THE EPIDEMIOLOGY OF INJURIES ACROSS THE WEIGHT TRAINING SPORTS: A SYSTEMATIC REVIEW

Abstract

Background: Weight training sports including weightlifting, powerlifting, bodybuilding, strongman, Highland Games and CrossFit are weight training sports that have separate divisions for males and females of a variety of ages, competitive standards and bodyweight classes. These sports may be considered dangerous due to the heavy loads commonly used in training and competition. Objectives: To systematically review the injury epidemiology of these weight training sports; and where possible gain some insight into whether this may be affected by age, sex, competitive standard and bodyweight class. Methods: An electronic search was performed using PubMed, SPORTDiscus, CINAHL and Embase for injury epidemiology studies involving competitive athletes in these weight training sports. Eligible studies included peer-reviewed journal articles only, with no limit placed on date or language of publication. Risk of bias was assessed in all studies using an adaption of musculoskeletal injury review method. Results: Only five of the 20 eligible studies had a risk of bias score ≥75%; meaning the risk of bias in these five studies was considered low. While 14 of the studies had sample sizes greater in 100 participants, only four studies utilized a prospective design. Bodybuilding had the lowest injury rates (0.12 - 0.7 injuries per lifter per year; 0.24 - 1 injury per 1000 hours), with strongman (4.5 - 6.1 injuries per 1000 hours) and Highland Games (7.5 injuries per 1000 hours) reporting the highest rates. The shoulder, lower back, knee, elbow and wrist/hand were generally the most commonly injured anatomical locations; with strains, tendinitis and sprains the most common injury type. Very few significant differences in any of the injury outcomes were observed as a function of age, sex, competitive standard or bodyweight class. Conclusion: While the majority of the research reviewed utilized retrospective designs, the weight training sports appear to have relatively low rates of injury compared to common team sports. Future weight training sport injury epidemiology research needs to be improved, particularly with regard to the use of prospective designs, diagnosis of injury and changes in risk exposure.

Full text

Weight training injuries
THE EPIDEMIOLOGY OF INJURIES ACROSS THE
WEIGHT TRAINING SPORTS: A SYSTEMATIC REVIEW
Corresponding Author
Justin W.L. Keogh PhD
Bond University
Faculty of Health Sciences and Medicine
Gold Coast
Australia
Tel: +61 7 559 54487
Fax: +61 7 559 54480
Email: jkeogh@bond.edu.au

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The Epidemiology of Injuries across the Weight Training Sports: A Systematic Review
Running head: Injuries in weight training sports
Authors:
Justin W. L. Keogh1,2,3 and Paul W. Winwood2,4.
1 Bond University
Faculty of Health Sciences and Medicine
Gold Coast
Australia
2 AUT University
Sports Performance Research Institute New Zealand (SPRINZ)
AUT Millennium
Auckland
New Zealand
3University of the Sunshine Coast
Faculty of Science, Health, Education and Engineering
Queensland
Australia
4Bay of Plenty Polytechnic
Department of Sport and Recreation
School of Applied Science

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Tauranga
New Zealand

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Key Points
The weight training sports appear to have lower rates of injury than many common team sports.
It is however acknowledged that this conclusion may partly reflect some limitations in the weight
training sport injury epidemiology literature, primarily study design, diagnosis of injury and
changes in risk exposure.
Each of the weight training sports tended to have some subtle differences in their injury
epidemiology, particularly their proportional injury rates across the various anatomical locations
as well as the onset and severity of injury.
The intrinsic factors of sex, competitive standard, age and bodyweight class may only have a
relatively minor influence on the injury epidemiology of the weight training sports.

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Abstract
Background: Weight training sports including weightlifting, powerlifting, bodybuilding,
strongman, Highland Games and CrossFit are weight training sports that have separate divisions
for males and females of a variety of ages, competitive standards and bodyweight classes. These
sports may be considered dangerous due to the heavy loads commonly used in training and
competition. Objectives: To systematically review the injury epidemiology of these weight
training sports; and where possible gain some insight into whether this may be affected by age,
sex, competitive standard and bodyweight class. Methods: An electronic search was performed
using PubMed, SPORTDiscus, CINAHL and Embase for injury epidemiology studies involving
competitive athletes in these weight training sports. Eligible studies included peer-reviewed
journal articles only, with no limit placed on date or language of publication. Risk of bias was
assessed in all studies using an adaption of musculoskeletal injury review method. Results: Only
five of the 20 eligible studies had a risk of bias score ≥75%; meaning the risk of bias in these five
studies was considered low. While 14 of the studies had sample sizes greater in 100 participants,
only four studies utilized a prospective design. Bodybuilding had the lowest injury rates (0.12 -
0.7 injuries per lifter per year; 0.24 - 1 injury per 1000 hours), with strongman (4.5 - 6.1 injuries
per 1000 hours) and Highland Games (7.5 injuries per 1000 hours) reporting the highest rates.
The shoulder, lower back, knee, elbow and wrist/hand were generally the most commonly
injured anatomical locations; with strains, tendinitis and sprains the most common injury type.
Very few significant differences in any of the injury outcomes were observed as a function of
age, sex, competitive standard or bodyweight class. Conclusion: While the majority of the
research reviewed utilized retrospective designs, the weight training sports appear to have
relatively low rates of injury compared to common team sports. Future weight training sport

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injury epidemiology research needs to be improved, particularly with regard to the use of
prospective designs, diagnosis of injury and changes in risk exposure.
1. Introduction
Weight training is a popular physical activity that is typically performed to increase muscular
hypertrophy, strength and endurance. Weight training typically uses the force of gravity acting
upon resistances including the exerciser’s own bodyweight or specialized forms of equipment
such as barbells, dumbbells and resistance training machines to target specific muscle groups and
joint actions. While many people who regularly exercise perform weight training along with
cardiovascular or flexibility exercise for overall health benefit, several athletic groups also
compete in sports in which weight training is the primary form of training and/or the competitive
event. These sports include weightlifting, powerlifting, bodybuilding, strongman, Highland
Games and CrossFit.
Weightlifting requires the lifter to lift maximal loads for one repetition in two exercises; the
clean and jerk and the snatch. As these exercises require the barbell to be lifted explosively from
the floor to an overhead position, they may produce the greatest power outputs of any human
activity [1]. Up until 1972, weightlifting also involved a third lift, the overhead (shoulder) press.
Powerlifting is similar to weightlifting, with lifters attempting to lift the maximum loads for one
repetition. However, in powerlifting competitions the three lifts performed are the squat, bench
press and deadlift.
The Scottish Highland Games and strongman competitions are in some ways, the most similar
form of weight training competition to that done in ancient or medieval times, with some of the

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events found in the sports traditionally performed as tests of manhood in many countries. These
tests of manhood typically had farming and/or military applications and involved the lifting or
throwing of a variety of natural and man-made objects that have been available for hundreds or
thousands of years. Specifically, strongman events utilize a variety of heavy implements such as
stones for lifts and carries, tyres for flipping, logs and stones for overhead pressing and trucks or
sleds for pulling. While some of these strongman events are similar to weightlifting and
powerlifting with the athletes attempting to lift the heaviest load for one repetition, many of the
events are timed with the winner being the fastest athlete to complete the task. Highland Games
events are other ancient/mediaeval examples of tests of manhood and typically involve a range of
heavy throwing events such as the caber, stone put, hammer throw or sheaf toss as well as weight
for height and distance. The variety of weight for distance events are simply much heavier
versions of many of the throwing events currently seen in regular track and field competitions.
CrossFit is the newest of the weight training sports. CrossFit programs, known as ‘workouts of
the day’ (WODs), typically exceed 10-20 minutes and include a variety of bodyweight and
resistance exercises, gymnastics, weightlifting, powerlifting, and endurance activities. These
exercises are generally combined into high-intensity workouts that are performed in rapid
succession with limited or no recovery time. CrossFit athletes also compete in the CrossFit
games where the winner is decided by the athlete who completes the WOD in the shortest period
of time.
Bodybuilding differs from the other weight training sports in that it is not judged on the weight
lifted or the time taken to complete an event, but rather on the physical appearance of the athlete.
Bodybuilding competitors therefore also perform regular high intensity weight training to

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develop muscle bulk, balance between muscle groups (symmetry), muscular density and
definition, as these are the criteria they are judged on in competition.
Most of these weight training sports included in this review have annual world championship
events for male and female athletes, with some of these sports also offering various bodyweight
or age (Junior, Open and Masters) classes. However, weightlifting is the only one of these sports
currently included in the Olympic Games, although powerlifting (bench press only) is also a part
of the Paralympics. A picture of some common weight training exercises performed by the
athletes competing in the sports is provided in Figure 1.
PLEASE INSERT FIGURE 1 about here
Due to the intense, heavily loaded activities commonly performed by these athletes in training
and competition, the joint moments (torques) as well as shear and compressive forces produced
during these types of exercises can be very large [1-5]. Members of the public, sporting, medical
and scientific communities may therefore believe these activities are inherently dangerous and
their performance will result in numerous serious and/or long-term injuries. Such a view may
also reflect the many case-studies found in the literature in which needless weight training-
related severe injuries [6, 7] and catastrophic incidents have been reported [8, 9]. According to
the National Center for Catastrophic Sport Injury Research [10], catastrophic injuries can be
defined as “fatalities, permanent disability injuries, serious injuries (fractured neck or serious
head injury) even though the athlete has a full recovery, temporary or transient paralysis (athlete
has no movement for a short time, but has a complete recovery), heat stroke due to exercise, or
sudden cardiac arrest or sudden cardiac or severe cardiac disruption.” While these case studies

