The Truth Hurts: Part 1

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One of the most pervasive and harmful myths about CrossFit is one that many of us have readily accepted- CrossFit is relatively safe, but only when its constituent movements are performed with correct technique. On the surface this seems totally reasonable, but it has become the false premise upon which many serious claims about the safety of CrossFit rest.

I believe that this myth is borne from an attempt to reconcile an apparent tension between two major concepts taught by CrossFit. For the sake of this article, I will use the common definition of technique as whatever movement an athletes uses to accomplish a task. Though less well defined, I will consider good technique to be the movement which optimizes the athlete’s mechanical advantage, and bad technique can be considered any deviation from that.

The first of these concepts is that functional movements (defined as those movements uniquely capable of producing power) are inherently safe. The second concept is the importance of striving to move with near perfect technique. This emphasis on good technique is made repeatedly during the CrossFit Level 1 Course. This is for two important reasons: First, good technique is vital for efficiency and efficacy of our program’s results. Second, good technique aids in mitigating risk of injury.

Herein lies the tension. If functional movements are safe, why do we need to do them correctly in order to prevent injury? It should not be a point of contention to claim that all forms of exercise carry some level of risk. This makes terms like “safe,” and “dangerous,” useless without qualification. When we say that functional movements are safe, we mean that they are safe relative to performing non-functional movements, and certainly safer than doing nothing at all. We also point out that these movements are unavoidable in daily life, so while training them is optional, performing them is not.

Our injury myth answers the apparent tension stated above by admitting that functional movements (and CrossFit) are safe, but only as long as technique is good. The myth also retains the important emphasis on technique by holding that when technique goes south, functional movements become dangerous.

While we have acknowledged that there is a relationship between poor technique and injury, we need to be careful about what that relationship is if we want to be accurate. The assumption underlying our myth is that poor technique is a necessary cause of injury.

Yet common sense tells us this must be an oversimplification. We all know someone who does CrossFit in his garage, performing nearly every movement with poor technique, and yet claiming he is fittest and healthiest he has ever been. Most people also know someone who suffers from an injury that occurred when his or her technique appeared correct.

A survey of literature on the subject also seems to reject this oversimplified view of injury. In their paper Understanding Injury Mechanisms: A Key Component of Preventing Injuries in Sport, authors Bahr and Krosshaug describe the complexity of contributing factors that precipitate injury:

“…although the injury may appear to have been caused by a single inciting event, it may result from a complex interaction between internal and external risk factors. Internal factors such as age, sex, and body composition may influence the risk of sustaining injuries, predisposing the athlete to injury, and are therefore by definition risk factors. In addition, external factors such as shoe traction and floor friction may modify injury risk, making the athlete even more susceptible to injury. It is the presence of both internal and external risk factors that renders the athlete susceptible to injury, but the mere presence of these risk factors is not sufficient to produce injury.”

The authors go on to describe the inciting event that causes  injury as “the final link in the chain.” In an effort to combine this epidemiological view of injury causation with a more biomechanical view, they offer the following model:

F3.large

Regardless of the accuracy of Bahr and Krosshaug’s model, the concept proves useful. In light of the inherent complexity of injury precipitation, the view that poor technique alone (biomechanical factors) is a sufficient cause of injury seems indefensible. Rather, they view these biomechanical factors as necessary conditions that occur as part of a larger chain of events leading to injury.

Interestingly, the field of ergonomics and the study of workplace injury proves to be a useful source of data. For example, interdisciplinary research scientist Dr. Shrawan Kumar has published some of the most extensive treatments of the subject of injury. In his book Selected Theories of Musculoskeletal Injury Causation Kumar writes that the precipitation of injury is “..an interactive process between genetic, morphological, psychosocial and biomechanical factors.” Kumar goes on to outline the extent to which these different variables can be combined prior to an injury event, offering a model that is strikingly similar to that described by his peers in sports medicine.

