The Physician and Sportsmedicine

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ipsm20

Injury in CrossFit®: A Systematic Review of

Epidemiology and Risk Factors

Miguel Ángel Rodríguez , Pablo García-Calleja , Nicolás Terrados , Irene

Crespo , Miguel del Valle & Hugo Olmedillas

To cite this article: Miguel Ángel Rodríguez , Pablo García-Calleja , Nicolás Terrados ,
Irene Crespo , Miguel del Valle & Hugo Olmedillas (2020): Injury in CrossFit®: A Systematic
Review of Epidemiology and Risk Factors, The Physician and Sportsmedicine, DOI:
10.1080/00913847.2020.1864675

To link to this article: https://doi.org/10.1080/00913847.2020.1864675

Accepted author version posted online: 15

Dec 2020.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ipsm20
Publisher: Taylor & Francis & Informa UK Limited, trading as Taylor & Francis Group

Journal: The Physician and Sportsmedicine

DOI: 10.1080/00913847.2020.1864675

Injury in CrossFit®: A Systematic Review of

Epidemiology and Risk Factors

T
IP
Injury in CrossFit®

R
Miguel Ángel Rodríguez (graduate)1 , Pablo García-Calleja (graduate)1, Nicolás Terrados

SC
(PhD) 2,3, Irene Crespo (PhD)1,4, Miguel del Valle (professor)5 and Hugo Olmedillas (PhD)1,3

U
AN
1. Department of Functional Biology, University of Oviedo, Oviedo, Spain.

2. Unidad Regional de Medicina Deportiva, Avilés.

M

3. Health Research Institute of the Principality of Asturias (ISPA), Oviedo, Spain.

D

4. Institute of Biomedicine, University of León, León, Spain.

TE

5. Department of Cellular Morphology and Biology. University de Oviedo, Oviedo, Spain.

EP

*Correspondence:
C

Hugo Olmedillas, PhD

AC

Departamento de Biología Funcional

Área de Educación Física
Universidad de Oviedo
Campus del Cristo B
C/ Julián Claveria s/n
33006 Oviedo, Spain
Phone : +34.985104208
E-mail: olmedillashugo@uniovi

1
Funding

The author(s) received no financial support for the research, authorship and/or publication of

this article.

Author Contributions

MA.R and H.O were responsible for conception and design and for the search procedure.

T
MA.R, H.O, and P.G.C were responsible for the analysis of the data. All authors made substantial

IP
contributions to conception and design and interpretation of the data, drafted the manuscript and

R
gave final approval of the final version.

SC
Injury in CrossFit® training: A Systematic Review
of Epidemiology and Risk Factors U
AN
M
D
TE
EP
C
AC

2
 T
IP
R
Abstract

SC
Objective: To review the characteristics of the injuries among CrossFit® practitioners, including

U
prevalence and incidence, nature, location and risk factors.
AN
Methods: PubMed/MEDLINE, EMBASE, Web of Science, Scopus, and SPORTDiscus databases

were searched from inception through August 2020, and English-language articles reporting on
M

CrossFit®-related injuries were included. Data including sample (sex, age and demographics) and
D

injuries’ characteristics (prevalence, incidence rate, nature, location, percentage of injuries requiring
TE

surgery andrisk factors) were extracted.

Results: Overall, twenty-five studies involving a total of 12,079 CrossFit® practitioners met the
EP

inclusion criteria. The mean prevalence of injuries among the included studies was 35.3%, with an
C

incidence rate varying between 0.2 and 18.9 per 1000 hours of training. The most injured areas were
AC

shoulder (26%), spine (24%) and knee (18%). Among the studies that reported the injuries requiring

surgery, the mean percentage was 8.7%. Regarding the risk factors associated with injuries, older

age, male sex, a greater body mass index, the existence of previous injuries, the lack of coach

supervision, the experience on CrossFit® and the participation in competitions were reported by the

studies.

Conclusions: CrossFit® training has an injury incidence rate similar to weightlifting and

3
powerlifting. Findings from the studies suggest that the most affected areas are shoulder, spine and

knee. The limited quality of the studies prevents us from draw solid conclusions about injury risk

factors.

Level of Evidence of the Included Studies: III

Keywords: high-intensity functional training; athletic injuries; incidence; risk factors.

T
IP
R
Introduction

SC
CrossFit® is an emerging physical conditioning program based on constantly varied, high-

intensity, multi-joint functional movements. [1] The number of practitioners has grown

U
considerably in the last few years, with over 15,000 affiliates worldwide. [2] This training model
AN
has demonstrated to improve cardio-respiratory fitness, stamina, strength, power, balance and

flexibility, [3] which are determining parameters in fitness and health status. Training is scheduled
M

as daily sessions called “workouts of the day” (WODs), which are composed of different exercise
D

modalities including calisthenics (pull-ups, rope climb, burpees, etc.), metabolic conditioning
TE

(cardiovascular exercises such as running or skip rope) and weightlifting, which includes both