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highlighting the risks of weight training are important to acknowledge, the primary objective of
this analysis was to systematically review the injury epidemiology of these weight training sports
using a list of injury epidemiology outcomes advocated by the International Olympic Committee
(IOC) [11]. The secondary objective was to gain some insight into whether demographic
characteristics such as age, sex, competitive standard and bodyweight class influenced the injury
epidemiology of these weight training sports.
2. Methods
2.1 Search Strategy and Inclusion Criteria
No review protocol for this paper currently exists, although this manuscript is an update of a
previous literature review published as a chapter in a 2009 IOC text on sporting injury [12]. The
original book chapter included 10 journal articles (all of which are cited in the current review) as
well as two abstracts. Neither of these abstracts was deemed eligible for this current review, as
neither contained sufficient detail to determine their risk of bias (ROB). As a result of the
increased research into weight training injury and the emergence of CrossFit and to a lesser
extent strongman as new participation sports since the previous book chapter, the authors believe
such an update has considerable merit.
A search was conducted using PubMed, CINAHL, SPORTDiscus and Embase up to the 15th of
September 2015. As the focus was on quantifying the injury epidemiology of the weight training
sports, a three level approach was utilized. The first level involved using derivatives of the terms
injury, weightlifting, powerlifting, bodybuilding, strongman, Highland Games and CrossFit so to
identify injury studies involving these sports. The second level meant that the studies had to
utilize an injury epidemiology rather than case study design. The third level required the studies

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to contain key words relating to injury which included; wound, rupture, sprain, strain and tear.
The full search strategy for the PubMed search was ((injur*[Text Word] OR rupture*[Text
Word] OR sprain*[Text Word] OR strain*[Text Word] OR tear*[Text Word]) OR "Wounds and
Injuries"[Mesh]) AND ("Weight Lifting"[Mesh] OR weight lift*[Text Word] OR
weightlift*[Text Word] OR power lift*[Text Word] OR powerlift*[Text Word] OR body
build*[Text Word] OR bodybuild*[Text Word] OR strongman[Text Word] OR "strong
man"[Text Word] OR "Highland Game"[Text Word] OR "Highland Games"[Text Word] OR
"Cross fit"[Text Word] OR CrossFit[Text Word])) AND (injur* AND weight lift* OR
weightlift* OR power lift* OR powerlift* OR body build* OR bodybuild* OR strongman OR
strong man OR Highland Game OR Crossfit OR CrossFit).
To be included in this review, the studies had to be full peer-reviewed journal articles that
contained a description of the injury epidemiology of at least one of the weight training sports.
Articles in any language were accepted, with this resulting in the inclusion of 15 articles written
in English along with two Chinese, two German and one Korean article. As neither of the two
authors were able to read Chinese, German or Korean, the authors sought the assistance of one
Chinese colleague, one German colleague and Google Translate to assist in the translation of
these articles, respectively. The two authors provided their Chinese and German colleagues with
sufficient assistance to quantify the risk of bias and to extract the relevant information for the
systematic review, as performed by the two authors on the remaining 16 papers.
No restrictions were placed on the year of publication and no effort was made to contact any of
the study authors to identify additional studies. All of these studies involved adults, except
Brown and Kimball [13] who examined the retrospective injury epidemiology of 71 adolescent

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powerlifters aged 14-19 years. For those interested in a more in-depth discussion on the injury
risk of weight training for children, the reader should consult any of the following review articles
[14-16].
After removal of duplicate studies, all study titles were screened by two independent reviewers
(JK and PW). All potentially eligible articles were retrieved in full-text and evaluated for
eligibility by the same reviewers (authors). Reference lists of these articles were also scanned
for other potentially relevant articles that were not initially identified in the database searches.
All included article titles were then tracked forward by citation tracking using Google Scholar to
find any other potentially relevant articles that could be included in the review. Any
disagreements between the two authors regarding the inclusion of studies within this review were
resolved in a consensus meeting.
2.2 Risk of Bias Assessment and Data Extraction
The ROB of the eligible studies was assessed by both authors (and where relevant the Chinese
and German colleagues) independently using a checklist (Electronic Supplementary Material
Table S1) developed for assessing the ROB in studies examining musculoskeletal injury [17-19].
Any disagreements between the two authors regarding the ROB of the eligible studies were
resolved in a consensus meeting. The results of the bias assessment are displayed in Table 1. All
items were scored as positive (+) or negative (-) for studies with a low and high ROB,
respectively. When no clear information regarding the item was given or when it was unclear
whether the ROB criteria for an item was met, the item was scored as negative. The total ROB
score for each study was calculated by counting the number of items that were scored positively,

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expressed as a percentage of all items. Articles with a ROB score ≥75% were considered as
having a low ROB [19].
PLEASE INSERT TABLE 1 about here
2.3 Data Analysis
Consistent with the IOC recommendations [11], the data from the included epidemiology studies
was categorized into the following primary sections: Who is affected by injury?; Where does
injury occur?; When does injury occur?; What is the outcome?; What are the risk factors?; and
What are the inciting events. Where data were reported for specific demographic groups based
on age, sex, competitive standard or bodyweight class, results for these additional sub-group
analyses were also reported. The primary variable of interest was injury rates which were
reported in two ways; 1) injury per athlete per year; and/or 2) injury per 1000 hours of exposure
where possible. Within each of the result sections, a discussion of the results has also been
provided. This was done as the authors felt this approach made for an easier integration of the
large amounts of data presented and their potential interpretations, applications and limitations.
3. Results and Discussion
3.1 Literature Search
An examination of 4021 titles (including 411 duplicates) revealed 184 potentially relevant full-
text articles which were retrieved. After review of the full-text, a further 167 articles were
excluded. The 17 eligible studies were then reviewed, with their reference lists also checked to
identify other potentially eligible studies that may have been missed in the initial search. This
process revealed another two eligible studies, resulting in a total of 19 studies. The 19 studies

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were then forward tracked in time by citation tracking using Google Scholar in which one more
study was found resulting in a total of 20 studies in this review. A pictorial representation of the
literature search is presented in Figure 2.
PLEASE INSERT FIGURE 2 about here
Within the 20 eligible studies, data were presented for weightlifting (eight studies) and
powerlifting (six studies). Four studies for bodybuilding, one study of strongman, one study of
Highland Games and two studies for CrossFit injury epidemiology were also identified. There
was often considerable intra- and/or inter-study variation in the age, sex, body mass and standard
of the lifters, with a small number of the studies reporting data for these sub-groups.
Specifically, several studies categorized (at least some of) their data by sex [20-24], competitive
standard [20, 23, 25, 26], age [20, 26] and bodyweight class [20, 26].
3.2 Risk of Bias
The results of the ROB assessment are displayed in Table 1. Five of the 20 studies had a score
≥75% and were considered to have a low ROB [19]. The definition of injury was clearly
described in 14 studies [13, 20, 22, 24-34], with these definitions typically requiring an injury to
involve physical damage to the athlete that caused the athlete to modify or cancel at least one
training session. A summary of the definitions provided in these papers is provided in Table 2.
Four of the included studies used a prospective design [22, 24, 27, 28]. Three studies did not
clearly describe the participants’ competitive level and/or demographic characteristics [33, 35,
36]. Fourteen studies used subject sample sizes ≥100 [20-23, 25, 26, 28, 30, 32-34, 36-38]. The
criteria for the inclusion of participants (i.e. random or the data collection was performed with

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the entire target population) was clear in eight studies [13, 22-24, 27-29, 37]. Only one of the 20
studies’ data analysis did not represent at least 80% of the included participants [32]. Seven
studies employed an appropriate duration of data collection [20, 24-27, 29, 34]; (i.e. for
prospective studies at least a 6-month follow up, for retrospective studies up to a 12 month recall
period). One study used different modes of data collection [20] (e-mail, telephone, interview,
etc.). A diagnosis of all injuries was conducted by health professionals in five studies [22, 24, 27-
29] and partially in another five studies [13, 20, 21, 26, 31]. Changes in risk exposure (e.g.
seasonal changes, training versus competition) were taken into account in six studies [22-24, 26,
28, 37]. Eleven studies reported number of injuries by exposure time to weight training [20, 24-
27, 29-33, 38].
PLEASE INSERT TABLE 1 about here
PLEASE INSERT TABLE 2 about here
3.3 Who Is Affected By Injury?
Injury incidence rates reported in Table 3 were somewhat consistent, with most studies reporting
~1 - 2 injuries per lifter per year or ~2 - 4 injuries per 1000 hours. However, there were some
exceptions to this rule. Studies reporting lower injury rates included three bodybuilding studies
(0.12 - 0.7 injuries per lifter per year or 0.24 - 1 injury per 1000 hours) [21, 31, 38] and two of
the six powerlifting studies (0.3 - 0.4 injuries per lifter per year and 1.0 - 1.1 injuries per 1000
hours) [29, 30]. Studies reporting higher injury rates included the only studies on strongman (2.0
injuries per lifter per year and 5.5 injuries per 1000 hours of training) [26] and Highland Games
(7.5 injuries per 1000 hours of training and competition) [32].