https://books.google.com/books?hl=en&lr=&id=skg9AAAAIAAJ&oi=fnd&pg=PA3&dq=kumar+musculoskeletal+injury&ots=MO9oLdbJ_q&sig=mbRQbBZC3bP3uovB5az-Kko4sts#v=onepage&q=kumar%20musculoskeletal%20injury&f=false

S. Kumar, “Selected theories of musculoskeletal injury causation”

While different models of ergonomic injury place more or less weight on contributing factors such as biomechanics and genetics, all current models stress the complexity and unpredictability of injury. From this we see that while biomechanical factors such as technique may be a necessary part of the causal chain leading to injury, but appear to be insufficient to cause injury alone. These models also neatly explain the coach’s real world observations that:

1. An overall correlation between poor technique and increased likelihood of injury seems to exist, yet;

2. Some athletes train with poor technique for years without experiencing injury;

3. Some athletes are injured during training in which no discernible breakdown in technique occurs.

Yet when someone argues that ‘poor technique causes injury’ he usually does not mean what his words imply. When presented with the complex nature of training injury, he will usually fall back to something like ‘training repeatedly with poor technique, over time, will lead to injury.’

This is a much more reasonable claim, but it begs the question: Just how dramatically does the chance of injury increase when an athlete trains with poor technique?

At this time, we know of three academic studies of CrossFit injury rates. Two have been published in peer-reviewed journals (Girodano and Hak). The third was conducted by Dr. Yuri Feito and we expect to see it published soon. All three studies found CrossFit’s injury rate to be below or equal to that of general fitness training (2.4-3.1 injuries per 1000 hours of training). These studies were all solicited surveys completed by a broad array of CrossFit participants.

How do we interpret these relatively low injury rates in light of the hypothesis that poor technique dramatically increases the risk of injury? The only suitable explanation is that only a very tiny percentage of those surveyed were training with poor technique.

But is this a probable explanation? As someone who has visited hundreds of CrossFit gyms and trained thousands of  relatively new CrossFit athletes, I can say with certainty that there are many, many people training CrossFit regularly with poor technique.  Even CrossFit’s best athletes occasionally train with less than perfect form.

How do we reconcile this observation with the fact that CrossFit’s injury rates are so low? Only by abandoning the belief that poor technique is inherently dangerous. While poor technique might be a contributing factor to injury, the fact is the available injury data doesn’t support the idea that it is as dangerous as some claim it to be.

Our myth has been dispelled.

“CrossFit is relatively safe but only when its constituent movements are performed with correct technique,” is clearly an oversimplified statement that should be replaced with this one: “CrossFit is relatively safe even when performed with poor technique, but it is safer and more effective when performed with good technique.”

Why is this so important? The myth that poor technique makes CrossFit dangerous is a key assumption underlying the argument that the CrossFit Level 1 Certificate Course is an insufficient credential for opening an affiliate, the argument that CrossFit Trainers need to be licensed by the state, and the argument that only elite athletes should be doing CrossFit. We will look at this flawed argument in greater detail in Part 2.

27 comments

  1. Correct me if I’m wrong here, but you guys’ blog posts about both the Giordano and Hak studies were largely critical of their methods AND results…

    Giordano piece:
    “Fortunately Giordano’s piece hasn’t received as much media attention as other flawed studies on CrossFit have. Perhaps the OJSM’s publicist isn’t as effective as the NSCA’s.”

    Hak piece:
    “The full text of the study has already surfaced here, and there are some serious problems with it.”

    Further, though, can either one of these studies REALLY be considered a true picture of the injury situation? Giordano had a grand total of 386 participants fit the inclusion criteria, and Hak came up with a whopping 132. Let’s say there’s 10,000 CrossFit gyms with an average of 150 members each. That’s a population of approximately 1.5 million CrossFitters. Even if we go on the low-end and say 100 members per gym, that’s still a population size of 1 million. So Giordano captured anywhere from .0257% to .04% of the population while Hak can claim about .0088% to .0132%. Heck, some boxes have more members than Hak had in that study. All that considered, and assuming you guys do actually LIKE those two studies, it is really fair to extrapolate such a small sample size to such a large population? All selection bias, etc. aside (can we really consider an online survey to be an accurate depiction of a huge population?), I’d say that in order to claim CrossFit is no more dangerous than general fitness, you’d need more participants in a study. Do you guys think those sample sizes are big enough?

