if the patient is adverse to surgical options, many may be able to continue to modify activities while still performing most CrossFit WODs without surgical intervention. The athlete who has failed conservative measures and is looking to return back to high level CrossFit should be referred for surgical considerations. Here again, diagnostic injections into the bicepital groove may help surgeons identify the pain generator. Surgical options include labral repair with or without biceps tenodesis. Finally, the athlete should be aware that surgery will generally involve 4-6 months of rehabilitation for full recovery.
Myer CA, Hegedus EJ, Tarara DT, et al. A user’s guide to performance of the best shoulder physical examination tests. Br J Sports Med 2013;47:903–907. PMID: 23322891
Hegedus et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. PMID: 22773322