Physical Therapists Need to Work to Better Understand CrossFit

As a physical therapist who works with CrossFit athletes I want to address a huge problem we have in my professional community. Many PTs don’t know what to do with CrossFit athletes.

When CrossFit first came on the scene, a lot of PTs would encounter athletes who had injuries from their sport. Perhaps shoulder pain from kipping pull-ups, or low back pain from deadlifts or kettlebell swings, maybe knee pain from box jumps. Whatever it was, it seemed like we were seeing CrossFit injury after CrossFit injury. Was it that CrossFitters were injuring themselves more than other athletes? Was it that their sport was bad and full of terrible ideas and awful coaching? More on this later, but I think what we were seeing was a quick growth of a popular sport (lots of people participating) and a community of people who not only were pushing themselves in the gym, but who were interested in getting better and back into the gym quickly (ie seeking rehab quickly). Unfortunately, when these athletes came into the clinic, rather than addressing the movements and helping them to scale or perform more efficiently or more safely, the practitioner would meet the patient with these comments:

  • “Well that doesn’t sound very safe.”
  • “You probably need to stop doing that.”
  • “You can go ahead and quit CrossFit now because its just a fad.”
  • “Oh man…. CrossFit is going to keep me in business...”

My personal experience was different.

I am part of the cult. I drank the Kool-aid. CrossFit changed my life... Additionally, even in Seattle, where fitness and nutrition are paramount to our culture, I have worked much of my professional career with unhealthy adults riddled by disease.  You don’t see it on the outside –  but they are metabolic disasters – high blood pressure, high cholesterol, sleep apnea, anxiety, depression, skinny fat, workaholics, you name it …

Over time, as I started to treat more and more athletes from the CrossFit community, other practitioners could at least agree with me on one thing: these are people who care about their health. They may have joint pain or a musculoskeletal injury, but if they are no longer taking medication for Diabetes Type 2, can we consider that a win? If they are combating generations of obesity with activity and loving it, that is positive, right?

These athletes care about nutrition, sleep, lifestyle changes to better themselves… they are encouraged by the changes and the challenge that CrossFit brought to their life. They have surrounded themselves with other like-minded folks.

But agreeing on these points was where it ended and to some extent where it continues to end with PTs. In large part, CrossFit is misunderstood and certainly not something which is well respected in the physical therapy community. Despite the positives, CrossFit is described as being aggressive, excessive, cult-like and inappropriate for the masses. The ladies of CrossFit are called ugly by other females (a different topic for a different day .... can we stop with the body shaming already!). The men are labeled as selfishly obsessed with fitness and body fat percentage. The (mis)understanding is that CrossFit athletes cheat form to achieve faster results, aren't real athletes, are fixated on their sport and are generally extreme in all aspects of their personality.

Obviously this perception needs to change. These are gross generalizations and misconceptions of the sport.  I feel that CrossFit has been misrepresented by stereotypes more than any other sport in history. But, what is the problem? What is the solution? How do we move forward to educate a rehab community who doesn’t want to be the bad guy but perhaps doesn’t fully understand the sport and certainly is at a loss for what might be more helpful than just saying: “don’t do that”.

How do we as rehab specialists reel in a patient so that they can not only recover from injury, but return to the gym an improved athlete, more resilient to the risks of their sport? So, to address these questions, let’s address a few truths:


CROSSFIT SEEMS HARD TO DEFINE.

In reality, it has been defined and all the principles and learning materials taught through CrossFit are available here: https://www.crossfit.com/. CrossFit has made every attempt to be transparent to its consumer. Below, a few definitions:

FITNESS

  • CrossFit is advertised, in four words, as “the sport of fitness” 
  • Actual definition of CrossFit: constantly varied, functional movement executed at a high intensity in order to achieve fitness
  • Fitness: work capacity performed across broad time and modal demands
  • Heath: work capacity performed across broad time and modal demands over time (ie. fitness over a lifetime)

 

FUNCTIONAL MOVEMENT

Principles of functional movement (according to CF):  

  • universal motor recruitment patterns 

  • core to extremity movements

  • compound movements—i.e. multi-joint

  • Natural and safe

  • Can produce power.  These movements have the capacity to move large loads over long distances, and to do so quickly

Examples: deadlift – lift something off ground; clean and jerk – get heavy bag of soil into truck bed; kipping pull up – get police officer up and over a fence when running after a criminal

INTENSITY

a few physics definitions:

Force x distance is also defined as WORK.

So, Power = work over time. 

CrossFit defines intensity as power and notes that intensity “is the independent variable most commonly associated with maximizing favorable adaptation to exercise.” In other words, intensity is what gives us results. 

Essentially then, CrossFit is:

constantly varied, functional movement executed with enough power/intensity to achieve fitness.