Olympic (snatch and clean and jerk) [4] and powerlifting movements (squat, bench press and
EP

deadlift). [5,6] The risk of injury in these sports modalities is similar in comparison with other non-
C

weightlifting and powerlifting, [7] although the demanding training programs have been suggested
AC

to increase this risk, especially when they are performed inappropriately. An excess in volume loads

and in the number of training sessions can lead to early fatigue, higher perception of effort and a

risky movement execution. [8] Given the growing popularity of CrossFit®, proper education is

necessary for athletes in order to avoid possible risks arising from bad practice. The analysis of

injury patterns constitutes a fundamental part of this process, allowing athletes, coaches and

healthcare professionals a better knowledge about the inappropriate habits that harm physical

4
integrity and how to heal it. There are some reviews in the literature on injuries in CrossFit®, [3,9–

12] but ours is the only systematic review focused exclusively on injuries that has included all the

studies published on this topic to date. Consequently, the purpose of this systematic review was to

collect and summarize the characteristics of CrossFit®-related injuries, including epidemiology,

location, type of injury and risk factors.

T
IP
R
Materials and Methods

SC
The study was conducted in accordance with the methods outlined in the Cochrane

U
Handbook and is reported according to the PRISMA (Preferred Reporting Items for Systematic
AN
Reviews and Meta-Analyses) statement. [13]

Search Strategy and Eligibility

M

All studies were identified through a search on electronic databases, including

D

PubMed/MEDLINE, EMBASE, Web of Science, Scopus, and SPORTDiscus, from inception until
TE

August 16th, 2020. Reference lists of the included articles were also searched for additional

references. The following search terms were applied for each database: “high-intensity functional
EP

training”, “CrossFit”, “athletic injuries” and “injury”, and were combined using the Boolean
C

operators “OR” and “AND”. No limitations on dates of publication were applied. Details of the
AC

search strategy for PubMed/MEDLINE are shown in Appendix 1.

Inclusion criteria consisted of the following: (1) include CrossFit® practitioners, (2) analyze

musculoskeletal injuries in this population (prevalence, incidence, nature, location and/or risk

factors), and (3) have been published in English.

Articles were excluded if were published only in abstract format, or were a case studies or

reviews.

5
 Screening

Two reviewers independently screened the titles and abstracts of all studies. Duplicate

articles were removed using Mendeley reference manager. Both reviewers assessed the full text of

all potentially eligible articles identified in order to evaluate their possible inclusion in the review.

Disagreements over article inclusion were settled through discussion with a third reviewer until

T
IP
consensus was reached.

R
Data Extraction and Risk of Bias Assessment

SC
Data were extracted in duplicate and independently by two reviewers using an electronic

U
data extraction form. The data extracted included the following: author and year, characteristics of
AN
participants (number, sex and age) and data referred to injuries (prevalence, incidence and

percentage of the main regions affected). The Centre for Evidence-Based Medicine (EBM) level of
M

evidence was used to rate each study. [14] The level of evidence assesses research design quality.
D

Two reviewers independently assessed the methodological quality of the included studies using the
TE

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. [15]
EP

Data Analysis
C

Results for injury prevalence and location are displayed as percentages, while data referred
AC

to injury incidence are presented as the number of reported injuries per 1000 hours of training.

Because of the low levels of evidence and the retrospective nature of the included studies,

the pooling of results for meta-analysis was not performed. Instead, a descriptive analysis was

carried out, and the statistics of the outcome measures were shown as averages when possible

(injury locations and prevalence) and as a narrative description otherwise (type of injury, risk

6
factors, etc.

Results

Selection of the Studies

T
As reported in Figure 1, the search strategy retrieved 280 records. After duplicates were

IP
removed, 127 studies remained in the review process, of which 91 were excluded after title and/or

R
abstract analysis; 36 full-text copies of the remaining studies were obtained and subjected to further

SC
evaluation. The full text of the 36 remaining articles was screened, leading to the exclusion of 11

publications. At the end of the process, 25 publications meeting the eligibility criteria were included

U
for qualitative analysis. [16–40] It is worth noting that two articles analyzed data extracted from the
AN
same study. [26,27]
M

Study Characteristics

The characteristics of the included studies are summarized in Table 1. The studies included
D
TE

were retrospective excepted three which were conducted prospectively. [19,24,30] Four studies

obtained information of the injuries through medical records of hospitals or sports medicine clinics,
EP

[18,27,36,37] while the rest collected data by conducting printed or electronic self-reported surveys.
C

Participant Characteristics
AC

Overall, 12,079 subjects were included in the qualitative analysis. The number ranged from

54 [17] to 3,049. [38] Except for two (n=685) that did not report the gender, [18,29] 6,454 males

and 4,940 females participated in the investigations. The average age of participants varied between

25.2 [26,27] and 38.8 years. [37]

Injury Profile

7
 Prevalence and Incidence

The mean prevalence of musculoskeletal injuries was 35.3% (ranging from 12.8% [24] to

73.5% [40] among the studies). The incidence rate varied between 0.2 [39] and 18.9 [30] per 1000

hours of training.