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The manner in which the injury incidence rate data was presented for the weightlifting study of
Kim and Kim [24] precluded direct comparison of the other studies. While Kim and Kim [24]
reported injuries per 1000 athlete exposures, they did not normalize their data to the number of
weightlifters nor provide the number of weightlifters included in this study. Therefore, it was
not possible to determine the number of injuries per lifter per year or the number of injuries per
1000 hours as presented in previous studies.
PLEASE INSERT TABLE 3 about here
As only one study was found for the sports of strongman and Highland Games, it is difficult to
be certain that these sports have a greater injury risk compared to the other weight training
sports. Winwood et al. [26] did however quantify injury rates associated with different types of
strongman training, reporting that although only 31% of strongman training involves specific
implement (event) training, implement training accounted for 1.9 times more injury than
traditional training (e.g. squat, deadlift, bench press etc.) when normalized by time of exposure.
Such results may indicate that strongman exercises by the nature of their dynamic movements
may involve somewhat higher injury risk than traditional weight training exercises performed
with barbells, dumbbells or weight training machines.
A number of the studies also reported the athlete injury rate (i.e. the proportion of athletes who
had suffered an injury [22, 23, 28, 30, 31, 34], with this varying from 16 - 90%. Drawing
comparisons between these studies is difficult as the time frame of data collection differed. At
one extreme, Junge et al. [28] and Engebretzen et al. [22] collected data during Olympic
competitions (16 and 17 days, respectively), whereas other studies [30, 31] collected data over

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the athletes’ entire career. In contrast, Wang et al. [23] provided no specific timeframe for the
duration of the data collection.
3.4 Where Does Injury Occur?
3.4.1 Anatomical Location
Inspection of the individual studies revealed that the five most commonly injured sites were
typically the shoulder, lower back, knee, elbow and wrist/hand across the weight training sports
(see Table 4). Almost all of these data were reported as percentage of overall injuries, with
Raske and Norlin [25] and Kim & Kim [24] the only studies to also report incidence rates for each
anatomical location. The finding that shoulder injuries accounted for a high percentage of all
weight training sports injuries in the studies (6 - 36%) may reflect the frequent use of heavy
loads and exercises such as the bench press and overhead presses (e.g. strict press, push press or
jerk) by these athletes. Kobler and colleagues [39] suggested that the susceptibility of the
shoulder complex to weight training injury is in part due to the high compressive loads these
exercises apply to a traditionally non-weight bearing joint. Furthermore, the bench and overhead
presses may place the shoulder in somewhat unfavorable positions, such as end-range external
rotation while under heavy loads, predisposing the shoulder to both acute and chronic injuries
[39, 40].
PLEASE INSERT TABLE 4 about here
There were some subtle between-sport differences in the most common sites of injury. In
descending order, the three most frequent injury sites appeared to be: weightlifting (knee, lower
back and shoulder); powerlifting (shoulder, lower back and knee); bodybuilding (shoulder, knee

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and lower back); strongman (lower back, shoulder and bicep); Highland Games (shoulder, knee
and lower back); and CrossFit (shoulder, lower back and knee). However, it must be
acknowledged that there was some between-study variation in the anatomical location categories
and/or definitions utilized in these studies. Further, as anatomical location of injury was only
examined in two studies of CrossFit, one study of strongman and one study of Highland Games,
further research is required to better characterize the most commonly injured anatomical
locations in these sports.
The subtle differences in the most commonly injured anatomical locations for these weight
training sports begs the question about what aspects of these sports may alter the most commonly
injured body parts (anatomical locations), particularly as athletes in all of these weight training
sports often perform similar exercises including squats, power cleans, deadlifts and/or overhead
presses. One answer may lie in the different competitive goals and training practices of each of
the sports. Typically, weightlifters, powerlifters, strongman and perhaps Highland Games
athletes lift heavier loads (at a higher percentage of one repetition maximum (1RM)) for fewer
repetitions with longer rest periods between sets than bodybuilders or CrossFit athletes [41-45].
Further, there may often be considerable between-sport differences in the manner in which these
exercises are commonly performed that may alter the relative loading and hence injury risk to
various anatomical locations.
The possibly higher rate of knee injuries for weightlifters (10 - 32%) compared to the other
weight training sports (5 - 28%) may reflect differences in the manner in which the squat (and
their derivatives) are performed by these groups. For example, weightlifters perform the clean
and jerk, snatch, front squat and high-bar back squats through a full range of motion whereby the

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gluteals may come to rest on the calf musculature at the bottom of the lift. Such a range of
motion and the bar position requires the weightlifter to maintain a vertical trunk position and
utilise large degrees of dorsiflexion and anterior knee translation. This contrasts with
powerlifters and strongman athletes who typically position the bar further down their back than
the other groups during the squat, with this typically referred to as low-bar squat [41, 44]. This
low-bar squat results in a greater forward inclination of the trunk at the bottom of the lift than the
high-bar / front squat favored by weightlifters [46]. By virtue of these differences in trunk
inclination, dorsiflexion and anterior knee translation, the high-bar or front squat has a larger
knee resistance moment arm and smaller hip/lower back resistance moment arm than the low-bar
squat. Such differences in resistance moment arms suggest that the high-bar or front squat may
require greater knee extensor torques and produce greater mean compressive patello-femoral
forces than low-bar squats [2, 46]. Therefore, the lower frequency of knee injuries for some of
the weight training sports including powerlifting and strongman compared to weightlifting may
reflect the reduced mechanical stress that low-bar squats apply to the knee compared to high-bar
or front squats.
Overall, the subtle differences in the most commonly injured anatomical locations of injury for
the weight training sports suggests that differences in exercise/event load, selection as well as the
actual technique and body positioning in a particular exercise/event can alter the mechanical
stress placed on specific anatomical locations and therefore the subsequent injury risk. A
detailed analysis of the injury inciting events is outlined in section 3.8.

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3.4.2 Environmental Location
Only four studies have documented the number of injuries that lifters experienced in competition
[22, 24, 26, 28], with many studies combining data from training and competition. Junge et al.
[28] found that 90% of injuries (n = 26) reported by weightlifting athletes at the 2008 Summer
Olympic Games occurred during competition [22]. This was higher than the 45% of competition
injuries (n = 18) reported by weightlifters in the 2012 Summer Olympic Games [22]. In contrast,
Kim and Kim [24] reported that 1.5% of the injuries (n = 3) reported by Korean weightlifting
athletes over a 271 day period occurred during competition. Winwood and colleagues [26] found
that strongman athletes experienced 1.6 ± 1.5 training injuries per athlete per year compared to
0.4 ± 0.7 competition injuries per athlete per year. While such findings would suggest that the
risk of injury in training is greater than in competition, weight training athletes will often train
many hours per week but only compete a handful of times per year, meaning the training
exposure is substantially greater than that of competition. To address these limitations, future
studies should seek to report the training and competition injury data per 1000 hours of training
and competition exposure. Such an approach is warranted in that athletes in the weight training
sports (with the possible exception of bodybuilding) are generally subjecting their bodies to
greater levels of musculoskeletal stress in a competitive rather than training environment.
Three studies also specifically recorded injuries that did not occur as a direct result of weight
training [20, 27, 38]. Keogh et al. [20] observed that 13% and 15% of the injuries reported by a
group of 101 powerlifters resulted from cross-training (e.g. ball sports or cardiovascular training)
or were of unknown origin, respectively. Calhoon et al. [27] reported similar results with 36% of
the weightlifting injuries recorded in the United States Olympic Training Centre occurring
outside of their regular weightlifting training sessions. In contrast, Eberhardt et al. [38] found

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that only 1% of the injuries reported by 250 bodybuilders occurred during non-weight training
activities.
3.5 When Does Injury Occur?
3.5.1 Injury Onset
As seen in Table 5, there have only been eight studies that have reported data on injury onset in
the weight training sports [20, 22-28], with these studies conducted on weightlifting,
powerlifting and strongman athletes. These studies reported the onset for all injuries collectively
with no injury onset data given for each anatomical location. While most of these studies
recorded acute and chronic injuries, there were a number of exceptions. Two weightlifting
studies only reported chronic injuries [28, 38], one weightlifting study only reported acute and
recurrent injuries [24] and Keogh et al. [20] also incorporated acute-to-chronic or “other” onset
categories. With the exception of Wang et al. [23] and perhaps Kim and Kim [24], these studies
suggest that athletes in weightlifting, powerlifting and strongman experienced a greater rate of
acute (26 - 72%) than chronic (25 - 50%) onset injuries.
PLEASE INSERT TABLE 5 about here
3.5.2 Chronometry
Only two studies have directly examined the chronometry of injury in the weight training sports
[26, 37]. Winwood and colleagues [26] found that half (51%) of the training injuries reported by
strongman athletes occurred in the general preparation phase of their yearly training plan.
Winwood and colleagues [26] also requested the participants to estimate the time their injuries
occurred during training sessions and competitions, via a tertile classification system i.e. early,

