Common Injuries Related to Weightlifting:

MR Imaging Perspective
Joseph S. Yu, M.D.1 and Paula A. Habib, B.A.1

ABSTRACT

Weightlifting has evolved to become a ubiquitous form of exercise. Resistance

training has been shown to have beneficial effects on both muscle and osseous maintenance
and development. Competitive weightlifting sports continue to enjoy tremendous popular-
ity, with participants striving to establish new standards in performance and more

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demanding personal goals. Thus, it is not surprising that we have also seen an increase
in injuries related to weightlifting. Many of these injuries are radiographically occult and
are best suited for evaluation by magnetic resonance (MR) imaging because many involve
the soft tissues. In this article, we discuss some of the factors that contribute to these
injuries and address the mechanisms of injury and the MR imaging manifestations of
the more common injuries.

KEYWORDS: Injury, weightlifting, magnetic resonance imaging

Strength training has been an essential ingre-
dient for the success of athletes since the 1970s. Knowl-
edge and a heightened awareness of health have
contributed to the promotion of this type of training in
the general population. Weightlifting, in particular, has
become a standard fitness regimen in the arsenal of
training in many sports, from professional football to
recreational golf. It is estimated that 21% of the pop-
ulation of the United States participate in weight-related
activities, including nearly one third of males.1 Advances
in exercise physiology and research related to the aging
process have also contributed literature proposing the
advantages of weight training for the preservation of
bone and muscle integrity throughout life.2–6 Compet-
itive weightlifting and powerlifting are sports that con-
tinue to gain in popularity, and recruitment into
organized federations created to enhance competition
between their members allows lifters to pursue records
that push the envelope of what is physically possible.
Some world records in powerlifting exceed the body
weight by a factor of five times.7 However, weightlifting
is not without risk, and indulgence without supervision
or proper attention to technique can lead to several
injuries.8 About 25 to 30% of weightlifters report an
injury sufficiently severe to seek medical attention.1,7
The purpose of this study is to review some of the
common injuries associated with weightlifting, their
causes, and their appearance on magnetic resonance
(MR) imaging. In this article, we categorize injuries
according to anatomy, with attention to specific exercises
and competitive disciplines that can render a specific
body part susceptible to injury. We attempt to identify
risk factors that can increase the likelihood of sustaining
an injury and discuss how different tissues are at risk
with different types of motion.
MECHANISMS OF INJURY
Injuries related to weightlifting can affect any tissue.
There are many important factors that contribute to

