Exercise Selection and Common Injuries in Fitness Centers: A Systematic Integrative Review and Practical Recommendations

Abstract

Weight resistance training (RT) is an essential component of physical conditioning programs to improve the quality of life and physical fitness in different ages and populations. This integrative review aimed to analyze the scientific evidence on the relationship between exercise selection and the appearance of musculoskeletal injuries in physical fitness centers (PFC). The Pub-Med or Medline, EMBASE or Science Direct, Google Scholar and PEDro databases were selected to examine the available literature using a Boolean algorithm with search terms. The review process was performed using the five-stage approach for an integrative review and it was reported according to the PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSiST) guidelines. A total of 39 peer-reviewed articles (Price index = 71.7%) met the inclusion criteria and evaluated the link between exercise selection and the incidence of injuries in exercisers who regularly attend PFC. Most injuries occur to the shoulders, elbows, vertebrae of the spine, and knees. Although the injury etiologies are multifactorial, the findings of the reviewed articles include the impacts of overuse, short post-exercise recovery periods, poor conditioning in the exercised body areas, frequent use of heavy loads, improper technique in certain exercises, and the abuse of performance and image-enhancing drugs. Practical recommendations addressed to clinical exercise physiologists, exercise professionals, and health professionals are given in this paper. The exercise selection in RT programs requires professional supervision and adhering to proper lifting techniques and training habits that consider the anatomical and biomechanical patterns of the musculoskeletal structures, as well as genetic, pedagogical, and methodological aspects directly related to the stimulus-response process to mitigate the occurrence of RT-related injuries in PFC.

Full text

Int. J. Environ. Res. Public Health 2022, 19, 12710. https://doi.org/10.3390/ijerph191912710 www.mdpi.com/journal/ijerph
Systematic Review
Exercise Selection and Common Injuries in Fitness Centers: A
Systematic Integrative Review and Practical Recommendations
Diego A. Bonilla
1,2,3,4,
*, Luis A. Cardozo
5
, Jorge M. Vélez-Gutiérrez
1,6
, Adrián Arévalo-Rodríguez
1,7
,
Salvador Vargas-Molina
1,8
, Jeffrey R. Stout
9
, Richard B. Kreider
10
and Jorge L. Petro
1,2
1
Research Division, Dynamical Business & Science Society—DBSS International SAS,
Bogotá 110311, Colombia
2
Research Group in Physical Activity, Sports and Health Sciences—GICAFS, Universidad de Córdoba,
Montería 230002, Colombia
3
Research Group in Biochemistry and Molecular Biology, Faculty of Sciences and Education, Universidad
Distrital Francisco José de Caldas, 110311, Bogotá, Colombia
4
Sport Genomics Research Group, Department of Genetics, Physical Anthropology and Animal Physiology,
Faculty of Science and Technology, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain
5
Research and Measurement Group in Sports Training (IMED), Faculty of Health Sciences and Sports,
Fundación Universitaria del Área Andina, Bogotá 111221, Colombia
6
ARTHROS Centro de Fisioterapia y Ejercicio, Medellín 050012, Colombia
7
Centro de Capacitación en Acondicionamiento y Preparación Física (CCAPF), 111511 Bogotá, Colombia
8
Faculty of Sport Sciences, EADE-University of Wales Trinity Saint David, 29018 Málaga, Spain
9
Physiology of Work and Exercise Response (POWER) Laboratory, Institute of Exercise Physiology and
Rehabilitation Science, University of Central Florida, Orlando, FL 32816, USA
10
Exercise & Sport Nutrition Laboratory, Human Clinical Research Facility, Texas A&M University, College
Station, TX 77843, USA
* Correspondence: dabonilla@dbss.pro, Tel.: +57-320-335-2050
Abstract: Weight resistance training (RT) is an essential component of physical conditioning pro-
grams to improve the quality of life and physical fitness in different ages and populations. This
integrative review aimed to analyze the scientific evidence on the relationship between exercise
selection and the appearance of musculoskeletal injuries in physical fitness centers (PFC). The Pub-
Med or Medline, EMBASE or Science Direct, Google Scholar and PEDro databases were selected to
examine the available literature using a Boolean algorithm with search terms. The review process
was performed using the five-stage approach for an integrative review and it was reported accord-
ing to the PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSiST) guide-
lines. A total of 39 peer-reviewed articles (Price index = 71.7%) met the inclusion criteria and evalu-
ated the link between exercise selection and the incidence of injuries in exercisers who regularly
attend PFC. Most injuries occur to the shoulders, elbows, vertebrae of the spine, and knees. Alt-
hough the injury etiologies are multifactorial, the findings of the reviewed articles include the im-
pacts of overuse, short post-exercise recovery periods, poor conditioning in the exercised body ar-
eas, frequent use of heavy loads, improper technique in certain exercises, and the abuse of perfor-
mance- and image-enhancing drugs. Practical recommendations addressed to clinical exercise
physiologists, exercise professionals, and health professionals are given in this paper. The exercise
selection in RT programs requires professional supervision and adhering to proper lifting tech-
niques and training habits that consider the anatomical and biomechanical patterns of the muscu-
loskeletal structures, as well as genetic, pedagogical, and methodological aspects directly related to
the stimulus–response process to mitigate the occurrence of RT-related injuries in PFC.
Keywords: resistance training; musculoskeletal pain; exercise movement techniques; muscle
strength; sports injury
Citation: Bonilla, D.A.; Cardozo,
L.A.; Vélez-Gutiérrez, J.M..; Arévalo-
Rodríguez, A.; Vargas-Molina, S.;
Stout, J.R.; Kreider, R.B.; Petro, J.L.
Exercise Selection and Common In-
j
uries in Fitness Centers: A System-
atic Integrative Review and Practical
Recommendations. Int. J. Environ.
Res. Public Health 2022, 19, 12710.
https://doi.org/10.3390/
ijerph191912710
Academic Editor: Laura Guidetti
Received: 31 July 2022
Accepted: 2 October 2022
Published: 5 October 2022
Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional
claims in published maps and institu-
tional affiliations.
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/license
s/by/4.0/).

Int. J. Environ. Res. Public Health 2022, 19, 12710 2 of 35
2
1. Introduction
Due to the improvement in neuromuscular performance, weight resistance training
(RT) is an essential component of physical conditioning programs that seek to improve
activities of daily living, self-care, and the quality of life in different ages and populations
[1,2]. In fact, the improvement in health-related variables is associated with the augmen-
tation of muscle mass and strength levels [3]. In this sense, several authors consider mus-
cular strength as a transversal axis within physical exercise programs [4]. Notably, the
physiological adaptations generated by the strength training (i.e., maximal dynamic
strength, local and global muscular power or endurance) benefit other physical abilities
such as cardiovascular fitness, balance, range of motion, and speed both in untrained sub-
jects and elite athletes [5–8]. Thus, an adequate prescription of weight RT, as a method of
strength training, based on the individual response and objectives or adaptations to be
achieved is extremely important.
Clinical exercise physiologists, exercise professionals [9], and athletic trainers [10] are
in charge of designing physical exercise programs either for prescribing exercise, promot-
ing regular physical activity, or reaching fitness or performance goals. To give an adequate
dosage of exercise stress-induced stimuli, exercise professionals and personal trainers
have to consider the individual characteristics (e.g., genetics, developmental conditions,
morphological features demographics, environment, etc.) and the adaptive response
[11,12]. Thus, the exercise dosage should be given within an orderly scheme of actions
based on: (i) planning, where the establishment of periods (periodization) and more spe-
cifically the programming would indicate the number of days to train (frequency), accord-
ing to the availability of the subject; (ii) a greater or lesser rest time between the exercise
sessions (density); (iii) a necessary number of repetitions above or below the subject’s rate
of perceived exertion that also considers the movement velocity during RT as a standard-
ized method for load progression (intensity). In general, the whole scheme of actions en-
compasses a maximum number of repetitions per body region (methodological organiza-
tion) that is divided into almost equal subunits of muscular stress (sets) with adequate
rest (pauses) between them (volume) [13–15].
The aforementioned frames the operative elements of exercise prescription, under-
standing it as “the professional work consisting of prescribing, ordering, or determining
a set of physical exercises aimed at maintaining or improving physical condition or
health” [16]. It must be noted that postural malalignments associated or not to sedentary
behavior [17], altered motor control [18], reduced physical fitness [19], and poor exercise
execution [20] are among the potential risk factors for exercise-related injuries. Indeed,
several cases of postural problems and morphological alterations in both the general [21]
and young [22] populations are associated with musculoskeletal dysfunctions or physical
injuries that in some cases have not been adequately treated by the health care institutions
[23,24]. Hence, some concerns and questions that need to be answered with scientific ar-
gumentation beyond expertise and pragmatism arise regarding the exercise selection and
the potential injury risk within physical fitness centers (PFC): When to include a given
exercise? Does the exercise order matter? How do movement patterns impact on exercise
outcomes? Is there a higher risk of injury when doing certain exercises? This represents a
challenge for the exercise professionals and personal trainers at the moment of adequately
selecting the exercises that will be prescribed in the training program. It can be assumed
that prescribing exercise should consider aspects related to exercise dosage (magnitude of
the stimulus), body posture, and biomechanics, especially in some body regions such as
the craniocervical region and its impact on motor control, disturbances of anatomical
pathways, and the myofascial network or meridians. Notwithstanding, there is no clarity
on this in the current literature. Thus, the purpose of this integrative review was to analyze
the scientific evidence on the relationship between the selection of weight resistance exer-
cises in physical fitness programs and the potential appearance of musculoskeletal injuries
within PFC in healthy individuals.

Int. J. Environ. Res. Public Health 2022, 19, 12710 3 of 35
3
2. Methods
This study implemented the five-stage approach of Whittemore and Knafl [25],
which is used as the established guideline for an integrative review. We aimed to synthe-
size the available literature regarding exercise selection and injuries reported in PFC
through the combination of experimental and non-experimental studies, which allows for
greater impacts when reporting evidence-based recommendations. Nevertheless, the
basic methodology was optimized by improving the problem formulation, literature
search, evaluation, analysis, and presentation of findings stages in order to systematize
the review process and improve the scientific robustness according to the recommenda-
tions given by Hopia et al. (2016) [26] and the PRISMA in Exercise, Rehabilitation, Sport
Medicine and Sports Science (PERSiST) guidelines [27]. Considering that this review was
not eligible to be registered in PROSPERO, as it focused on physical fitness and perfor-
mance, the summary information was uploaded to Figshare to make it publicly accessible
in order to avoid unnecessary duplication (doi: 10.6084/m9.figshare.20412486).
2.1. Eligibility Criteria
The inclusion criteria for this systematic review were as follows: (1) experimental or
theoretical articles (randomized controlled trials, case studies, narrative reviews, system-
atic reviews, and meta-analyses—the latter must comply either with PRISMA
COCHRANE declarations or be registered in PROSPERO); (2) peer-reviewed articles pub-
lished between 2009 and 2021; (3) publications written in English, Spanish, and German;
(4) full text available; (5) articles focused on exercise selection and RT programs on differ-
ent physiological or anatomical markers related to the development of injuries and epide-
miological analysis of injuries in healthy subjects across the lifespan who attend athletic,
private, public, or school or university PFC. Studies that did not correspond to original
research (e.g., editorials, notes, dissertations), focused on injury rehabilitation, or included
patients suffering from any disease were excluded.
2.2. Information Sources
The PubMed or MEDLINE and EMBASE or Science Direct databases were selected
to examine the available literature. Further papers were sought by hand-searching in
Google Scholar and the PEDro database.
2.3. Search Strategy
The search was developed using free language terms related to exercise selection and
common injuries in subjects who strength train in fitness centers. The following Boolean
algorithms were used to perform the search: PubMed/MEDLINE “exercise selection” OR
“resistance training” OR “bodybuilding” AND (“risk factors” OR “sports injuries”) NOT disease
NOT patient and “exercise selection” OR “bodybuilding” AND “injuries”; EMBASE/Science
Direct (“exercise selection” OR “resistance training” OR “bodybuilding”) AND (“risk factors”
OR “sports injuries”) NOT disease NOT patient.
2.4. Study Selection and Data Collection Process
Three of the authors independently searched the selected databases for articles
(D.A.B., L.A.C., and J.L.P.). Those publications that met the inclusion criteria were selected
to continue with the data analysis and synthesis phases, for which a table was designed
to report the results and compare the main findings (citation or country, language, type
of study, methodology, and conclusions). Discrepancies were identified and resolved
through discussion (with a fourth author when necessary). As with previous review arti-
cles published by our research group [28,29], we calculated the Price’s index to measure
the obsolescence of the literature as the ratio of the number of references published in the
last five years to the total number of references. The study selection took place during

Int. J. Environ. Res. Public Health 2022, 19, 12710 4 of 35
4
December 2021 and March 2022, although an updated search was conducted in June 2022
prior to manuscript submission.
3. Results
The preliminary search for abstracts, after using the Boolean search algorithm in the
selected databases, generated 564 articles in total. After removing duplicates (n=216), the
abstracts were carefully reviewed (n = 348) for potential inclusion in the review; however,
309 papers were excluded after the evaluation process given they included populations
with health problems, did not correspond to the types of articles detailed in the inclusion
criteria, did not have a direct relationship with the proposed topics to be analyzed, were
focused on injury rehabilitation, or did not have sufficient scientific robustness (published
in predatory journals). Thus, a total of 39 peer-reviewed articles (Price index = 71.7%) met
the requirements of this integrative review. Figure 1 shows the flow chart of the literature
search.
Figure 1. PRISMA flow diagram.
The selected articles are synthesized in Table 1, in which the most relevant results are
reported according to the aim of this integrative review. To minimize the risk of bias, the
process of generating the table was supervised by at least two authors in order to discuss
and compare the study conclusions until a consensus was reached.