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mid or late within a training session or competition. The most common time for a training injury
was “early” in the training session (36% of all training injuries), whereas the most common time
for competition injury was late in the competition (44% of all competition injuries) [26]. Xiaojun
et al. [37] found that nearly half of all injuries (49%) reported by bodybuilders occurred in the
three months comprising winter, whereas only 9% of injuries occurred in the three months of
summer.
The limited data on chronometry of weight training injuries appears somewhat consistent with
aspects of the literature for team sports. Specifically, team sport athletes may suffer more injuries
during the final third (15 minutes) of each half of a football (soccer) match and during the pre-
season than regular season [47, 48]. Collectively, the results found in the review and that in
previous studies of team sports may suggest that fatigue and a lack of “conditioning” are also
possible risk factors for injury in the weight training sports [47, 48].
3.6 What is the Outcome?
3.6.1 Injury Type
Nine studies provided data on the injury type experienced by weight training athletes (see Table
6), with strains, tendinitis and sprains generally the most common across the sports with some
minor exceptions. The three most common injury types for these sports were (in descending
order): weightlifting (strains, sprains and tendinitis), powerlifting (strains, tendinitis and
arthritis), bodybuilding (sprains, tendinitis and cartilage degeneration), strongman (muscle
strains, tendon injuries and ligament sprains/tears) and Highland Games (tendinitis, strains and
cartilage damage). The results demonstrate that the three sports in which competition and
training performance is based on lifting heavier loads than ones competitors (weightlifting,

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powerlifting and strongman) have muscle strains as the most common injury type (6 - 62%). In
contrast, bodybuilders who typically train at a lower percentage of 1RM experience a lower
proportion of muscle injuries (7 - 34 %), but report a greater proportion of cartilage (28 - 32%)
and tendon injuries (29 - 63%). Such results suggest that the greater loads used by powerlifters,
weightlifters and strongman athletes predispose them to a higher proportion of acute-type muscle
strain injuries; with the greater volume of exercise performed by bodybuilders tending to
produce a greater proportion of chronic-type connective tissue injuries.
PLEASE INSERT TABLE 6 about here
3.6.2 Severity of Injury and Associated Time Loss
Fourteen studies reported data on the injury severity/time loss associated with injuries, with a
summary of these studies provided in Table 7. Two studies (both on powerlifting) reported that
the average injury was symptomatic for ~12 days [13, 29]. A number of other studies also
recorded the time that each injury affected training, but reported this in specific time bands such
as < 1 day, 1 - 7 days, 8 - 14 days and > 14 or 30 days (one month) [22, 25, 27, 32, 35, 36]. With
the exception of Raske and Norlin [25], all of the studies reporting data on severity/time loss of
injury indicated that the majority of weight training injuries were symptomatic for less than two
weeks, a value similar to the two powerlifting studies reporting mean injury durations of 12 days
[13, 29]. Another four studies [20, 23, 26, 37] assessed the time loss by categorizing the effect
on the injury had on the athletes’ training, with injuries classified as mild (exercise execution
required modification), moderate (stopped performing the exercise) or major (training stopped
completely for a period of at least a week). In general, these four studies also observed most
injuries (78 - 99%) to be of a mild or moderate severity.

Weight training injuries
PLEASE INSERT TABLE 7 about here
3.6.3 Clinical Outcome
The clinical outcome of injury can be described using a variety of outcomes including recurrent
(repeat) injury, catastrophic incidents, non-participation injury (injuries that force the athlete to
retire) and residual effects (injuries resulting in long-lasting or permanent symptoms or
disability) [11]. Results of this review indicate there is little clinical outcome epidemiological
data specifically determined for the weight training sports.
Winwood and colleagues [26] reported that 115 (44%) of the 260 injuries reported by strongman
athletes over the course of the year were repeated (recurrent) injuries. Kim and Kim [24]
reported that 145 (70%) of the 207 injuries reported by Korean weightlifters were recurrent
injuries. In contrast, Kulund et al. [35] reported that only three of the 111 injuries reported by a
group of 80 weightlifters were recurrent. Unfortunately, the study of Kulund et al. [35] is limited
in that the duration over which data collection occurred was not stated.
Some insight into the potential of the weight training sports to result in non-participation injuries
was obtained by Raske and Norlin [25]. Over the course of five years of data collection, it was
reported that 38% of the elite weightlifters and powerlifters retired, with almost half (43%) of
these lifters citing injury as the reason for retiring [25]. Such results may suggest that
participation in the weight training sports has the potential to lead to a range of residual effects
that may affect these athletes after retirement. This view is supported by the findings that
arthritis (3 - 29 %) and cartilage degeneration (13 - 32%) are some of the most commonly

Weight training injuries
reported injuries in powerlifting, bodybuilding and Highland Games [21, 32]. A review by
Kujala et al. [49] also supports this view, whereby power athletes (defined as weightlifters,
wrestlers, boxers and track and field sprinters, jumpers and throwers) had a risk ratio (RR) of
2.68 for developing arthritis of the hip, knee and ankle compared to sedentary controls.
However, similar risks of arthritis were also found for endurance (RR = 2.37) and team sports
(RR = 2.42) athletes. This suggests that while high level sports participation may increase the
risk of arthritis in later life, the weight training sports do not impose greater risks than that found
in endurance and team sports.
Currently, no injury epidemiology studies have assessed the rate of acute catastrophic incidents.
Therefore, it is unclear how frequent such catastrophic incidents may be in the different weight
training sports and how these might be affected by a variety of intrinsic and extrinsic factors.
The case study literature does however indicate that the potential for catastrophic incident exists
in the weight training sports with serious injury and even death possible [8, 9].
3.6.4 Economic Cost
No economic cost data appears to have been reported in any of the weight training injury
epidemiology studies to date, even though there exists the potential for weight training to have
economic costs related to the pain, discomfort and disability that the athletes may experience [50,
51]. Some insight into the economic cost of injuries may be obtained from outcomes including
the cost of injury-related treatment during the athletes’ competitive years, the duration and nature
of injury-related treatment after retiring as well as the loss of school or work time associated with
injury. Although the economic cost of injury in the weight training sports did not appear to be
reported in any the studies eligible for inclusion in this review, the potential for weight training

Weight training injuries
to result in residual adverse effects that may have economic costs during their competitive
careers and retirement has been examined in the wider sports injury literature [49]. However, the
results of a systematic review and meta-analysis suggest that participation in the weight training
sports may be somewhat cost neutral or even beneficial. Specifically, Kujala et al. [49] reported
that cardiovascular disease risk was reduced or similar in retired endurance (RR = 0.24 - 0.73),
team (RR = 0.48 - 0.86) and power sport (RR = 0.49 - 0.94) athletes compared to sedentary
controls. Similar results were observed for hospital utilization rates, whereby endurance, team
and power sport athletes had RRs of 0.71, 0.86 and 0.95 compared to sedentary controls,
respectively [49].
3.7 What Are the Risk Factors?
There are a variety of potential extrinsic and intrinsic risk factors that may predispose athletes to
injury in the weight training sports. Identification of the relevant modifiable risk factors may
therefore allow specific injury prevention programs to be tailored to these weight training sports;
whereas a description of relevant non-modifiable risk factors may be useful for individuals who
are considering participating in these sports.
3.7.1 Intrinsic Factors
Several studies of weight training athletes have examined the effect of intrinsic factors including
sex [20-24], competitive standard (e.g. high level and low level) [20, 23, 25, 26], age (e.g. Open
vs Masters) [20, 26] and bodyweight class (e.g. lightweight vs heavyweight) [20, 26] on the
injury epidemiology of the weight training sports. In general, these intrinsic factors had
relatively little effect on the injury epidemiology of the weight training sports. The exceptions to
this generalisation are described below.