Sports Specific Injuries; Editors in Chief, David Karasick, M.D., Mark E. Schweitzer, M.D.; Guest Editor, Lawrence M. White, M.D., F.R.C.P.C.
Seminars in Musculoskeletal Radiology, Volume 9, Number 4, 2005. Address for correspondence and reprint requests: Joseph S. Yu, M.D., Professor
of Radiology, The Ohio State University Medical Center, Department of Radiology, 633 Means Hall, 1654 Upham Drive, Columbus, Ohio 43210.
1
Department of Radiology, Ohio State University Medical Center, Columbus, Ohio. Copyright # 2005 by Thieme Medical Publishers, Inc., 333
Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 1089-7860,p;2005,09,04,289,301,ftx,en;smr00370x.
289
290 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 9, NUMBER 4
major weightlifting injuries, including inadequate con-
ditioning, poor technique, lack of strength or endurance,
improperly selected resistance, lack of sufficient warm-
up and stretching, loss of balance, and fatigue.9–12
Weightlifting injuries that affect the musculoskeletal
system are primarily categorized as injuries that involve
the myotendinous unit or osseous skeleton. Injuries
affecting the ligaments are uncommon and are usually
associated with dislocations.
Myotendinous Unit
A tear in the myotendinous unit occurs when the tension
in the unit exceeds the strength of the weakest structural
element.13 The point of failure is dependent on several
factors including preexisting conditions such as tendi-
nosis, the position of overload, and the velocity of
injury.14 Myotendinous injuries constitute about two
thirds of all injuries and can affect both the highly
trained athlete and the novice lifter.
The myotendinous unit is composed of muscle,
the myotendinal junction, and tendon.15 The basic
function of muscles is to produce joint motion by
creating tensile forces that are transmitted through the
myotendinal junction to the origin and insertion of
tendons. There are two types of muscle contraction,
eccentric and concentric contraction.16 In eccentric con-
traction, the muscle fibers lengthen when the resisting
force is greater than the force generated by the muscle.17
Concentric contraction occurs when the resisting load is
less than the force generated by the muscle, shortening
the muscle. Eccentric muscle activation increases the
potential for injury, particularly when it is acting to
absorb kinetic energy, because it creates greater tensile
forces within the muscle than can be produced during
concentric contraction.17,18 Muscles that extend across
two joints are at most risk for strains because their
primary function is eccentric contraction. Muscles that
are particularly susceptible to injury include the biceps
brachii, rectus femoris, biceps femoris, semimembrano-
sus, semitendinosus, adductor, vastus medialis, soleus,
and medial gastrocnemius muscles.19,20
The composition of the muscle can also increase
its risk for injury. Differences in muscle fiber types reflect
the speed of contraction and the endurance of the
muscle.13 A type 1 fiber, considered slow twitch, has
slow contraction and relaxation times but is resistant to
fatigue. A type 2 fiber, considered fast twitch, has fast
contraction and relaxation times and is well suited for
intense activities of short duration. Muscles with a high
proportion of type 2 fibers are capable of generating
more force but are also more susceptible to fatigue.
Fatigued muscles absorb less energy and are more likely
to sustain an injury.
The myotendinal junction is a specialized region
of highly folded membranes at the muscle-tendon inter-
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face and this folding increases the junctional surface
area by 10 to 20 times, which decreases the stress per
unit area.17 But because the capacity for energy absorp-
tion is less than that of either muscle or tendon, it
is more susceptible to strains. A normal tendon does
not rupture when subjected to extreme loading, but
muscles subjected to forceful stretching consistently
disrupt near the muscle-tendon junction or near the
bone-tendon junction.13,21 For a tendon to fail in its
midsubstance, an underlying abnormality must exist
within it.22–24
Types of Strains
The myotendinal junction is the site of most strains;
however, the muscle alone can occasionally be injured.
Pathologically, a strained muscle demonstrates a combi-
nation of torn fibers, inflammation, edema, and hemor-
rhage with protein degradation and regeneration.25
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The severity of an acute strain depends on the
rate, magnitude, and duration of stress loading.19,26,27
A strain is graded according to loss of function and
strength and the area of tissue involved. A first-degree
strain of the myotendinal junction is considered a
stretching injury without tearing and is characterized
by edema and hemorrhage surrounding the myotendinal
junction and edema tracking along the muscle fascicles
and interstitial connective tissue.19,28 This type of injury
typically heals without sequelae and the imaging findings
tend to resolve completely. A first-degree strain of the
muscle produces minimal disruption of the tissue and is
associated with less than 5% loss of function. A diffuse,
infiltrative pattern of edema and hemorrhage character-
izes the injury, appearing similar to a muscle contusion
(Fig. 1).25
A second-degree strain of the myotendinal junc-
tion represents a partial tear and is characterized by
irregular thinning and laxity of the tendon owing to
partial disruption of the fibers. Edema and hemorrhage
are more pronounced, becoming interspersed within the
fascial planes between the muscle fascicles and muscle
groups (Fig. 2).26,29 This injury is often associated with
the formation of a hematoma. Restoration of function
is largely dependent on the magnitude of fiber disrup-
tion, but conservative treatment is often sufficient in
reestablishing normal strength and range of motion. A
second-degree strain of the muscle is associated with
more pronounced loss of muscle strength, which is
dependent on the volume of fiber separation. Imaging
findings remain abnormal for a much longer period of
time.26
Third-degree strains occur at the myotendinal
junction and represent a complete rupture of the
tendon, enthesis, or osseous avulsion of the tendinous
attachment. A complete rupture is often accompanied
by tendon retraction, which becomes more pronounced

