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Weight Training Injuries: Part 1: Diagnosing and Managing Acute Conditions

Ronald K. Reeves, MD; Edward R. Laskowski, MD; Jay Smith, MD


This is the first of two articles on weight training injuries. The second appears in March.

In Brief: When patients present with acute weight training injuries, familiarity with the demands of the activity can help physicians get the most out of the patient history. Probable risk factors for injury include errors in technique (described in a sidebar), skeletal immaturity, and anabolic steroid abuse. Common acute injuries in weight training include sprains, strains, tendon avulsions, and compartment syndrome. Possible nonmusculoskeletal problems include retinal hemorrhage, radiculopathy, and various cardiovascular complications. Treatment of acute musculoskeletal injuries varies, but usually includes sports medicine mainstays such as prompt RICE. Chronic weight training injuries will be described in part 2 of this series.

Over the past 20 years, the popularity of weight training has exploded. More than 45 million Americans train with weights regularly. Fortunately, serious injuries are relatively rare. In 120216, weight training injuries accounted for an estimated 43,400 emergency department visits out of a total of 5.6 million visits for all sports (1). In 1995, the last year for which statistics are available, emergency room visits for weight training injuries totaled 56,400, out of more than 5.4 million visits for all sports (2).

This article, the first of a two-part series, focuses on the diagnosis and treatment of acute weight training injuries. Part 2, to appear in an upcoming issue, will cover overuse and chronic conditions in weight lifters.

Out of the Circus

In the late 1800s, weight training was primarily the activity of circus strongmen. The first European weight lifting championship was held in Rotterdam in 1896, and the first world championship was in Vienna in 182021. In the first modern Olympics in 1896, Viggo Jensen and Launceston Elliot tied with lifts of 245 lb. The International Weightlifting Federation was founded in 1905, and since the 1970s the popularity of weight lifting has soared.

Though the popular image of a weight lifter is a bodybuilder such as Arnold Schwarzenegger or Lee Haney, most people who weight train do so as part of a comprehensive fitness program.

Weight Training Methods

There are several different styles of weight lifting/training. In this article the term "weight training" refers to exercises that use weight or resistance to build strength and muscle mass. The term "weight lifting" here refers to specific competitive activities such as Olympic lifting and power lifting. Though each style and method predisposes participants to a characteristic set of injuries, many injuries are common to all types of weight lifting/training.

The use of machines may be the most common method of fitness-related weight training at present. Machines allow exercisers to circuit train or to focus on individual muscles or muscle groups (eg, shoulders, hamstrings).

Circuit training. Circuit training involves a rapid transition from one muscle-group exercise to the next with 15 to 30 seconds of rest between exercises. Participants use weights that are about 40% to 60% of their one-repetition maximum (1RM). Strength and aerobic gains from circuit training are modest—30% to 50% of the gains seen in dedicated strength or aerobic exercise regimens. The primary benefit of circuit training is the shorter workout time. Ballor et al (3) showed that alternating 15 seconds of exercise with 15 seconds of rest allows the greatest amount of work in the shortest time. This technique, when properly used, poses minimal risk of musculoskeletal injury, though the brief recovery time between exercises presents a risk for overuse injuries (1,4).

Focused weight training. Focused weight training emphasizes specific muscle groups and can be performed with strength training machines or free weights; typically, both are used. Focused weight trainers usually lift weights as part of a comprehensive recreational fitness program. Training structure, loads, and training volumes vary. Focused weight trainers draw from other styles of weight training or competitive weight lifting and are at risk for acute and overuse injuries. Because training commonly produces discomfort, pain from overuse injuries is often misinterpreted as a normal result of the training. As in many other lifting styles, athletes often ignore the pain until performance suffers.

Bodybuilding. Bodybuilding is exceedingly popular with younger people. The primary goal is to attain significant, symmetric muscle hypertrophy. Strength gains are secondary. Bodybuilding involves exhaustive workouts primarily involving free weights, using multiple sets and exercises and special training techniques for each muscle. Weight loads are frequently 80% to 100% of 1RM, with 1 to 12 repetitions. Special techniques are periodically used to alter training and facilitate consistent gains; examples include:

  • eccentric contractions or "negatives,"
  • forced repetitions to muscle failure,
  • supersets (rapidly paired exercises of different muscle groups in the same anatomic region), and
  • compound sets (rapidly matched exercises of the same muscle group).