    • Drew,
      I don’t mean to sound dismissive, but your concerns and questions are all based on misunderstandings of what I have previously written.

      If you read carefully, my critique of Giordano’s study was not based on his data, but on his misuse of the term “injury rate,” which he later addressed and corrected in an editorial comment published alongside the original study. My critique of the Hak study was also not based on his data, but on a non-sequitur in his conclusions that he claimed was a typo and the paper’s citation of the CHAMP hit-piece. Neither of these issues precludes us from using their data when relevant.

      You also critique these studies for being small in size. This is probably fair, but is irrelevant in this case. In this article I do not make a positive argument for the claim that CrossFit is just as safe as any other form of exercise (though I think that is probably true). If I was making that claim, I would need better evidence and larger studies to be convincing.

      Instead, this article is a refutation of the claim that CrossFit is dangerous when performed with poor technique. My appeal to these two studies is not to establish them as perfect representations of CrossFit’s injury rate but to show that even if they are flawed, they undermine the belief that CrossFit is dangerous when done with poor technique. The burden of proof here is on anyone making the claim I’m refuting, and any and all evidence is admissible. In this case, the only academic evidence we have happens to point to the contrary. Holding out belief for a future study that shows CrossFit to be dangerous would be an act of blind faith.

      • Right, but would a better conclusion not be something like “CrossFit is potentially riskier when performed with poor technique, but is safer and more effective when performed with good technique”? Using the phrase “CrossFit is RELATIVELY SAFE even when performed with poor technique” tells me, as a coach, that you guys, as CrossFit, are comfortable with me having a room full of people deadlifting with poor form. Yes, according to your conclusion, it would be safer and more effective if they were deadlifting with good technique, but, according to your conclusion, they’re all relatively safe. You could argue that as a good coach, I should be making them all lift with good form. But I’m not talking about “good coaches” here, I’m talking about an average CrossFit coach who is basing his coaching philosophies off of CrossFit’s position…and according to this article, CrossFit’s position is that even with a rounded back, locked-out knees, off-set feet, and eyes towards the ceiling (all aspects of poor deadlift form), our athlete is “relatively safe” as opposed to potentially at risk.

    • I hesitate to comment any further since I can see where these threads seem to go.. I don’t wish to debate the efficacy of CrossFit or offend the author.. Yet there is something I can’t quite get out of my head. Like you, I had concerns about the sample sizes in the two linked studies. Russell Berger wrote back: “We are talking about three independent studies that have come the the same conclusions, surveying over 1000 CrossFit participants from a wide variety of backgrounds.” I don’t wish to debate what was written, not written, implied, or assumed.. I just want to know, with full disclosure of my ignorance to the answer: are we adding the sample sizes of the three studies together to get “over 1000”? With only have a minor in statistical math, I admittedly don’t know it all, but this doesn’t seem legit. So I’ll assume that’s not what he meant. Could there a thousand person sample in the study by Dr. Yuri Feito? I think that’d be great.

      • Jenyao,

        No worries, you won’t offend me. I used the 1000 participants as a rough estimate because I couldn’t remember the exact number of one of the studies off the top of my head, I did not mean to imply we should add these studies together to make some sort of greater ‘super-study.’ My point again is that three independent studies have been conducted on CrossFit participant injury rates. These studies all found that injury rate to be very low. It would be pretty remarkable if each of the only three studies to ever look at this topic managed to arrive at the same false conclusion. These studies may not be perfect, but the consistency of their results makes it highly improbable that the true injury rate of CrossFit is far from what they found.

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  4. Right, but your phrasing, in this case, is in bold and presented as your conclusion to the article. As a casual reader, my takeaway would be “CrossFit is saying it’s ok to have poor form.” My issue is an issue with the phrasing. As I said, there’s a huge difference between “relatively safe” (which implies that it’s ok to deadlift with bad form) and “potentially riskier” (which implies that something should be done about said technique).