Figure 1 Grade 1 strain of the gastrocnemius muscle. Axial T2-weighted (A) and coronal short inversion time inversion recovery (STIR)
(B) images of the calf show focal, feathery high signal intensity within the medial gastrocnemius muscle (arrows) consistent with
interstitial edema and hemorrhage.
Figure 2 Grade 2 strain of the popliteus muscle. Sagittal T2-
weighted image of the knee shows localized high signal intensity
in the popliteus muscle (arrow) indicating muscle fiber disruption.
COMMON INJURIES RELATED TO WEIGHTLIFTING/YU, HABIB 291
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with delayed diagnosis (Fig. 3).14 Edema may be suffi-
ciently severe in the acute phase of the injury to obscure
visualization of the anatomic structures, rendering it
difficult to differentiate a complete tear from a large
partial tear. Clinically, muscle paresis is evident. Resto-
ration of function requires surgery. Otherwise, the
muscle atrophies and becomes infiltrated with lipoid
tissue.28
Osseous Injuries
Weightlifting injuries can result in several osseous in-
juries, depending on the mechanism of injury. Injuries
caused by a cumulative load can produce overuse syn-
dromes and stress fractures, whereas injuries related
to acute overloading can produce avulsion fractures,
macrofractures, and joint dislocations.30,31 Adolescent
lifters have a higher incidence of osseous injuries than
their adult counterparts, particularly in the spine and
pelvis.7,32
A common overuse disorder caused by chronic,
cumulative overloading of the shoulder is atraumatic
clavicular osteolysis. This disorder is the result of re-
peated episodes of minor trauma to the acromioclavic-
ular joint, which produces osteolysis of the distal
clavicle.33,34 This painful condition is characterized by
widening of the interval between the clavicle and the
acromion process owing to bone lysis of the distal
292 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 9, NUMBER 4
Figure 3 Grade 3 strain of the Achilles tendon. (A) Sagittal T1-weighted image of the ankle shows marked thickening of the Achilles
tendon (arrows) as well as loss of the surface contour both anteriorly and posteriorly. (B) Sagittal STIR image shows intense high signal
intensity between the tendon proper and the musculotendinous junction of the Achilles tendon (curved arrow) indicative of complete
fiber disruption, edema, and hemorrhage.
clavicle, which usually begins  6 to 8 weeks after the
initial insult. The process is self-limiting if the lifter
ceases to perform exercises that target the upper extrem-
ity and upper torso until the symptoms resolve. Occa-
sionally, however, the disorder becomes recalcitrant to
conservative treatment and does require surgical resec-
tion of the distal clavicle.35–37 The distal clavicular
abnormality is clearly depicted on MR imaging, consist-
ing of edema in the distal clavicle, widening of
the acromioclavicular joint, and articular erosions
(Fig. 4).34,38
Repeated trauma can also lead to periostitis and
stress fractures (Fig. 5).39 Heavy forearm exercises, for
instance, may cause periostitis of the ulna, referred to as
forearm splints analogous to shin splints.40 Development
of a stress fracture of the ulna has been reported
with heavy biceps preacher curls using a straight
barbell, an exercise performed with the upper arm resting
on an inclined bench and the elbow flexed against
resistance.41 Intense acceleration in weight training
has been associated with stress fractures of the clavicle
and ribs as well.42 Fractures of the distal radius and
ulna have been described in adolescent weightlifters
who have performed exercises requiring a barbell to be
lifted above the head.43 The two contributing factors
identified when fractures occur are maximal weight
and a loss of balance that causes the barbell to
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drift back behind the head so that the wrists become
hyperextended.
Loss of balance and overloading have also been
identified as strong contributing factors in the develop-
ment of acute-onset low back pain. Sudden loss of
balance triggers corrective neuromuscular responses
with forceful muscle contractions that can overload and
injure spinal tissues.44 Avulsion fractures frequently
involve the extensor mechanism of the knee, the biceps
and triceps tendons, and the tendinous attachments of
the pelvis.14,32,42 They are usually the result of maximal
loading during a particular exercise, which prevents the
completion of the motion. Ultimately, failure occurs at
the enthesis.45 A squat is an exercise performed with a
barbell rested squarely on the upper back and the trunk
lowered against resistance by simultaneous flexion of the
hip and knee. Descent stops when the top of the leg is
parallel with the floor, and then active contraction of the
gluteal and hamstring muscles of the posterior thigh and
the quadriceps muscles of the anterior thigh reverse the
movement. This motion exerts tremendous stress on
the ischial insertion of the hamstring muscles and the
quadriceps tendon insertion on either the superior
pole of the patella or tibial tubercle. Cases of complete
rupture are rare but have been reported when there
is underlying tendinosis, prior surgery, or antecedent
injury.14,46
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Figure 4 Osteolysis of the distal clavicle. Oblique coronal T1-weighted (A) and fast spin-echo fat-saturated T2-weighted (B) images of
the shoulder show edema in the distal clavicle, widening of the acromioclavicular joint, and erosive changes in the articular surface of the
distal clavicle (curved arrows). Periosteal reactive changes are not uncommon (straight arrow in B).

