10 Critical Principles Physical Therapists Need to Know About Crossfit for Successful Rehabilitation

By djpope

December 22, 2013

Crossfit, injury, physical therapy, Rehabilitation


1) What Crossfit is:

I field emails every day with questions about crossfit injuries.  The biggest complaint I hear from these individuals about other physical therapists is that they don’t understand crossfit.  Obviously, understanding what you’re trying to send your patients back to and what they’ll have to be capable of performing is going to be critically important in the rehab process.

To add to that, the amount of misinformation and bias out there in regards to crossfit is staggering.  I can’t tell you how many times I’ve been wearing a crossfit shirt and I’ll hear negative remarks about crossfit from other therapists who have never even set a foot in a crossfit gym or have any idea of what crossfit even is.  

I was at CSM (Combined sections meeting, a very large physical therapy conference) and one of the presenters named Joe Black made a very interesting statement.  He sends his patients to crossfit after therapy to address some of the problems he found in therapy.  He believes that crossfit can be helpful in the rehab process (With a well designed program I completely agree).  This was a very refreshing statement.  Many therapists hold the completely opposite opinion.  In fact there was a whole presentation at CSM that year talking about the dangers of high intensity programs like crossfit.

After Joe’s statement you wouldn’t believe the gasps from the audience.  They sounded disgusted.  You would have thought that Joe just took off his shirt and looked just like Edward Norton from American History X.

Edward Norton

Obviously there is a lot of negative belief about crossfit in the therapy world.  Crossfit is certainly not a perfect system and I don’t mean to raise it up on a pedestal but crossfit is certainly not the demon it is made out to be.  I really feel that this sentiment is largely based in a lack of understanding of crossfit in general.

To this date there is very little research to objectively measure risk of injury in crossfitters.  However, the research that is out there thus far demonstrates crossfit as about as risky as competitive weightlifting and powerlifting.   In this particular study crossfit demonstrated a 10 times decreased risk of injury compared to recreational running.  (Chris Beardsley puts this information into perspective in his review of this particular study HERE).  If you’re familiar with the research on risk of injury in sports you’ll know that competitive weightlifting and powerlifting is among the safest of sports, contrary to popular belief.  (Meanwhile it’s fine to have 8 year olds bash their heads together in american football, sorry just venting).  Purely recreational running has been shown to be much more risky but physical therapists routinely treat runners to get them back to running without as much negative sentiment.

If you really want to learn more about crossfit (and I really feel you should if you’re seeing the population) then you can find out more HERE.  Visit some of the gyms you’re getting patients from.  Take a few classes, befriend the coaches.  It’s going to make a world of difference for your patients.

2) Crossfit Athletes go to Physical Therapists and Other Rehab Specialists because they want to Return to Crossfit.  

HammerOne of the fastest ways to drive away and destroy rapport with crossfitters is to tell them what they’re doing is inherently dangerous.  We just spoke before how this isn’t really true and physical therapists already don’t have the best rapport with crossfitters because of the above stated stigmas.  When I introduce myself to crossfit coaches as a therapist I’ll commonly be asked, “what kind of therapist are you?” as if to see if I’m on board with the whole idea of crossfit or not. My goal as a physio treatment is to give patients the tools to promote longevity in their sports and other recreational activities.  Instead of stating that crossfit will eventually hurt you, let’s figure out how we can keep people healthy.  Not everyone will be able to return to every aspect of crossfit, but we should be trying if it’s reasonable and our patients desire it.

3) Crossfit Has Enormous Benefit to Patients

As therapists we only see the dark side of crossfit.  We see the injuries.  We hear about rhabdo.  We hear biased comments from the strength and conditioning community.   We see the youtube videos.  We start to think that crossfit is a cult of people performing high rep barbell exercises poorly while standing on kettlebells because they aren’t being taught how to exercise properly.  Obviously this isn’t the case.  The crossfit coaches I’ve met have been some of the brightest trainers and are generally very passionate about their jobs.

As a therapist I’m constantly racking my brain to figure out how to get people more active and to engage in better lifestyle decisions.  If you’ve ever been a personal trainer then you can understand just how difficult it is to get people moving more and getting healthy.  Crossfit is making our jobs easier.  It’s espousing all of these things and people are getting pumped about it.

Side Note: For some reason there has always been a social stigma toward people who are making positive changes in their lives.  Why is it a bad thing that people are so excited about fitness?  Shouldn’t we be more concerned about people whose social outlets are riddled with alcohol, drug use and copious amounts of pork roll?  I’m pretty sure drinking alcohol, eating poorly and staying up too late at night is worse then eating paleo, drinking coconut water, working hard and getting to bed early (Even though the latter is less socially acceptable).  We can work with a few injured people.  I’d be much happier to see some more shoulder impingement and less diabetes, heart disease and morbid obesity.

4) Crossfitters Are Not the Typical Patient

madelyn-maddy-curley-female-crossfit-athlete-sweat-for-it4Crossfitters generally love high intensity, difficult exercise.  They are not afraid to push, it’s usually one of the reasons they are attracted to crossfit in the first place.  Many crossfitters have a background in sports or other forms of high intensity exercise.  If you treat these patients like the 65 year old total knee replacement patient that they’re sitting next to, chances are they will start to doubt what it is you’re doing with them.  I’m not saying we should prematurely throw too much at these patients but if your clinic has nothing but fluorescent dumbbells and your patients are only getting basic therapy exercises, chances are you’re missing the mark, and your patients will feel this way.