T
IP
Nature and Location

R
Six studies collected the type of injuries, reporting that tendinopathies, [30,31] joint injuries

SC
[22,28,30,33] and muscle injuries (e.g.: strains) [22,26,30] were the most frequent. By contrast,

fractures and dislocations were found to be less prevalent.

U
AN
Overall, the shoulder (26% of the total injuries), the spine, (24%) and the knee (18%) were

the injuries most reported (Figure 2). Eleven studies described the shoulder as the area most
M

frequently injured, [21–23,28,30,32–35,38,40] six reported the spine [16–20,24] and three, the

knee. [26,36,37] Among the spine injuries, lower back was the most affected area (80.3% of total
D

spine injuries). [18,20–23,28,30,33]

TE

Five studies offered the time lost data from CrossFit® practice. The most frequent lost time
EP

described by the studies ranged from one week to more than two weeks. [20,25,29,31,33] Six

studies indicated the number of injuries requiring surgery, [18,26,29,35,36,40] which were 8.7% of
C

the total. Two studies specified the areas subjected to a surgical intervention, and concluded that the
AC

knee were the most predisposed joint requiring surgery (51.25% of total surgeries). [35,36]

Risk factors

8
 The vast majority of injuries were caused by weightlifting movements, [24,29,33,34]

specially the following exercises: deadlift, [16,24,34] snatch, [24,34] clean and jerk, [34] squat [16]

and overhead press. [24]

Furthermore, the incidence of muscle injuries has been related to the time of participation

in CrossFit®, [16,21,23,25,28,30,32,35,38,39] the existence of previous injuries, [17,24,28,30] the

weekly training frequency, [16,20,22,23] the participation in competitions [16,22,23,28,32,35] and

T
IP
male sex. [24,27,33] (Figure 3) Other factors as advanced age, [37] stretching before CrossFit®

practice, [16] alternating different training loads, [30] and do not visit a physical therapist on a

R
SC
regular basis [20] have also been mentioned as associated risk elements.

Study Quality
U
Overall, twenty cross-sectional [16–18,20–23,25–29,31–33,35–40] and four cohort studies
AN
[19,24,30,34] were part of this systematic review. All the studies have a level III of evidence, and

there were no randomized controlled trials or level 1 studies included. The results of the quality
M

assessment are presented in Appendix 2.

D
TE

Discussion
EP

This systematic review concluded a prevalence of injuries of 35.3%, with an incidence rate
C

ranging from 0.2 to 18.9 per 1000 hours of training. Shoulder, spine and knee were the most injured
AC

areas, with a mean of 8.7% injuries requiring surgery. Older age, male sex, a greater body mass

index, the existence of previous injuries, the lack of coach supervision, the experience on CrossFit®

and the participation in competitions were indicated as possible risk factors for the development of

injuries.

9
Prevalence and incidence rate

The incidence rates comparable both to the rates found in team sports as soccer or

rugby (3-4.2 injuries per 1000 hours), [9] and related sports as weightlifting (2.4-3.3) and

powerlifting (1.0-4.4). [7] This similarity is not surprising, since these modalities are an

essential part of CrossFit® training along with gymnastics and metabolic conditioning.

T
However, injury rates were higher than bodybuilding (0.2-1) and much lower in comparison

IP
with Strongman (4.5-6.1). [41] It is noteworthy that three studies showed higher incidence

R
rates per 1000 hours: 7.1, [32] 9.5, [19] and 18.9. [30] These discrepancies with respect to

SC
other studies could be related to a response bias, although there are not apparent causes that

explain this controversy.

U
AN
Injury location

Regarding the location of the injuries, shoulder, spine and knee were the most
M

damaged areas. Shoulder injuries are commonly experienced by gymnasts [42] and both
D

weightlifters and powerlifters. [7] This study did not aim to find the positions that may have
TE

led to injuries, but we speculate thatmovements as pull-ups, bar dips or rope climb have a

large demand on shoulder range or motion and stability, while others as the bench press and
EP

the snatch force the shoulder to a position of extreme flexion and abduction. With respect to

the most harmful discipline, a similar distribution was reported between gymnastics (49% of
C

total injuries) and weightlifting (51%), according to the study by Summit et al., [29] which
AC

focused exclusively on shoulder injuries. In relation to lower lumbar spine injuries, exercises

as squat and deadlift may be prone to increased risk, since they are performed with heavy

loads and high speeds. Moreover, these movements require a repetitive hyperextension of

the lower back and a correct alignment of the spine throughout each repetition, so the fatigue

generated by the large number of repetitions can prevent an adequate technique and increase

10
 the risk of spondylolysis back injuries. [18] In addition, other essential-CrossFit® exercise

as the tire flip can also contribute to low back injuries, since this discipline requires lumbar

spine to make constant flexo-extension movements to displace the tire. In connection with

the above, the knee plays a decisive role in load- carrying, being a particular load-bearing

joint in which soft tissues act as the major stabilizing factors. [43] Knee injuries required

frequently surgical intervention, so this joint constitutes a delicate area. Although only two