Weight training injuries
Where significant sex differences were observed, these exceptions suggested that female lifters
had significantly lower overall injury rates (1.3 vs 2.1 injuries per lifter per year) [21], a lower
rate of recurrent injuries (173 vs 362 injuries per 1000 hours of exposure) [24], a significantly
lower rate of acute injuries (50 vs 61%) [20], a significantly higher rate of knee injuries (28 –
32% vs 10 – 29%) [21, 23] and a significantly lower rate of chest (0 vs 4%) and thigh (0 vs 7%)
injuries [20] than their male counterparts. While the potential mechanisms contributing to the
relatively small number of sex-related differences in aspects of their injury epidemiology are not
well understood, female lifters’ higher rate of knee injuries appears consistent with some
findings for other sports and activities [52].
For the studies reporting significant differences between elite (international) and non-elite
(national) lifters, elite lifters had a significantly lower rate of injuries (3.6 vs 5.8 injuries per
1000 hours) and acute injuries (50 vs 72%) than non-elite lifters [20]. Elite lifters also had
significantly less chest (0 vs 8%) and shoulder injuries (32 vs 42%) but significantly more thigh
injuries (10 vs 0%) than non-elite lifters [20].
For studies comparing the effect of age and bodyweight class, a significantly greater rate of
competition injuries per athlete per year were reported among younger (≤30 years) compared to
older (> 30 years) strongman athletes (0.5 vs 0.3 injuries per year); as well as in heavyweight
(>105 kg) than lightweight competitors (≤105 kg) (0.5 vs 0.3 injuries per year) [26]. Some
significant age- and bodyweight class-related differences were also observed for the severity of
strongman injury [26]. Interestingly, despite the heavier loads that these athletes train and
compete with, the >105 kg strongman athletes had proportionally less severe (18 vs 26%) and

Weight training injuries
moderate injuries (47 vs 53%) than the ≤105 kg athletes. Older strongman athletes (>30-years
old) also experienced almost twice as many severe injuries (26 vs 15%) as the ≤30 year group.
While based on a limited number of peer reviewed studies, it appears that the intrinsic factors of
sex, competitive standard and age and bodyweight class may have only have a relatively minor
influence on the injury epidemiology of the weight training sports. This suggests that athletes of
both sexes as well as a variety of competitive standards, ages and bodyweight classes may
participate in these activities with similar risks of injury.
3.7.2 Extrinsic Factors
Factors such as coaching, the rules of the sport as well as the training environment could be
extrinsic factors related to injury in the weight training sports. However, no experimental studies
have so far been conducted to examine this possibility for the weight training sports.
3.8 What are the Inciting Events?
Several studies included in this review have attempted to gain insight into events that may
contribute to injury in weight training sports [23, 26, 37, 38]. As an example, Wang et al. [23]
sought to determine the inciting events that weightlifters thought contributed to injury.
Weightlifters felt that 60% of their injuries were associated with tiredness (fatigue), 31% with
technical errors and 21% with excessive overload. The bodybuilders in the study by Xiaojun and
colleagues [37] felt that 21% of their injuries were caused by fatigue (and poor recovery), 18%
by training with overly heavy loads and 14% by insufficient preparation (i.e. warm up).
Bodybuilders in the Eberhardt et al. [38] study felt that their injuries were a result of improper
warm-up (42%), too vigorous exercising (35%) or by lack of “guarding assistance”, better

Weight training injuries
known as appropriate spotting by training partners (7%). Strongman athletes cited poor
technique as the most frequent contributing factor to injury (25%), with a wide variety of other
minor inciting events influencing injury as well [26].
Unfortunately, the validity of the relatively limited inciting event data for the weight training
sports appears questionable for several reasons. These include: 1) the retrospective design of the
studies; 2) the relative lack of clear definitions within and between studies for an inciting event;
and 3) the self-report nature of this data. Notwithstanding these limitations, fatigue has
previously been implicated as an inciting factor to sporting injury [47, 48]. Lifters may therefore
need to perform the most demanding, challenging and high-risk exercises during the initial part
of their training sessions to help minimize their risk of injury.
Nine studies have also sought to examine the inciting factors to injury by determining which
exercises/events/disciplines are most associated with injury [20, 25, 26, 30-32, 34, 35, 38] (see
Table 8). Keogh et al. [20] and Siewe et al. [30] reported that the squat, deadlift and bench press
were the most common injury-causing exercises for powerlifters (31 - 61%). Kulund et al. [35]
found that the clean and jerk, squat and the snatch were the three most commonly cited injury-
causing exercises for weightlifters (21 - 46%). In contrast, the squat (11 - 24%), bench press (6 -
16%) and shoulder press (9 - 14%) were the most common injury-causing exercises for
bodybuilders [31, 38] and strongman athletes [26]. For CrossFit athletes, powerlifting,
gymnastics and Olympic lifting exercises (23, 20 and 17%, respectively) were most commonly
cited as causing injury [34]. McLennan et al. [32] observed that the weight toss, caber toss and
hammer throw (31, 25 and 20%, respectively) accounted for most Highland Games event
injuries, with no data available on the injuries attributable to the weight training.

Weight training injuries
PLEASE INSERT TABLE 8 about here
The results of these studies into the inciting events for the weight training sports are of some
interest but only go so far into describing the factors contributing to injury in these sports. The
reason for this is that the most common inciting event exercises were typically the competitive
events in the sports (i.e. powerlifting, weightlifting and Highland Games). As such, these
exercises were likely to be performed more frequently in training and competition than other
exercises and hence be more highly associated with injury. This relationship between exercise
frequency (exposure) and injury risk was also observed among strongman competitors.
Specifically, strongman athletes reported that the six most commonly performed exercises
(farmer’s walk, log press, stones, tire flip, axle clean and press and yoke walk) [41] accounted
for 77% of all injuries reported by strongman athletes during event specific strongman training
[26]. Future studies will need to calculate the relative exposure of the most common exercises to
better identify which exercises may be inherently more risky than others.
4.0 Conclusion
Results of the 20 studies included in this systematic review suggest that most of the weight
training sports have injury rates of ~1-2 injuries per athlete per year and ~2-4 injuries per 1000
hours of training/competition exposure. The majority of injuries reported in these studies were
of minor or moderate severity and affected the shoulder, lower back and knee. While the injury
epidemiology was relatively similar across the six weight training sports, Highland Games (7.5
injuries per 1000 hours) and strongman (5.5 injuries per 1000 hours) appeared to have higher
rates of injury than the other four sports. While many between-sport similarities in injury

Weight training injuries
epidemiology were observed, each of the weight training sports tended to have some subtle
differences in the proportional injury rates across the various anatomical locations as well as the
onset and severity of injury. Additional research is required to substantiate the magnitude of
these between-sport comparisons, particularly in strongman and Highland Games, each of which
had only one injury epidemiology study included in this review. While it is acknowledged that
the 20 studies included in this systematic review is very small compared to samples for other
sporting activities, the injury rate of the weight training sports appears considerably smaller than
many other commonly performed sports. For example, recent studies on soccer, rugby union and
cricket have reported ~15-81 injuries per 1000 hours [53-55]. Such comparisons suggest that
participation in the weight training sports results in fewer injuries than many other popular team
sports.
As the weight training sports are performed by a wide variety of people differing in their age,
sex, competitive standard and bodyweight class, additional research should also focus on direct
comparisons between these sub-groups of weight training athletes. Further cohort studies also
need to be conducted to determine how other intrinsic factors e.g. anthropometric profile,
flexibility and muscular strength/endurance imbalances [56-59], extrinsic factors e.g. use of
weight belts [60, 61] and inciting events e.g. fatigue, exercise technique and selection [62-64]
may modulate the injury risk. Such studies will inform the development of research-based injury
prevention programs which can then be tested for their efficacy in randomized controlled trials,
similar to that done for sports such as soccer and handball [65].
Considerable improvements in the standard of injury epidemiology research for the weight
training sports are also required. Currently, many of the studies included in this review only

Weight training injuries
reported data for a subset of the variables recommended by the IOC for a full understanding of
the epidemiology of sporting injury [11]. In particular, environmental location, onset,
chronometry, clinical outcome and economic cost were infrequently (if at all) reported in the
eligible studies. Greater detail on the training performed by each athlete (e.g. training frequency,
number of set and repetitions, exercise performed and loads used etc.) for each weeks training
would also be most useful. Such data (if involving a large enough sample of randomly selected
athletes over a sufficient period of time) may allow some insight into how alterations in the
training program may influence the rate of injury in these sports. A reduction in the risk of bias
should also be a focus of future research, with current studies primarily limited by their study
design, participant inclusion, duration of data collection, confirmation of injury diagnosis and
changes in risk exposure. It is recommended that future studies utilize prospective research
designs, with the participants followed for a minimum of six months. The generalizability of
results would be improved if the invited participants were randomly selected from the available
populations. It would also be useful to confirm injury diagnosis via medical examination. While
a medical examination may be difficult to include in the retrospective designs commonly used in
the literature, future prospective studies could more easily utilize a medical examination to
increase the validity of the data especially for injury type [66]. This type of research may be
most easily conducted at institutes of sport and national and Olympic training centres as done by
Calhoon et al. [27] and Kim and Kim [24] or at specific competitions such as Olympic Games
[22, 28].
In conclusion, the weight training sports appeared to have relatively similar injury epidemiology
characteristics regardless of the age, sex, bodyweight class or competitive standard of the athlete.
The injury rates for the weight training sports appeared considerably lower than that reported for

Weight training injuries
many team sports. However, the risk of bias assessment performed in this review suggests
greater methodological rigor is required in future weight training sport injury epidemiology
studies to confirm the relative safety of the weight training sports.
Compliance with Ethical Standards
Funding
No sources of funding were used to assist in the preparation of this article.
Conflicts of Interest
Justin Keogh and Paul Winwood declare that they have no conflicts of interest relevant to the
content of this review.
Acknowledgements
The authors would like to thank Meng-Xiao Michelle Miao and Petra Pühringer for their
expertise in translating the text of the studies written in Chinese and German, respectively.

