Injuries

# General

## Prevention and Prehab

### Self Mysofascial Release

This is great for any kind of tendonitis, tightness, and general aches. Accomplishes much of what stretching does, but better (and without actually stretching!)

**Further Reading:**

* Foam rolling
* T-Nation: Feel Better for 10 Bucks
* The Trigger Point Therapy Book
* Trigger Point Massage, by Christian Lemburg, Crossfit Journal

### Stretching

Much debate exists on the topic of stretching. Stretching has been attributed with such different properties as injury prevention, reducing DOMS, decreasing performance and *obviously* increasing flexibility.

In the book Starting Strength coach Rippetoe clearly indicates that that unless your flexibility is hindering you from performing the exercises correctly, doing full range of motion compound exercises is all the stretching you will need.

He does recommend several stretches for new lifters to use for groin/hamstring flexibility for squats, wrist/elbow/shoulder-flexibility for Power Cleans and so forth, but stretching as such is not part of the programme, unless it constitutes a problem for a specific lift.

The beneficial and detrimental effects of stretching have been analyzed in several studies. This author (not Mark Rippetoe) would say that a general rule of thumb could be to do a couple of minutes of dynamic stretches pre-workout as part of the warm-up, ie. air squats, shoulder dislocations and leg kicks are all examples of good dynamic stretches. This can be followed up by static stretching post-workout. I would like to repeat, that stretches in general are only needed for problem areas, otherwise it is probably more or less inconsequential.

NEVER stretch a cold muscle, make sure you are warmed up first, and only do very light stretches before and during exercise. Save the serious stretching (i.e. 30+ seconds per stretch) for after your exercise, and on your off-days (highly recommended to stretch on the off-days). Pay special attention to shoulder girdle and pectoral flexibility, as well as hamstring flexibility.

**Further Reading:**

* How NOT to Warm-Up

**References:**

* Stretching and DOMS
* Stretching and DOMS II
* Stretching and injuries

#### Static Stretching

Static stretching shouldn't be done frivolously, but should instead be reserved for specific problem areas that require increased flexibility.

##### Hamstring Stretch

Do this stretch, except keep both legs straight. The lower leg stays flat on the floor with your knee straight and your foot straight up and down (in other words, don't allow your leg to rotate laterally/outward). The other leg also stays straight. This will help "stretch your hips apart" as well as loosen up those banjo-string hammies.

You can also do this stretch with a towel. Same rules apply, keep your legs straight. Another variation is to do these in a doorway. Your lower leg stays flat on the ground and runs through the doorway. The upper leg is held flat against the door frame.
Another necessary stretch will be to start in a full squat position with your hands flat on the ground about 2 feet in front of you. Straighten your knees while keeping your hands flat on the ground. You should feel a VERY powerful stretch in your hamstrings. Keeping your knees straight, walk your hands inward toward your feet until you are able to touch your palms to the ground without bending your knees.

Be sure to do these stretches AFTER your workout, not before, as pre-workout stretching can actually weaken your muscles.

* 5 Reasons You Shouldn't Do Static Stretches

**Further Reading:**

* The Third World Squat

**References:**

* Static stretching and performance decrease
* Static stretching and performance increase

#### Dynamic Stretching

**Air Squats**

**Shoulder Dislocations**

File:Shoulder Dislocations

**Leg Kicks**

**Arm Swings**

File:Arm Swings

**Further Reading:**

* What is Joint Mobility?

**References:**

* Dynamic stretching and performance increase

### Supplements

* Glucosamine, Chondroitin and MSM should be a staple of your daily supplement regimen. This will take care of many joint/ligament/tendon issues before they ever begin.
* Cissus is a bit more expensive, but if the above isn't working for you, it's worth the money. This stuff works really well for joint repair.
* Fish Oil/Flax Seed Oil lubricates your joints and posses potent anti-inflamatories. And it's a bargain.
* Vitamin C supplements to assist in production of collagen.

## Recovery and Rehab

### The Proactive Patient

**No matter what your current issue is, I recommend everyone read THIS article, titled The Proactive Patient.**

### The RICE Method

Rest, Ice, Compression, Elevation

The RICE method often helps with many types of joint and muscle injuries. The method will ease pain and help speed recovery. The RICE method is very helpful if you use it right away after an injury.