T
IP
studies reported the number of knee injuries treated by surgery and these results may not be

conclusive, more than a half of the knee injuries required surgical intervention. [35,36]

R
SC
Similar results have been obtained in a large epidemiological study on several sport

disciplines, with 80% of the knee injuries resulting in surgery. [44] In order to reducing knee

U
injuries associated to powerlifting movements, a well-learned correct technique under expert
AN
supervision and with progressive loads seems to enough to protect knee structures. [45]

Additionally, it has been concluded that quadriceps fatigue is an important factor to consider
M

during the execution of a squat exercise. An excessive fatigue may affect lifting technique by
D

performing a stoop (back) lift rather than a squat lift, increasing the risk of low-back injuries.
TE

[46]
EP

Risk factors
C

Several factors have been related with the development of injuries during CrossFit®
AC

practice. Regarding biological characteristics, an older age was a significant risk factor in

two studies, [21,37 ] while the gender also seems to have influence, since males were found

to be most prone to suffer injuries. [24,27,33] Certain anthropometric characteristics have

been suggested to increase the risk of injury, since those participants who are larger are more

likely to train with higher loads. [23] Another risk factor is the history of previous injuries,

[17,24,28,30] which is currently well documented in the literature referred to other sports.

11
[47,48]

Regarding the factors related to CrossFit®, a longer period of training has been

significantly associated with a greater number of injuries. [16,23,25,28,32,35,38]

Accordingly, Sprey et al. [25] concluded that those athletes who have participated in

CrossFit® for more than six months were 70% more prone to become injured, regardless of

T
the other characteristics assessed. This result could be explained by a greater exposure in

IP
training or competing, which equates a greater chance of injury. In this context, greater

R
weekly training hours [16,20,23] was found to be significantly associated with a high rate of

SC
injuries. This situation agrees with the certainty that high-performance sport exposes athletes

to risky behaviors, compromising health and maximizing the risk of injuries. [49]

U
Otherwise, two of the included studies report an inverse association, concluding a
AN
greater risk of injury in those athletes with less experience in CrossFit®, [25] and in those

with lower weekly training hours. [21,39] Furthermore, the study by Minghelli & Vicente
M

[22] reported an inverse association between competing and being more susceptible to
D

injuries, which can be due to a best physical condition in CrossFit® competitors. It is

TE

expected that beginners are more likely to be injured as a consequence of the complexity and

the extreme demand of CrossFit® programs, which are frequently performed with high loads
EP

and an improper technique. Hence, factors such as grip width, speed of movement, barbell
C

positioning, and direction of gaze might increase the risk of injury when their execution is
AC

not correct. [50] In this regard, it would be convenient for CrossFit® centers to include

scaling workouts (on-ramp classes) for novice participants, with the aim of establishing a

gradual individualized progress and prevent potential overuse injuries.

Strengths and Limitations

Although other reviews have been made on injuries and CrossFit®, the strength of our

12
systematic review lies in being the first that has comprehensively examined the existing

literature and has included all the studies on this topic to date. In this regard, the study by

Gianzina et al. [3] performed a complete review of both risk and benefits from CrossFit®

practice, but it is not such specific as our review (they have eight of the twenty-five studies

included in our review). Tibana et al. [10] performed a narrative review about injuries in

participants of extreme conditioning programs, being not exclusive of CrossFit®

T
IP
practitioners. The systematic review by Dominski et al. [12] is the most similar in design to

ours, but we have appreciated that they finished the search in 2017, and only seven of the

R
SC
twenty-five studies encompassed in our systematic review were analyzed. In this regard,

several studies have been published in 2020. [16,19,20,26,27,30,32,39] Our systematic

U
review also differs from those of Claudino et al. [11] and Klimek et al., [9] which have
AN
included a very small number of studies (six and three, respectively), so our review offers a

more representative perspective of the whole literature on the topic.

M

There are several limitations relative to the design of the studies included that are
D

worth mentioning. First, the definition of “injury” used by the included studies is an
TE

important bias. Ten studies used a complete and clear definition of injury, [19–

21,25,28,29,33,35,38,39] but the rest of studies differed in their definitions, which were
EP

diverse from each other (Table 2). As example, the study by Hak et al. [40] defined injury as

“any injury sustained during training which prevented the participant training, working or
C

competing in any way and for any period of time”. This definition could be considered
AC

ambiguous, and it may be related with the percentage of injury prevalence (73.5%)

concluded in this study, which were much higher than others. The different level and

proficiency of the practitioners and the coach supervision could undermine the results and

would have been analyzed by all the studies. Second, the retrospective nature of the includes

studies (excepting three [19,24,30]) introduces the risk of recall bias, since participants who

13
 have been injured during the period of time analyzed may have forgotten the exact number

of injuries or the body regions affected. This design prevents knowing the predictors of

injuries, so studies with a prospective approach should be carried out in order to recognize

the specific cause of injuries. Thus, it has been suggested that injuries which symptoms

extends over time or need medical attention are usually more remembered than minor

injuries. [51] Furthermore, only four studies resorted to medical sources to obtain the data,