Int. J. Environ. Res. Public Health 2022, 19, 12710 27 of 35
27
Table 1. Synthesis of the selected articles for the integrative review.
Type of Study Participants Aim Instruments o
r
procedure Main findings/conclusions Reference
Narrative Review/Qualitative
Analysis
30 references (includes
articles from their year
of publication until
2009)
To analyze the influential
factors in the development of
patellofemoral pain
syndrome.
Literature search of
epidemiological and clinical
aspects. A retrospective,
citation-
b
ased methodology
was applied.
Besides genetic characteristics or some
noxa, patellofemoral malalignment,
high loads and overuse, uncontrolled
exercises, and AAS represent risk
factors for injuries. Individual training
concepts with controlled exercises that
reduce peak loads are desireable.
Jagodzinski et al.,
2009 [30]
Cross-sectional/Quantitative
Analysis
n = 413
(216M; 197F)
Only 60 subjects
participated in the
laboratory analysis.
To assess the predisposing
factors, signs, and symptoms
usually associated with OVR
or OVT in members of PFC.
Questionnaire of 41
questions to evaluate
OVR/OVT + POMS
questionnaire +
hematological and
biochemical (CK activity,
cortisol, total T, free T)
analyses
The absence of predisposing factors
and signs/symptoms associated with
OVR or OVT states was evidenced in
fitness practitioners in Sao Paulo,
Brazil. Thus, detecting people engaged
in excessive exercise training needs to
be confirmed.
Ackel-D’Elia et al.,
2010 [31]
Narrative Review/Qualitative
Analysis
91 references from
which 27 were clinical
trials (from their year of
publication until 2010)
To review the current
epidemiology of injury related
to the safety and efficacy of
RT among youth and to
provide age-appropriate
training recommendations for
children and adolescents
Literature search with
practical and applied
aspects. A retrospective,
citation-based methodology
was applied.
Lack of supervision in strength
training in the youth population is
associated with an injury rate due to
inadequate technical execution and
load control. Musculoskeletal injuries
during RT do not appear to be superior
to other sports modalities and
activities.
Faigenbaum &
Myer, 2010 [32]
Narrative Review/Qualitative
Analysis
82 references (includes
articles from their year
of publication until
2009).
To present an overview of the
literature pertaining to
shoulder injuries in the RT
population and to elucidate
the etiological risk factors
hypothesized to be associated
with the more common
injuries.
Literature search in
PUBMED, CINAHL,
SPORTDiscus, and OVID
databases using key words
including resistance
training, shoulder,
bodybuilding
,
weightlifting,
shoulder injury, and
shoulder disorder.
Up to 36% of documented RT-related
injuries and disorders occur at the
shoulder complex. Deltoid to external
rotators and upper to lower trapezius
muscles should be strengthened to
mitigate strength imbalances
associated with RT. Train flexibility to
increase internal rotation and avoid the
end-range “high-five” position may
prevent the development of anterior
shoulder instability and pain.
Kolber
et al., 2010 [33]

Int. J. Environ. Res. Public Health 2022, 19, 12710 28 of 35
28
Table 1. Cont.
Type of Study Participants Aim Instruments or
procedure
Main findings/conclusions Reference
Narrative Review/Qualitative
Analysis
38 references (includes
articles from year of
publication to 2010).
To introduce the history
of strength training,
explain the many different
styles of strength training,
and discuss common
injuries specific to each
style.
Literature search with
practical and applied
aspects. A retrospective,
citation-based
methodology was
applied.
The most common acute non-urgent
injuries are muscular strains and
ligamentous sprains, while urgent
injuries are fractures, dislocations, and
tendon ruptures. Patellar dislocation
and acute meniscal tears are rarely
reported. Most injuries are related to
accidents or overexertion although
each style of strength training has its
own principal injuries, both acute and
chronic, related to the individual
technique.
Lavallee & Balam,
2010 [34]
Narrative Review/Qualitative
Analysis
68 references (includes
articles from year of
publication to 2011).
To review the possible
role and effects of
eccentric strength training
for injury prevention and
use this, together with
injury biomechanics, as a
basis to suggest an
eccentric exercise
classification criteria
applicable to the track and
field athletes.
Literature search with
practical and applied
aspects. A retrospective,
citation-based
methodology was
applied.
Hip flexion or knee extension exercises
that actively lengthen the hamstrings
should be trained. Focus on the long
head of the biceps femoris, proximal
semitendinosus, adductor magnus, and
semimembranosus, based on
plyometric and eccentric exercises.
Malliaropoulos et al., 2012
[35]
Non-randomized prospective
controlled study/Quantitative
Analysis
A cohort of children aged 7
to 9 years: 446 boys and
362 girls in the
intervention group (2675
person-years) and 807 boys
and 780 girls in the control
group (5661 person-years).
To evaluate whether an
extended exercise
intervention program (40
min per day of school
physical education for 4
years including strength-
based exercises) in
children could produce
long-term skeletal
b
enefits
without increasing the
fracture incidence.
BMC (g) and bone
width (cm) were
assessed by DXA of the
whole body, lumbar
spine, femoral neck, and
trochanter + fracture
index recorded in the
city hospital records.
A 4-year exercise program in children
aged 7 to 9 years increased bone mass
and size without affecting the fracture
risk. In the girls, there was a gradually
higher gain in femoral neck and
trochanter BMCs and femoral neck
width with each tertile of higher
duration of physical activity. A similar
pattern was found in the children,
reaching significance in the lumbar
spine BMC and femoral neck width.
Löfgren
et al., 2012 [36]

Int. J. Environ. Res. Public Health 2022, 19, 12710 29 of 35
29
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
Narrative Review/Qualitative
Analysis
63 references (includes
articles from their year of
publication until 2012)
To discuss the
biomechanical factors
related to ACL loading
during common weight-
bearing and non-weight-
bearing exercises and to
guide clinicians regarding
exercise selection and
progression for patients
with ACL pathology or
reconstruction.
Literature search on tensile
strength and strain energy
density data of the ACL in
different exercises.
It highlights that the load on the
ACL is greater in exercises without
supporting body mass (double-leg
and single-leg squats, lunges); for
example, squatting with a vertical
trunk position, which decreases
hamstrings activity and increases
quadriceps activity, leading to
higher ACL loading. Caution
should be taken in exercises with
high knee flexion angle or heel raise
since they generate more ACL
loading.
Escamilla
et al., 2012 [37]
RCT/Quantitative Analysis
n= 37 healthy males (only
22 were included in the
analysis) were divided
into two 6-week training
groups: RT and RT + TS
To investigate the
effectiveness of a training
program including focused
TS exercises on improving
lower extremity
biomechanics, athletic
performance, and trunk or
core measures (control,
endurance, and strength)
compared with a program
incorporating only RT.
ACL strain analyzed by
biomechanical loading
without anticipation with
Vicon MX-F40 and Bertec
4060-10 systems + trunk
control and core strength
using a sudden force release
test with an OMEGA DM-465
load cell system + core
endurance using McGill
protocols for lateral plank,
pronated plank, and trunk
flexor exercises + lower limb
strength + sports
performance analysis.
Despite the lack of differences
between groups, which may have
been due to inter-subject variability
and sample size, RT generated
greater risk of ACL rupture while
the RT + TS program was able to
limit potential negative effects. In
addition, only the RT + TS group
generated improvements in CORE
strength and endurance.
Jamison
et al., 2012 [38]
Prospective Clinical
Trial/Quantitative Analysis
n= 24 volunteers: eight RT-
trained individuals using
AAS; eight RT-trained
individuals who had never
used AAS; and eight
subjects without any
To examine in vivo
mechanical properties of
patellar tendons subjected
to long-term exposure to
overloading and AAS
abuse by comparing highly
trained individuals using
Supplementation and drugs
report + maximal knee
extension isometric torque
using an isokinetic
dynamometer (System 3,
Biodex Medical Systems) +
muscle thickness, pennation
The CSA of the tendon was greater
in RT-trained subjects who did not
use AAS. The patellar tendon
generated more stiffness, more
stress, and greater tensile modulus
in subjects using AAS, which may
Seynnes
et al., 2013 [39]

Int. J. Environ. Res. Public Health 2022, 19, 12710 30 of 35
30
history of regular RT or
AAS abuse
AAS to trained and
untrained subjects without
any history of AAS.
angle, fascicle length, CSA of
the patellar tendon, and
tendon mechanical and
material properties using
ultrasonography (10–25 MHz
transducer MyLab25)
limit tendon safety probably due to
alterations in collagen remodeling.

Int. J. Environ. Res. Public Health 2022, 19, 12710 31 of 35
31
Table 1. Cont.
Type of Study Participants Aim Instruments or
procedure
Main findings/conclusions Reference
Narrative Review/Qualitative
Analysis
39 references (includes
articles from year of
publication to 2013).
To discuss the PRT-
related injuries and
present an overview of
documented shoulder
injuries among older
adults, presenting a brief
review of its anatomy,
and to discern the possible
mechanisms of injury and
risk factors.
Literature search in
PubMed database using
the following specific
search terms: strength-
training injuries,
resistance-training injuries,
sports injuries in the
elderly, shoulder complex,
shoulder injury, and
shoulder disorder.
The combination of unfavorable
positions, fatigue, and unproper
technique during exercises, such as
bench press, behind-the-neck pull-
downs, military presses, and chest
flies may lead to AI and rotator cuff
injuries (especially in older
population). Preventive exercise
based on the lower trapezius and
external rotators is advised to
mitigate strength imbalances.
Sousa et al., 2013 [40]
Cross-sectional/Quantitative
Analysis
n = 159 healthy male
subjects (123 with weight
RT training experience and
36 with no history of
weight RT participation as
control group)
(i) To determine if men
who participate in weight
RT present with clinical
characteristics of shoulder
hyperlaxity and AI. (ii) To
determine if there is
difference between the
presence of these
conditions among weight
RT participants when
compared with a control
group.
(iii) To investigate the
association of exercise
selection with clinical
characteristics of AI.
A detailed questionnaire to
document specific training
patterns that included
frequency, presence of
pain, and exercise selection
+ load and shift test (to
detect and quantify
anterior glenohumeral
joint instability) +
apprehension test (to
detect anterior
glenohumeral joint
instability) + relocation test
(to diagnose anterior
instability). All
measurements were
performed on the non-
dominant arm.
The rates of pain and positive
apprehension and relocation tests
were significantly higher in trained
subjects than in untrained subjects.
The injury risk in the weight RT
population might be reduced by
changes in exercise selection and
technique. For example, it is
advisable to make modifications in
exercises such as behind-the-neck
pull-down or military press by
bringing the bar down to the front
chest (avoiding the high-five
position). Also, incorporating
reinforcement work in the external
rotators might prevent the injury
risk for anterior shoulder instability
and pain.
Kolber
et al., 2013 [41]

Int. J. Environ. Res. Public Health 2022, 19, 12710 32 of 35
32
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
Narrative Review/Qualitative
Analysis
49 references (includes
articles from their year of
publication until 2014).
To overview the
frequency, type, and
developmental
mechanisms of shoulder
injuries as a function of
various sports.
Selective literature search in
the PubMed database taking
into account authors’
experience and research
results as well as international
and national
recommendations.
Acute (e.g., traumatic dislocations,
acromioclavicular joint dislocations,
traumatic tendon ruptures, labral
and cartilage defects, and fractures)
and chronic (e.g., bursitis and
tendinitis, secondary forms of
impingement with rotator cuff and
labral lesions) injuries are are
particularly common in throwing
and impact sports (e.g., tennis, golf,
handball, and volleyball) but also in
contact and extreme sports (e.g.,
judo, martial arts, bodybuilding,
weightlifting, motocross, and
downhill mountain biking). The
type and frequency of injuries are
strongly dependent on the risk and
load profile of the individual.
Doyscher
et al., 2014 [42]
Retrospective cross-sectional
study/Quantitative Analysis
n = 71 (54M; 17F) German
elite and competitive
bodybuilders (33.9 ± 9.2
years).
To investigate rates of
injury, pain during
workouts or overuse
syndromes, as well as the
influence of particular
intrinsic and external
factors
Five-parts questionnaire:
demographics and general
information + workout-related
data and pain symptoms +
frequency and localization of
previous injuries or
musculoskeletal disorders +
general health disorders +
lifestyle, nutrition, and
medical therapy
The squat and bench press exercises
most frequently generate pain in
lower and upper limbs during
workouts, respectively. The highest
injury rates were found in the
shoulder, elbow, lumbar spine, and
knee (> 40 years-old athletes
exhibiting higher injury rates). The
injury rate in elite and competitive
b
odybuilders (0.24 injuries per 1000
h of bodybuilding) is lower
compared to other weightlifting
(e.g., powerlifting, strongman, or
Olympic lifting).
Siewe et al., 2014 [43]

Int. J. Environ. Res. Public Health 2022, 19, 12710 33 of 35
33
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
Narrative
Review/Qualitative
Analysis
83 references (includes
articles from year of
publication to 2011).
(i) To provide a review of the
literature with respect to
regionspecific tendon
properties, in association
with patellar tendinopathy;
(ii) to outline the automated
tracking method as used by
recent studies for the
determination of
regionspecific mechanical
properties to inspire future
research; (iii) to discuss
potential treatment strategies
for the management of
patellar tendinopathy.
Literature search in PubMed
database using the following
specific search terms: patellar
tendinopathy, patellar tendinitis,
jumper’s knee, patellar tendon,
tendon injury, region specific
tendon properties, mechanical
properties, tendon strain, treatment.
Patellar tendinopathy is a common
musculoskeletal disorder affecting a
wide range of amateur and elite
athletes, especially those that
participate in jumping events.
Tendinopathy appears to result in
an increased tendon CSA
concomitant with decreased
stiffness. The use of eccentric
exercise or heavy–slow strength
training can optimize the
prevention and recovery of patellar
tendinopathy and pain reduction in
athletes. In general, any activity that
exposes a region of the tendon to
the largest forces could be
considered a potential risk factor.
Pearson & Hussain, 2014
[44]
Narrative
Review/Qualitative
Analysis
49 references (includes
articles from their year
of publication until
2015).
Planning proposals for
strength–power training,
allowing for logical
integration and manipulation
of training variables
including exercise selection.
Literature search with practical and
applied aspects. A retrospective,
citation-based methodology was
applied.
To maximize the transfer-of-
training effect and reduce injuries in
strength or power athletes, it is
doubtful that single-joint exercises
will have as much impact on
performance as multijoint training
exercises. Advanced athletes require
greater variation in exercise
selection, volume, and intensity of
training compared to beginning
athletes.
DeWeese
et al., 2015 [45]
Cross-
sectional/Quantitative
Analysis
n = 142 male
bodybuilders (35–55
years); 88 reported
consuming AAS in the
last two years while 54
did not have used
AAS.
To provide more quantitative
data on the association of
AAS use with tendon rupture
by assessing the history of
tendon rupture in a large
cohort of AAS users and
comparison nonusers.
Medical history + history of surgical
interventions + epidemiological
instrument + anthropometric
assessment + anti-doping and
PIEDs analysis in urine and hair +
medical evaluation (cardiovascular
function).
AAS abusers have a higher tendon
injury risk than non-AAS-using
bodybuilders. In addition, upper
body tendon ruptures were
exclusively reported in the
participants who consumed AAS.
Kanayama
et al., 2015 [46]