Figure 5 Tibial stress fracture from repetitive jump squats. (A) Axial proton density image of the knee shows reactive bone changes in
the tibial tubercle manifested by a band of low signal intensity (black arrows) that is separated from the periosteum by fluid. (B) Sagittal
STIR image shows marrow edema manifested by high signal intensity surrounding the stress fracture (arrow) in the anterior aspect of
the tibia.
294 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 9, NUMBER 4
Figure 6 Pectoralis major muscle tear. Fat-saturated fast spin-echo axial (A) and coronal (B) images of the chest show a complete
avulsion of the pectoralis major muscle at the musculotendinous junction (arrows). The muscle is partially retracted, resulting in a gap
between the muscle and its insertion.
SPECIFIC INJURIES
The Chest
A common core exercise utilized by athletes is the bench
press. In this exercise, a person lying supine brings a
weighted barbell from a position of full arm extension
down to the chest by passive flexion of the elbows and
then reverses the motion by pushing the bar against
gravity to a position of full arm extension. The bench
press motion involves movement in the sagittal (flexion/
extension), coronal (abduction/adduction), and trans-
verse (horizontal adduction) planes.47 It is an efficient
method of increasing upper body strength and
power and developing the triceps brachii muscles and
chest musculature. The bench press presents a challenge
to the lifter because the shoulder girdle is the principal
support for the motion of the barbell to and from the
chest.
A rupture of the pectoralis major muscle is a well-
known injury among weightlifters.48,49 The pectoralis
major muscle is a fan-shaped muscle with two origins.
The clavicular head arises from the anterior surface of
the medial two thirds of the clavicle, and the sternal head
arises from the anterior surface of the manubrium and
sternal body.50 The muscle fibers converge just proximal
to its insertion on the lateral lip of the bicipital groove of
the humerus. The main function of this muscle is
adduction, flexion, and internal rotation of the humerus;
thus, an injury can occur during the bench press motion
when it is associated with forced abduction of the upper
arm, a point of maximal eccentric contraction.
MR imaging is particularly useful in determining
the extent of the tear when surgery is contemplated
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(Fig. 6).50–54 The location of a tear dictates whether
surgery should be performed. Tendon avulsion from the
humerus is generally surgically repaired, whereas muscle
or myotendinous injuries are treated conservatively.55
The majority of tears are partial tears at the myotendi-
nous junction, whereas complete tears involve the in-
sertion, occurring in  20% of cases.50 In acute tendon
avulsions, there are variable degrees of tendon retraction,
ranging from 0 to 13 cm.50
An unusual disorder associated with weightlifting
is development of a stress fracture of the manubrium
sterni.56,57 It occurs when there is a discrepancy between
rapid development of the anterior chest musculature and
the strength of the bones.
The Shoulder
Weightlifting exercises that target the shoulder muscles
can place considerable stress across the shoulder, effec-
tively converting this non–weight-bearing joint into one
that is weight bearing. Shoulder injuries constitute 6 to
28% of weightlifting injuries according to one study.7
Heavy bench presses, squats, and military presses can
strain the trapezius and paracervical musculature as well
as the rotator cuff and biceps tendon. In the bench press,
the shoulder muscles have to alternate between maximal
concentric and eccentric contraction when stabilizing,
lifting, or lowering the barbell. A weightlifter who
pushes to achieve higher limits of performance and the
inherent unfavorable position of the rotator cuff during
lifting are two factors that contribute to rotator cuff
tears.58 Repeated trauma to the glenohumeral joint can
contribute to labral tears, labrocapsular dysfunction, and