T
IP
[18,27,36,37] so the self-reported diagnosis (through surveys) used by the rest of

investigations might be prone to a misdiagnosis, and the total number of injuries can be

R
SC
underreported or misinterpreted. In this regard, collecting data through questionnaires

constitutes another risk of bias, [52] because those individuals with a history of injuries may

U
be more responders than those who have not developed any injury. In addition to all of the
AN
above, a major limitation of our study is the inability to perform a meta-analysis, due to the

differences in reported data and the poor methodological quality of the included studies.
M

Future research using prospective designs is required for obtaining objective data to
D

identify risk factors (including harmful exercises or routines, participation in other sports,
TE

etc.), specifically related with the incidence of injuries and their exact typology. In addition,

expanding knowledge about strategies to prevent injuries is the next step for physicians and
EP

trainers, who should individualized CrossFit® progression and adapt routines according to the

level of each participant, taking care of the correct execution technique.

C
AC

Conclusion

CrossFit® training has an injury incidence rate similar to weightlifting and powerlifting.

Shoulder, spine and knee are the most injury areas. The poor methodological quality of the

studies prevents us from establish firm conclusions about the risk factors for injury.

14
 T
IP
R
Declaration of conflicting interest

SC
The author(s) declared no potential conflicts of interest with respect to the research,

authorship and/or publication of this article.

U
AN
References

1. Glassman, G. Understanding CrossFit. CrossFit Journal.

M

http://journal.crossfit.com/2007/04/understanding-crossfit-by-greg.tpl. Published
D

April 1, 2007. Accessed February 1, 2020.

TE

2. CrossFit | About Affiliation. https://www.crossfit.com/affiliate. Accessed February 9,

EP

2020.

3. Gianzina EA, Kassotaki OA. The benefits and risks of the high-intensity CrossFit
C

training. Sport Sci Health 2019;15(1):21-33. doi:10.1007/s11332-018-0521-7.

AC

4. International Weightlifting Federation -International Weightlifting Federation.

https://www.iwf.net/. Accessed January 25, 2020.

5. IPF- International Powerlifting Federation IPF.

https://www.powerlifting.sport/?gclid=Cj0KCQiAyKrxBRDHARIsAKCzn8wJBJTa

15
 oU w8NqaTtzRA-l9uchZbeCyZaDzIABgufSfdC_x2XlUQAc8aAjjLEALw_wcB.

Accessed January 25, 2020.

6. Maté-Muñoz JL, Lougedo JH, Barba M, et al. Muscular fatigue in response to

different modalities of CrossFit sessions. PLoS One 2017;12(7).

doi:10.1371/journal.pone.0181855.

T
IP
7. Aasa U, Svartholm I, Andersson F, et al. Injuries among weightlifters and

powerlifters: A systematic review. Br J Sports Med 2017;51(4):211-219.

R
doi:10.1136/bjsports-2016-096037.

SC
8. Bergeron MF, Nindl BC, Deuster PA, et al. Consortium for health and military

U
performance and American College of sports medicine consensus paper on extreme
AN
conditioning programs in military personnel. Curr Sports Med Rep 2011;10(6):383-

389. doi:10.1249/JSR.0b013e318237bf8a.
M

9. Klimek C, Ashbeck C, Brook AJ, et al. Are Injuries More Common With CrossFit Training
D

Than Other Forms of Exercise? J Sport Rehabil 2018;27(3):295-299. doi:10.1123/jsr.2016-

TE

0040 LK

10. Tibana RA, Frade De Sousa NM. Are extreme conditioning programmes effective and safe?
EP

A narrative review of high-intensity functional training methods research paradigms and

findings. BMJ Open Sport Exerc Med 2018;4(1):e000435. doi:10.1136/bmjsem-2018-000435

C
AC

11. Claudino JG, Gabbett TJ, Bourgeois F, et al. CrossFit Overview: Systematic Review and

Meta-analysis. Sport Med - Open 2018;4(1):11. doi:10.1186/s40798-018-0124-5 LK

12. Dominski FH, Siqueira TC, Serafim TT, et al. Injury profile in CrossFit practitioners:

systematic review. Fisioter e Pesqui 2018;25(2):229-239. doi:10.1590/1809-

2950/17014825022018

13. Panic N, Leoncini E, de Belvis G, et al. Evaluation of the endorsement of the preferred

16
 reporting items for systematic reviews and meta-analysis (PRISMA) statement on the quality

of published systematic review and meta-analyses. PLoS One 2013;8(12):e83138.

doi:10.1371/journal.pone.0083138.

14. Saeed M, Swaroop M, Ackerman D, Tarone D, et al. Fact versus Conjecture: Exploring

Levels of Evidence in the Context of Patient Safety and Care Quality. London (UK):

IntechOpen; 2018.

T
IP
15. Study Quality Assessment Tools | National Heart, Lung, and Blood Institute

R
(NHLBI). https://www.nhlbi.nih.gov/health-topics/study-quality-assessment- tools.

SC
Accessed February 1, 2020.