    • Drew,
      I made it very clear that CrossFit teaches the importance of improving technique for both safety and performance. Your concern is about reading comprehension, which I think is a reflection of your own issues with understanding our writing here (see previous comments on Giordano/Hak studies). Find me a single CrossFit Affiliate who confuses my point with “CrossFit is saying it’s ok to have poor form.” And I’ll add an eye-catching disclaimer to the article.

  5. Russell

    Were I to pull a random sentence from the article and attack it, I would agree with your rebuttal that this is an issue of reading comprehension. As I said, you’re trying to separate your phrasing from the point you’re trying to make in the article, and I’m telling you that in this case, the two are one and the same. Your phrasing, “CrossFit is relatively safe even when performed with poor technique” is also your conclusion. So yes, I know you guys preach good technique and emphasize it at L1 seminars, but my question is this: of the two conclusions below, which is MORE right:

    “CrossFit is relatively safe, even when performed with poor technique”

    Or

    “CrossFit is potentially risky when using poor technique”

    You tell me.

    • “Were I to pull a random sentence from the article and attack it, I would agree with your rebuttal that this is an issue of reading comprehension”

      That is exactly what you are doing.

      To answer you question, your second phrase would be a poor choice for two reasons. First, because CrossFit carries an element of risk even when performed with good technique (as does all exercise). Second, because the entire thrust of this article is to give perspective to what “Safe” and “dangerous” actually means. My phrasing makes it clear that relative to other forms of training, and relative to not training, doing CrossFit poorly is safe. Your phrasing gives no perspective and would be useless except to perpetuate fear of training with poor technique, which is unwarranted.

      • But you see that your conclusion…

        “relative to other forms of training, and relative to not training, doing CrossFit poorly is safe” (your words)

        is based on…

        “three academic studies of CrossFit injury rates” (quote from the article)

        which you earlier said the following about…

        “In this article I do not make a positive argument for the claim that CrossFit is just as safe as any other form of exercise (though I think that is probably true). If I was making that claim, I would need better evidence and larger studies to be convincing” (your earlier rebuttal)

        So you’ve positioned yourself as claiming that CrossFit with poor technique is safe based on three studies that are, in your own words, too small to be convincing. The evidence you present in this article (i.e. alluding to injury rates, etc.) is all from these studies.

        And to claim that perpetuating fear of training with poor technique is unwarranted is to simultaneously claim that perpetuating acceptance of training with poor technique IS warranted. Is that the position I am to take as a coach?

      • There is nothing inconsistent about my quotes above. I am not making the claim that I know the exact injury rate of CrossFit and so I don’t need a conclusive study to prove that point.
        I’m making an argument to the best explanation of the data we do have (which should not be simply ignored as you imply) that CrossFit is relatively safe compared to other forms of training. The exact rate of injury is still up for question, but we can reasonably conclude that CrossFit doesn’t have any systemic injury problems, despite the fact that we all know there are many, many people training daily with poor technique.

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  7. I’m a coach and casual reader, and I agree with Drew Hammond, it seems like this article is saying that is not completely wrong to lift with poor form, to me, as a coach, is not acceptable. And the conclusion of the article is totally shocking: ““CrossFit is RELATIVELY safe even when performed with poor technique..”. Sorry, but relatively is too much of a loose term, and I too agree with the “CrossFit is potentially risky when using poor technique” would be more accurate. IMHO.

    • Jorge,
      I specifically defined what “relative” meant in the last article, and of you feel this is inaccurate please suggest why. “Potentially risky” is far more ambiguous.
      Like Drew you are primarily concerned with what it “seems” like this article is saying, not what I’ve actually written.

  8. Provocative article. I am troubled by the sample sizes in the studies and the reference to outliers as evidence to support the idea that poor technique isn’t necessarily the root cause of injury. The possibility of unreported injuries seems to be overlooked. As a body worker with a predominantly CrossFit athlete clientele, I see plenty of injuries, whether from over-training, poor form, or any combination of contributing factors described in this article. I would like to see more extensive research on this topic.