Int. J. Environ. Res. Public Health 2022, 19, 12710 34 of 35
34
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
RCT/Quantitative Analysis
n = 15
(11M; 4F) divided into
three groups: control,
acute training group, and
training group for four
weeks.
To describe the
distribution of
macrophages and matrix
proteins in human MTJ
and adjoining muscle
fibers and to investigate
the influence of heavy
RT (quadriceps and
hamstrings muscle
groups) on this
distribution.
Sample from the semitendinosus
and gracilis tendons +
immunohistochemical analysis of
collagen types and macrophage
density. Subjects were healthy
except for an isolated ACL
rupture and scheduled for
reconstruction surgery; however,
they were able to perform daily
activities so could not be
classified as inactive.
Quadriceps exercises included leg
press and leg extensions.
Hamstrings exercises included
Nordic hamstring, lying leg curls,
supine one-leg curls, and reverse
hyperextensions. The 4-week heavy
RT program resulted in more
collagen XIV, macrophages, and
Tenascin-C content in the
endomysium, which may indicate
an optimal remodeling process and
adaptations for injury prevention in
the MTJ region.
Jakobsen
et al., 2017 [47]
Case study/Quantitative
Analysis
An amateur 25-years old
b
odybuilder with 4 years
of experience.
To describe the case of a
young man who self-
aministred PIEDs and
suffered from pain and
reduced mobility of the
right elbow for several
months.
Medical history (repeated
hospital admissions) +
biochemical analysis + ultrasound
and NMR imaging of the subject’s
right arm + X-ray of the left
shoulder.
X-ray showed osteoarthritic
changes at the glenohumeral
junction and reverse Hill–Sachs
defect, in addition to abnormal
hepatomarkers. The causes are
attributed to the excessive use of
PIEDs and injected oils, lack of load
control, and psychological
problems.
Hameed
et al., 2016 [48]
Systematic Review
/
Qualitative
Analysis
67 references (includes
articles from january 1995
to january 2014).
To summarize and
update scientific
knowledge on different
topics and guidelines
related to the
prescription of strength
training in young
prepubertal and
adolescent populations.
Literature search in PubMed,
Scopus, SportDiscus,
ScienceDirect, and Google Scholar
databases using the following
specific search terms: children,
adolescents, youth, youth
athletes, pediatric, strength
training, resistance training,
weight training, motor
performance skill.
Causes of strength-training-related
injuries in young population are
due to misuse of equipment,
excessive loads, faulty techniques,
or lack of qualified supervision.
Avoid or minimize exercises that
involve excessive load or
compression or shear stress to the
spine. Qualified adult instruction,
low coach/athlete ratio, frequent
and quality feedback, and
execution of new exercises without
fatigue are recommended.
Peña et al., 2016 [49]

Int. J. Environ. Res. Public Health 2022, 19, 12710 35 of 35
35
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
RCT/Quantitative Analysis
n = 88
(59F; 29M) Portuguese
adolescents (15-17 years
old) were randomly
assigned to a control (n =
46) or experimental (n = 42)
group.
(i) To evaluate the effects
of a 32-weeks resistance
and stretching training
program applied in
physical education classes
on forward head posture
and protracted shoulder.
(ii) To evaluate in
adolescents submitted to
strength and stretching
exercises the effects of a
16-week detraining period.
Strengthening and stretching
exercises + posture alignment
assessment (cervical and
shoulder angle) with
photogrammetric method
using a software for postural
analysis + ASES questionnaire
for self-assessment of
shoulder pain and function,
as well as neck pain.
A 32-week posture corrective exercise
program (strength and stretching), in
addition to physical education classes,
improves postural control with
increases in cervical and shoulder
angles in adolescents aged 15 to 17
years. In addition, when a four-month
detraining period is given, the
adaptations are not lost.
Ruivo et al., 2016 [50]
RCT/Quantitative Analysis
n = 33
(15F; 18 M) physically
active participants were
randomly assigned to hip
flexor training (n = 16) or
control (n = 17); only 26
completed the study and
were included in the
analysis.
To investigate the
feasibility and effect of a
novel simple hip flexor
strength training program
in healthy subjects, using
elastic bands as external
loading.
Maximal isomeric hip flexion
strength in the dominant leg
using a hand-held
dynamometer (Powertrack II
Commander, JTECH Medical)
+ delayed onset muscle
soreness (pain) using
numerical rating scale + rate
of perceived exertion using
the BorgCR10 scale
A 6-week hip flexor strength training
program using elastic bands with
isometric action on the dominant leg
improved hip flexor muscle strength by
17%. These types of interventions may
favor the prevention and treatment of
acute long-term hip flexor injuries,
such as acute rectus femoris injuries
and longstanding iliopsoas-related pain
and impingement.
Thorborg
et al., 2016 [51]
Systematic Review/Qualitative
Analysis
20 references (includes
articles from their year of
publication until 2015).
To systematically review
the injury epidemiology of
weight training sports
using a list of injury
epidemiology outcomes
advocated by the IOC and
to evaluate if demographic
features influence the
injury epidemiology.
Literature search in PubMed,
SPORTDiscus, CINAHL, and
Embase databases using
Boolean algorithms
containing key words such as
wound, rupture, sprain,
strain, and tear in weight
training sports (weightlifting,
powerlifting, bodybuilding,
strongman, Highland Games,
and CrossFit).
Mild (exercise execution required
modification) to moderate (stopped
performing the exercise) injuries were
reported in the shoulders, knee, and
lower back. The injury rate in weight
sports (≈1–2 injuries per athlete per
year and ≈2–4 injuries per 1000 h of
training/competition exposure) was
lower than those reported in most team
sports, with Highland Games and
strongman having the highest rates.
Keogh & Winwood,
2017 [52]

Int. J. Environ. Res. Public Health 2022, 19, 12710 36 of 35
36
Table 1. Cont.
Type of Study Participants Aim Instruments or
procedure
Main findings/conclusions Reference
Narrative Review/Qualitative
Analysis
134 references (includes
articles from 1982 to 2016).
To synthesize and review
the most recent literature
related to young athlete
development as it pertains
to resistance training and
physical literacy.
Literature search in
PubMed and SPORTDiscus
databases using: strength
training OR resistance
training AND children,
strength training OR
resistance training AND
adolescents, strength
training OR resistance
training AND injury
prevention, physical
literacy, and young athlete
development.
Weight RT training serves as injury
prevention. A multifaceted RT
program with skilled instruction can
ensure that diversification of motor
skill development occurs before the
onset of puberty, preventing
patellofemoral disorders, fractures,
or ACL tears.
Zwolski
et al., 2017 [53]
Narrative Review/Qualitative
Analysis
110 references (includes
articles from year of
publication to May 2017).
To provide an evidence-
based framework for the
selection of hamstring
strengthening exercises
that reduce the rate of
injury to this muscle
group.
Literature search in Scopus
and PubMed databases
using three Boolean
algorithms.
The benefits of strength training
may be due to increased biceps
femoris long head fascicle length,
possibly a rightward shift in the
angle of peak knee flexor torque,
and improved eccentric knee flexor
strength.
Bourne
et al., 2018 [54]
RCT/Quantitative Analysis
21M (22.4 ± 2.2 years old
with at least three years of
strength training
experience performing
traditional and Romanian
deadlifts).
To determine which
deadlift technique is a
better training protocol
b
etween the conventional
and Romanian deadlifts as
indicated by the greater
demand in muscle
activities and joint kinetics.
Fifty-nine markers were
placed on anatomical
landmarks for kinematic
analysis using a six-camera
VICON motion capture
system + ground reaction
force data using AMIT
force plates + EMG analysis
using the Desktop DTS, a
three-channel wireless
system.
The conventional deadlift resulted in
significantly greater EMG activities
of
the rectus femoris and gluteus
maximus than those of the
Romanian deadlift. Additionally,
convenitional deadlift produced
greater knee and ankle net joint
torques than the Romanian version.
In conclusion, the conventional
deadlift might be a better technique
for training lower extremity
muscles.
Lee et al., 2018 [55]

Int. J. Environ. Res. Public Health 2022, 19, 12710 37 of 35
37
Systematic Review with Meta-
Analysis/Qualitative and
Quantitative Analysis
Six references (includes
articles from year of
publication 2017). A total o
f
7738 subjects aged from 12
to 40 years.
To systematically identify
and analyze qualitatively
and quantitatively RCTs of
strength training-based
sports injury prevention
programs.
Literature search in
PubMed, Embase, Web of
Science, and SPORTDiscus
databases for RCTs using
keywords related to
exercise programs,
prevention, injury, and
diagnoses.
Significant reduction in acute
hamstring and ACL injuries by
incorporating strengthening of the
frequently injured muscles. To
prevent ACL injury and reduce
anterior knee pain, it is advisable to
improve strength and coordination
in the knees, pelvis, and core.
Incorporate familiarization phase,
recovery weeks, and individualized
programs to reduce the risk of injury
from overuse.
Lauersen
et al., 2018 [56]

Int. J. Environ. Res. Public Health 2022, 19, 12710 38 of 35
38
Table 1. Cont.
Type of Study Participants Aim Instruments or
procedure
Main findings/conclusions Reference
Cross-sectional/Quantitative
Analysis
n = 104
(53F; 51M) subelite
Swedish powerlifters
To investigate the
prevalence, localization,
and characterization of
injuries among Swedish
subelite classic powerlifters,
with an emphasis on
differences between men
and women, and to
investigate whether
training and lifestyle factors
are associated with an
injury.
Web-based adapted
questionnaire: the majority
of questions required a
dichotomous answer
(yes/no), while the other
questions offered several
categorical answers or
called for an open-ended
response.
The lumbopelvic region, shoulder,
and hip present more injuries in
b
oth sexes (70% reported a current
injury, and 87% reported being
injured during the past 12 months).
Women more frequently
experienced injuries in the neck and
thoracic region than men.
Incorporating rehabilitation
exercises, emphasis on technique,
warm-up, and flexibility are
associated with significant
improvements.
Strömbäck
et al., 2018 [57]
Narrative Review/Qualitative
Analysis
62 references (includes
articles from year of
publication to 2016).
To review the National
Strength and Conditioning
Association’s 2016 Position
Statement on Long-Term
Athletic Development.
Literature search in the
PubMed database using the
following specific search
terms: youth sports injuries,
early sports specialization,
training and maturation,
training versus
developmental stage, and
long-term athletic
development.
Weight RT has been shown to
reduce the risk of injury in youth
population. Besides adequate
recovery time, it is recommended
that children and adolescents train
strength two to three days per week
(between 60 and 80% 1RM, 8 to 15
reps). Exercises that increase the
genu varu/valgus, joint
hypermobility, leg length
discrepances, pelvic rotation,
height, muscle tightness, large Q
angle, and ratio of explosive-to-
static strength might increase the
risk of injuries.
Walters et al., 2018 [58]
RCT/Quantitative Analysis
67 New Zealand school
boys (aged 12–14 years)
were randomily assigned
to either combined RT (n =
21), combined RT +
To investigate how
combined RT with or
without weightlifting
movements affect injury
risk factors (jump landing
kinematics and interlimb
Anthropometric measures +
resistance training skills
battery + tuck jump
assessment + single-leg
horizontal jump + modified
A 28-week combined RT program
improved tuck jump scores more
than combined RT + weightlifting
and regular physical education
curriculum. Practitioners can use a
combination of traditional RT,
Pichardo et al., 2019 [59]

Int. J. Environ. Res. Public Health 2022, 19, 12710 39 of 35
39
weightlifting (n = 19), or
control (n = 27)
asymmetry) as well as
resistance training skill.
star excursion
b
alance test +
isometric midthigh pull test
plyometric, and weightlifting
training to reduce injury risk factors
associated with jump landings and
improve resistance training skill
competency.