16.
U
Alekseyev K, John A, Malek A, et al. Identifying the Most Common CrossFit
AN
Injuries in a Variety of Athletes. Rehabil Process Outcome

2020;9:117957271989706. doi:10.1177/1179572719897069.
M

17. Chachula LA, Cameron KL, Svoboda SJ. Association of Prior Injury With the
D

Report of New Injuries Sustained During CrossFit Training. Athl Train Sport Heal
TE

Care J Pract Clin 2016;8(1):28-34.

EP

18. Hopkins BS, Cloney MB, Kesavabhotla K, et al. Impact of CrossFit-Related Spinal

Injuries. Clin J Sport Med. 2019;29(6):482-485.

C

doi:10.1097/JSM.0000000000000553.
AC

19. Larsen RT, Hessner AL, Ishøi L, Langberg H, Christensen J. Injuries in Novice

Participants during an Eight-Week Start up CrossFit Program-A Prospective Cohort

Study. Sport (Basel, Switzerland) 2020;8(2):21. doi:10.3390/sports8020021.

20. Lima PO, Souza MB, Sampaio TV, et al. Epidemiology and associated factors for

CrossFit-related musculoskeletal injuries: a cross-sectional study. J Sports Med Phys

17
 Fitness 2020;60(6):889-894. doi:10.23736/S0022-4707.20.10364-5.

21. Mehrab M., de Vos RJ, Kraan GA, et al. Injury Incidence and Patterns Among Dutch

CrossFit Athletes. Orthop J Sport Med 2017;5(12):2325967117745263.

doi:10.1177/2325967117745263.

22. Minghelli B, Vicente P. Musculoskeletal injuries in Portuguese CrossFit

T
IP
practitioners. J Sports Med Phys Fitness 2019;59(7):1213-1220.

R
23. Montalvo AM, Shaefer H, Rodriguez B, et al. Retrospective Injury Epidemiology

SC
and Risk Factors for Injury in CrossFit. J Sports Sci Med 2017;16(1):53-59.

24. Moran S, Booker H, Staines J, et al. Rates and risk factors of injury in CrossFitTM: a
U
prospective cohort study. J Sports Med Phys Fitness 2017;57(9):1147-1153.
AN
doi:10.23736/S0022-4707.16.06827-4.
M

25. Sprey JWC, Ferreira T, de Lima MV, et al. An Epidemiological Profile of CrossFit
D

Athletes in Brazil. Orthop J Sport Med 2016;4(8):2325967116663706.

TE

doi:10.1177/2325967116663706.

26. Stracciolini A, Quinn B, Zwicker RL, et al. Part I: Crossfit-Related Injury

EP

Characteristics Presenting to Sports Medicine Clinic. Clin J Sport Med

C

2020;30(2):102-107. doi:10.1097/JSM.0000000000000805.
AC

27. Sugimoto D, Zwicker RL, Quinn BJ, et al. Part II: Comparison of Crossfit- Related

Injury Presenting to Sports Medicine Clinic by Sex and Age. Clin J Sport Med

[Published online December 12, 2019]. doi:10.1097/JSM.0000000000000812.

28. da Costa TS, Louzada C, Miyashita GK, et al. CrossFit®: Injury prevalence and main

risk factors. Clinics (Sao Paulo) 2019;74:e1402. doi:10.6061/clinics/2019/e1402.

18
29. Summitt RJ, Cotton RA, Kays AC, et al. Shoulder Injuries in Individuals Who

Participate in CrossFit Training. Sports Health 2016;8(6):541-546.

doi:10.1177/1941738116666073.

30. Szeles PRQ, da Costa TS, da Cunha RA, et al. CrossFit and the Epidemiology of

Musculoskeletal Injuries: A Prospective 12-Week Cohort Study. Orthop J Sport Med

T
2020;8(3):2325967120908884. doi:10.1177/2325967120908884.

IP
31. Tafuri S, Salatino G, Napoletano PL, et al. The risk of injuries among CrossFit

R
athletes: An Italian observational retrospective survey. J Sports Med Phys Fitness

SC
2019;59(9):1544-1550. doi:10.23736/S0022-4707.18.09240-X.

32.
U
Teixeira RV, Dantas M, Motas DG De, et al. Retrospective Study of Risk Factors
AN
and the Prevalence of Injuries in HIFT. Int J Sports Med 2020;41(3):168-174.

doi:10.1055/a-1062-6551.
M

33. Weisenthal BM, Beck CA, Maloney MD, et al. Injury rate and patterns among
D

crossfit athletes. Orthop J Sport Med 2014;2(4):2325967114531177.

TE

doi:10.1177/2325967114531177.
EP

34. Elkin JL, Kammerman JS, Kunselman AR, Gallo RA, et al. Likelihood of Injury and

Medical Care Between CrossFit and Traditional Weightlifting Participants. Orthop J

C

Sport Med 2019;7(5):2325967119843348. doi:10.1177/2325967119843348.