Rest. For most injuries, rest the area until the pain decreases. For simple sore muscles, however, gentle stretching will reduce stiffness more quickly. Hold the stretch for 30 to 60 seconds, then rest and repeat five to 10 times. Do this several times a day.

Ice. Ice is the most effective treatment for reducing inflammation, pain and swelling of injured muscles, joints and connective tissues—such as tendons, ligaments, and bursas. The cold helps keep blood and fluid from building up in the injured area, reducing pain and swelling. Apply ice as soon as possible after injury, even if you are going straight to the doctor. To speed recovery and ease pain, raise the injured area and apply ice for 20 minutes (10 to 15 minutes in children) every two to three hours while awake. For best results, place crushed ice in a plastic bag and wrap with a moist towel. Use an elastic bandage to hold the pack in place. During the first 48 to 72 hours, or as long as there is any swelling, do not apply heat to an injury. Heat increases blood flow to the affected area, which makes swelling and pain worse.

Compress. Between icings, wrap the injured area with an elastic bandage to help control swelling and provide support. Begin wrapping at the farthest point away from the body and wrap toward the heart. For example, to wrap an ankle you would begin at the toes and wrap to the mid-calf. Don't sleep with the wrap on, unless told to do so by a doctor. And don't wrap too tightly! If the wrap begins to cause pain or numbness, or if toes become cool or white, remove the elastic bandage and wrap it more loosely.

Elevate. Raising the injured area above your heart will allow gravity to help reduce swelling by draining excess fluid. At night, place a pillow under the area to support and raise it.

### Bill Starr Rehab for Muscle Pulls

Mark Rippetoe:

Here is the tried-and-true injury rehab method for muscle-belly injuries we got from Starr and that has worked for years better than any other method I've ever used. It also works well on orthopeadic injuries in general, and should be tried before anything more elaborate is used. Wait 3-4 days until the pain starts to "blur",which indicates that the immediate process of healing has stopped the bleeding and has started to repair the tissue. Then use an exercise that directly works the injury, i.e. that makes it hurt, in this case the squat. Use the empty bar and do 3 sets of 25 with perfect form, allowing yourself NO favoring the injured side. If it's ready to rehab you will know by the pain: if the pain increases during the set, it's not ready, if it stays the same or feels a little better toward the end of the set, it is ready to work.

The NEXT DAY do it again, and add a small amount of weight, like 45 x 25 x 2, 55 x 25. Next day, 45 x 25, 55 x 25, 65 x 25. Continue adding weight every day, increasing as much as you can tolerate each workout. It will hurt, and it's supposed to hurt, but you should be able to tell the difference between rehab pain and re-injury. If you can't, you will figure it out soon enough. This method works by flushing blood through the injury while forcing the tissue to reorganize in its normal pattern of contractile architecture.

After 10 days of 25s, go up in weight and down in reps to 15s, then to 10s, and finally to fives. During this time do NO OTHER HEAVY WORK, so that your resources can focus on the injury. You should be fixed in about 2 weeks, squatting more than you hurt yourself with.

This method has the advantage of preventing scar formation in the muscle belly, since the muscle is forced to heal in the context of work and normal contraction, using the movement pattern it normally uses. The important points are 1.) perfect form with 2.) light weights that can be handled for high reps, 3.) every day for two weeks, and 4.) no other heavy work that will interfere with the system-wide processes of healing the tear.

It is also very important through the whole process of healing the injury that ice be used, during the initial phase after the injury and after the workouts. Use it 20 on/20 off, many times a day at first and then tapering off to morning, after the workout, and before bed. Ice is your best friend in a muscle belly injury, holding down inflammation and fluid accumulation ("swelling") while at the same time increasing beneficial blood flow through the injury. But DO NOT USE ICE MORE THAN 20 MINUTES AT A TIME. More than that can cause more damage than it repairs.

This may actually be the most useful post on this entire little forum of mine, and if you use this method exactly you can save yourself many weeks of lost training and long-term problems with muscle-belly scarring. Try it and see.

### Overuse Injures and Tendonitis

1. The term tendonitis is largely a misnomer - you probably don’t have swelling at the tendon (the definition of tendonitis). Instead, it’s likely tendonosis, a term which simply means pain at the tendon, and is therefore vague enough to be essentially meaningless, diagnostically.

2. Tendonosis, in CrossFitters, is almost universally caused by overuse (repetitive stress over a period of time) as opposed to by acute tendon trauma during a specific incident.

