As a Sports Physiotherapist (and Crossfit enthusiast), I take notice when people in my Box complain of pain. The shoulder seem to be the most common area of complaint amongst my peers, and according to this article the shoulder is indeed the most common area of injury in Crossfit.


Why the Shoulder?

The prevalence of shoulder injuries during Crossfit may be due to the following reasons…

1) Certain movements in Crossfit (kipping , handstand pushups, overhead squat to think of a few) require the shoulder to be loaded in positions that are beyond their usual everyday physiological motion.
2) Due to the high number of repetitions performed during Crossfit workouts, fatigue of the shoulder muscles often occurs. Muscular fatigue may contribute to loss of proper exercise technique and resultant injury.
3) Muscular fatigue may be more problematic for a shallow ball and socket joint like the shoulder (see Fig 1) which relies on sustained muscular activation for congruency (ref)

    Figure 1 : Shallow ball and Socket joint



So whats wrong with my shoulder?

The first job of a physiotherapist when assessing the shoulder is to come up with a hypothesis to whats causing the shoulder pain. The physiotherapists need to decide if…..

1) The cause of the shoulder pain is actually the shoulder, or if it is referred from other structures (ie the neck).
2) The pain is related to a stiff shoulder ( Frozen shoulders and arthritic shoulders fit into this category)
3) The pain is related to an unstable shoulder (dislocations and subluxations)
4) The pain is related to soft tissues of the shoulder
5) There are a combination of factors at play

Most Crossfit injuries are related to number 4, soft tissues of the shoulder.

Soft tissue structures that surround the shoulder (tendons, muscles, ligaments, bursae) are all interwoven and interconnected. We used to think that we could test these structures individually , but to date research has shown that we cant. Therefore a common term has been coined to encompass all soft tissue shoulder injuries including subacromial pain (impingement) syndrome, bursitis, rotator cuff tendinopathy, biceps tendinopathy and symptomatic rotator cuff tears. This term is called Rotator cuff related shoulder pain (RCRSP) (ref)


What are the signs and symptoms of a soft tissue injury to the shoulder or RCRSP?

Most people with RCRSP have shoulder pain around the deltoid area (see Fig 2) or upper shoulder. Pain is activity related, typically worse when reaching overhead or behind the back, with minimal pain at rest except when lying on shoulder (ref). Some stiffness or restriction of range can occur in this group but its usually mild.

                   Figure 2: Area of RCRSP


Can an Xray or MRI help with my diagnosis?

Imaging of the shoulder (scans , x-rays etc) is often not helpful in helping to form a diagnosis. It has been shown that there is a poor correlation between the pain a patient feels and the structural pathology seen on his scan (read here for more detail on this). Imaging can however be useful to rule out fractures, cancer and sinister pathology.


How do I know my shoulder pain is soft tissue related and not a frozen shoulder or an unstable shoulder?

Frozen shoulders are extremely painful and present with much more joint stiffness than soft tissue injuries of the shoulder. Patients with true frozen shoulder have a very hard time lifting their arm, putting their arm behind their back and externally rotating their shoulder. If your shoulder has come out of its socket in the past, or if it frequently feels like it may come out of the socket, you may have an unstable shoulder. 


I think i have a soft tissue injury of the shoulder- What can i do?

In most cases (but not all) load needs to be reduced for a period of time. This does not necessarily mean stopping all load on the shoulder. It may mean reducing load, changing angle of load, reducing repetitions of load or reducing frequency of load.

As a rule of thumb i often tell my patients that some pain is allowed during training but it needs to be manageable. The most important factor is how the shoulder feels within 24hours of loading. If pain settles quickly within 24 hours after load and there is no flare up of pain, then the load is usually a good amount. If the shoulder feels worse after load and takes more than 24 hours to settle then the load is probably to much for the shoulder at this point and needs to be decreased. As the pain improves more load can be added to the shoulder


The role of the physiotherapist

A physiotherapist would be able to differentiate between all the 5 groups of pathologies above via some questions and simple movement tests. Neuromodulatory techniques (soft tissue work, mobilizations, acupunctures,taping) can be used to decrease shoulder pain.
Most importantly a physio should educate you about load management and give you a personalized exercise programme in order to load the shoulder in the right way. 


How long will my shoulder take to get better

Every person is different and many factors influence how much pain a patient feels and how quickly they recover. Most RCRSP should improve between 6-12 weeks with the right management, but some will take longer.


Should I stop crossfit

No! Even if you need to offload the shoulder for a few weeks, there are other exercises you can do to maintain fitness and strength. Crossfit has NOT been shown to cause more injuries then many other sports, and as we all know, exercising has many more benefits then not exercising!




All information, content, material of this article is for informational puposes inly and is not intended to serve as a substitute for the consultantion, diagnosis and/or medical treatment of a qualified healthcare provider.
















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