Crossfit athletes use kettlebells, barbells and gymnastic rings.  If you’re looking to return these athletes to crossfit then their program should most likely contain these tools.  Crossfit athletes also perform high intensity exercise.  Some of your therapy might end up getting these patients pretty sweaty.  This is the language of crossfit.  I go have a catch with my baseball patients when they’re ready for it.  I take my crossfit patients to the olympic lifting platform when they’re ready for it also.

5) Physical Therapists and Rehab Professionals can be of Tremendous Benefit to these Athletes

Therapists can be of benefit not just for getting these individuals out of pain, but in returning to crossfit, addressing additional issues down the kinetic chain, screening for risk of injury and educating patients about the body and proper biomechanics during exercise.  In my mind this is the same as returning post ACL repair patients back to their sport.  Therapists have a tremendous set of skills and in my opinion, largely undervalue their abilities.

6) Different Crossfitters have Different Goals

Not everyone wants to squat 500lbs or make it to the crossfit games, but some do.  This is one of the first questions I’ll ask these athletes.  Do you want to be competitive?  How competitive?  Do you care about getting really strong?  Is your main goal to be able to play with your kids and keep your body strong and healthy?   This makes an enormous difference in the rehab process.  Often times our biases can get in the way of seeing what our patients really want.  We can’t lump all “crossfitters” into the same boat.  Our therapy should reflect the patient’s goals as an individual.

7) Crossfit is Getting Extremely Popular

One of the potential reasons therapists are seeing more crossfit injuries is simply because more and more people are engaging in crossfit.  I continue to see runners on a daily basis with injuries and I know one of the reasons this is occurring is simply because there are so many runners out there.  This is all the more reason to start learning more about crossfit.

8) Exercise Technique, Programming, Modification and Progression is Pivotal

rorym_USAW_HBergeron_SnatchIn my opinion our jobs as therapists is not only to get our patient out of pain but to figure out why they got hurt in the first place and to correct it.  To do this we’re going to have to have some sort of idea of what movements our patients are going to be doing in the gym and what safe technique looks like.  Once someone’s knee pain has died down, let’s load these patients up with a squat and see how it looks.  Shoulders hurt?  What does your press look like? etc etc.

Another thing to think about is the patient’s exercise program.  If your patient has knee pain, are they squatting 4-5 times per week?  Maybe they need to decrease the volume and frequency some.  Crossfit has a lot of shoulder intensive exercise.  Is their crossfit coach programming enough rest and modifying frequency, volume and intensity accordingly?  I spend copious amounts of time developing smart programming for competitive crossfitters that takes these things into consideration that you can learn more about HERE.

Another thing to keep in mind is that every individual will have an optimal dosage of exercise.  Most crossfit gyms attempt to program based on their population.   Keep in mind that crossfit is a group exercise program and not every person will fit the standard program provided by their gym.  Therapists can help patients to learn how to modify the program at their gym and how to bridge back to their normal routine post injury.

Most crossfit gyms also have some sort of progression for new members.  Not everyone who comes through the door is doing muscle-ups, high rep snatches and butterfly pullups on the first day and most people probably have no business trying these things on the first day.  As a crossfit coach and athlete I feel very comfortable teaching my patients better exercise technique and reviewing programming but if you don’t have this knowledge then speaking with the patient’s crossfit coach is going to be very important.

9) Graduated Return to Crossfit is Extremely Important


We know the reinjury rates are very high for our patients when they return to sport.  We’ve seen great benefit for bridging programs for return to sport.  I regularly prescribe long ball toss programs to my pitchers returning to sport and the Santa Monica PEP program to my ACL patients returning to sport.  Just like these sports we need to bridge our patients back to their sport.  I want to see how my achilles tendinopathy patients tolerate crossfit movements like double unders and box jumps before they go back to the gym and try them on their own.  You can bet there will be a gentle progression of exercises before my patients jump straight back into their previous routine.  I’ll also put my patients through a crossfit workout right in the clinic to see how things shake out in a controlled environment before they’re thrown back in the fire at their own gym.

I get a bit concerned when I see patients return from an injury and jump straight back into their regular programming.  If you don’t have the tools or know how to do this, then speak with their crossfit coach.  I know very little about swimming technique and don’t pretend to.  I’ll communicate with that athlete’s swim coach though to troubleshoot technique and get that patient back swimming in a smart way.  Most crossfit coaches are very passionate about helping their clients and are very open to suggestions from therapists. (We could also learn quite a bit from the coaches)

10) The Entire Kinetic Chain is Extremely Important in Crossfit Athletes

Crossfit emphasizes full range of motion in every exercise.   For example, if someone lacks ankle mobility, hip and core stability, thoracic extension, scapular stability then they’re going to have trouble with some of the basic crossfit exercises like snatch and clean and jerk.  If that athlete has shoulder pain during snatching it could be coming from an ankle restriction.  I like to use the Selective Functional Movement Assessment (SFMA) or Functional Movement Screen (FMS) as well as looking at the basic crossfit movements in order to break down where the problem is coming from and come up with a comprehensive program to treat the patient.

Tools like the FMS and Y-balance tests can also be used to assess risk of injury, identify some issues that might be leading to the patient’s pain and to help direct future treatment.

So there you have it.  I admit I did release a bit of steam with this article but hopefully it was all good information!  Crossfit in general is poorly understood and I don’t think it’s fair to condemn something because we don’t understand it.

I have a lot of fun working with crossfitters and I hope you do too,

Dan Pope DPT, CSCS

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