    • Jenyao,

      We are talking about three independent studies that have come the the same conclusions, surveying over 1000 CrossFit participants from a wide variety of backgrounds. Despite the limitations of any of these studies, the fact that all three found roughly the same low injury rate is not something we can ignore. The fact that these studies were all solicited surveys should bias the data in favor of over-estimating injury, not the opposite, and yet they still show CrossFit to be relatively safe. This is in no way contradicted by your personal experience. Any profession that serves those with sports injuries is going to see significant numbers of people with sports injuries.

      • Thanks for your reply. I guess I’m less interested in the question of injury rate, and more curious about the causes. I found a major point in the article to be that poor form isn’t necessarily what we should be looking at when evaluating injuries. Apologies if I read too much between the lines.

      • That was not a point I ever made in the article. The point I made related to injuries is that biomechanical factors like poor technique (while likely a necessary cause of injury) are not a sufficient cause of injury. This just means that injury precipitation is complex and individual, which explains why so many people train with poor technique without getting hurt while others do.

  9. Interesting point of view. But there were some questions :
    Similarly, whether the ” functional exercises ” safe? What kind of exercise is ” functional “? Do you know about the definition of functional exercise on ACSM? Are you aware of the fact that any activity ( even ” lying on the couch ” ) has its risks ?

    • CrossFit defines functional movements as those with which athletes can generate relatively high amounts of power output. I have no idea how the ACSM defines FM, or if they have ever attempted to. I am well aware that all activity comes with risk of injury, and made that comment above.

  10. I could be completely off but the article (though well written and sited) is a bit of a swing and a miss, IMHO. I’ve never come across a critic of CrossFit who says the things that are said in this article, for the reasons in this article. If there are any, there in an extreme minority, and they’re probably not trainers/teacher or students of movement.

    Most of the criticism I’ve ever seen of the L1 Cert is that it’s simply not enough training to qualify someone to train anyone. Heck, even CrossFit HQ doesn’t consider a L1 Cert good enough to qualify someone to JUDGE an official CrossFit competition; but it’s good enough to qualify someone to TRAIN dozens, if not hundreds, of people to perform the most complicated movements in sports; *the clean & jerk and the snatch? Not to mention you’re expected to negotiate the numerous complexities in identifying who should be allowed to do certain exercises when it isn’t covered in the L1?

    Unless the form of the cert has changed drastically, a attendee of the L1 Cert gets about 45 minutes of group training on how to teach any movement in the L1 Cert, which overall is a whirlwind 16 hours over 2 days. Simply put, the L1 Cert isn’t enough trainer training, to ID – let alone teach – proper form.

    So, I hope that I’ll be forgiven for the comparison, but to me this reads a bit like a William Lane Craig article: Listen to the criticism/argument, create a straw man ( https://en.wikipedia.org/?title=Straw_man ), completely (and rightly) demolish it with poise and nuance, and say that the objection has been dealt with. Nothing in the article is wrong that I can see, but none of it addresses the problem that most people that (at least I have encountered) are pointing to.

    Again, I could be completely wrong.

    • Adam,

      First, the CrossFit L1 is not sufficient to be a Judge because it is a trainer course, not a judging course. These are completely different activities, hence the creation of this: https://oc.crossfit.com. You also must be misremembering the CF-L1, which even in the early days included multiple hours of practical movement training.

      You’ve accused me of making a “straw man” argument, but haven’t in any way explained how this is the case. In your words, you claim that the criticism you’ve seen regarding the L1 is that ” it’s simply not enough training to qualify someone to train anyone.” Correct me if I’m wrong, but it seems obvious that this claim is based on the belief that ‘unqualified’ trainers would be dangerous.

      So by exposing the myth that the inexperience of new CrossFit L1 trainers makes CrossFit dangerous, I have undermined the claim you put forward. The only way this would constitute a straw-man fallacy is if you have some other basis of concern about the L1 being insufficient for training others. I look forward to your response.

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