3. Such overuse tendonosis, is also by far the most common CrossFit ailment, and odds are good you’ll face bouts of it (most commonly in the elbow, though also frequently in the shoulder or outer knee) at multiple points along your years of training.

4. During such bouts of tendonosis, a good rule of thumb is: if it hurts, don’t do it. Thus, try a few light cleans this evening. You’ll know pretty quickly whether they’re a good or bad idea.

5. For a period of about two weeks, stop whatever movement caused the tendonosis (pullups, overhead presses, running, etc.) completely.

6. After two weeks, start the movement again. Slowly. If it’s pullup related, say, try two or three slow pullups, two or three times a day. Up the volume each week, but bit by bit. It should take you at least six weeks to get back to full out. This is, by far, the most important solution to overuse trauma: stop doing what hurts, then start it again, but gradually build it back up.

7. Beyond that, targeted stretching helps. This is the main focus of PT. PT stretches aren’t top secret, however, so you can do the same stuff on your own, in less time and for free. Most people don’t actually stick with the exercises, or push themselves through parts of the exercises that are uncomfortable, without outside supervision, which is why appointments make sense. As a CrossFitter, that likely isn’t a problem for you.

Therefore:

For elbow / bicep pain, the useful exercises are: http://www.nismat.org/ptcor/tennis\_elbow/

For shoulder pain, the useful exercises are: http://familydoctor.org/familydoctor/en/prevention-wellness/exercise-fitness/injury-rehab/rotator-cuff-exercises.html

For knee pain, the useful exercises are: http://www.nismat.org/ptcor/itb\_stretch

Do them regularly on your own. Outside of that, simply focus on slowly (slowly!) building up volume on the causative movements.

8. While that alone should fix you, you might also consider checking out Z Health and the Egoscue Method. Poor body mechanics - often in body parts seemingly unrelated to pain - can be a significant contributing factor. (Caveat emptor: this last bit is a newer area for me, and one about which I’m still devouring as much research as possible, so I can speak less authoratatively to the benefits of this one. Nonetheless, in my own case, I’m increasingly convinced that my ankle fracture last October was the inevitable outcome of serious hip flexor activation issues that translated to knee mobility issues that translated to everted feet.)

### Self Mysofascial Release

If you aren't doing this already, and you have tendonitis, muscular tightness and/or lower back fatigue/aches, you need to be.

**Further Reading:**

* Foam rolling
* Trigger point therapy
* Trigger Point Article by Christian Lemburg

### NSAIDS

Non-Steroidal Anti-Inflammatory Drugs. They knock the hell out of most any inflammation. Many lifters swear by NSAIDS, and they are by far the best medications available over the counter for musculoskeletal pain. However, side effects are common and can be severe for people with stomach problems.

Always take NSAIDS with food, because there is a risk of developing stomach ulcers (NSAIDS block prostaglandins, which play a role in inflammation but also direct your stomach lining to release the mucous that protects it from its own digestive juices). This risk increases greatly with extended use, so you should never attempt to use NSAIDS for long-term pain relief unless advised by a doctor.

1) Ibuprofen (common brand names are Advil and Motrin). Available over the counter in 200mg tablets, you can take two tablets every 6 hours as needed. Prescription strength is 600mg or 800mg (studies have shown the same reported pain relief between 800mg and 600mg doses, but with less risk of stomach ulcers with the lower dose).

2) Naproxen (two common brand names are Aleve and Naprosyn). Available over the counter in 220mg tablets, you can take one or two tablets every 6 hours as needed.

3) Aspirin. Bears mentioning only because it is a very common NSAID, but it is less effective for musculoskeletal pain than Ibuprofen or Naproxen, with higher gastrointestinal toxicity and an anticoagulation effect that lasts for days (vs. hours for the other two). Skip this one.

Naproxen works better than Ibuprofen for some people. Try both to see which you prefer, but do not mix and match them to try to gain more pain relief because taking more than one NSAID will further increase your risk of stomach ulcers.

I listed the common brand names for familarity purposes, but seriously...don't waste money on brand names: you're only paying for their advertising and flashy packaging. The FDA requires that all generic medications have the same active ingredients and the same level of effectiveness as their brand-name counterparts.