***

But what does this mean to each patient who walks through your door?  Well, it means something different because every gym programs workouts differently and emphasizes different aspects of CrossFit. If you want to generally learn more about CrossFit, you can do so HERE. I also recommend visiting some of the gyms in your area and getting to know the coaches. Take a class, feel it out. Get a sense of what your patients are participating in, what the coaches are teaching, how the workouts are programmed, what equipment is used, what form is emphasized, etc. You will likely find that the generalizations you hear about are misinformed opinions. Who knows...? You might like it...!


CROSSFIT ATHLETES ARE TREATED DIFFERENTLY THAN OTHER ATHLETES.   

I am met with this myself. If I take a continuing education course and someone sees my quads, they comment with a snicker "whoa! muscle imbalance..." Um, excuse me - shall I call you skinny fat to your face? This is ridiculous behavior.  I worked hard for those quads and frankly, I look better in jeans than you do. These things are silently said in my head as I flash a passive aggressive Seattle smile.

I literally will be walking down the street and someone will ask me what I do for exercise and they’ll tell me that they can tell I work out. I say, “CrossFit” and they will roll their eyes, “of course you do - you guys are crazy…” Even, if I tell them I did ballet for 20 years first, they are stuck on CrossFit. Something about CrossFit is dangerous or sexy or untouchable. But the truth is that really it isn’t … anyone can do it … everyone should.

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I digress, but the point I am trying to make is that this sort of weird response to “what do you do for exercise” happens in healthcare too. If the first thing you do when a patient tells you they are a CrossFitter is roll your eyes or tell them it is inherently dangerous, then you have immediately discredited yourself as someone who could possibly help them. We don’t do this with other athletes who are involved in “dangerous” sports. I recently wrote a blog about how dancing affected my hips … not to mention the eating disorders, self-loathing and perfectionistic personality that resulted. But, as PTs we would never tell a dancer that their sport was dangerous and that they should just stop. What about distance running? Football? Soccer? Concussions anyone…? No. We don’t.

We don’t because we are familiar with these sports and feel that we have some tools to help. We also know that our patients are not going to stop participating in these sports. This is the crucial point! So, we form rapport with the patient and we do our best to help. Why is this different with CrossFit?  It comes down to a lack of understanding.  If you are a practitioner and need help better understanding the sport and how to address issues your patients are facing, please consider contacting me for consulting. But, please don’t shame your patient’s choice to participate in the sport.

My goal as a physical therapist is always to give patients the tools to improve their ability to participate in the things that they wish too. Of course I will be honest with them about my expectations (do your exercises, don’t work through pain, earn the right to progress to the next level or ability) and we will make a gradual and safe return to their sport – but like it or not, my PT goals are not necessarily their goals … their goals need to be considered. Within reason, but we need to work to get people back to the things they want to do!

Usually, the compromise is that I tell these clients that they need to “earn it” – they need to pass my benchmarks for movement positions, efficiency, safety, endurance and strength. But, you know what? My 12-year-old gymnastics patient has to pass her own benchmarks before I allow her back in competition for her floor routine. My 45-year old marathoner has to pass benchmarks before running more than 5 minute intervals if her endurance for good form is limited to that time frame. This treatment style of mine is not unique to my CrossFit patients. This is an approach I use for all my patients, athletes or no. 

Earn your movements and do your exercises.


CROSSFIT IS NOT ALL BAD  

Ok, so moving on…

CrossFit has enormous benefits to the athletes who participate. I have seen people make enormous strides, do things they never (and I never) imagined they could, and become incredibly encouraged and excited by the “sport of fitness”. 

A Ballard CrossFit athlete's first bar muscle up was achieved during the 2016 Open!

A Ballard CrossFit athlete's first bar muscle up was achieved during the 2016 Open!

This woman!  Incredible. 

This woman!  Incredible. 

If CrossFit is a gateway to a lifestyle of fitness prioritization, activity and health, then I say, bring it! As therapists we only see the negatives of CrossFit: injuries, poor form, weird aggressive programming, cringe-worthy YouTube videos, rhabdomyolysis … But, this is not the norm.  At the end of the day CrossFit is fun – just like rugby or intramural softball, bowling, or taking up kick boxing … there are things that could be done better.  But, its fun! And people are enjoying themselves. That should be a factor. Again, as rehab specialists, it is not our role to define what is a bad or good mode of exercise in the world, but rather, to help our patients perform their desired exercise at their level with good technique and a good understanding of the movement standards, progressions, and quality expectations.