Weight training injuries
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1
Table 1. Risk of bias assessment of the studies
Risk of bias assessment of the studies
Study
1
2
3
4
5
6
7
8
9
10
11
Overall risk of
bias rating (%)
Weightlifting
Calhoon et al.
[27]
+
+
+
-
+
+
+
+
+
-
+
82
Engebretsen et al.
[22]
+
+
+
+
+
+
-
+
+
+
-
82
Junge et al. [28]
+
+
+
+
+
+
-
+
+
+
-
82
Kim & Kim [24]
+
+
+
-
+
+
+
+
+
+
+
91
Konig & Biener
[36]
-
-
-
+
-
+
-
+
-
-
-
27
Kulund et al. [35]
-
-
-
-
-
+
-
+
-
-
-
18
Raske & Norlin
[25]
a
+
-
+
+
-
+
+
+
-
-
+
64
Wang et al. [23]
-
-
+
+
+
+
-
+
-
+
-
55
Powerlifting
Brown & Kimball
[13]
+
-
+
-
+
+
-
+
23%
b
-
-
47
Goertzen et al.
[21]
c
-
-
+
+
-
+
-
+
23%
b
-
-
38
Haykowsky et al.
[29]
+
-
+
-
+
+
+
+
+
-
+
73
Keogh et al. [20]
+
-
+
+
-
+
+
-
57%
b
-
+
60
Siewe et al. [30]
+
-
+
+
-
+
-
+
-
-
+
55
Bodybuilding
Eberhardt et al.
[38]
-
-
+
+
-
+
-
+
-
-
+
45
Siewe et al. [31]
+
-
+
-
-
+
-
+
39%
b
-
+
49
Xiaojun et al. [37]
-
-
+
+
+
+
-
+
-
+
-
55
Strongman
Winwood et al.
[26]
+
-
+
+
-
+
+
+
41%
b
+
+
76
Highland Games
McLennan et al.
[32]
+
-
+
+
-
-
-
+
-
-
+
45
CrossFit
Hak et al. [33]
+
-
-
+
-
+
-
+
-
-
+
45
Weisenthal et al.
[34]
+
-
+
+
-
+
+
+
-
-
-
55
Number of 20
studies with “Yes”
response
14
4
17
14
8
19
7
19
6.8
6
11

Weight training injuries
2
Method for assessing risk of bias. (1) Definition of injury clearly described. (2) A prospective design was
used. (3) Clear description of the subject demographics within the study is given. (4) Subject sample size
is ≥100 (5) The process of inclusion of participants was at random or the data collection was performed
with the entire target population. (6) Data analysis was conducted in at least 80% of the included subjects.
(7) Data collection was appropriate. For prospective studies at least a 6-month follow up, for retrospective
studies up to a 12 month recall period (8) Same mode of data collection (e-mail, telephone, interview,
etc.) was used. (9) The injury diagnosis was conducted by health professionals. (10) Changes in risk
exposure were taken into account (i.e. seasonal changes, periodized block, training versus competition).
(11) Number of injuries reported by exposure time to weight training.
Note: If ther
e was insufficient information in the article to permit a judgment for a particular criterion, the
answer was “No: high risk of bias” for that particular criterion. % Indicates % of injuries diagnosed by
medical professional; + indicates yes: low risk of bias; - indicates no: high risk of bias.
a Study includes powerlifting and weightlifting athletes. b Percentage of subjects that reported the injury
was medically diagnosed. c Study includes powerlifting and bodybuilding athletes.

Weight training injuries
3
Table 2. Summary of studies injury/pain definition
Study
Injury/Pain definition
Weightlifting
Calhoon et al.
[27]
Injuries were defined by classifications:
Acute injuries are “injuries with rapid onset due to
traumatic episode, but
with short duration”. A chronic injury is “an injury with long onset and
duration”. A recurring injury involves recovery and re-injury for a particular
condition.”
Engebretsen et
al. [22]
Injury was defined as a “new or recurring musculoskeletal complaints or
concussions or illnesses incurred during competition or training
during the
London Olympic Games (27 July–
12 August 2012) receiving medical
attention, regardless of the consequences with respect to absence from
competition or training.”
Junge et al. [28]
An injury was defined as “any musculoskeletal complaint (traumatic and
over
use) newly incurred due to competition and/or training during the
XXIXth Olympiad in Beijing that received medical attention regardless of the
consequences with respect to absence from competition or training.”
Kim & Kim
[24]
An injury was defined as “any musculoskeletal symptoms and signs that
required medical attention.”
Konig & Biener
[36]
No formal definition of injury provided.
Kulund et al.
[35]
No formal definition of injury provided.
Wang et al. [23]
No formal definition of injury provided.
Powerlifting
Brown &
Kimball [13]
Subjects responded to questionnaire items on types and sites of injuries that
were severe enough to cause them to discontinue training for at least one day.
Goertzen et al.
[21]
a
No formal definition of injury provided.
Haykowsky et
al. [29]
Injury was defined as “the number and severity of powerlifting-related
injuries that required medical intervention (from a physician, chiropractor, or
physical therapist) and that resulted in an interruption in training for more
than one day within the last year was assessed.”.
Keogh et al.
[20]
Injury was defined as “any physical damage to the body that caused the lifter
to miss or modify one or more training sessions or miss a competition.”
Raske & Norlin
[25]
b
The definition of injury was “an inability to train or compete as planned.”
Siewe et al. [30]
Injury was defined as “an incident leading to an interruption in training or

Weight training injuries
4
competition.”
Bodybuilding
Eberhardt et al.
[38]
No formal definition of injury provided.
Siewe et al. [31]
Injury was defined as “an incident provoking an interruption in either training
or competition.”
Xiaojun et al.
[37]
No formal definition of injury provided.
Strongman
Winwood et al.
[26]
Injury was defined as “any physical damage to the body that caused the
strongman athlete to miss or modify one or more training sessions or miss a
competition.”
Highland
Games
McLennan et al.
[32]
Injury was defined as “a mishap occurring during meets or training that
resulted in the inability to compete or practice normally.”
Crossfit
Hak et al. [33]
Injury was defined as “any injury sustained during training which prevented
the participant training, working or competing in any way and for any period
of time.”
Weisenthal et al.
[34]
‘‘Injury’’ encompassed 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 training and other outside routine physical
activities for >1 week; 2) Modification of normal training activities in
duration, intensity, or mode for >2 weeks; and 3) Any physical complaint
severe enough to warrant a visit to a health professional.
a Study includes powerlifting and bodybuilding athletes. b Study includes powerlifting and
weightlifting athletes.

Weight training injuries
5
Table 3. Summary of the incidence & frequency of weight training injuries.
Study
Athletes
Study design
Study
duration
Number
of
injuries
Clinical
incidence
(injuries/
lifter/y)
Injury
incidence/rate
(injuries/1000
hr)
Sport
injuries/1000
athlete
exposures
(1000 AE’s)
Athlete rate
(% injured)
Weightlifting
Calhoon et al.
[27]
Open elite (NS)
Prospective
72 mo
560
3.3a
Engebretsen et
al. [22]
149 M & 103 F
open elite
Prospective
17 daysb
44
18c
Engebretsen et
al. [22]
149 M open
elite
Prospective
17 daysb
27
18c
Engebretsen et
al. [22]
103 F open elite
Prospective
17 daysb
16
16c
Junge et al. [28]
255 elite M &
F
Prospective
16 daysb
43
17c
Kim & Kim [24]
National M
(NS)
Prospective
271 days
125
100 & 362d
Kim & Kim [24]
National F (NS)
Prospective
271 days
82
129 & 173d
Konig & Biener
[36]
121 M
Retro quest
EC
202
1.7e
Kulund et al.
[35]
80 M
Retro quest
NS
111
1.4e
Raske & Norlin
[25]
f
50 open elite M
Retro quest
24 mo
108
1.1
2.4
Raske & Norlin
[25]
g
50 open non-
elite M
Retro quest
24 mo
98
1.0
2.9
Wang et al. [23]
195 open M
Retro quest
NS
NS
74
Wang et al. [23]
70 open F
Retro quest
NS
NS
90
Powerlifting
Brown &
Kimball [13]
71 junior
novice M
Retro quest
17 mo
98
1.0
2.8