Bodybuilders are at risk for both acute injuries (ie, from loss of control of a weight) and overuse injuries. Many turn to ergogenic agents such as anabolic steroids, human growth hormone, and nutrition supplements in an attempt to enhance training effects.

Olympic weight lifting. Olympic weight lifting involves a single-repetition maximum lift in two exercises: the snatch and the clean and jerk (figure 1). The combined weight of the two lifts is the score in competition. Failure to observe proper technique in both lifts places athletes at risk for acute injuries from loss of control of the weight.


Power lifting. Power lifting competitions involve three lifts: the squat, the bench press, and the dead lift (figure 2). As in Olympic lifting, the athlete seeks a single-repetition maximum in each exercise to generate a total score. Injuries in power lifting are similar to those seen in Olympic lifting, body building, and focused weight training.


Injury Rates and Risk Factors

Studies examining the incidence and types of weight training injuries report varying injury rates, but similar distributions of injury types (table 1: not shown).

Brown and Kimball (5) found that 39.4% (28 of 71) of adolescent power lifters entered in a teenage power lifting championship (ages 14 to 19) sustained injuries during training. The authors suggest that the high rate of injuries may have been from lack of supervision. Risser et al (6) in a retrospective survey observed that only 7.6% (27 of 354) of adolescent football players in a supervised weight training program sustained injuries, and Zemper (7) found only a 0.3% rate of weight training injuries in a 4-year study of a national sample of college football players who trained under supervision.

There are no risk-factor studies of weight training injuries, but poor technique, lack of supervision, skeletal immaturity, and steroid abuse are recognized as contributing factors (1,5,6). For a discussion of common weight training techniques that can cause injuries, see "Honing Technique to Avoid Injury," below.

Multiple cases of weight-training injuries associated with steroid abuse have been reported. The risks and benefits of these agents have been extensively reviewed elsewhere (8). In brief, steroids are classified as controlled substances by the US Food and Drug Administration, making steroid use other than for approved medical indications illegal. Though steroid abuse causes significant gains in strength and muscle mass, side effects may include acne, male pattern baldness, testicular atrophy, liver function abnormalities and hepatomas, myocardial ischemia, gynecomastia, hypertension, aggressiveness, and death (9). Steroids may cause physiologic changes in muscle, tendon, and ligaments, making them more susceptible to failure under load or repetitive use.

Steroid abuse has been associated with many acute injuries. Patients should be questioned regarding any history of such abuse. If individuals have such exposure, appropriate risk factor education and assistance with discontinuation should be offered.

Children's skeletal immaturity presents a particular risk for growth plate injuries from weight training. Therefore, the American Academy of Pediatrics has issued guidelines for weight training in children (10). These guidelines call for close supervision by knowledgeable trainers and medical professionals for children and adolescents who strength train and advise that adolescents reach Tanner stage 5 before participating in vigorous weight training.

Musculoskeletal Injuries

Though strains and sprains represent a large proportion of weight training injuries, they often do not come to medical attention unless the injury is particularly severe or symptoms are prolonged.

Ligament sprains. Sprains cause pain, tenderness, and swelling at a ligament. The severity can be graded by the degree of laxity noted on examination (table 2). In general, a grade 1 sprain is painful without ligament laxity on examination, grade 2 lesions involve slight laxity, and grade 3 injuries feature gross instability.

Table 2. Grading of Ligament Sprains and Muscle Injuries

Physical Exam Findings

Grade Sprains Strains

1 Pain on palpation, solid end-point on examination Pain on palpation, little or no weakness, no palpable defect or asymmetry
2 Pain on palpation, mild laxity compared to contralateral ligament Significant pain and mild weakness
3* Significant laxity without a solid endpoint Possible muscle asymmetry with a palpable defect, significant weakness

*A grade 3 muscle injury may be a partial or complete rupture.