Int. J. Environ. Res. Public Health 2022, 19, 12710 40 of 35
40
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
Prospective Clinical
Trial/Quantitative Analysis
n = 100
(80F; 20M) healthy adults
(22 to 64 years)
To identify the injury
rate during HIFT (e.g.,
“boot camp”-style
classes, military
training, or CrossFit).
Self-reported injury rate and
injury location + self-
reported training time +
demographic data + record
of exercise types and pain
The injury rate during HIFT was 9.0
injuries per 1000 training hours. No
sex differences were found. The most
common locations injured were knees
and back, particularly with non-
b
allistic weightlifting (free weights),
plyometrics, and calisthenics, as well
as burpees and squats.
Batterson et al., 2020 [60]
Narrative Review/Qualitative
Analysis
55 references (includes
articles from year of
publication to 2020).
To overview injuries
and overload damage in
weight RT.
Literature search with
clinical and practical
aspects. A retrospective,
citation-
b
ased methodology
was applied.
The shoulder, knee, and lower back
are the most common locations for
injuries. Exercises such as behind-the-
neck presses, behind-the-neck lat
pulls, biceps curls with the straight
b
ar, triceps presses with the straight
b
ar, good mornings, and exercises in
maximum stretch should generally
be avoided.
Ritsch
2020 [61]
Systematic Review/Qualitative
Analysis
12 references from 2010 to
2018.
To analyze in detail the
prevalence of injuries
occurring in training
based on the CrossFit®
,
cross-training, or HIFT
modalities.
Literature search in
PubMed, Web of Science,
SPORTDiscus, and Scopus
databases using Boolean
algorithms containing
CrossFit, extreme
conditioning program,
cross-training, HIFT (high-
intensity functional
training), and HIPT (high-
intensity power training).
The shoulder joint is the anatomical
area with the highest prevalence of
injury in CrossFit®, cross-training, or
HIFT methodologies (9/12 studies).
The rate or ratio of injury depends on
a wide variety of variables to
consider (previous injuries, protocol
used, presence of qualified coaches,
etc.).
Barranco-Ruiz et al., 2020
[62]

Int. J. Environ. Res. Public Health 2022, 19, 12710 41 of 35
41
Table 1. Cont.
Type of Study Participants Aim Instruments or
procedure
Main findings/conclusions Reference
Retrospective cross-sectional
study/Quantitative Analysis
n = 213
(112M; 101F) from three
Brazilian PFC.
To verify the anatomical
sites with the highest
occurrence of injuries and
the number and possible
risk factors for injuries in
HIFT practitioners in the last
six months.
Questionnaire as
retrospective survey to
evaluate injury rate.
In total, 38.50% of the participants
had suffered some type of injury
caused by the HIFT training routine,
and about 70.7% experienced their
first injury only after initiating
training. The injury rate was 7.1
injuries for every 1000 h of training
(higher risk in advanced
practitioners), and the majority of
the injuries affected the shoulder,
lumbar area, knee, and wrist. Injury
causes were incorrect execution
techniques, recurrent efforts, and
high loads.
Texeira et al., 2020 [63]
Case study with literature
review/Quantitative and
Qualitative Analysis
A 26-years old elite
weightlifter with 4 years of
experience.
To describe the case of a elite
weightlifter who suffered
from bilateral quadriceps
muscle/tendon rupture.
Also, to assess the risk
factors, types of
presentation, and
management of such cases
by revieweling literature.
Medical history + clinical
examination + NMR
imaging of both legs +
literature search in
PubMed using Boolean
terms with keywords such
as bilateral quadriceps
muscle, quadriceps muscle,
rupture, tear, lacerations,
and sports.
The case of the elite weightlifter who
ruptured both his quadriceps
muscles/tendons during competition
was retrospectively found to have a
history of AAS use. The literature
review revealed 11 cases of sports-
related bilateral quadriceps tendon
ruptures, five of which were
weightlifters and two were in
bodybuilders (5/7 had a history of
AAS use, infuencing the extensor
mechanism strength).
Dhillon et al., 2020 [64]
Clinical trial/Qualitative
Analysis
n = 11
(26.8 ± 2.4 years) healthy
male participants with > 3
years of RT experience
(i) To quantify, with
musculoskeletal modeling,
the loading of key upper
limb and torso muscles
during several pull-up
variants. (ii) To examine the
effect of different kinematic
strategies on muscle
Retro-reflective passive
markers (21) were placed
on anatomical landmarks
of the thorax, clavicle,
humerus, and forearm, and
a scapula tracker
incorporating three
markers was placed along
There is potential injury risk in
concentric loading of vulnerable
structures, specifically the rotator
cuff muscles, under complex and
strenuous movement patterns
involving high upper limb elevation.
Given their heavy load and
multiplanar complexity, pull-ups
Urbanczyk et al., 2020
[65]

Int. J. Environ. Res. Public Health 2022, 19, 12710 42 of 35
42
recruitments. (iii) To
highlight potential injury
risks in concentric loading of
vulnerable structures in
these tasks.
the scapular spine +
kinematic data using a 9-
camera optical motion
system (200 Hz Vicon) +
external kinetic data using
a force platform (1000 Hz
Kistler) + UK National
Shoulder Model was used
to simulate biomechanics o
f
the clavicle, scapula,
humerus, and forearm
should be implemented as a late-
stage component in shoulder
rehabilitation and conditioning
programs. All three pull-up variants
(front, wide, and reverse grips)
should be incorporated into the
exercise program with systematic
progression to provide greater
global strengthening of the torso and
upper limb musculature.

Int. J. Environ. Res. Public Health 2022, 19, 12710 43 of 35
43
Table 1. Cont.
Type of Study Participants Aim Instruments or procedure Main findings/conclusions Reference
RCT/
Qualitative Analysis
n = 29 female soccer
players (16.4 ± 1.6 years)
were randomly assigned to
experimental (n = 18) or
control (n = 11).
To evaluate the changes in
b
iomechanical risk factors
for an ACL injury after
participation in a pelvic
and core strength training
program in female team
players.
All measures were collected
during bilateral and unilateral
drop jumps. Knee frontal
plane projection angle + hip,
knee, and ankle peak flexion
angles + jump height
An in-season 8-weeks pelvic and
core strength training program
(twice per week) resulted in
improvements on ACL injury risk
factors and vertical drop jump
performance. Strengthening this
body part might support injury
prevention while increasing
jumping performance.
Ferri-Caruana et al., 2020
[66]
Systematic Review/Qualitative
Analysis
11 references (includes
articles from from year of
publication to January
2020).
To analyse the literature
concerning powerlifting
injuries, focusing on the
injury rates, areas of
injury, and biomechanical
movement analysis.
Literature search in PubMed
and Google Scholar databases
using the search terms
powerlifting and injury.
The injury rates in powerlifting
were between 1.0 and 4.4 per 1000 h
of training (lower than other
strength sports). Most injuries were
found in shoulders, lower back,
elbows, and knees. Experienced
lifters were more prone to overuse
or chronic injuries, whereas novice
lifters were more likely to
experience acute injuries.
Dudagoitia et al., 2021
[67]
RCT/
Qualitative Analysis
n = 48 recreationally active
men (22.4 ± 2.6 years) were
randomly assigned to
experimental (n = 32) or
control (n = 16).
To examine the effects of
core muscle strengthening
on lower extremity joint
kinematics and muscle
activation of selected trunk
and lower extremity
muscles during side-step
cutting.
Kinematic data of the trunk,
hip, knee, and ankle joints
using a 3-dimensional motion
capture system (Motion
Analysis Corp) +
electromyography analysis
(LXM5308) + core stability test
using prone and sideplank
endurance tests
A 10-week core strength training
program alters the motor control
strategy and at-risk biomechanical
parameters associated with an ACL
injury during the cutting maneuver
b
y reducing the knee valgus and hip
adduction angles and increasing the
vastus medialis/lateralis and
hamstring/quadricep activation
ratio.
Jeong et al., 2021 [68]
AAS: anabolic androgenic steroids; ACL: anterior cruciate ligament; AI: anterior instability; BMC: bone mineral content; CK: creatine kinase; CSA:
cross-sectional area; DXA: dual-energy X-ray absorptiometry; EMG: electromyography; F: females; Free T: free testosterone; HIFT: high-intensity
functional training; IOC: International Olympic Committee; M: males; MTJ: myotendinous junction; PFC: physical fitness centers; PIEDs: perfor-
mance- and image-enhancing drugs; POMS: profile of mood states; PRT: long-term progressive training; OVR: overreaching; OVT: overtraining;
NMR: nuclear magnetic resonance; RCT: randomized controlled trial; RT: resistance training; Total T: total testosterone; TS: quasistatic trunk stabili-
zation.

Int. J. Environ. Res. Public Health 2022, 19, 12710 44 of 35
44
The neuromuscular control and integrity of muscle and joint structures are compro-
mised when some training principles are violated; therefore, it is very important to un-
derstand and integrate them into weight RT programs. DeWeese et al. [45] suggested de-
veloping exercise programs within periodization models, given that it is easier to manip-
ulate training variables such as the intensity, volume, variation, and specificity of the ex-
ercises while avoiding overuse, allowing adequate overload and gradual increases to
avoid abrupt stimuli that might increase the risk of injury. In fact, the RT program varia-
bles should be set according to the level of experience and learning capacity from the eas-
iest to the most complex techniques [32,48]. Several articles have aimed to examine the
impact of strength training (including weight RT) on reducing injuries in different ana-
tomical locations while improving different parameters of physical fitness and body com-
position. The evidence shows injury-preventing structural and neural adaptations in the
musculoskeletal tissue (e.g., increase in the tensile properties of hamstring muscles, aug-
mented length in the long head of the biceps femoris, protective effects of eccentric actions
on knee flexors) after weight RT provided the selected exercises obey the biomechanical
pattern of the joints and muscles involved [54]. Indeed, Escamilla et al. [37] found that the
load generated on the anterior cruciate ligament (ACL) increased or decreased according
to the degree of flexion of the knee joint, whether or not the exercise included body weight
and variations in exercise technique. For instance, heavy RT may contribute to the optimal
remodeling process and adaptations for injury prevention by increasing the endomysium
content of collagen XIV, macrophages, and tenascin-C in the MTJ region [47].
However, there is a wide variety of injuries caused by strength training within the
PFC or training programs, most of the time caused when fitness practitioners do not have
adequate professional supervision. In this regard, when a qualified professional advises
and follows-up the RT program, the predisposing factors and risk of injury decrease
[31,32]. Thus, the injuries that can be caused by inadequate strength training, depending
on the type of exercise practiced or the type of strength sport practiced [34]. Epidemiolog-
ically, shoulder injuries constitute a large proportion of RT-related injuries
[43,57,61,63,67], followed by elbow or knee injuries and lower back pain, mainly due to
inadequate exercise selection, technique, and overuse [34,41,67]. The susceptibility of the
shoulder complex to RT-related injuries is due in part to the stress placed on a joint that is
anatomically non-load-bearing but assumes the role of an active joint with high-load re-
petitive lifting [42]. For example, impingement injuries are possible when the subacromial
space is at its smallest, at 120° humeral elevation, 90° abduction, and 45° external rotation
[65]. This position is reached during the pull-up motion (when supraspinatus is most ac-
tive), especially with a narrow grip such as during front and reverse pull-ups (since it
increases the required abduction moment). Nevertheless, wide pull-ups reduce the high
stresses in both the deltoid and supraspinatus by emphasizing the back muscles (i.e., la-
tissimus dorsi, trapezius, and rhomboid major) [65]. It is noteworthy that the injury risk
might be higher when the fatigue level rises due to the increased eccentric loading on the
supraspinatus. Similarly, the end-range “high-five” position (upper arm in 90° abduction,
elbow in 90° flexion, and terminal external rotation of the shoulder) has been described as
a posture of high injury risk during resistance exercises [33].
At the knee level, the analyzed articles indicated a moderate prevalence of injuries in
this area caused by multiple factors [43,44]. For instance, patellofemoral pain is attributed
to overuse, a lack of sufficient recovery periods, high loads without adequate prior condi-
tioning, and an absence of technique supervision [30]. Although the prevalence of ACL
rupture in PFC is low [57,62], the RT-related injuries can occur with movements of ex-
treme internal rotation of the femur, with external rotation of the tibia, or when there is a
large anterior displacement of the tibia [69]. Some factors have been found to increase or
decrease the risk of injury in strength training. Jamison et al. [38] compared two RT pro-
grams, one of them with quasistatic trunk stabilization, and found a higher risk of ACL
rupture in the program without trunk stabilization due to an increase in the tension of this

Int. J. Environ. Res. Public Health 2022, 19, 12710 45 of 35
45
ligament. Likewise, Lauersen et al. [56] concluded that improving strength and coordina-
tion in the knees, pelvis, and core might support the prevention of ACL injury and reduce
anterior knee pain. Recently, Ferri-Caruana et al. [66] showed that an in-season 8-week
pelvic and core strength training program reduced the values of ACL injury risk factors.
It is important to note that the stress on the ACL is greater when lower-limb strength
exercises do not support the body mass (double-leg and single-leg squats, lunges) [37].
On the other hand, despite their prohibition, fitness practitioners have shown a high
prevalence in the use of pharmacological ergogenic aids [70], particularly the so-called
performance- and image-enhancing drugs (PIEDs) [71]. These are considered doping sub-
stances and include synthetic derivatives of testosterone known as anabolic androgenic
steroids (AAS), which have anabolic (related to the growth and increase in muscle mass)
and androgenic (related to male sexual characteristics) effects [72]. The use of AAS is fre-
quent in amateur and competitive bodybuilders [73], and importantly has been associated
with an increased risk of musculoskeletal injuries [48][30][46][74], besides pathological
issues derived from its injection, such as avascular lesions (necrosis) in the muscle and
proteinaceous or hemorrhagic lesions in the intramuscular self-administration areas
[75,76].
4. Discussion
This systematic integrative review aimed to summarize different aspects of exercise
selection along with the incidence of injuries in exercisers who perform RT programs in
PFC. The collective findings of this study indicate that the selection of exercises in weight
RT programs and their relationship with the occurrence of injuries is multifactorial in na-
ture (based on pedagogical, methodological, genetic, biomechanical, and anatomical–
physiological principles).
4.1. Underlying Factors
Similar to any other biological system, all principles converge to establish an optimal
allostatic load that evokes adaptation and supercompensation (reach a new level above
the initial value) [77]. It is worth noting that the allostatic load is defined as the cost that
biological systems have to pay for being forced to adapt to a new set point [78]. Hence,
the human body is able to reset the primary mediators of the physiological, anatomical,
or psychological response at a new level that is different from the normal (homeostatic)
operating range in a process that is called allostasis or “stability through change” [79].
Importantly, exercisers need to fulfill not only their energy, macronutrient, and micronu-
trient requirements but also their post-exercise recovery time requirements for adequate
functioning in cases of exercise-induced physiological stress and subsequent adaptation
[11]. For example, a relative energy deficiency in sports and suboptimal sleep may place
athletes or exercisers at greater risk of musculoskeletal injury and bone stress fractures
[80,81]. In agreement with Jagodzinski et al. [30], a similar discussion on this allostatic
basis highlights a plethora of injury causes ranging from genetics to the individual’s med-
ical history, training load, psychological factors (e.g., fear), and adaptive response.
Clinical exercise physiologists, exercise professionals, and athletic or personal train-
ers should adopt a systemic (integrative and multifactorial), evolutionary (intuitive), and
adaptive (ever-changing based on individualization) perspective or ‘bio-logic approach’
[82] that allows an understanding of the flow of information through interactions between
system components and their regulatory aspects for a given phenotype and the allostatic
load (Figure 2). In fact, the allostatic load has been proposed as a promising and underuti-
lized measure that might be useful to assess the spinal cord injury time course [83]. This
is in agreement with the fact that the total workload (with changes in external or internal
loads) seems to affect injury prevention or management the most [84]. A multidomain
intelligence platform that not only identifies target deficits that underlie second injury risk
in sports (i.e., phenomic profiling) but also drives precision treatment to optimally en-
hance the athlete’s functional adaptability has been recently developed [85].