Weight training injuries
6
Goertzen et al.
[21]
39 open M
Retro quest &
orthopedic
exam
18 mo
120
2.1
Goertzen et al.
[21]
21 open F
Retro quest &
orthopedic
exam
18 mo
40
1.3
Haykowsky et al.
[29]
9 M & 2 F open
elite blind
Retro quest
12 mo
4
0.4
1.1
Keogh et al. [20]
82 M & 19 F
Retro quest
12 mo
118
1.2
4.4
Keogh et al. [20]
82 M
Retro quest
12 mo
98
1.2
4.7
Keogh et al. [20]
19 F
Retro quest
12 mo
20
1.1
3.1
Keogh et al. [20]
36 national
Retro quest
12 mo
50
1.4
5.8
Keogh et al. [20]
65 international
Retro quest
12 mo
68
1.0
3.6
Keogh et al. [20]
59 lightweight
Retro quest
12 mo
62
1.1
4.3
Keogh et al. [20]
42 heavyweight
Retro quest
12 mo
56
1.3
4.4
Keogh et al. [20]
59 open
Retro quest
12 mo
62
1.1
4.0
Keogh et al. [20]
42 masters
Retro quest
12 mo
56
1.3
4.7
Raske & Norlin
[25]
f
50 Open elite
M
Retro quest
24 mo
114
1.1
2.7
Siewe et al.
[30]
219 M & 26 F
open & elite
Retro quest
EC
NS
0.3
1.0
43
Bodybuilding
Eberhardt et al.
[38]
250 open M
Retro quest
46 mo
311
0.4
1.0
Goertzen et al.
[21]
240 open M
Retro quest &
orthopedic
exam
18 mo
235
0.7
Goertzen et al.
[21]
118 open F
Retro quest &
orthopedic
exam
18 mo
53
0.3
Siewe et al. [31]
54 M & 17 F
open & elite
Retro quest
EC
NS
0.12
0.24h
45
Xiaojun et al.
104 elite
Retro quest
12 mo
180
1.8

Weight training injuries
7
[37]
74 M & 30 F
Strongman
Winwood et al.
[26]
213 low & high
level M
Retro quest
12 mo
257
1.6 & 0.4i
5.5
Winwood et al.
92 low level
Retro quest
12 mo
NS
1.4 & 0.3i
5.4
[26]
82 high level
Retro quest
12 mo
NS
1.5 & 0.5i
4.9
Winwood et al.
71 ≤ 105 kg
Retro quest
12 mo
NS
1.6 & 0.3i
6.1
[26]
100 >105 kg
Retro quest
12 mo
NS
1.6 & 0.5i
4.5
Winwood et al.
91 ≤ 30 y
Retro quest
12 mo
NS
1.6 & 0.5i
5.5
[26]
82 >30 y
Retro quest
12 mo
NS
1.5 & 0.3i
5.4
Highland
Games
McLennan et al.
[32]
45 elite + 125
amateur
Retro quest
120 mo
729
7.5
CrossFit
Hak et al.
[33]
93 M & 39 F
open
Retro quest
EC
186
3.1
Weisenthal et al.
[34]
231 M & 150 F
open
Retro quest
6 mo
84
19j
NS Not stated. EC Study duration was the athlete’s entire career for the sport. Retro quest Retrospective questionnaire, mo Month. y Year. hr
Hours. M Male, F Female. a From subset of 27 resident lifters. b Data collected during an Olympic competition (16 or 17days). c % of
athletes injured during the Olympic competition. d Acute and recurrent (respectively). e Total number of injuries per lifter over unknown
duration. f Data from 2000. g Data from 1995. h Values indicate injury rate. i Values indicate training injuries and competition injuries per
lifter/per year (respectively). j % of injuries over 6 months.

Weight training injuries
8
Table 4. Summary of weight training injuries by (in general) the most frequently anatomical locations.
Study
Athletes
Study design
Number of
injuries
Most frequently injured anatomical locations
Shoulder (%)
Lower
Back (%)
Knee (%)
Elbow
(%)
Wrist/Hand (%)
Weightlifting
Calhoon et al. [27]
Open elite
(NS)
Prospective
560
18
23
19
3
10
Kim & Kim [24]
National M &
F (NS)
Prospective
207
7
8
10
4
21
Konig & Biener
[36]
121 M
Retro quest
202
22a
21
25
6
2
Kulund et al. [35]
80 M
Retro quest
111
23
7
23
10
23
Raske & Norlin
[25]
b
50 open elite
M
Retro quest
108
14
18
20
7
10
Raske & Norlin
[25]
c
50 open non-
elite M
Retro quest
98
22
18
18
9
5
Wang et al. [23]
195 open M
Retro quest
NS
15d
19
29
9e
20
Wang et al. [23]
70 open F
Retro quest
NS
18
32
17
Powerlifting
Brown & Kimball
[13]
71 junior
novice M
Retro quest
98
6
50
8
6
4
Goertzen et al. [21]
39 open M
Retro quest &
orthopedic
exam
120
32
33f
10
13
6
Goertzen et al. [21]
21 open F
Retro quest &
orthopedic
exam
40
22
24f
28
10
10
Haykowsky et al.
[29]
9 M & 2 F
open elite
Retro quest
4
25
25
25

Weight training injuries
9
blind
Keogh et al. [20]
82 M & 19 F
Retro quest
118
36
24
9
11
Keogh et al. [20]
82 M
Retro quest
98
34
24
10
9
Keogh et al. [20]
19 F
Retro quest
20
45
20
0
20
Keogh et al. [20]
36 national
Retro quest
50
42
20
10
10
Keogh et al. [20]
65
international
Retro quest
68
32
27
9
12
Raske & Norlin
[25]
a
50 open elite
M
Retro quest
114
26
15
12
7
2
Siewe et al.
[31]
219 M & 26 F
open & elite
Retro quest
NS
Most injured
siteg
2nd most
injured
siteg
3rd most
injured
siteg
4th most
injured
siteg
6th most injured
siteg
Bodybuilding
Eberhardt et al.
[38]
250 open M
Retro quest
311
23
9
5
11
23
Goertzen et al. [21]
240 open M
Retro quest &
orthopedic
exam
235
34
10a
17
21
16
Goertzen et al. [21]
118 open F
Retro quest &
orthopedic
exam
53
29
14a
31
10
12
Siewe et al.
[31]
54 M & 17 F
open & elite
Retro quest
NS
2nd most
injured siteg
Most
injured
siteg
5th most
injured
siteg
4th most
injured
siteg
7th most injured
siteg
Xiaojun et al. [37]
104 elite
74 M & 30 F
Retro quest
180
Most injured
siteg
6th most
injured
siteg
Strongman
Winwood et al.
[26]
213 low &
high level M
Retro quest
257
21
24
11
6
0.4

Weight training injuries
10
Highland Games
McLennan et al.
[32]
45 elite + 125
amateur
Retro quest
729
18
17f
17
14
11
CrossFit
Hak et al.
[33]
93 M & 39 F
open
Retro quest
186
26
20f
10
13f
10
Weisenthal et al.
[34]
231 M & 150
F open
Retro quest
84
25
14
13
5
6
NS Not stated. M Male. F Female. Retro quest Retrospective questionnaire. a Shoulder girdle. b Data from 2000. c Data from 1995.
d Combined data for males and female lifters. eArm and elbow. f Entire vertebral column. g No percentage given, or percentage given based
on if athlete had an injury to that site in their entire career.

Weight training injuries
11
Table 5. Summary of onset of weight training injuries.
Study
Athletes
Study design
Number of injuries
Injury onset
Acute (%)
Chronic (%)
Weightlifting
Calhoon et al. [27]
Open elite (NS)
Prospective
560
60
30
Engebretsen et al. [22]
149 M & 103 F open elite
Prospective
44
NS
34
Junge et al. [28]
255 elite M & F
Prospective
43
NS
>40
Kim & Kim [24]
National M (NS)
Prospective
125
27
NS
Kim & Kim [24]
National F (NS)
Prospective
82
35
NS
Wang et al. [23]
195 open M & 70 open F
Retro quest
257
26
42
Powerlifting
Keogh et al. [20]
82 M & 19 F
Retro quest
118
59
41
Keogh et al. [20]
82 M
Retro quest
98
61
39
Keogh et al. [20]
19 F
Retro quest
20
50
50
Keogh et al. [20]
36 national
Retro quest
50
72
28
Keogh et al. [20]
65 international
Retro quest
68
50
50
Raske & Norlin [25]a
50 M & 10 F open elite PL
50 M & 5 F open elite WL
Retro quest
254
25
25
Strongman
Winwood et al. [26]
174b low & hih level M
Retro quest
258
68
31
Winwood et al. [26]
92b low level
Retro quest
136
68
33
Winwood et al. [26]
82b high level
Retro quest
121
69
31
Winwood et al. [26]
71b ≤105 kg
Retro quest
100
68
32
Winwood et al. [26]
100b >105 kg
Retro quest
154
68
32
Winwood et al. [26]
91b ≤ 30 y
Retro quest
128
65
35
Winwood et al. [26]
82b > 30 y
Retro quest
129
72
28
NS Not stated. M male. F Female. Retro quest Retrospective questionnaire. a Data from 2000 and consisting of a mixed group of powerlifters
(PL) and weight lifters (WL). b Number of injured athletes