Medial and lateral collateral knee ligament sprains may occur during squats, leg presses, and lunges with high loads or improper lower-extremity placement. Complete ligament disruption due to weight training is uncommon, but Freeman and Rooker (11) reported on a bodybuilder who had a history of steroid use and presented with a spontaneous anterior cruciate ligament rupture.

Most sprains and strains can be managed nonoperatively with protection, rest, ice, compression, and elevation (PRICE).

In addition to knee sprains, medial meniscus cartilage tears have been associated with knee flexion exercises (hamstring curls) and dead lifts (12).

Muscle strains and ruptures. The hallmarks of acute muscle strain are pain, muscle belly or myotendinous junction tenderness, limited range of motion, and relatively preserved strength (table 2). Grade 1 and grade 2 muscle strains are quite painful and are distinguished by the absence (grade 1) or presence (grade 2) of weakness. Hamstring muscle and low back (including paraspinal muscle) strains are particularly common among those who train with weights.

Muscle ruptures are essentially severe (grade 3) muscle strains. They are distinguished from strains by significant weakness and possibly a palpable muscle defect at the myotendinous junction. Tendon avulsions—disruption of the tendon-bone interface—are less common. In either injury, patients often report feeling a sudden "pop." Table 3 lists several reports of muscle ruptures and tendon avulsions in weight trainers. Steroid abuse was a factor in several of these injuries.

Table 3. Rare Weight-Training-Related Musculoskeletal Injuries and Other Acute Events

Muscle and Tendon Ruptures
Bilateral quadriceps muscle/tendon ruptures (29)*
Distal biceps brachii tendon avulsion (30)*
Patellar tendon rupture (31)
Pectoralis major muscle rupture (1)
Pectoralis major tendon avulsion (32)
Triceps tendon avulsion with radial neuropathy (33)*

Acute Fractures and Dislocations
Lunate dislocation (34)
Second rib fracture associated with bench press (35)
Talar dome fracture associated with squatting (36)

Acute Medical Events
Aortic dissection (24)*
Death (37,38)
Effort thrombosis (39)
External iliac artery stenosis (40)
Myocardial infarction (41,42)*
Pulmonary embolism (43)*
Spontaneous pneumothorax (44)
Stroke (45)*
Subarachnoid hemorrhage (23)
Tetraplegia (46)

*Associated with anabolic steroid use.

In most instances, treatment is surgical repair or reattachment unless the lifter does not intend to return to his or her sport.

Pelvic avulsions. Avulsion of the anterior superior iliac spine (ASIS) is etiologically similar to a tendon avulsion; both are caused by excessive tension. In adolescents, the unfused ossifying iliac crest apophysis is relatively weak and susceptible to injury. Young weight trainers report a sudden pain and may feel a "pop" in the anterior pelvis when attempting forceful hip extension while the knee is flexed. This injury can also occur with lumbar hyperextension exercises and dead lifts (12). Typically, sartorius muscle contraction avulses the bony fragment. Examination reveals swelling and tenderness, and radiographs confirm the diagnosis.

Treatment is generally nonoperative, and most patients respond well to crutch ambulation and PRICE. Hip and lower-extremity strength training is initiated after symptoms subside. Some authors have reported success with open reduction and internal fixation (13,14).

Ischial apophysis and hamstring avulsions may also occur during weight training. Like ASIS avulsions, ischial apophysis avulsions occur in skeletally immature athletes and are most commonly associated with sprinting, running, or jumping activities (15). Weight training activities that can lead to ischial apophysis and hamstring avulsions include dead lifts, squats, and hamstring curls. The authors are unaware of any case reports of ischial apophysis avulsion injuries associated with weight training, though they may occur in skeletally immature athletes. Hamstring avulsions in adults have been reported.

Treatment is somewhat controversial, though ischial avulsion injuries can usually be managed nonoperatively. Orava and Kujala (16) reported their surgical experience with several cases of hamstring avulsions associated with dead lifts and squats. They recommend early surgical repair to prevent muscle contracture that may otherwise preclude anatomic reconstruction.