Int. J. Environ. Res. Public Health 2022, 19, 12710 46 of 35
46
Figure 2. An integrative view of the multifactorial nature of injury risk. (A) General features of the
interoception–allostasis process. While allostasis represents the adaptive process of stability
through change, interoception refers to encoding representations of the internal (physiological) state
of the body
[86]
. (B) Modulation of endogenous pain. Nociplastic pain conditions include the com-
bination of central and peripheral pain sensitization, hyper-responsiveness to painful and non-pain-
ful sensory stimuli, and associated features (fatigue, sleep, and cognitive disturbances)
[87]
. (C)
Detailed representation of the interoceptive–allostatic control (as a closed-loop system) of the hu-
man body in response to any stimuli. The injury or pain etiology might be discussed in terms of the
role of the input signal (stimuli—distal physiology or external world), receptors (sensory surfaces,
biological receptors), transmitters (spinal cord, anatomy trains), decoders (central nervous system),
regulator elements (autonomic nervous system), and output signal (response, physiological effects).
This block diagram was taken from Sennesh et al. (2022)
[88]
. (D) Representation of the changes in

Int. J. Environ. Res. Public Health 2022, 19, 12710 47 of 35
47
injury risk in response to stress exposition. Importantly, exercise selection is one of the many factors
that might impact the allostatic load in fitness practitioners; therefore, it might influence the mus-
culoskeletal or connective tissue overload. However, several other variables should be considered
to avoid the risk of injury in PFC. AL: allostatic load. Source: designed by the authors (D.A.B.).
4.2. Exercise Modifications
As an element of the connective tissue, the anatomy trains cover most of the body
and their relevance lies in the continuity between anatomical regions and the role in coor-
dinating muscle activity, besides acting as a proprioceptive organ [89]. The anatomy trains
might represent one of the mechanisms of transmitting, interpreting, and regulating ex-
ternal signals in the human body, including (i) the spiral line, (ii) the superficial back line,
and (iii) the superficial front line. For instance, knee and shoulder pain or injuries have
been associated with a compromise of the spiral line, which has helical paths that originate
in the skull and then pass through the contralateral shoulder, serratus, anterior superior
iliac spine, tensor fascia latae, lateral tibial condyle, and tibialis anterior, finally reaching
the fibularis longus tendon [90,91]. However, it is important to point out that this theoret-
ical model that aims to represent the human body through a fascial continuum requires
further research due to the lack of scientific consensus [92].
Maintaining balanced posture is an aspect to be considered in the selection of exer-
cises and their methodological progression. The degree of instability that could be
achieved during certain RT movements requires greater activation of the stabilizing mus-
cles of the trunk, which influences the rate of force development [93]. Therefore, perform-
ing any upper limb RT exercise unilaterally with free weights, a pulley cable, or an elastic
band (standing, seated, or kneeling) will cause the increased resistance on one side of the
body to significantly impact the stabilization demands at the central level, providing ad-
ditional core muscle activation and stress [94]. Interestingly, two randomized controlled
trials have shown that core strength training would not only reduce the ACL injury risk
but also improve athletic performance [66,68]. However, it needs to be noted that some
unstable positions or postural malalignments during strength exercises might put at risk
the spine if high loads are used [95,96]. Furthermore, during typical activities of daily liv-
ing, individuals frequently perform inadequate body positions or physical movements
(with no mention of predisposing factors) that might cause spine alterations such as ky-
phosis, lordosis, and scoliosis [97–99], which can increase the risk of acute injury during
weight RT programs. For example, some biceps exercises involve positions that increase
thoracolumbar kyphosis (e.g., dumbbell concentration curl) instead of movements that
allow the same elbow flexion with thoracolumbar and humerus stability (Figure 3).

Int. J. Environ. Res. Public Health 2022, 19, 12710 48 of 35
48
Figure 3. Seated bicep curls: (A) one-arm dumbbell concentration curl increases thoracic–lumbar
kyphosis; (B) EZ bar Scott (preacher) curl provides proper positioning of the cervical and thoracic
vertebrae. Source: Taken from Gym Visual available at https://gymvisual.com/ under copyright and
owned by Aliaksandr Makatserchyk. Accessed on 14 January 2022.
Another example of an exercise frequently used in the RT programs is the standing
cable overhead triceps extension during the work of the triceps brachii. Inadequate use of
the pulleys leads to a high level of stress on the lumbar spine when the trunk is brought
forward and the flexed neck position. This generates a postural imbalance due to excessive
tension of the myofascial and posteromedial muscle chains (Figure 4).
Figure 4. Standing cable overhead triceps extensions: (A) this posture generates tension in the my-
ofascial and muscular chains in different ways; (B) recommended posture. Source: Taken from Gym
Visual available at https://gymvisual.com/ under copyright and owned by Aliaksandr Makatser-
chyk. Accessed on 14 January 2022.

Int. J. Environ. Res. Public Health 2022, 19, 12710 49 of 35
49
In ball-and-socket joints such as the shoulder complex, which was found to be one of
the most common RT-related injury sites, the mechanical impact will depend on the move-
ment of the humerus over other bone surfaces [100,101]. In fact, common weight RT exer-
cises may place the shoulder in unfavorable positions that require the arm to extend hor-
izontally behind the neck or may require the “high-five” position of being abducted and
externally rotated (Figure 5).
Figure 5. Representation of the “high-five” position: (A) traditional technique requiring a “high-
five” end-position range (upper arm in 90° abduction, elbow in 90° flexion, and terminal external
rotation of the shoulder), where the risk of injury increases with the anterior instability; (B) modifi-
cation to avoid the “high-five” end-position. Raising the arms slightly in front of the head without
extending completely in military press is advisable to decrease injury or pain risk. Source: taken
from Gym Visual available at https://gymvisual.com/ under copyright and owned by Aliaksandr
Makatserchyk. Accessed on 14 January 2022.
Likewise, behind-the-neck presses lead to a dangerous position where the scapulo-
humeral portion reaches horizontal abduction along with forced external rotation. This
greatly affects the scapulothoracic friction with an important rotational compromise of the
scapula (depending on mobility) and a reduction in the existing space of the subdeltoid
region impacting the supraspinatus tendon and the subacromial bursa, among others [41].
Thus, the combination of a high load, several repetitions, and fatigue in maintaining an
unfavorable position can generate undue stress on the shoulder complex and higher in-
jury risk. Similarly, special attention should be paid when altering the positions of the
hands and feet for higher muscle hypertrophy in the deltoid muscles or the gastrocnemius
and soleus muscles, respectively [102,103]. In the case of the pectoralis major, the evidence
is inconclusive as to whether different angles (incline, flat, or decline) might be better for
muscle development or activation [104–106]; however, the wide grip should be modified
to avoid excessive horizontal abduction and the externally rotated position [107]. Consid-
ering the abovementioned examples, the professional in charge of prescribing and select-
ing the strength exercises must analyze each one of them, evaluate the possible risk of
injury (benefit/cost ratio), make the necessary adjustments during progressions, and fol-
low training guidelines [49,50].
It is important to consider that the fibrous connective tissues, which inform about the
positional state and joint kinesthesia to the CNS by means of mechanoreceptors, might
present neurophysiological changes after an injury. Afferent activity induced by periph-
eral injury has been shown to trigger a long-lasting increase in the excitability of spinal
cord neurons, profoundly changing the gain (or receptive capacity) of the somatosensory

Int. J. Environ. Res. Public Health 2022, 19, 12710 50 of 35
50
system (allodynamic response) [108]. The afferent information would involve changes in
the reception caused by the joint deafferentation [109]. Here, interoception provides per-
formance metrics for visceromotor regulation as a feedback element for allostasis [88] (Fig-
ure 2). It is worth noting that injury-related changes also include disturbances in anatom-
ical pathways as a function of the fascial network and its distal dysfunctional components
in anatomical areas (such as the shoulder and knee) [110]. Motor coordination changes
occur constantly in cases of chronic musculoskeletal pain, including lumbar pain [111]. To
clarify, nociception does not necessarily mean pain. Due to noxious stimuli, such as a mus-
cle or joint injury, nociceptors are activated and produce pain; however, if the stimulus is
repetitive, like in chronic lumbar pain or osteoarthritis, a sensitivity to the nociceptive
system can be developed and this would increase the response to non-harmful stimuli
[112]. Considering chronic pain is a widespread problem around the world, pain neuro-
science education (PNE) has been developed as an approach to pain treatment. It posi-
tively influences brain maps associated with fear or beliefs about exercise as a painful
activity, which may diminish menaces and strengthen safety [113].
4.3. Practical Recommendations
1. Establish the objectives prior to the start of the weight RT program and opt for a non-
linear (undulating) periodization model ordering the exercises to be implemented.
Undulating periodization of RT has been shown to be more effective than a linear
approach to increase strength and body composition in several populations [114–
117].
2. Consider all training variables that directly impact the targeted phenotype, regard-
less of the work demand by large or small muscle groups. Refer to Rosa et al. (2022)
for a recent meta-analysis on the comparison of the effectiveness of single versus
multijoint resistance exercises on muscle hypertrophy [118].
3. Dedicate familiarization training sessions for teaching, observing, or correcting exer-
cise techniques. This needs to be done independently of the experience level of the
athletes or exercisers and the resistance to be used (machines, free weights, suspen-
sion).
4. The principle of safety in RT indicates that the exercises selected must preserve the
integrity and health of the subjects. Start from easy to more complex exercises (from
machines to free weights with low load) or those that require greater control (free
weights with moderate-to-high loads or suspension RT).
5. To reduce the risk of injuries, ask for any pre-existing injuries or medical conditions,
monitor for fatigue, and modify or eliminate suboptimal movement patterns or exer-
cises entirely in persons not capable of performing them [60].
6. The exercises selected should consider all of the muscles and joints involved in the
biomechanical movement, avoiding methodological errors such as prescribing the
“bench press” for the exclusive development of the pectoralis. All muscles involved
in each exercise should be analyzed for a correct prescription, thereby avoiding over-
use injuries in certain body regions [41,58].
7. Precondition the muscle regions involved in sequential exercises (derived from
weightlifting) with pulling or pushing exercises.
8. Prioritize movements that require large muscle groups at the beginning of the ses-
sion. In this sense, fitness practitioners should perform the most demanding, chal-
lenging exercises early in their training sessions and should avoid tiredness, fatigue,
technical errors, and excessive overload [43].
9. Although further research is warranted, practitioners should be aware of the role of
myofascial fasciae and muscle chains involved in human movement to avoid incor-
rect body positions. Readers are encouraged to read a recent systematic review on
exercise interventions to improve postural problems [119].
10. The exercises selected should obey the optimal range of motion of the joints involved,
avoiding overloading the joint limits.

Int. J. Environ. Res. Public Health 2022, 19, 12710 51 of 35
51
11. Due to the frequent reinforcement in RT of the imbalance of the external rotators and
scapulothoracic muscles to the internal rotators at the shoulder, besides the stretch-
ing of the internal rotators, the incorporation of exercises to strengthen the lower tra-
pezius, scapulothoracic muscles, and external rotators might mitigate common
strength imbalances (anterior shoulder instability) and pain.
12. To prevent frequent RT-induced shoulder disorders the end-range “high-five” posi-
tion (upper arm in 90° abduction, elbow in 90° flexion, and terminal external rotation
of the shoulder) should be avoided [33,41]. Therefore, practitioners are encouraged
to select exercises that require bringing the bar to the front of the torso (latissimus
pull-downs or barbell presses to the front) instead of behind the neck.
13. In case of musculoskeletal discomfort when performing one of the exercises, opt for
another exercise that meets the same objective (i.e., changing the prescription and
technique of the exercises). The injury risk in some exercises is easily “mitigated” by
a variation in execution. For example, biceps curls with an EZ bar instead of a straight
bar; triceps presses with a 45° grip or rope; and no maximum stretch in exercises such
as pullovers, flies, and dips.
14. Core training should be considered for ACL injury prevention. It has been demon-
strated that it improves the extremity alignment in the frontal plane and muscle ac-
tivation during sports-related tasks [68].
15. The rating of perceived exertion and pain scales have been recognized as valid mark-
ers of internal load [120] and pain thresholds [121]. These easy-to-apply methodolo-
gies help to accurately monitor intensity and to adjust the RT program [11], taking
advantage of the interoception process for control within the allostasis model [88].
PNE might be used as an intervention strategy to reduce kynophobia (refer to Vélez-
Gutiérrez et al. [122] for a recent short commentary on cortical changes).
16. Amateur and competitive bodybuilders should be aware that the consumption of
AAS is a significant risk factor for several musculoskeletal disorders besides upper-
and lower-limb injuries. Relevant predictors of the high frequency of PIED use in-
clude age, sex, educational level, and socioeconomic status [123,124], as well as psy-
chological aspects associated with the constant dissatisfaction with body image of
people attending PFC (e.g., bigorexia) [125].
5. Conclusions
The selection of exercises and their relation to the potential injury risk in the weight
RT programs relate to multifactorial inputs that include anatomical and biomechanical
patterns of the musculoskeletal structures, as well as genetic, pedagogical, and methodo-
logical aspects directly related to the stimulus–response process. The most prevalent inju-
ries occur in the joints of the shoulder, knee, elbow, and vertebrae of the spine. Musculo-
skeletal pain and injury risk are mostly caused by overuse, short recovery periods be-
tween sessions, improper technique, poor conditioning in these body regions, and the fre-
quent use of high loads. Special care should be taken when monitoring PIED users. Be-
sides summarizing the individual characteristics of the selected studies and discussing
them as a whole to contribute to the design and development of future research, this paper
provides theoretical aspects based on a ‘bio-logic’ approach and practical recommenda-
tions addressed to clinical exercise physiologists, exercise professionals, and athletic or
personal trainers in order to improve the selection of exercises and mitigate the occurrence
of RT-related injuries in PFC. Nevertheless, it should be emphasized that the prevention
of injuries during strength-based RT programs has been clinically addressed at length in
the sports field and less from the perspective of fitness in PFC, which warrants further
research. In any case, “no pain, no gain” should not be a training maxim, as highlighted
by Ritsch (2020) [61]. The key to the prevention of injuries in recreational weightlifters and
bodybuilders is having professional supervision and adhering to proper lifting techniques
and training habits that might positively impact the allostatic load and exercise-induced
adaptations.