# Arm, Wrist and Hand

## Golfers / Tennis Elbow

**Further Reading:**

* Read more about Golfer's Elbow here

### Prevention and Prehab

On things like pull-ups, squats, deadlifts, rows, etc., keeping a STRAIGHT (unflexed) wrist. On pull-ups for example, this means holding the bar with the "hooks" of your fingers rather than the palm of your hand. Loading your arms with a flexed wrist causes many of these problems to begin with. Think of how golfers have to hold a club when they swing and you can see why it's called "golfers" elbow. This holds true for tennis elbow too.

Golfer's elbow — also known as medial epicondylitis — is similar to tennis elbow. But it occurs on the inside — rather than the outside — of your elbow. And it's not limited to golfers. The pain may spread into your forearm and wrist.

Tennis elbow - lateral epilcondilitis - is similar to golfer's elbow. But Tennis elbow occurs on the outside — rather than on the inside — of your elbow.

**Further Reading:**

* http://www.handuniversity.com/topics.asp?Topic\_ID=4

### Recovery and Rehab

* REST, REST, REST. and when you think it's gone, REST. You'll have to wait up to six weeks for the pain to completely dissipate, and only then will it be the trick to prevent it from returning again
* heat pre-wo, ice post-wo
* wrist/forearm strengthening and stretching
* golfers/tennis elbow strap supports (supports the tendon at its' insertion to the bicep)

Many sources of tendonitis can be treated and greatly relieved with trigger point therapy.

**Further Reading:**

* The Trigger Point Therapy Workbook
* Trigger Point Article by Christian Lemburg

# Shoulders

## Rotator Cuff (RC) Weakness / Shoulder Instability

If you've experienced a lot of "snapping, crackling and popping" in your shoulder socket or what feels like a partial dislocation (subluxations), it ain't Rice Crispies. You are probably suffering from RC Weakness. The best way to fix the problem is to strengthen the RC while avoiding exercises that will exploit the weakness. Snatches, overhead squats, pull-overs, upright rows, behind-the-neck presses and behind-the-neck pull-ups will all put your shoulder in a disadvantageous position and exacerbate the problem if one already exists. Focus on keeping "active shoulders" at all times and strengthening the full range of shoulder movements, especially movements that rotate the upper arm in the shoulder socket.

### Prevention and Prehab

With any PUSHING exercise you try to push the arms away from you as hard as you can. For example, in overhead squats you drive the shoulders up the whole time, with handstands you push down into the floor (when upside down) so that your shoulders don't shrug down (also gives more control over the handstand because it activates all the muscles in the shoulder to stabilize the joint), with pushups you push down into the floor especially when working towards planche and dips you depress your shoulder girdle like Tom said.

With any PULLING exercise you generally tend to try to keep the ball of the shoulder in the socket with active shoulders. So with pullups of any variation you might notice that you tend to pull the shoulder ball into the socket before starting any of the exercises especially weighted pullups. The same with any type of rows or inverted pullups. The tendency of the shoulder to pull out of the socket in the pulling movements can cause subluxations/dislocations/strains in people newer to lifting which is why active shoulders is strongly recommended for kipping pullups. Plus, like Roger said earlier it tends to put the shoulder in a more advantageous position for the muscles that are pulling namely the lats and chest.

A few notable exceptions to the pulling 'rule' are disadvantaged lever positions like front lever and cross where pulling/pushing is sort of more blended even though it uses the pulling muscles.

Doing this stretch before your workouts is one of the best things that you can do to keep your shoulders healthy:

File:DC Training Shoulder Stretch

### Recovery and Rehab

As the full compliment of your rehab, I would work on TGU's, overhead presses, pullups, dips, highpulls, and pushups. This will work on pulling and pushing in many planes. Always keep your shoulders strong and active, with your shoulder blades pushing through the force in your hands. When at the top of the dip, push yourself up as high as you can, spread your chest and drive your shoulder blades down through your hands. As you descend into the bottom of the dip, keep your shoulders back and don't let them travel too far forward. If you get pains in the front of your shoulder, it is because your shoulders are moving too far forward. For the highpulls, keep your elbows as high above the bar as possible, hands close but not touching, and shrug your shoulders as your arms raise up. You can do it just from standing or with a sumo-deadlift as well. Pushups, same thing. As you reach the top of the pushup, push through your hands with your shoulders.