Acute fractures. Fortunately, fractures account for only a small percentage of weight training injuries. The presentation may be acute and dramatic or chronic and insidious. Grumbs et al (17) reported on two adolescent boys who performed clean and jerk lifts; each lost control of the overhead weight and sustained bilateral radius or bilateral radius and ulna fractures. Reider et al (18) reported nonunion of a scaphoid fracture in a 17-year-old boy who developed wrist pain while attempting a 430-lb bench press 5 months before presentation. The patient did not seek immediate medical attention because he assumed the injury was merely a sprain. Table 3 lists other related case reports.

Acute Medical Conditions

Various other uncommon medical conditions have been linked with weight training (table 3). Tremendous blood pressure elevations during maximal lifts may contribute to vascular injuries. Studies of blood pressures during weight lifting have reported readings as high as 480/350 mm Hg (19). MacDougall et al (20) also studied blood pressure responses in several lifting situations and found that blood pressure elevations were similar across contraction types (eccentric, concentric, isometric) when intensity was controlled. Narloch and Brandstater (21) demonstrated that slow exhalation during the strain phase of a lift significantly reduces blood pressure elevation. Thus, avoiding Valsalva's maneuvers during weight lifting may help limit blood pressure elevations.

Retinal hemorrhages cause acute unilateral changes in vision and typically resolve without surgical intervention (22). Subarachnoid hemorrhage and stroke are rare, but patients who have known aneurysms and bleeding risks should be advised to avoid heavy weight training (23). Many of the vascular complications noted in table 3 were associated with steroid abuse, which may be a more significant risk factor than weight training itself.

In four aortic dissections described by de Virgilio et al (24), two patients had a history of steroid abuse and hypertension. All four patients had cystic degeneration of the aortic media, but it is unknown if this was related to weight training or to an unidentified factor such as occult hypertension or unrecognized Marfan syndrome.

Rhabdomyolysis and acute compartment syndromes of the limbs have been reported by several authors (25,26). Clinical suspicion of compartment syndrome should be high when patients present with progressively severe muscle pain following strenuous workouts, especially if eccentric exercises were involved. The cardinal signs of acute compartment syndromes are pain and pressure in a muscle or muscle compartment, pain with stretching of that muscle, paresis, and paresthesias. A pulse may or may not be palpable. Compartment pressures should be measured when this condition is suspected. However, compartment syndrome is a clinical diagnosis based on the examination and the patient's overall medical status. Fasciotomy for pressure relief must be performed in a timely fashion to minimize permanent nerve and muscle injury.

Rhabdomyolysis in isolation or due to compartment syndrome can be life threatening because of the potential for acute renal failure and electrolyte abnormalities. Creatine kinase elevations to 76,000 IU/L have been reported (26). Treatment involves aggressive hydration, urine alkalization, and brisk diuresis.

Since acute radiculopathies are often associated with heavy lifting, many assume that weight lifters are at increased risk for radiculopathy. Certainly, acute radiculopathy can occur during weight training, and Jordan et al (27) have reported three patients who developed acute cervical radiculopathies while training. In an epidemiologic study of possible risk factors for cervical and lumbar disc herniation, Mundt et al (28) did find a possible association between free weight training and cervical radiculopathy (relative risk, 1.87; 95% confidence interval, 0.74 to 4.74). They found no increased risk for lumbar disc herniation.

Weight Training Awareness

Knowing weight lifting methods and the demands of the sport can make the patient history more productive. A detailed history and physical examination often leads to a narrow, focused differential diagnosis. Part 2 of this series will cover the diagnosis and treatment of chronic conditions that can result from weight training, including stress fractures, chronic degeneration of the spine, and weight lifter's headache.

Physicians who get to know the culture of weight training can ensure that their patients get the most benefit from the activity in the safest possible way.


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Honing Technique to Avoid Injury

Most patients who work out with weights do either circuit training or focused strengthening of specific muscle groups. To help them improve their form, avoid injury, and get the most from their workouts, it's a good idea to advise them about five common mistakes and safer alternative techniques.

Technique 1: Latissimus Dorsi Pull-Down

Problem: When the weight is lowered behind the neck, this exercise excessively flexes the cervical spine and loads the shoulders at the extreme of external rotation. The line of pull does not oppose the muscle fibers of the latissimus dorsi, and this does not maximally challenge the muscle. The behind-the-neck position increases the load on the cervical disks and the risk of spinous process fracture. The exercise puts the shoulder at a mechanical disadvantage that may contribute to rotator cuff injury or anterior shoulder instability. An excessively wide grip on the bar should also be avoided because it may increase shear forces across the glenohumeral joint.