And, let’s be realistic here. Most CrossFit athletes are adults… these are adults making decisions for themselves. More often than not, I see ego get in the way of good decisions. In addition to my real-life job as a PT, I am a CrossFit coach. It is not uncommon that I give an athlete in my class the ‘evil eye’ for choosing an inappropriate weight or movement. The members at my gym and my CrossFit patients tease that I have "resting judgy face." But … they know. And they can make a decision. They also know the consequences. It is not the programming or the coaching in these cases … this is the choice of an adult client who is wanting to push themselves. I would argue that regardless of this, this athlete still is getting more input from their CrossFit coaches than they would from the personal trainer giving them a free consult at 24-hour Fitness. We don’t shame our patients who go to those types of gyms, and who knows what they are doing there!?

Again, get to know the gyms and coaches in your area. Start to accept that CrossFit is here to stay and though there are dangers and there is, of course, room for improvement (as there is in any sport), there is a lengthy list of reasons why a patient or client SHOULD be doing CrossFit. Take the story of Constance Tillet: 

All this said, there is bad coaching and programming out there. You know what? There are some awful physical therapists too! If you are educated about the sport and can help promote proper movement, you are aiding in the solution. Don’t assume that just because something is under-studied or misunderstood, it is bad or dangerous. Be informed.


CROSSFIT ATHLETES ARE FUN TO TREAT IN REHAB

CrossFit athletes, just as any other athletes, are incredibly motivated to return to the gym. They listen and they do the work! Here’s the kink though – you need to return them to CrossFit. Manual therapy is helpful. Dry needling – great! Graston technique – these athletes love it. Kinesiotape? Now you’re talking. Restorative exercises: necessary. But, the real meat and potatoes is in returning them to their sport.  You are going to need to see them do these things.  You need to understand the kipping pull up – not just call it dangerous – and actually be able to teach it and help your client improve upon it.

You need to know how to swing a kettlebell, do a handstand, demonstrate variations for ring dip progressions. You need to understand the difference between Olympic Weightlifting and Power Lifting.

Me at CrossFit Belltown receiving training in Olympic Weightlifting at the CrossFit specialty course on Weightlifting 

Me at CrossFit Belltown receiving training in Olympic Weightlifting at the CrossFit specialty course on Weightlifting 

I’m not saying that every PT needs to know everything about CrossFit, but be mindful that this athlete has these functional goals.  If I had a hockey player come to my clinic, I might let them know that I have a friend who better understands the sport and send them that way. But, it is not beneficial to either of us for me to pretend I can help him and then actually tell him all the reasons his sport is dangerous.

Rehab specialists are crucial resources to CrossFit athletes. We can be the bridge between injury and return to sport. But, we have to be willing to learn about CrossFit. We can learn from the sport – I have learned so much by breaking down movements and prescribing the components of a skill as part of a patient’s rehab program. They buy in (doing something they like and knowing that I understand, respect and participate in their sport), and I get the compliance I want. CrossFit is no different than running or dancing or swimming in that there are restorative exercises that can help as well as drills to practice the movement patterns. It is our job then to teach application.


CROSSFIT TECHNIQUE AND PROGRAMMING MATTER

Our main role though, is to determine the root cause of the problem.  It is not enough to decrease pain and return a patient to sport.  We need to pick apart the WHY of the problem.

Is the problem technique?  If you can, watch them do kipping pull ups, squatting, pressing, whatever it is that is the issue.  Even if you aren’t familiar with the sport, you are familiar with what the body is designed to do in these functional positions.  Remember, CrossFit is functional movement – its just performed quickly and with load at times.

Is the patient overtraining with too much volume or too difficult of progressions, weights, rep schemes?  Are they recovering properly with sleep and/or nutrition.  A very common conversation in my clinic happens with athletes over 30 or 40 who are still trying to keep up with the 20 somethings.  Sometimes you need more days off.  You certainly need more sleep and taking an active rest day is important: time to do your mobility, take an Epsom salt bath, time to do your PT exercises.  So, ask about programming and find out if they are overdoing it.

Remember to scale them back to their sport, just as you would with any other sport.  There is no protocol for a return to CrossFit (CrossFit is so many exercises we cannot easily make this objective!). But, we need to consider: volume, weight, difficulty, and type of movement (strength, cardio, gymnastics) as we write their programs.  Discuss return with the patient’s coach and make sure that your patient is willing to dial it back because again, more often than not, it is adult decision making influenced by ego that is a problem.

CrossFit is here to stay so remind your patients of that.  It will be there when they are pain-free/moving better, appropriate to be Rx’ing workouts again. Keep modifying a workout until the patient is ready for full return.  Supplement CrossFit WODs with accessory work to drill positions, strengthen weaknesses, mobilize tightness and improve endurance for these positions.

Me congratulating a Ballard CrossFit athlete after an Open workout in 2016!

Me congratulating a Ballard CrossFit athlete after an Open workout in 2016!

Enjoy these patients.  They are fun to work with.  And, again, for CrossFit questions, feel free to contact me at Arrow Physical Therapy!