**Shoulder Rehab Protocol, 5 Circuits**

File:DieselCrew.com - Shoulder Rehab Protocol

**Further Reading:**

* Rotator Cuff Exercises
* How To Improve Scapular Stability For Healthy Shoulders

# Back

## Lower Back Rounding

This is the infamous "butt wink," This stems from hamstring tightness pulling your lumbar spine at the bottom position. Weak spinal erectors and tight hamstrings are the most frequent culprits. It's actually not a huge issue unless it is severe and will often be present to some extent in all trainees. It's worth noting that butt wink is more severe when there is less weight on the bar rather than more. In other words, just because you are witnessing major butt winking when you do a bodyweight squat, does not mean it's the same when expressed under a loaded barbell.

### Recovery and Rehab

Things you can do to reduce butt wink:

1. Work on calf and hamstring flexibility
2. Do NOT go up on your tiptoes
3. Stretch your hamstrings.
4. Warm-up sufficiently
5. Stretch your hamstrings.

## Lordosis

**Further Reading:**

http://stronglifts.com/lordosis-why-it-causes-lower-back-pain-how-to-fix-it/

# Knees

## Iliotibial Band Syndrome (ITBS)

ITBS, aka runner's knee, is an inflamatory overuse injury commonly felt on the outer (lateral) side of your knee. Usually the pain is at its worst during knee flexion (ie. going down stairs).

Common causes include:

* Leg Length differences
* Flat Feet
* Worn out footwear (ie. irregular soles)
* Increasing workout duration/intensity too excessively
* Running on banked surface (i.e. a running track)
* Running on inclined, declined, or angled surfaces
* Inadequate warmup/cooldown

### Prevention and Prehab

Properly warming up before exercise and cooling down after, plus some stretching will help prevent this syndrome. Also not only is the POSE running technique a more efficient way of running, but if you are a runner, using this technique will greatly diminish the onset of ITBS from ever occurring.

### Recovery and Rehab

* RICE
* Stretching and More Stretching
* Foam rolling
* Trigger point therapy
* Strengthening the adductors
* Walking stiflegged
* IT Band Support Straps

# Legs, Ankles, and Feet

## Shin Splints

Shin splints is the general name given to pain at the front or inner side of the lower leg. Shin splints is not a diagnosis in itself but a description of symptoms of which there could be a number of causes.

**Further Reading:**

* Shin Splints

# Other

## Overtraining

Overtraining is one of the most misunderstood concepts in weight training. People think that if you do too much at once, it is "overtraining," aka "going too hard." What most people consider overtraining is actually known as "overreaching." Overtraining might be better called "under-recovering."

Overtraining isn't something that happens in a single workout or even a single week of workouts, but somthing that progressively builds over weeks and months until you are overtrained. Furthermore overtraining is systemic, so it is impossible to overtrain a single muscle. So doing too many leg curls, or bicep curls, or even squats and deadlift isn't going to make you overtrained. However doing these twice a day every day of the week could overtrain you in several weeks.

In fact there is nothing in existence that will overtrain you after doing it once. Take the fabled widow-maker 20 rep squats for example. People do these with their ten rep max and they take everything out of you, leaving you weeping and bleeding on the floor, a broken shell of a man. Doing this once will not overtrain you, because in the time that you aren't doing it your central nervous system will have time to recover. Doing it 3x/week won't overtrain you because the 4 days that you aren't doing it will allow your CNS to recover. Doing it everyday would overtrain you, because the time that you aren't doing it isn't enough time to recover the CNS.

What makes you overtrained is accumulating more fatigue than your central nervous system has the ability to recovery from. HOWEVER, even if you train balls-to-the-walls 7 days a week your CNS is still able to recover a percentage of that fatigue and that is why it can take so long to become overtrained. Imagine a waitress who refills your coffee slightly faster than you can guzzle it down, maybe by only a sip or two. After a few hours of this the cup will eventually overflow and that is basically what overtraining is. But it takes a long time for this to develop, so don't be overly concerned about what you do today making you overtrained tomorrow. Additionally, as a beginner you'd be hard pressed to overtrain at all on Starting Strength. The amount of fatigue that a novice trainee is able to accumulate is easily recovered from between workouts.

Common symptoms of overtraining are increased heart rate when you awake in the morning, insomnia, decreased appetite, rapid weight loss, irritability, lack of motivation for the gym, and loss of sex drive

**Further Reading:**

* Overtraining: What it is and What it isn't and Why you've stalled
* What About Recovery? by Grag Glassman
* Planned Overtraining

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