AC

35. Escalante G, Gentry CR, Kern BD, et al. Injury patterns and rates of Costa Rican

CrossFit® participants - a retrospective study. Sport Med J / Med Sport

2017;13(2):2927-2934.

36. Everhart JS, Kirven JC, France TJ, et al. Rates and treatments of CrossFit-related

19
 injuries at a single hospital system. Curr Orthop Pract 2019;30(4):347-352.

doi:10.1097/BCO.0000000000000766.

37. Everhart JS, Kirven JC, France TJ, et al. Independent risk factors for recurrent or

multiple new injuries in CrossFit athletes [published online ahead of print, 2020]. J

Sports Med Phys Fitness 2020;10.23736/S0022-4707.20.11040-5.

T
doi:10.23736/S0022-4707.20.11040-5.

IP
38. Feito Y, Burrows EK, Tabb LP. A 4-Year Analysis of the Incidence of Injuries

R
Among CrossFit-Trained Participants. Orthop J Sport Med

SC
2018;6(10):2325967118803100. doi:10.1177/2325967118803100.

39. U
Feito Y, Burrows E, Tabb L, Ciesielka KA. Breaking the myths of competition: a
AN
cross-sectional analysis of injuries among CrossFit trained participants. BMJ Open

Sport Exerc Med 2020;6(1):e000750. doi:10.1136/bmjsem-2020-000750.

M

40. Hak PT, Hodzovic E, Hickey B. The nature and prevalence of injury during CrossFit
D

training. J Strength Cond Res [Published online November 22, 2013.

TE

doi:10.1519/JSC.0000000000000318.
EP

41. Keogh JWL, Winwood PW. The Epidemiology of Injuries Across the Weight-

Training Sports. Sport Med 2017;47(3):479-501. doi:10.1007/s40279-016-0575-0.

C
AC

42. Caine D, Nassar L. Gymnastics injuries. Med Sport Sci 2005;48:18-58.

doi:10.1159/000084282.

43. Kurosawa H, Fukubayashi T, Nakajima H. Load-bearing mode of the knee joint:

Physical behavior of the knee joint with or without menisci. Clin Orthop Relat Res

1980;NO 149:283-290. doi:10.1097/00003086-198006000-00039.

20
44. Joseph AM, Collins CL, Henke NM, et al. A multisport epidemiologic comparison of

anterior cruciate ligament injuries in high school athletics. J Athl Train 2013;48(6):810-817.

doi:10.4085/1062-6050-48.6.03

45. Hartmann H, Wirth K, Klusemann M. Analysis of the load on the knee joint and vertebral

column with changes in squatting depth and weight load. Sport Med 2013;43(10):993-1008.

doi:10.1007/s40279-013-0073-6

T
IP
46. Trafimow JH, Schipplein OD, Novak GJ, et al. The effects of quadriceps fatigue on the

technique of lifting. Spine (Phila Pa 1976). 1993;18(3):364-367. doi:10.1097/00007632-

R
SC
199303000-00011

47. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in

U
elite football: A prospective study over two consecutive seasons. Br J Sports Med
AN
2006;40(9):767-772. doi:10.1136/bjsm.2006.026609.
M

48. Toohey LA, Drew MK, Cook JL, et al. Is subsequent lower limb injury associated with

previous injury? A systematic review and meta-analysis. Br J Sports Med. 2017;51(23):1670-

D

1678. doi:10.1136/bjsports-2017-097500.
TE

49. Chen Y, Buggy C, Kelly S. Winning at all costs: a review of risk-taking behaviour and
EP

sporting injury from an occupational safety and health perspective. Sport Med - Open

2019;5(1):15. doi:10.1186/s40798-019-0189-9.
C

50. Bengtsson V, Berglund L, Aasa U. Narrative review of injuries in powerlifting with special
AC

reference to their association to the squat, bench press and deadlift. BMJ Open Sport Exerc

Med 2018;4(1):e000382. doi:10.1136/bmjsem-2018-000382.

51. Twellaar M, Verstappen FT, Huson A, et al. Physical characteristics as risk factors for sports

injuries: a four year prospective study. Int J Sports Med 1997;18(1):66-71. doi:10.1055/s-

2007-972597.

21
 52. Gabbe BJ, Finch CF, Bennell KL, et al. How valid is a self reported 12 month sports injury

history? Br J Sports Med 2003;37(6):545-547. doi:10.1136/bjsm.37.6.545

T
IP
R
SC
Figure Legends
U
AN
Figure 1. Flow diagram of the study selection process.
M

Figure 2. Graphic representation of injury location and percentages of total

injuries.
D

Figure 3. Risk factors associated with a higher injury rate.

