The sporting shoulder: building resilient overhead athletes in London’s Hyrox, CrossFit and racket-sport communities

Nathan Choi, Shoulder Specialist Physiotherapist

As a Senior Physiotherapist at LDN, and the clinic's Shoulder Lead, I split my clinical time between our Old Street, Elephant & Castle and Kentish Town clinics. A large portion of my caseload is shoulder-related, often from Hyrox or CrossFit, and just as often from tennis and badminton (I’m a keen shuttler myself). My aim in this article is to share how I assess, explain and rehabilitate painful shoulders, and why a few evidence-based principles consistently help our patients get back to pressing, serving and smashing with confidence.

What really causes shoulder pain?

Most non-traumatic shoulder pain I see falls under the umbrella of rotator-cuff-related shoulder pain (RCRSP). It’s driven by a mix of tissue load, capacity and movement habits rather than a single “impinged” structure. Recent clinical practice guidelines emphasise thorough history, irritability-based examination, and progressive, individualised rehabilitation ahead of routine imaging or passive treatments.

When imaging is performed, it’s vital to keep perspective. Large population studies show rotator cuff tears are common in people without symptoms and increase with age; meaning scans don’t always explain pain. In one mass-screening study, full-thickness tears were present in ~20–22% of adults and were twice as likely to be asymptomatic as symptomatic. That pattern has been replicated in UK cohorts too. 

This context helps in clinic. For instance, a CrossFit coach I saw in Old Street was worried by an MRI report listing “partial-thickness supraspinatus tear with AC joint changes”. Framed appropriately, the scan became a neutral data point, not a sentence to stop training. We focused on load management and progressive strength, and he returned to overhead pressing with a plan, not fear.

Scapula: don’t over-medicalise, but don’t ignore it either

Scapular “winging” or “dyskinesis” often alarms athletes. A balanced view is best. Reviews highlight that dyskinesis can be present with or without symptoms, so it isn’t a diagnosis by itself. At the same time, adding scapular-focused exercise to shoulder rehab tends to improve pain and function, suggesting it’s a useful treatment target, not a label.

In practice, that means coaching smooth upward rotation and posterior tilt during presses and pulls, and progressing serratus anterior and lower-trap work alongside cuff loading, especially for athletes who live overhead.

Hyrox and CrossFit shoulders: exposure, not avoidance

Hyrox demands hybrid capacity: repeated runs punctuated by wall balls, sleds, farmer carries and rowing. CrossFit layers in kipping gymnastics and Olympic lifts. Epidemiology varies by study, but consistently shoulders sit among the top injury locations, with injury rates broadly comparable to other sports. In CrossFit, pooled analyses report ~26% of injuries affect the shoulder, with incidence around 2-3 per 1000 training hours; specific estimates for the shoulder alone hover near ~1.9 per 1000 hours. Hyrox-specific injury data are emerging; early analyses also flag the shoulder as a frequent site.

At Elephant & Castle we recently helped a Hyrox competitor who flared with wall balls above 8 kg. The fix wasn’t simply “stop wall balls”; it was dose and form: temporarily reducing volume and load, improving thoracic extension and squat depth to keep the ball path efficient, and building deltoid and cuff capacity with heavy-slow pressing and tempo eccentrics. She completed her next race with a progressive plan that respected tissue irritability and recovery windows.

Racket sports: rotation rules

Tennis and badminton are unilateral, high-repetition overhead sports. Two recurring themes I assess are:

1. Total rotational motion (TROM) at 90° abduction-external plus internal rotation. For overhead athletes, aiming for symmetry within ~5° of the non-dominant side is associated with healthier shoulders and is used in return-to-sport decision-making.

2. Posterior shoulder tightness. Systematic reviews suggest cross-body adduction stretching can improve posterior tightness and internal rotation (GIRD), while the sleeper stretch may be less comfortable and not clearly superior; newer work still supports stretching but with low-certainty evidence, particularly when combined with manual techniques.

   
   

A recent club-level badminton player patient had pain on late cocking and a loss of horizontal adduction. Cross-body stretching with scapular stabilisation, cuff and scapular loading, and serve-pattern drills restored his range and power without provoking symptoms.

Assessment that matters to athletes

Beyond a careful history and clinical exam, I like to include simple, reproducible field measures that speak an athlete’s language:

• Strength: handheld dynamometry where available; otherwise pragmatic isometrics in testing positions, aiming for ≥90% limb symmetry when pain allows.

• TROM: measure ER + IR at 90° abduction; target symmetry within ~5°. PMC

• Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST): a reliable, quick measure of closed-chain shoulder performance that responds to training.

These numbers help us make criteria-based rather than time-based decisions, and they give athletes objective feedback on progress.