Int. J. Environ. Res. Public Health 2022, 19, 12710 52 of 35
52
Author Contributions: Conceptualization, D.A.B., J.M.V.-G., and A.A.-R.; methodology, D.A.B.;
search and data collection; D.A.B., L.A.C., and J.L.P.; writing—original draft preparation, D.A.B.,
J.M.V.-G., A.A.-R., L.A.C., and J.L.P.; writing—review and editing, S.V.-M., J.R.S., and R.B.K.; pro-
ject administration, D.A.B. All authors have read and agreed to the published version of the manu-
script.
Funding: This research received no funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: We would like to thank the research assistants at DBSS International for the
first version of the drafted manuscript and attendees at the Ibero-American Symposium in Sports
and Physical Activity: Nutrition and Training—SIDANE that has been held in Colombia, Costa Rica,
México, and Peru, where this topic has been fully covered.
Conflicts of Interest: D.A.B. has conducted academic-sponsored research on resistance training and
has received honoraria for selling linear position transducers and speaking about exercise sciences
at international conferences and private courses. J.M.V.-G. receives honoraria for rehabilitation ser-
vices and is the current managing director of IPS ARTHROS, a physiotherapy and exercise center.
A.A.-R. and S.V.-M receive honoraria for personalized training services and are managers of phys-
ical fitness centers. J.R.S. has conducted industry-sponsored research on exercise sciences over the
past 25 years. J.R.S. has also received financial support for presenting at industry-sponsored scien-
tific conferences. R.B.K. has conducted industry-sponsored studies at the universities he has been
affiliated with and occasionally serves as a scientific and legal consultant related to exercise and
nutrition intervention studies. The other authors declare no conflicts of interest. All authors are re-
sponsible for the content of this article.
References
1. Barbieri, D.; Zaccagni, L. Strength training for children and adolescents: Benefits and risks. Coll. Antropol. 2013, 37 (Suppl. 2),
219–225.
2. Cannataro, R.; Cione, E.; Bonilla, D.A.; Cerullo, G.; Angelini, F.; D’Antona, G. Strength training in elderly: An useful tool against
sarcopenia. Front. Sports Act. Living 2022, 4, 287. https://doi.org/10.3389/fspor.2022.950949.
3. Kraschnewski, J.L.; Sciamanna, C.N.; Poger, J.M.; Rovniak, L.S.; Lehman, E.B.; Cooper, A.B.; Ballentine, N.H.; Ciccolo, J.T.
Is strength training associated with mortality benefits? A 15 year cohort study of US older adults. Prev. Med. 2016, 87, 121–127.
https://doi.org/10.1016/j.ypmed.2016.02.038.
4. Sanchez-Moreno, M.; Rodriguez-Rosell, D.; Pareja-Blanco, F.; Mora-Custodio, R.; Gonzalez-Badillo, J.J. Movement Velocity as
Indicator of Relative Intensity and Level of Effort Attained During the Set in Pull-Up Exercise. Int. J. Sports Physiol. Perform.
2017, 12, 1378–1384. https://doi.org/10.1123/ijspp.2016-0791.
5. Vikmoen, O.; Raastad, T.; Seynnes, O.; Bergstrom, K.; Ellefsen, S.; Ronnestad, B.R. Effects of Heavy Strength Training on Run-
ning Performance and Determinants of Running Performance in Female Endurance Athletes. PLoS ONE 2016, 11, e0150799.
https://doi.org/10.1371/journal.pone.0150799.
6. Aagaard, P.; Andersen, J.L. Effects of strength training on endurance capacity in top-level endurance athletes. Scand. J. Med. Sci.
Sports 2010, 20, 39–47. https://doi.org/10.1111/j.1600-0838.2010.01197.x.
7. Chaabene, H.; Prieske, O.; Negra, Y.; Granacher, U. Change of direction speed: Toward a strength training approach with ac-
centuated eccentric muscle actions. Sports Med. 2018, 48, 1773–1779. https://doi.org/10.1007 / s40279-018-0907-3.
8. Eckardt, N. Lower-extremity resistance training on unstable surfaces improves proxies of muscle strength, power and balance
in healthy older adults: A randomised control trial. BMC Geriatr. 2016, 16, 191. https://doi.org/10.1186/s12877-016-0366-3.
9. Maiorana, A.; Levinger, I.; Davison, K.; Smart, N.; Coombes, J.; Accredited Exercise Physiologists, E.; Sports Science, A. Exercise
prescription is not just for medical doctors: The benefits of shared care by physicians and exercise professionals. Br. J. Sports
Med. 2018, 52, 879–880. https://doi.org/10.1136/bjsports-2016-096994.
10. Hegedus, E.J.; Hegedus, S.R.; Wright, A.; Dickson, T.; Stern, B.D. Individualized Exercise Prescription for Athletes Using a
Construct-Based Model. Sports Med. 2022, 52(10), 2315-2320. https://doi.org/10.1007/s40279-022-01670-7.
11. Bonilla, D.A.; Perez-Idarraga, A.; Odriozola-Martinez, A.; Kreider, R.B. The 4R's Framework of Nutritional Strategies for Post-
Exercise Recovery: A Review with Emphasis on New Generation of Carbohydrates. Int. J. Environ. Res. Public Health 2020, 18,
103. https://doi.org/10.3390/ijerph18010103.
12. Herold, F.; Muller, P.; Gronwald, T.; Muller, N.G. Dose-Response Matters!—A Perspective on the Exercise Prescription in Ex-
ercise-Cognition Research. Front. Psychol. 2019, 10, 2338. https://doi.org/10.3389/fpsyg.2019.02338.

Int. J. Environ. Res. Public Health 2022, 19, 12710 53 of 35
53
13. Grgic, J.; Lazinica, B.; Garofolini, A.; Schoenfeld, B.J.; Saner, N.J.; Mikulic, P. The effects of time of day-specific resistance training
on adaptations in skeletal muscle hypertrophy and muscle strength: A systematic review and meta-analysis. Chronobiol. Int.
2019, 36, 449–460. https://doi.org/10.1080/07420528.2019.1567524.
14. Schoenfeld, B.J.; Ogborn, D.; Krieger, J.W. Dose-response relationship between weekly resistance training volume and increases
in muscle mass: A systematic review and meta-analysis. J. Sports Sci. 2017, 35, 1073–1082.
https://doi.org/10.1080/02640414.2016.1210197.
15. Harries, S.K.; Lubans, D.R.; Callister, R. Systematic Review and Meta-analysis of Linear and Undulating Periodized Resistance
Training Programs on Muscular Strength. J. Strength Cond. Res. 2015, 29, 1113–1125.
https://doi.org/10.1519/jsc.0000000000000712.
16. Lucini, D.; Pagani, M. Exercise Prescription to Foster Health and Well-Being: A Behavioral Approach to Transform Barriers into
Opportunities. Int. J. Environ. Res. Public Health 2021, 18, 968. https://doi.org/10.3390/ijerph18030968.
17. Cheung, M.C.; Lai, J.S.K.; Yip, J.; Cheung, J.P.Y. Increased Computer Use is Associated with Trunk Asymmetry That Negatively
Impacts Health-Related Quality of Life in Early Adolescents. Patient Prefer. Adherence 2021, 15, 2289–2302.
https://doi.org/10.2147/PPA.S329635.
18. Hides, J.A.; Mendis, M.D.; Franettovich Smith, M.M.; Miokovic, T.; Cooper, A.; Low Choy, N. Association between altered
motor control of trunk muscles and head and neck injuries in elite footballers—An exploratory study. Man. Ther. 2016, 24, 46–
51. https://doi.org/10.1016/j.math.2016.05.001.
19. Knapik, J.J. The importance of physical fitness for injury prevention: Part 1. J. Spec. Oper. Med. 2015, 15, 123–127.
20. Eickhoff-Shemek, J.M.; Topalian, T. Virtual Fitness Programs: Safety and Legal Liability Issues to Consider: Part 1. ACSM'S
Health Fit. J. 2022, 26, 48–51. https://doi.org/10.1249/fit.0000000000000729.
21. Wong, A.Y.L.; Karppinen, J.; Samartzis, D. Low back pain in older adults: Risk factors, management options and future direc-
tions. Scoliosis Spinal Disord. 2017, 12, 14. https://doi.org/10.1186/s13013-017-0121-3.
22. Noll, M.; Candotti, C.T.; da Rosa, B.N.; do Valle, M.B.; Antoniolli, A.; Vieira, A.; Loss, J.F. High prevalence of inadequate sitting
and sleeping postures: A three-year prospective study of adolescents. Sci. Rep. 2017, 7, 1–6. https://doi.org/10.1038/s41598-017-
15093-2.
23. Mañago, M.M.; Glick, S.; Hebert, J.R.; Coote, S.; Schenkman, M. Strength Training to Improve Gait in People with Multiple
Sclerosis: A Critical Review of Exercise Parameters and Intervention Approaches. Int. J. MS Care 2019, 21, 47–56.
https://doi.org/10.7224/1537-2073.2017-079.
24. Rahyussalim, A.J.; Zufar, M.L.L.; Kurniawati, T. Significance of the Association between Disc Degeneration Changes on Imag-
ing and Low Back Pain: A Review Article. Asian Spine J. 2019, 13, 245. https://doi.org/10.31616/asj.2019.0046.
25. Whittemore, R.; Knafl, K. The integrative review: Updated methodology. J. Adv. Nurs 2005, 52, 546–553.
https://doi.org/10.1111/j.1365-2648.2005.03621.x.
26. Hopia, H.; Latvala, E.; Liimatainen, L. Reviewing the methodology of an integrative review. Scand. J. Caring Sci. 2016, 30, 662–
669. https://doi.org/10.1111/scs.12327.
27. Ardern, C.L.; Buttner, F.; Andrade, R.; Weir, A.; Ashe, M.C.; Holden, S.; Impellizzeri, F.M.; Delahunt, E.; Dijkstra, H.P.;
Mathieson, S.; et al. Implementing the 27 PRISMA 2020 Statement items for systematic reviews in the sport and exercise medi-
cine, musculoskeletal rehabilitation and sports science fields: The PERSiST (implementing Prisma in Exercise, Rehabilitation,
Sport medicine and SporTs science) guidance. Br. J. Sports Med. 2022, 56, 175–195. https://doi.org/10.1136/bjsports-2021-103987.
28. Bonilla, D.A.; De Leon, L.G.; Alexander-Cortez, P.; Odriozola-Martinez, A.; Herrera-Amante, C.A.; Vargas-Molina, S.; Petro, J.L.
Simple anthropometry-based calculations to monitor body composition in athletes: Scoping review and reference values. Nutr.
Health 2021, 28, 95–109. https://doi.org/10.1177/02601060211002941.
29. Gho, C.; Petro, J.L.; Bonilla, D.A. Influencia de la acupuntura sobre el tratamiento de lesiones deportivas y el rendimiento atlé-
tico: Una revisión integradora. Rev. Int. Acupunt. 2020, 14, 64–75. https://doi.org/10.1016/j.acu.2020.04.003.
30. Jagodzinski, M.; Haasper, C.; Krettek, C. Disorders of the patellofemoral joint induced by weight training. Unfallchirurg 2009,
112, 381–385. https://doi.org/10.1007/s00113-009-1621-2.
31. Ackel-D'Elia, C.; Vancini, R.L.; Castelo, A.; Nouailhetas, V.L.A.; Silva, A.C.d. Absence of the predisposing factors and signs and
symptoms usually associated with overreaching and overtraining in physical fitness centers. Clinics 2010, 65, 1161–1166.
https://doi.org/10.1590/s1807-59322010001100019.
32. Faigenbaum, A.D.; Myer, G.D. Resistance training among young athletes: Safety, efficacy and injury prevention effects. Br. J.
Sports Med. 2010, 44, 56–63. https://doi.org/10.1136/bjsm.2009.068098.
33. Kolber, M.J.; Beekhuizen, K.S.; Cheng, M.S.; Hellman, M.A. Shoulder injuries attributed to resistance training: A brief review.
J. Strength Cond. Res. 2010, 24, 1696–1704. https://doi.org/10.1519/JSC.0b013e3181dc4330.
34. Lavallee, M.E.; Balam, T. An overview of strength training injuries: Acute and chronic. Curr. Sports Med. Rep. 2010, 9, 307–313.
https://doi.org/10.1249/JSR.0b013e3181f3ed6d.
35. Malliaropoulos, N.; Mendiguchia, J.; Pehlivanidis, H.; Papadopoulou, S.; Valle, X.; Malliaras, P.; Maffulli, N. Hamstring exer-
cises for track and field athletes: Injury and exercise biomechanics, and possible implications for exercise selection and primary
prevention. Br. J. Sports Med. 2012, 46, 846–851. https://doi.org/10.1136/bjsports-2011-090474.
36. Löfgren, B.; Dencker, M.; Nilsson, J.-Å.; Karlsson, M.K. A 4-year exercise program in children increases bone mass without
increasing fracture risk. Pediatrics 2012, 129, e1468–e1476. https://doi.org/10.1542/peds.2011-2274.