Figure 7 Posterior labral periosteal sleeve avulsion (POLPSA)
lesion. Axial gradient fast gradient recalled echo (GRE) image of
the shoulder shows a typical appearance of the POLPSA lesion
on MR imaging. The periosteal sleeve formed by the avulsed
periosteum tends to remain attached to the posterior glenoid
(arrow), creating a redundant recess that communicates with the
joint. Note the posterior displacement of the posterior labrum.
resultant shoulder instability, which may also precipitate
rotator cuff disease.58,59
The biomechanics involved in repeatedly moving
from a horizontally adducted to a horizontally abducted
position frequently produces compression of the distal
clavicle.47 The prevalence of atraumatic osteolysis of the
distal clavicle has been reported to be  28% in elite
weightlifters.36 Bilateral glenohumeral joint dislocations
have been reported in lifters using wide benches, which
causes the glenohumeral joint to act as the fulcrum of the
bench press motion.60–62 In most cases of dislocation,
fatigue is a major contributing factor.39
Labrocapsular dysfunction may lead to shoulder
instability. Although the forces that act on the shoulder
during a maximal bench press are not sufficient to cause a
dislocation, they are sufficient to cause subluxation over
time. The subluxation can contribute to the avulsion of
the posterior scapular periosteum or may be its end result
(Fig. 7).59,63 Conservative measures may be insufficient
in relieving symptoms, and surgical débridement and
posterior labral repair are often required to reestablish
pain-free participation in weightlifting.63
The Arm
Injuries of the arm are relatively common, accounting for
about one fourth of all injuries incurred while weightlift-
ing.64 The elbow and wrist are particularly susceptible
to acute injuries when resistance training significantly
COMMON INJURIES RELATED TO WEIGHTLIFTING/YU, HABIB 295
increases stress in the arm, leading to rupture of the
biceps or occasionally triceps muscle and, less frequently,
fracture of the radius and ulna and dislocation of the
elbow. Chronic overloading may cause several overuse
syndromes including medial and lateral epicondylitis,
ulnar neuropathy, tendinosis of the triceps and biceps
tendons, and exercise-induced compartment syndrome.
Excessive repetitive, high-resistance arm or wrist
curls can elicit development of intersection syndrome,
characterized by pain and swelling along the volar radial
aspect of the wrist. It is a friction syndrome that occurs
where the abductor pollicis longus and extensor pollicis
brevis cross over the radial wrist extensors.65 Medial
epicondylitis is a common disorder caused by repetitive
dumbbell curls performed with supination or straight-
bar barbell curls.39 It is characterized by chronic pain in
the insertion of the common tendon of the forearm
flexors on the medial epicondyle. Conversely, bar curls
utilizing an EZ curl bar, curved so that the wrist may be
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pronated, exaggerate the stress on the common tendon
of the forearm extensor muscles.
Injuries to the biceps brachii muscle can occur
proximally or distally. The biceps muscle is composed of
two heads.66 The short head inserts on the coracoid
process along with the coracobrachialis muscle as a
conjoined tendon. The long head courses within the
bicipital groove, where it is invested by a double layer of
synovium and becomes an intracapsular structure. Dis-
tally, the tendon of the biceps brachii muscle inserts on
the radial tuberosity of the proximal radius. The majority
of injuries of the biceps muscle occur in the distal
tendinous insertion (Fig. 8).67–69 It is most susceptible
to injury during maximal eccentric contraction while
attempting to lift a heavy weight or when resisting
downwardly directed kinetic energy with partial con-
traction of the biceps muscle.70 Anabolic steroid use has
been implicated as a contributing factor in this injury.71
Distal biceps tendinosis has also been shown to precede
spontaneous tendon rupture.23,24 MR imaging is partic-
ularly useful in distinguishing complete tears from par-
tial tears as well as complications of rupture including
hematoma formation, retraction, and associated brachia-
lis muscle tear.68,69
Triceps tendon tears are rare.45,72–75 This injury
differs from other tendon rupture because it may occur
through healthy tissue.72 There is a strong association
with prior anabolic steroid use or a history of antecedent
corticosteroid injection into the triceps tendon.76–79
The muscle comprises three heads, all inserting on the
olecranon process. The long head arises from the in-
fraglenoid tubercle of the scapula, the lateral head arises
from the lateral and posterior aspect of the humerus, and
the medial head arises further distally from the medial
and posterior aspect of the humerus.80 Complete tears
are more common than partial tears. The mechanism of
injury for triceps tendon tears is forced flexion of
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Figure 8 Rupture of the biceps brachii tendon. (A) Sagittal T2-weighted image of the elbow shows the free end of a completely
ruptured biceps brachii tendon (arrow). Note that retraction is common in this injury, resulting in a contracted ‘‘ball’’ of muscle high in the
humerus. This is a common injury during the deadlift, where there is maximal eccentric contraction of the biceps muscle. (B) Axial T2-
weighted image proximal to the level of the radial tuberosity shows significant interstitial edema where the biceps tendon usually exists
(circle).