TE
EP
C
AC

22
Table 1. Description of the samples and statistical data of musculoskeletal injuries.

N Injuries

Incidenc Injuries
Total Male:femal e requirin
Stud Prevalenc
N e Age Country (n per g
y e (%)
ratio 1000 surgery
hrs) (%)
Alekseyev et al, 2020 885 1.99 29 USA and 33.3 ─ ─

T
[16] 14 other
countries

IP
Chachula et al, 2016 54 2.86 ─ USA 44.0 ─ ─
[17]

R
Da Costa et al, 2019 414 1.42 31. Brazil 37.9 3.2 ─

SC
[28] 0±
6.6
Elkin et al, 2019 [34] 122 0.77 37. USA 60.7 ─ ─
5
Escalante et al, 2017 159 1.24 U
31. Costa Rica 46.5 3.3 3.0
AN
[35] 3±
8.7
Everhart et al, 2019 848 1.01 36. USA ─ ─ 15.8
M

[36] 4±
11
837 1.03 ─ ─ ─
D

Everhart et al, 2020 36. USA

[37] 1±
TE

10.
9–
38.
8±
EP

11.
1
Feito et al, 2018 [38] 304 1.06 36. USA 30.5 0.3-0.6 ─
C

9 8±
9.8
AC

Feito et al, 2020 [39] 155 1.19 37. USA 32.3 0.2-0.5 ─
1 3± competitor
9.6 s
0.4-1.3
non
competitor
s
Hak et al, 2013 [40] 132 2.38 32. ─ 73.5 3.1 7
3

23
 Hopkins et al, 2017 498 ─ ─ USA ─ ─ 6.7
[18]

Larsen et al, 2020 [19] 168 0.44 29. Denmark 13.1 9.5 ─
2±
7.9
Lima et al, 2020 [20] 413 1.08 29. Brazil 24.0 0.8 ─
4±
6.9
Mehrab et al, 2017 449 1.45 31. Netherland 56.1 ─ ─
[21] 9± s

T
8.3

IP
Minghelli & Vicente, 270 1.29 30. Portugal 29.6 1.3 ─
2019 [22] 7±
8.0

R
Montalvo et al, 2017 191 0.97 31. USA 26.0 2.3 ─

SC
[23] 7±
9.4
Moran et al, 2017 [24] 117 1.29 35. United 12.8 2.1 ─
0± Kingdom

U
10.
0
AN
Sprey et al, 2016 [25] 566 1.33 31. Brazil 31.0 ─ ─
3±
7.0
M

Stracciolini et al, 2020 115 0.92 25. USA ─ ─ 3.5

[26]/ Sugimoto et al, 2±
2020 [27] 10.
D

4
Summit et al, 2016 [29] 187 ─ ─ USA 23.5 1.9 2.3
TE

Szeles et al, 2020 [30] 406 0.95 32. Brazil 32.8 18.9 ─
EP

Tafuri et al, 2019 [31] 454 2.52 28. Italy 39.9 ─ ─

8±
C

7.9
Teixeira et al, 2020 213 1.11 29. Brazil 38.5 7.1 ─
AC

[32] 7±
6.5
Weisenthal et al, 2014 381 1.54 ─ USA 19.4 ─ ─
[33]

Hrs: hours; N: number; SD: standard deviation. Age is given in mean ± standard deviation.

24
Table 2. Injury criterion among the included studies.

Injury criterion Studies

Any new musculoskeletal pain,
feeling, or injury that results from a
CrossFit® workout and leads to 1 or
more of the following options:
(1) Total removal from CrossFit®
• Da Costa et al, 2019 [28]
• Escalante et al, 2017 [35]
• Feito et al, 2018 [38]
• Feito et al, 2020 [39]
• Larsen et al, 2020 [19]

T
training and other outside routine • Lima et al, 2020 [20]
physical activities for >1 week. •

IP
Mehrab et al, 2017 [21]
(2) Modification of normal training
• Sprey et al, 2016 [25]
activities in duration, intensity, or
• Summit et al, 2016 [29]

R
mode for >2 weeks.
(3) Any physical complaint severe • Weisenthal et al, 2014 [33]

SC
enough to warrant a visit to a health
professional.
Any physical complaint during • Hak et al, 2013 [40]
CrossFit® training that caused to miss • Minghelli & Vicente, 2019 [22]
or modify one or more training
sessions or hindered activities of daily U • Montalvo et al, 2017 [23]
AN
• Moran et al, 2017 [24]
living (“time-loss” definition); or • Szeles et al, 2020 [30]
sought advice or treatment from health
professionals.
M

Change in the current state of health to • Stracciolini et al, 2020 [26]

a less-healthy state as a direct result of • Sugimoto et al, 2020 [27]
CrossFit®.
D

The onset of harm to a joint. • Chachula et al, 2016 [17]

TE

Not clearly defined (medical • Everhart et al, 2019 [36]

diagnosis). • Everhart et al, 2020 [37]
EP

• Hopkins et al, 2017 [18]

Not defined (self-determined by • Alekseyev et al, 2020 [16]
participants). • Elkin et al, 2019 [34]
C

• Tafuri et al, 2019 [31]

• Teixieira et al, 2020 [32]
AC

25
 Fig 1
AC
C
EP
TE
D
M
AN
U
SC
R
IP
T

266
 Fig 2
AC
C
EP
TE
D
M
AN
U
SC
R
IP
T

277
 Fig 3
AC
C
EP
TE
D
M
AN
U
SC
R
IP
T

288