Weight training injuries
12
Table 6. Summary of most common types of weight training injuries.
Study
Athletes
Study design
Number of
injuries
Injury type
Arthritis
(%)
Cartilage
damage/
degeneration
(%)
Sprain
(%)
Strain (%)
Tendinitis (%)
Weightlifting
Calhoon et al.
[27]
Open elite (NS)
Prospective
560
13
45
24
Konig &
Biener [36]
121 M
Retro quest
202
3
39
29
Powerlifting
Brown &
Kimball [13]
71 junior novice M
Retro quest
98
4
62
12
Goertzen et al.
[21]
39 open M
Retro quest &
orthopedic exam
120
29
17
6
6
28
Goertzen et al.
[21]
21 open F
Retro quest &
orthopedic exam
40
17
9
17
11
25
Haykowsky et
al. [29]
9 M & 2 F open
elite blind
Retro quest
4
Most
common
injury
type
a
Bodybuilding
Eberhardt et al.
[38]
250 open M
Retro quest
311
39
10b
Goertzen et al.
[21]
240 open M
Retro quest &
orthopedic exam
235
18
32
6
7
23
Goertzen et al.
[21]
118 open M
Retro quest &
orthopedic exam
53
8
28
13
8
33
Xiaojun et al.
[37]
104 elite
74 M & 30 F
Retro quest
180
3c
63
34

Weight training injuries
13
Strongman
Winwood et al.
[26]
174d low & high
level M
Retro quest
174
3.5
7e
38
23f
Highland
Games
McLennan et
al. [32]
45 elite + 125
amateur
Retro quest
729
3
13
4
26g
38
NS Not stated. M Male. F Female. Retro quest Retrospective questionnaire. a Percentage not stated. b Includes muscle/joint injuries. c Bone
related injuries. d Number of injured athletes. e Ligament sprain/tear. f Includes tendon strains/tears. g Includes musculoligamentous injuries
to the back (14%).

Weight training injuries
14
Table 7. Summary of severity/time loss of weight training injuries.
Study
Athletes
Study
design
Number of
injuries
Severity/time loss
Mild
injury
(%)
Moderate injury
(%)
Major injury (%)
Time loss/injury
(%)
Weightlifting
Calhoon et al. [27]
Open elite
(NS)
Prospective
99 all injuries
≤ 7 day
Engebretsen et al.
[22]
149 M & 103 F
open elite
Prospective
44
43 ≥ 1 day
25 ≥ 7 days
Junge et al. [28]
255 open elite
M & F
Prospective
43
11.4% athletes
with time loss
injuries
a
Konig & Biener [36]
121 M
Retro quest
202
82 knee & 76
shoulder injuries
≤ 7 days
Kulund et al. [35]
80 M
Retro quest
111
57 all injuries
≤ 14 days
Wang et al. [23]
195 open M & 70
open F
Retro quest
257
45
55
1
Powerlifting
Brown & Kimball
[13]
71 junior novice
M
Retro quest
98
12 days
Haykowsky et al.
[29]
9 M & 2 F open
elite blind
Retro quest
4
12 days
Keogh et al. [20]
82 M & 19 F
Retro quest
118
39
39
22
Keogh et al. [20]
82 M
Retro quest
98
36
38
24
Keogh et al. [20]
19 F
Retro quest
20
50
40
10
Keogh et al. [20]
36 national
Retro quest
50
40
42
18
Keogh et al. [20]
65 international
Retro quest
68
38
37
25

Weight training injuries
15
Raske & Norlin [25]b
50 M & 10 F open
elite PL
50 M and 5 F open
elite WL
Retro quest
254
93 shoulder, 85
lower back & 80
knee injuries
> 30 days
Bodybuilding
Xiaojun et al. [37]
104 elite
74 M & 30 F
Retro quest
180
59
28
13
Strongman
Winwood et al. [26]
174c low & high
level M
Retro quest
261
33
47
20
Winwood et al. [26]
92c low level
Retro quest
138
32
51
17
Winwood et al. [26]
82c high level
Retro quest
122
31
43
25
Winwood et al. [26]
71c ≤105 kg
Retro quest
92
21
53
26
Winwood et al. [26]
100c >105 kg
Retro quest
85
35
47
18
Winwood et al. [26]
91c ≤ 30 y
Retro quest
130
41
45
15
Winwood et al. [26]
82c > 30 y
Retro quest
129
25
50
26
Highland games
McLennan et al. [32]
45 elite + 125
amateur
Retro quest
729
67 all injuries
≤ 7 days
CrossFit
Hak et al.
[33]
93 M & 39 F
open
Retro quest
186
7 all injuries
required surgery
NS Not stated. M Male. F Female. PL Powerlifters. WL Weightlifters. Retro quest Retrospective questionnaire.
a Length of time loss not stated. B Data from 2000. C Number of injured athletes.

Weight training injuries
Table 8. Summary of injury causation by training type and/or event.
Study
Athletes
Study
design
Number
of
injuries
Training type/event
Number and/or
percentage of
injuries/reported
pain
Weightlifting
Kulund et al.
[35]
80 M
Retro
quest
111
Clean and Jerk
Deep squats
Snatch
Deadlift
Press
51 (46%)
25 (23%)
23 (21%)
7 (6%)
5 (5%)
Powerlifting
Keogh et al.
[20]
82 M & 19
F
Retro
quest
118
Squat/Deadlift/Bench
press
Assistance exercises
Cross training
Unknown
52%
20%
13%
15%
Siewe et al.
[30]
54 M & 17
F open &
elite
Retro
quest
Squat
Bench Press
Deadlift
Others
65 (61%)a
60 (57%)a
33 (31%)a
43 (41%)a
Raske &
Norlin [25]
50 M & 10
F open elite
PL
50 M and 5
F open elite
WL
Retro
quest
254
Bench Press
Flies
Dips
Snatch
Clean and Jerk
43% and 44%b
47% and 52%b
36% and 39%b
33% and 31%b
33% and 31%b
Bodybuilding
Eberhardt et
al.
[38]
250 open M
Retro
quest
311
Bench press
Shoulder press
Squat
Others
16%
14%
11%
59%
Siewe et al.
[31]
54 M & 17
F open &
elite
Retro
quest
Squat
Bench press
Deadlift
Others
17 (24%)a
9 (13%)a
4 (6%)a
30 (42%)
a
Strongman
Winwood et
al. [26]
174c low &
high level
M
Retro
quest
268
Traditional training
Deadlift
Squats
Overhead press
Bench press
145 (54%)
47 (18%)
42 (16%)
24 (9%)
16 (6%)

Weight training injuries
Traditional other
Strongman training
Stone work
Yoke walk
Tire flip
Farmers walk
Axle work
Log lift/press
Strongman other
16 (6%)
123 (46%)
24 (9%)
21 (8%)
16 (6%)
12 (5%)
11 (4%)
11 (4%)
28 (10%)
Highland
Games
McLennan et
al. [32]
45 elite +
125 amateur
Retro
quest
729
Highland Games
event
Weight toss
Caber toss
Hammer throw
Stone throw
Weight for height
31%
25%
20%
13%
11%
CrossFit
Weisenthal et
al. [34]
231 M &
150 F
open
Retro
quest
84
Crossfit movement
type
Powerlifting
Gymnastics
Olympic lifting
Endurance
Other
19 (23%)
17 (20%)
14 (17%)
5 (6%)
13 (15%)
M Male. F Female. PL Powerlifters. WL Weightlifters. Retro quest Retrospective questionnaire.
a Reported pain as a result of the exercise. b Weight training exercise and shoulder injury
association from 1995 and 2000 (respectively). c Number of injured athletes.

List of Figures
Figure 1. Illustration of various events/poses in the weight training sports: (a) weightlifting
(Carl Pilon), (b) powerlifting (Mitya Galiano), (c) bodybuilding (Amanda Richards), (d)
CrossFit (CrossFit Auckland), (e) strongman (Shaun Ellis), and (f) Highland Games (Alain
Cadu). Photos reprinted with permission from respective photographers (acknowledged in
brackets). .................................................................................................................................... 2
Figure 2. Flow chart of the article selection process................................................................. 3

Figure 1. Illustration of various events/poses in the weight training sports: (a) weightlifting
(Carl Pilon), (b) powerlifting (Mitya Galiano), (c) bodybuilding (Amanda Richards), (d)
CrossFit (CrossFit Auckland), (e) strongman (Shaun Ellis), and (f) Highland Games (Alain
Cadu). Photos reprinted with permission from respective photographers (acknowledged in
brackets).
a
b
c
d
e
f

Figure 2. Flow chart of the article selection process
PubMed
N = 970
SPORTDiscus
N = 900
Embase
N = 1844
CINAHL
N = 307
4021 publications
Excluded
411 duplicates
3610 titles and
abstracts
184 titles and
abstracts
Excluded
Title and
abstract
selection 3426
Excluded 167
Case studies 109
Injury prevention/treatment/
recommendation articles/
reviews 22
Non-weight training sport
population 21
Abstracts and posters 4
Accident and emergency data 5
Other review articles 6
17 full-text articles
Added
Reference check 2
20 full-text articles
English
N = 15
Chinese
N = 2
German
N = 2
19 titles
Forward tracked 1
Korean
N = 1