the elbow against the resistance of a contracting triceps
muscle.80 During weightlifting, the tendon ruptures
during sustained extreme concentric contraction as
would occur with the bench press motion.81,82 MR
imaging is useful because it clearly distinguishes a com-
plete tear, which requires surgical repair, from a partial
tear, which generally heals well with conservative treat-
ment (Fig. 9).83
The Pelvis and Thigh
Weightlifting injuries of the lower extremity occur most
frequently because the lifter is unable to compensate for
the level of resistance or fails to maintain the appropriate
balance required to complete an exercise owing to either
improper technique or fatigue.12
The squat is a lift commonly employed to develop
the lower back and the leg musculature and requires
utilization of both upper and lower extremities. During
this exercise, the extensor muscles of the spine, hip, knee,
and ankle all participate in preventing the body from
collapsing under the load. The upper extremity supports
the bar on the upper trunk, and the lift is performed as a
knee bend. Whether performed as a front squat or back
squat, the maximum knee extensor moment is similar for
both exercises; however, there is a sizable difference in
the maximum trunk extensor moment and maximum
lumbar compressive and shear force depending on the
inclination of the trunk, which has a direct bearing on
injury risk.84
Hamstring injuries are relatively common in
weightlifters. Competitive lifters exerting maximum
effort during the squat or deadlift, in which a barbell
loaded with weights is picked up from the floor, are at
high risk for developing either avulsion of the hamstring
tendon insertion on the ischium (Fig. 10) or a tear of the
myotendinous junction.85–87 During the pushoff or
ascending phase of the squat, hamstring contraction is
considerable and tendons affected by tendinosis are at
most risk for rupture. MR imaging is useful in identify-
ing the site, extent, and character of the tear.88,89 It is
also useful in predicting the length of the recovery
period.90 When a complete rupture, greater than 50%
cross-sectional muscle involvement, peritendinous fluid
collections, hemorrhage, distal myotendinous tears, or
deep muscular tears are present, it is likely that the
recovery period will be a minimum of 6 weeks.90
A complete gluteus medius and minimus avulsion
from the greater trochanter is an unusual injury in
weightlifters, and we have seen two cases in our institu-
tion. The vast majority of patients with this injury are
elderly women.91,92 The larger the tear of the tendon,
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Figure 9 Rupture of the triceps tendon. (A) Lateral radiograph of the elbow shows posterior soft tissue swelling and a displaced
osseous fragment that has avulsed from the olecranon process (arrow). (B) Sagittal STIR image shows a complete rupture of the triceps
tendon associated with interstitial edema in the muscle as well as distention of both the deep and superficial olecranon bursae (curved
arrows). Injuries involving the triceps are less common than pectoralis muscle injuries, although bench-pressing athletes are at risk for
both injuries.

the more likely it is to be associated with muscle

atrophy.92 Adolescent lifters are more likely to have
osseous avulsion in the pelvis.93