Int. J. Environ. Res. Public Health 2022, 19, 12710 54 of 35
54
37. Escamilla, R.F.; MacLeod, T.D.; Wilk, K.E.; Paulos, L.; Andrews, J.R. ACL Strain and Tensile Forces for Weight Bearing and
Non—Weight-Bearing Exercises After ACL Reconstruction: A Guide to Exercise Selection. J. Orthop. Sports Phys. Ther. 2012, 42,
208–220. https://doi.org/10.2519/jospt.2012.3768.
38. Jamison, S.T.; McNeilan, R.J.; Young, G.S.; Givens, D.L.; Best, T.M.; Chaudhari, A.M. Randomized controlled trial of the effects
of a trunk stabilization program on trunk control and knee loading. Med. Sci. Sports Exerc. 2012, 44, 1924–1934.
https://doi.org/10.1249/MSS.0b013e31825a2f61.
39. Seynnes, O.R.; Kamandulis, S.; Kairaitis, R.; Helland, C.; Campbell, E.-L.; Brazaitis, M.; Skurvydas, A.; Narici, M.V. Effect of
androgenic-anabolic steroids and heavy strength training on patellar tendon morphological and mechanical properties. J. Appl.
Physiol. 2013, 115, 84–89. https://doi.org/10.1152/japplphysiol.01417.2012.
40. Sousa, N.; Mendes, R.; Monteiro, G.; Abrantes, C. Progressive resistance strength training and the related injuries in older adults:
The susceptibility of the shoulder. Aging Clin. Exp. Res. 2014, 26, 235–240. https://doi.org/10.1007/s40520-013-0157-z.
41. Kolber, M.J.; Corrao, M.; Hanney, W.J. Characteristics of anterior shoulder instability and hyperlaxity in the weight-training
population. J. Strength Cond. Res. 2013, 27, 1333–1339. https://doi.org/10.1519 / JSC.0b013e318269f776.
42. Doyscher, R.; Kraus, K.; Finke, B.; Scheibel, M. Acute and overuse injuries of the shoulder in sports. Orthopade 2014, 43, 202–208.
https://doi.org/10.1007/s00132-013-2141-x.
43. Siewe, J.; Marx, G.; Knöll, P.; Eysel, P.; Zarghooni, K.; Graf, M.; Herren, C.; Sobottke, R.; Michael, J. Injuries and overuse syn-
dromes in competitive and elite bodybuilding. Int. J. Sports Med. 2014, 35, 943–948. https://doi.org/10.1055/s-0034-1367049.
44. Pearson, S.J.; Hussain, S.R. Region-specific tendon properties and patellar tendinopathy: A wider understanding. Sports Med.
2014, 44, 1101–1112. https://doi.org/10.1007/s40279-014-0201-y.
45. DeWeese, B.H.; Hornsby, G.; Stone, M.; Stone, M.H. The training process: Planning for strength–power training in track and
field. Part 2: Practical and applied aspects. J. Sport Health Sci. 2015, 4, 318–324. https://doi.org/10.1016/j.jshs.2015.07.002.
46. Kanayama, G.; DeLuca, J.; Meehan, W.P., 3rd; Hudson, J.I.; Isaacs, S.; Baggish, A.; Weiner, R.; Micheli, L.; Pope, H.G., Jr. Rup-
tured Tendons in Anabolic-Androgenic Steroid Users: A Cross-Sectional Cohort Study. Am. J. Sports Med. 2015, 43, 2638–2644.
https://doi.org/10.1177/0363546515602010.
47. Jakobsen, J.R.; Mackey, A.; Knudsen, A.; Koch, M.; Kjaer, M.; Krogsgaard, M. Composition and adaptation of human myoten-
dinous junction and neighboring muscle fibers to heavy resistance training. Scand. J. Med. Sci. Sports 2017, 27, 1547–1559.
https://doi.org/10.1111/sms.12794.
48. Hameed, M.; Sahu, A.; Johnson, M.B. Muscle mania: The quest for the perfect body. BMJ Case Rep. 2016, 2016, bcr2016217208.
https://doi.org/10.1136/bcr-2016-217208.
49. Peña, G.; Heredia, J.; Lloret, C.; Martín, M.; Da Silva-Grigoletto, M.E. Iniciación al entrenamiento de fuerza en edades tempranas:
Revisión. Rev. Andal. Med. Deporte 2016, 9, 41–49. https://doi.org/10.1016/j.ramd.2015.01.022.
50. Ruivo, R.; Carita, A.; Pezarat-Correia, P. The effects of training and detraining after an 8 month resistance and stretching training
program on forward head and protracted shoulder postures in adolescents: Randomised controlled study. Man. Ther. 2016, 21,
76–82. https://doi.org/10.1016/j.math.2015.05.001.
51. Thorborg, K.; Bandholm, T.; Zebis, M.; Andersen, L.L.; Jensen, J.; Holmich, P. Large strengthening effect of a hip-flexor training
programme: A randomized controlled trial. Knee Surg. Sports Traumatol. Arthrosc. 2016, 24, 2346–2352.
https://doi.org/10.1007/s00167-015-3583-y.
52. Keogh, J.W.; Winwood, P.W. The Epidemiology of Injuries Across the Weight-Training Sports. Sports Med. 2017, 47, 479–501.
https://doi.org/10.1007/s40279-016-0575-0.
53. Zwolski, C.; Quatman-Yates, C.; Paterno, M.V. Resistance Training in Youth: Laying the Foundation for Injury Prevention and
Physical Literacy. Sports Health 2017, 9, 436–443. https://doi.org/10.1177/1941738117704153.
54. Bourne, M.N.; Timmins, R.G.; Opar, D.A.; Pizzari, T.; Ruddy, J.D.; Sims, C.; Williams, M.D.; Shield, A.J. An evidence-based
framework for strengthening exercises to prevent hamstring injury. Sports Med. 2018, 48, 251–267.
https://doi.org/10.1007/s40279-017-0796-x.
55. Lee, S.; Schultz, J.; Timgren, J.; Staelgraeve, K.; Miller, M.; Liu, Y. An electromyographic and kinetic comparison of conventional
and Romanian deadlifts. J. Exerc. Sci. Fit. 2018, 16, 87–93. https://doi.org/10.1016/j.jesf.2018.08.001.
56. Lauersen, J.B.; Andersen, T.E.; Andersen, L.B. Strength training as superior, dose-dependent and safe prevention of acute and
overuse sports injuries: A systematic review, qualitative analysis and meta-analysis. Br. J. Sports Med. 2018, 52, 1557–1563.
https://doi.org/10.1136/bjsports-2018-099078.
57. Strömbäck, E.; Aasa, U.; Gilenstam, K.; Berglund, L. Prevalence and Consequences of Injuries in Powerlifting: A Cross-sectional
Study. Orthop. J. Sports Med. 2018, 6, 2325967118771016. https://doi.org/10.1177/2325967118771016.
58. Walters, B.K.; Read, C.R.; Estes, A.R. The effects of resistance training, overtraining, and early specialization on youth athlete
injury and development. J. Sports Med. Phys. Fit. 2018, 58, 1339–1348. https://doi.org/10.23736/S0022-4707.17.07409-6.
59. Pichardo, A.W.; Oliver, J.L.; Harrison, C.B.; Maulder, P.S.; Lloyd, R.S.; Kandoi, R. Effects of Combined Resistance Training and
Weightlifting on Injury Risk Factors and Resistance Training Skill of Adolescent Males. J. Strength Cond. Res. 2021, 35, 3370–
3377. https://doi.org/10.1519/JSC.0000000000003341.
60. Batterson, A.M.; Froelich, R.K.; Schleck, C.D.; Laskowski, E.R. Injury Rate and Patterns in Group Strength-Endurance Training
Classes. Mayo Clin. Proc. 2020, 95, 468–475. https://doi.org/10.1016/j.mayocp.2019.03.032.
61. Ritsch, M. Verletzungen und Überlastungsschäden im Kraftsport. Sports Orthop. Traumatol. 2020, 36, 260–270.
https://doi.org/10.1016/j.orthtr.2020.07.004.

Int. J. Environ. Res. Public Health 2022, 19, 12710 55 of 35
55
62. Barranco-Ruiz, Y.; Villa-Gonzalez, E.; Martinez-Amat, A.; Da Silva-Grigoletto, M.E. Prevalence of Injuries in Exercise Programs
Based on Crossfit((R)), Cross Training and High-Intensity Functional Training Methodologies: A Systematic Review. J. Hum.
Kinet. 2020, 73, 251–265. https://doi.org/10.2478/hukin-2020-0006.
63. Teixeira, R.V.; Dantas, M.; Motas, D.G.; Gantois, P.; Aidar, F.J.; Dantas, P.M.S.; Queiros, V.S.; Cesario, T.M.; Cabral, B. Retro-
spective Study of Risk Factors and the Prevalence of Injuries in HIFT. Int. J. Sports Med. 2020, 41, 168–174.
https://doi.org/10.1055/a-1062-6551.
64. Dhillon, M.S.; Kumar, P.; John, R.; Hooda, A. Bilateral Quadriceps Rupture in an Elite Weight Lifter: A Case Report and Review
of Literature. Indian J. Orthop. 2020, 54, 339–347. https://doi.org/10.1007/s43465-020-00051-4.
65. Urbanczyk, C.A.; Prinold, J.A.I.; Reilly, P.; Bull, A.M.J. Avoiding high-risk rotator cuff loading: Muscle force during three pull-
up techniques. Scand. J. Med. Sci. Sports 2020, 30, 2205–2214. https://doi.org/10.1111/sms.13780.
66. Ferri-Caruana, A.; Prades-Insa, B.; Serra, A.P. Effects of pelvic and core strength training on biomechanical risk factors for an-
terior cruciate ligament injuries. J. Sports Med. Phys. Fit. 2020, 60, 1128–1136. https://doi.org/10.23736/S0022-4707.20.10552-8.
67. Dudagoitia, E.; García-de-Alcaraz, A.; Andersen, L.L. Safety of powerlifting: A literature review. Sci. Sports 2021, 36, e59–e68.
https://doi.org/10.1016/j.scispo.2020.08.003.
68. Jeong, J.; Choi, D.H.; Shin, C.S. Core Strength Training Can Alter Neuromuscular and Biomechanical Risk Factors for Anterior
Cruciate Ligament Injury. Am. J. Sports Med. 2021, 49, 183–192. https://doi.org/10.1177/0363546520972990.
69. Colado, J.C.; Garcia-Masso, X. Technique and safety aspects of resistance exercises: A systematic review of the literature. Phys.
Sportsmed. 2009, 37, 104–111. https://doi.org/10.3810/psm.2009.06.1716.
70. Macho, J.; Mudrak, J.; Slepicka, P. Enhancing the Self: Amateur Bodybuilders Making Sense of Experiences With Appearance
and Performance-Enhancing Drugs. Front. Psychol. 2021, 12, 648467. https://doi.org/10.3389/fpsyg.2021.648467.
71. Odriozola, J.M. Ayudas ergogénicas en el deporte. Arbor 2000, 165, 171–185. https://doi.org/10.3989/arbor.2000.i650.964.
72. Llewellyn, W. Molecular Nutrition, 9th ed.; Anabolics: Aurora, CO, USA, 2009; 212p.
73. Greenway, C.W.; Price, C. Muscle dysmorphia and self-esteem in former and current users of anabolic-androgenic steroids.
Perform. Enhanc. Health 2020, 7, 100154. https://doi.org/10.1016/j.peh.2019.100154.
74. Stannard, J.P.; Bucknell, A.L. Rupture of the triceps tendon associated with steroid injections. Am. J. Sports Med. 1993, 21, 482–
485. https://doi.org/10.1177/036354659302100327.
75. Powell, C.; Chang, C.; Naguwa, S.M.; Cheema, G.; Gershwin, M.E. Steroid induced osteonecrosis: An analysis of steroid dosing
risk. Autoimmun. Rev. 2010, 9, 721–743. https://doi.org/10.1016/j.autrev.2010.06.007.
76. Mendiratta, V.; Khan, A.; Solanki, R.S. Avascular necrosis: A rare complication of steroid therapy for pemphigus. Indian J. Der-
matol. 2008, 53, 28–30. https://doi.org/10.4103/0019-5154.39739.
77. Guidi, J.; Lucente, M.; Sonino, N.; Fava, G.A. Allostatic Load and Its Impact on Health: A Systematic Review. Psychother. Psy-
chosom. 2021, 90, 11–27. https://doi.org/10.1159/000510696.
78. McEwen, B.S. Stress, Adaptation, and Disease: Allostasis and Allostatic Load. Ann. N. Y. Acad. Sci. 1998, 840, 33–44.
https://doi.org/10.1111/j.1749-6632.1998.tb09546.x.
79. Sterling, P.; Eyer, J. Allostasis: A new paradigm to explain arousal pathology. In Handbook of Life Stress, Cognition and Health;
John Wiley & Sons: Oxford, UK, 1988; pp. 629–649.
80. Holtzman, B.; Popp, K.L.; Tenforde, A.S.; Parziale, A.L.; Taylor, K.; Ackerman, K.E. Low energy availability surrogates associ-
ated with lower bone mineral density and bone stress injury site. PM R 2022, 14, 587–596. https://doi.org/10.1002/pmrj.12821.
81. Huang, K.; Ihm, J. Sleep and Injury Risk. Curr. Sports Med. Rep. 2021, 20, 286–290. https://doi.org/10.1249/JSR.0000000000000849.
82. Bonilla, D.A.; Moreno, Y.; Petro, J.L.; Forero, D.A.; Vargas-Molina, S.; Odriozola-Martinez, A.; Orozco, C.A.; Stout, J.R.; Rawson,
E.S.; Kreider, R.B. A Bioinformatics-Assisted Review on Iron Metabolism and Immune System to Identify Potential Biomarkers
of Exercise Stress-Induced Immunosuppression. Biomedicines 2022, 10, 724. https://doi.org/10.3390/biomedicines10030724.
83. Krause, J.S.; DiPiro, N.D.; Saunders, L.L.; Newman, S.D.; Banik, N.L.; Park, S. Allostatic load and spinal cord injury: Review of
existing research and preliminary data. Top. Spinal Cord. Inj. Rehabil. 2014, 20, 137–146. https://doi.org/10.1310/sci2002-137.
84. Miranda-Comas, G.; Zaman, N.; Ramin, J.; Gluck, A. The Role of Workload Management in Injury Prevention, Athletic, and
Academic Performance in the Student-Athlete. Curr. Sports Med. Rep. 2022, 21, 186–191.
https://doi.org/10.1249/JSR.0000000000000964.
85. Kiefer, A.W.; Armitano-Lago, C.N.; Sathyan, A.; MacPherson, R.; Cohen, K.; Silva, P.L. The Intelligent Phenotypic Plasticity
Platform (IP(3)) for Precision Medicine-Based Injury Prevention in Sport. Methods Mol. Biol. 2022, 2393, 877–903.
https://doi.org/10.1007/978-1-0716-1803-5_47.
86. Corcoran, A.W.; Hohwy, J. Allostasis, interoception, and the free energy principle: Feeling our way forward. In The Interoceptive
Mind: From Homeostasis to Awareness; Tsakiris, M., De Preester, H., Eds.; Oxford University Press: Oxford, UK, 2018.
https://doi.org/10.1093/oso/9780198811930.003.0015.
87. Fitzcharles, M.A.; Cohen, S.P.; Clauw, D.J.; Littlejohn, G.; Usui, C.; Hauser, W. Nociplastic pain: Towards an understanding of
prevalent pain conditions. Lancet 2021, 397, 2098–2110. https://doi.org/10.1016/S0140-6736(21)00392-5.
88. Sennesh, E.; Theriault, J.; Brooks, D.; van de Meent, J.W.; Barrett, L.F.; Quigley, K.S. Interoception as modeling, allostasis as
control. Biol. Psychol. 2022, 167, 108242. https://doi.org/10.1016/j.biopsycho.2021.108242.
89. Benjamin, M. The fascia of the limbs and back—A review. J. Anat. 2009, 214, 1–18. https://doi.org/10.1111/j.1469-
7580.2008.01011.x.