Rehabilitation principles over presets

The 2022 Bern Consensus stresses integrating kinetic-chain work, scapular control and cuff strengthening according to irritability, not in a rigid order, but in a way that respects stage of recovery and the sport’s demands. I find this matches what works on the ground.

For Hyrox and CrossFit, that often looks like:

• Early: pain-tolerant isometrics, supported range work, and technique tweaks (e.g., neutral grip presses, landmine variations).

• Middle: heavier pressing and pulling (dumbbell and barbell), tempo eccentrics, serratus/lower-trap progressions, and graded exposure to kipping/jerk receiving positions.

• Late: sport-specific density—wall-ball EMOMs, sled push intervals, and barbell complexes—while ensuring recovery is built into the microcycle.

For racket sports:

• Early: address irritability and posterior soft-tissue restrictions with cross-body stretching and gentle loading.

• Middle: build external rotator capacity (especially infraspinatus) with controlled eccentrics and scapular-plane work; integrate trunk and hip power.

• Late: serve/smash progressions with volume and speed carefully titrated session to session.

When do we green-light return to sport?

Decision-making is shared with the athlete and coach, but I like to see:

• Full, pain-acceptable range with TROM symmetry within ~5°.

• Strength: ≥90% limb-symmetry index for ER/IR where measurable, or sport-specific strength landmarks.

• Functional testing: CKCUEST comparable to baseline/contralateral and tolerating sport-specific density sessions.

• Confidence: the athlete believes their shoulder is ready (don’t underestimate the psychology).

At Old Street, a competitive CrossFit athlete cleared return to ring muscle-ups after meeting those criteria and completing two progressive EMOM sessions without symptom spike. He’d failed a previous attempt when we rushed exposure before hitting TROM and ER strength target. A useful lesson for both of us.

Where injections, imaging and surgery fit

For persistent pain or suspected structural pathology, we work closely with our sports medicine and orthopaedic colleagues. UK pathways (BESS/BOA) encourage conservative care first, appropriate imaging when it changes management, and escalation for red flags or failed rehab. Frozen shoulder has its own pathway where image-guided injections can support progress through painful phases, again alongside active rehab.

Key takeaways for London’s overhead athletes

1. Don’t fear your scan. Findings like cuff tears and AC joint changes are common—even in pain-free people. We’ll treat you, not your MRI.

2. Load beats labels. Scapular “dyskinesis” is a clue, not a sentence. Targeted scapular and cuff strengthening helps many shoulders.

3. Expose, don’t avoid. Smart, staged exposure to Hyrox, CrossFit and racket-sport demands builds durable shoulders. 

4. Use criteria, not calendars. Objective markers—TROM symmetry, strength symmetry, CKCUEST; guide safe return.

If you’re struggling with shoulder pain - or you want a proactive screen before your next Hyrox race, CrossFit Open, club match or tournament - I’d be glad to help you at LDN PHYSIO. Let’s get you confidently overhead again.

References

1. Desmeules F, Lafrance S, et al. Rotator Cuff Tendinopathy: Diagnosis, Nonsurgical Medical Care, and Rehabilitation—A Clinical Practice Guideline. JOSPT, 2025. apta.org

2. Minagawa H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population.2013. PMC

3. Yamamoto A, et al. Prevalence and risk factors of a rotator cuff tear in the general population. 2010. jshoulderelbow.org

4. Hinsley H, et al. Prevalence of rotator cuff tendon tears in a UK population cohort. BMJ Open, 2022. BMJ Open

5. Schwank A, et al. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport. JOSPT, 2022. JOSPT

6. Sciascia A & Kibler WB. Current views of scapular dyskinesis and its clinical relevance. 2022. PMC

7. Melo ASC, et al. Effectiveness of specific scapular therapeutic exercises in shoulder pain: meta-analysis. 2024. PMC

8. Rodríguez MÁ, et al. Injury in CrossFit: systematic review. 2022. PubMed

9. Nicolay RW, et al. Upper-extremity injuries in CrossFit: review. 2022. PMC

10. Hülsmann M, et al. Musculoskeletal injuries in CrossFit: systematic review and meta-analysis. 2021. ResearchGate

11. Early Hyrox injury/emerging data summaries. ResearchGate

12. Wilk KE, et al. Return-to-sport participation criteria for the overhead athlete. 2020. PMC

13. Tucci HT, et al. CKCUEST reliability and validity. BMC Musculoskelet Disord, 2014–15. BioMed Central

14. Mine K, et al. Effectiveness of stretching for posterior shoulder tightness/GIRD. 2017. Human Kinetics Journals

15. Ceballos-Laita L, et al. Stretching for GIRD: systematic review and meta-analysis. 2024. MDPI

16. BESS/BOA. Shoulder pain diagnosis, treatment and referral guidelines / Patient Care Pathways. 2021–25.