Solution: The safer way to perform the exercise is to sit or kneel on one knee, lean back slightly at the hips, grip the bar slightly wider than shoulder width, and pull it down in front of the head.

Another exercise that effectively challenges the latissimus dorsi is seated rowing, an activity that minimizes shear force at the shoulder.


Technique 2: Knee Extension

Problem: Knee extensions are examples of open-kinetic-chain exercises, which isolate a particular muscle group—in this case, the quadriceps—and involve motion distal to the axis of the joint. During knee extensions, potentially damaging tibiofemoral shear forces are greater during the last 5° to 10° of extension and also if one "hyperextends" the knee. In addition, at the extremes of knee flexion (greater than 60°), increased patellar compression is potentially harmful (1,2).

Solution: Avoid "hyperextension" of the knee at the completion of knee extension, and train in a range that avoids extremes of knee flexion and extension, especially as the load is increased. Also, try to incorporate closed-kinetic-chain exercises, which involve predictable coordinated muscle contractions with motion at multiple joints in a limb whose segment meets fixed or constrained resistance.

Squats and leg presses can each be closed-kinetic-chain exercises, and shear force is generally less with these exercises, though a recent study (3) suggests that strain on the anterior cruciate ligament (ACL) is simmilar in both open- and closed-chain exercises.

Technique 3: Bench Press and Chest Fly

Problem: Hyperextension of the shoulders during bench press or chest fly exercises (dropping the elbows below or behind the plane of the body) places the pectoralis muscles at a mechanical disadvantage, contributes to glenohumeral instability through repetitive shoulder capsule trauma, and places excessive traction on the acromioclavicular joints (4).


Solution: The preferred way to perform the exercises is to adjust the exercise machine or starting position so that the elbows are even with or above the frontal plane when beginning the lift and during repetitions.


Technique 4: Military Press

Problem: Extreme shoulder external rotation and abduction during behind-the-neck military presses stress the shoulder capsule and inferior glenohumeral ligament, which can cause anterior shoulder instability (5,6). Extreme cervical flexion puts patients at risk for spinous process fracture and neck strains.


Solution: The safer way to do military presses is to lift the weight in front of the neck.


Technique 5: Squats

Problem: In a deep squat, when the thighs are parallel to the floor or lower, there is an excessive amount of shear load on the knee in a position in which the articular cartilage is thinnest. Descending to this position is done by power lifters who must meet technical specifications during competition, but they also place themselves at risk of cartilage damage.

Solution: Weight lifters should avoid deep squats and extremes of hyperflexion and hyperextension, and they should maintain lumbar spine stability during squat lifts.


  1. Beynnon BD, Fleming BC, Johnson RJ, et al: Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 1995;23(1):24-34
  2. Palmitier RA, An KN, Scott SG, et al: Kinetic chain exercise in knee rehabilitation. Sports Med 1991;11(6):402-413
  3. Beynnon BD, Johnson RJ, Fleming BC, et al: The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension: a comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997;25(6):823-829
  4. Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: an anatomic and clinical analysis. Am J Sports Med 1992;20(5):587-593
  5. Gross ML, Brenner SL, Esformes I, et al: Anterior shoulder instability in weight lifters. Am J Sports Med 1993;21(4):599-603
  6. Neviaser TJ: Weight lifting: risks and injuries to the shoulder. Clin Sports Med 1991;10(3):615-621

Dr Reeves is chief resident, Dr Laskowski is a consultant, and Dr Smith is a senior associate consultant in the department of physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minnesota. Dr Laskowski is codirector and Dr Smith is a staff physician at the Mayo Sports Medicine Center, and Dr Laskowski is an associate professor and Dr Smith is an assistant professor at Mayo Medical School in Rochester. Address correspondence to Edward R. Laskowski, MD, Mayo Sports Medicine Center, 200 First St SW, Rochester, MN 55905; e-mail to [email protected].



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