Int. J. Environ. Res. Public Health 2022, 19, 12710 56 of 35
56
90. Dischiavi, S.L.; Wright, A.A.; Hegedus, E.J.; Bleakley, C.M. Biotensegrity and myofascial chains: A global approach to an inte-
grated kinetic chain. Med. Hypotheses 2018, 110, 90–96. https://doi.org/10.1016/j.mehy.2017.11.008.
91. Joseph, L.H.; Pirunsan, U.; Sitilertpisan, P.; Paungmali, A. Effect of lumbopelvic myofascial force transmission on glenohumeral
kinematics–A myo-fascia-biomechanical hypothesis. Pol. Ann. Med. 2017, 24, 276–282.
https://doi.org/10.1016/j.poamed.2016.11.003.
92. Bordoni, B.; Myers, T. A Review of the Theoretical Fascial Models: Biotensegrity, Fascintegrity, and Myofascial Chains. Cureus
2020, 12, e7092. https://doi.org/10.7759/cureus.7092.
93. Atkins, S.J.; Bentley, I.; Brooks, D.; Burrows, M.P.; Hurst, H.T.; Sinclair, J.K. Electromyographic response of global abdominal
stabilizers in response to stable-and unstable-base isometric exercise. J. Strength Cond. Res. 2015, 29, 1609–1615.
https://doi.org/10.1519/JSC.0000000000000795.
94. Behm, D.G.; Leonard, A.M.; Young, W.B.; Bonsey, W.A.; MacKinnon, S.N. Trunk muscle electromyographic activity with un-
stable and unilateral exercises. J. Strength Cond. Res. 2005, 19, 193–201. https://doi.org/10.1519/1533-
4287(2005)19<193:tmeawu>2.0.co;2.
95. Vera-García, F.; Barbado, D.; Moreno-Pérez, V.; Hernández-Sánchez, S.; Juan-Recio, C.; Elvira, J. Core stability: Concepto y
aportaciones al entrenamiento y la prevención de lesiones. Rev. Andal. Med. Deporte 2015, 8, 79–85.
https://doi.org/10.1016/j.ramd.2014.02.004.
96. Vera-García, F.; Barbado, D.; Moreno-Pérez, V.; Hernández-Sánchez, S.; Juan-Recio, C.; Elvira, J. Core stability: Evaluación y
criterios para su entrenamiento. Rev. Andal. Med. Deporte 2015, 8, 130–137. https://doi.org/10.1016/j.ramd.2014.02.005.
97. Hazebroek-Kampschreur, A.; Hofman, A. Prevalence of trunk abnormalities in eleven-year-old schoolchildren in Rotterdam,
The Netherlands. J. Pediatr. Orthop. 1992, 12, 480–484. https://doi.org/10.1097/01241398-199207000-00012.
98. Zakeri, Y.; Baraz, S.; Gheibizadeh, M.; Saidkhani, V. Relationship between backpack weight and prevalence of lordosis, kypho-
sis, scoliosis and dropped shoulders in elementary students. Int. J. Pediatr. 2016, 4, 1859–1866.
https://doi.org/10.22038/IJP.2016.6846.
99. Katzman, W.; Cawthon, P.; Hicks, G.E.; Vittinghoff, E.; Shepherd, J.; Cauley, J.A.; Harris, T.; Simonsick, E.M.; Strotmeyer, E.;
Womack, C. Association of spinal muscle composition and prevalence of hyperkyphosis in healthy community-dwelling older
men and women. J. Gerontol. Ser. A Biol. Sci. Med. Sci. 2011, 67, 191–195. https://doi.org/10.1093/gerona/glr160.
100. Lugo, R.; Kung, P.; Ma, C.B. Shoulder biomechanics. Eur. J. Radiol. 2008, 68, 16–24. https://doi.org/10.1016/j.ejrad.2008.02.051.
101. Murray, I.R.; Goudie, E.B.; Petrigliano, F.A.; Robinson, C.M. Functional anatomy and biomechanics of shoulder stability in the
athlete. Clin. Sports Med. 2013, 32, 607–624. https://doi.org/10.1016/j.csm.2013.07.001.
102. Schoenfeld, B.J.; Sonmez, R.G.; Kolber, M.J.; Contreras, B.; Harris, R.; Ozen, S. Effect of hand position on EMG activity of the
posterior shoulder musculature during a horizontal abduction exercise. J. Strength Cond. Res. 2013, 27, 2644–2649.
https://doi.org/10.1519/JSC.0b013e318281e1e9.
103. Nunes, J.P.; Costa, B.D.V.; Kassiano, W.; Kunevaliki, G.; Castro, E.S.P.; Rodacki, A.L.F.; Fortes, L.S.; Cyrino, E.S. Different Foot
Positioning During Calf Training to Induce Portion-Specific Gastrocnemius Muscle Hypertrophy. J. Strength Cond. Res. 2020,
34, 2347–2351. https://doi.org/10.1519/JSC.0000000000003674.
104. Trebs, A.A.; Brandenburg, J.P.; Pitney, W.A. An electromyography analysis of 3 muscles surrounding the shoulder joint during
the performance of a chest press exercise at several angles. J. Strength Cond. Res. 2010, 24, 1925–1930.
https://doi.org/10.1519/JSC.0b013e3181ddfae7.
105. Saeterbakken, A.H.; Mo, D.A.; Scott, S.; Andersen, V. The Effects of Bench Press Variations in Competitive Athletes on Muscle
Activity and Performance. J. Hum. Kinet. 2017, 57, 61–71. https://doi.org/10.1515/hukin-2017-0047.
106. Stastny, P.; Golas, A.; Blazek, D.; Maszczyk, A.; Wilk, M.; Pietraszewski, P.; Petr, M.; Uhlir, P.; Zajac, A. A systematic review of
surface electromyography analyses of the bench press movement task. PLoS ONE 2017, 12, e0171632.
https://doi.org/10.1371/journal.pone.0171632.
107. Aasa, U.; Svartholm, I.; Andersson, F.; Berglund, L. Injuries among weightlifters and powerlifters: A systematic review. Br. J.
Sports Med. 2017, 51, 211–219. https://doi.org/10.1136/bjsports-2016-096037.
108. Wallden, M.; Nijs, J. Before & beyond the pain—Allostatic load, central sensitivity and their role in health and function. J. Bodyw.
Mov. Ther. 2021, 27, 388–392. https://doi.org/10.1016/j.jbmt.2021.04.003.
109. Kapreli, E.; Athanasopoulos, S. The anterior cruciate ligament deficiency as a model of brain plasticity. Med. Hypotheses 2006,
67, 645–650. https://doi.org/10.1016/j.mehy.2006.01.063.
110. Ajimsha, M.S.; Shenoy, P.D.; Gampawar, N. Role of fascial connectivity in musculoskeletal dysfunctions: A narrative review. J.
Bodyw. Mov. Ther. 2020, 24, 423–431. https://doi.org/10.1016/j.jbmt.2020.07.020.
111. Arendt-Nielsen, L.; Graven-Nielsen, T.; Svarrer, H.; Svensson, P. The influence of low back pain on muscle activity and coordi-
nation during gait: A clinical and experimental study. Pain 1996, 64, 231–240. https://doi.org/10.1016/0304-3959(95)00115-8.
112. Courtney, C.A.; Kavchak, A.E.; Lowry, C.D.; O’Hearn, M.A. Interpreting Joint Pain: Quantitative Sensory Testing in Musculo-
skeletal Management. J. Orthop. Sports Phys. Ther. 2010, 40, 818–825. https://doi.org/10.2519/jospt.2010.3314.
113. Robins, H.; Perron, V.; Heathcote, L.; Simons, L. Pain Neuroscience Education: State of the Art and Application in Pediatrics.
Children 2016, 3, 43. https://doi.org/10.3390/children3040043.
114. Prestes, J.; Frollini, A.B.; de Lima, C.; Donatto, F.F.; Foschini, D.; de Cássia Marqueti, R.; Figueira, A., Jr.; Fleck, S.J. Comparison
between linear and daily undulating periodized resistance training to increase strength. J. Strength. Cond. Res. 2009, 23, 2437–
2442. https://doi.org/10.1519/JSC.0b013e3181c03548.

Int. J. Environ. Res. Public Health 2022, 19, 12710 57 of 35
57
115. Vargas-Molina, S.; Petro, J.L.; Romance, R.; Bonilla, D.A.; Schoenfeld, B.J.; Kreider, R.B.; Benítez-Porres, J. Menstrual cycle-based
undulating periodized program effects on body composition and strength in trained women: A pilot study. Sci. Sports 2022, (In
Press, corrected proof, Available online 30 June 2022). https://doi.org/10.1016/j.scispo.2021.11.003.
116. Vargas-Molina, S.; García-Sillero, M.; Romance, R.; Petro, J.L.; Jiménez-García, J.D.; Bonilla, D.A.; Kreider, R.B.; Benítez-Porres,
J. Traditional and Undulating Periodization on Body Composition, Strength Levels and Physical Fitness in Older Adults. Int. J.
Environ. Res. Public Health 2022, 19, 4522. https://doi.org/10.3390/ijerph19084522.
117. Moesgaard, L.; Beck, M.M.; Christiansen, L.; Aagaard, P.; Lundbye-Jensen, J. Effects of Periodization on Strength and Muscle
Hypertrophy in Volume-Equated Resistance Training Programs: A Systematic Review and Meta-analysis. Sports Med. 2022, 52,
1647–1666. https://doi.org/10.1007/s40279-021-01636-1.
118. Rosa, A.; Vazquez, G.; Grgic, J.; Balachandran, A.T.; Orazem, J.; Schoenfeld, B.J. Hypertrophic Effects of Single- Versus Multi-
Joint Exercise of the Limb Muscles: A Systematic Review and Meta-analysis. Strength Cond. J. 2022, ahead of print.
https://doi.org/10.1519/ssc.0000000000000720.
119. Bayattork, M.; Skold, M.B.; Sundstrup, E.; Andersen, L.L. Exercise interventions to improve postural malalignments in head,
neck, and trunk among adolescents, adults, and older people: Systematic review of randomized controlled trials. J. Exerc. Re-
habil. 2020, 16, 36–48. https://doi.org/10.12965/jer.2040034.017.
120. Falk Neto, J.H.; Tibana, R.A.; de Sousa, N.M.F.; Prestes, J.; Voltarelli, F.A.; Kennedy, M.D. Session Rating of Perceived Exertion
Is a Superior Method to Monitor Internal Training Loads of Functional Fitness Training Sessions Performed at Different Inten-
sities When Compared to Training Impulse. Front. Physiol. 2020, 11, 919. https://doi.org/10.3389/fphys.2020.00919.
121. Lau, W.Y.; Blazevich, A.J.; Newton, M.J.; Wu, S.S.; Nosaka, K. Assessment of Muscle Pain Induced by Elbow-Flexor Eccentric
Exercise. J. Athl. Train. 2015, 50, 1140–1148. https://doi.org/10.4085/1062-6050-50.11.05.
122. Vélez-Gutiérrez, J.M.; Petro, J.L.; Aburto-Corona, J.A.; Vargas-Molina, S.; Kreider, R.B.; Bonilla, D.A. Cortical Changes as a
Result of Sports Injuries: A Short Commentary. Cuerpo, Cultura y Movimiento 2022, 12(2), 1-13. https://doi.org/10.15332/2422474X
123. Zahnow, R.; McVeigh, J.; Bates, G.; Hope, V.; Kean, J.; Campbell, J.; Smith, J. Identifying a typology of men who use anabolic
androgenic steroids (AAS). Int. J. Drug Policy 2018, 55, 105–112. https://doi.org/10.1016/j.drugpo.2018.02.022.
124. Rontogianni, M.O.; Kanellopoulou, A.; Markozannes, G.; Bouras, E.; Derdemezis, C.; Doumas, M.T.; Sigounas, D.E.; Tzovaras,
V.T.; Vakalis, K.; Panagiotakos, D.B.; et al. Prevalence and Determinants of Sex-Specific Dietary Supplement Use in a Greek
Cohort. Nutrients 2021, 13, 2857. https://doi.org/10.3390/nu13082857.
125. Schneider, C.; Agthe, M.; Yanagida, T.; Voracek, M.; Hennig-Fast, K. Effects of muscle dysmorphia, social comparisons and
body schema priming on desire for social interaction: An experimental approach. BMC Psychol. 2017, 5, 19.
https://doi.org/10.1186/s40359-017-0189-9.