Figure 10 Hamstring avulsion. Coronal STIR image of the pelvis
shows an avulsion of the hamstring tendon with hemorrhage in
between the free end of the tendon and the ischium, associated
with edema in the posterior musculature of the pelvis. This injury
is common during the pushing phase of the leg squat, particularly
with deep squats.
The Leg
Tendinosis of the quadriceps and patellar tendons is a
common disorder. Squats performed with maximal re-
sistance exert a tremendous load on the knee, particularly
when flexion exceeds 90 degrees.7 As with other tendons
in the body, it is difficult to rupture the extensor
mechanism unless it is associated with a preexisting
degenerative process.14 A common mechanism for rup-
ture is sudden loss of balance overloading the enthesis of
either the quadriceps tendon or patellar tendon during
active contraction of the quadriceps musculature.94
The most common appearance of the quadriceps
tendon is a smooth trilaminar tendon with an average
thickness of 6 to 10 mm in the anteroposterior dimen-
sion and an average width of 28 to 42 mm.95 Disconti-
nuity of any of the tendinous layers is consistent with a
partial tear, whereas transection of all layers is diagnostic
of a complete rupture.14,94 The patellar tendon is a
tapered structure, thin proximally and slightly thicker
distally, but does not exceed 7 mm in thickness, and
its width varies from 10 to 15 mm.96,97 As with the
298 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 9, NUMBER 4
Figure 11 Patellar tendon rupture. Sagittal T2-weighted images
of the knee shows a complete avulsion of the patellar tendon
from the inferior pole of the patella (arrow). There is fraying of the
free end of the tendon and a high-riding patella. Note that fluid
from the joint has extravasated into the prepatellar bursa and
anterior subcutaneous fat.
quadriceps tendon, the signal intensity of the patellar
tendon is homogeneously low except for small triangular
areas of intermediate signal intensity below the patella
and adjacent to the tibial tuberosity.98 The patellar
retinacula connect the insertions of the vastus medialis
and vastus lateralis muscles to the medial and lateral
margins of the patella.99 The patellar tendon ruptures
less frequently than the quadriceps tendon, and the in-
jury is often precipitated by tendinosis.100,101 Rupture of
the tendons of the extensor mechanism has been de-
scribed with sudden overloading of the extensors of the
lower extremities, as can occur with too rapid a descent
during a squat with maximum resistance. Several cases of
simultaneous bilateral failure of the knee extensors have
been reported.102
MR imaging is useful in distinguishing partial
from complete tears (Fig. 11). Complete tears are
frequently associated with retraction owing to muscle
contraction and a mass of edematous and hemorrhagic
tissue, which appears increased in signal intensity on
water-sensitive MR sequences, and fluid in the prepa-
tellar bursa.103–105
CONCLUSION
As weightlifting continues to gain popularity, the in-
cidence of injuries associated with both recreational
and competitive weightlifting sports is likely to increase
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proportionately. MR imaging remains an important
piece of the imaging armamentarium and should be
relied upon liberally for evaluation of injuries, particu-
larly in high-caliber athletes, because early diagnosis
often has an impact on treatment and return to a high
level of performance. The characteristic MR appearance
of a specific injury, the physical evaluation, and the
short- and long-term goals are factors that are essential
in restoring function and establishing appropriate ex-
pectations for the lifter’s ability to return to weight
training.
REFERENCES
1. Powell KE, Heath GW, Kresnow MJ, Sacks JJ, Branche
CM. Injury rates from walking, gardening, weightlifting,
outdoor bicycling, and aerobics. Med Sci Sports Exerc 1998;
30:1246–1249
Downloaded by: University of Connecticut. Copyrighted material.
2. Hortobagyi T, Devita P, Money J, Barrier J. Effects of
standard and eccentric overload strength training in young
women. Med Sci Sports Exerc 2001;33:1206–1212
3. Hortobagyi T, Devita P. Favorable neuromuscular and
cardiovascular responses to seven days of exercise with an
eccentric overload in elderly women. J Gerontol A Biol Sci
Med Sci 2000;55:B401–B410
4. Brown M, Holloszy JO. Effects of low intensity exercise
program on selected physical performance characteristics of
60- to 71-year olds. Aging (Milano) 1991;3:129–139
5. Krebs DE, Jette AM, Assmann SF. Moderate exercise
improves gait stability in disabled elders. Arch Phys Med
Rehabil 1998;79:1489–1495
6. Tsuzuku S, Ikegami Y, Yabe K. Effects of high-intensity
resistance training on bone mineral density in young male
powerlifters. Calcif Tissue Int 1998;63:283–286
7. Raske A, Norlin R. Injury incidence and prevalence among
elite weight and power lifters. Am J Sports Med 2002;30:
248–256
8. Mazur LJ, Yetman RJ, Risser WL. Weight-training injuries.
Common injuries and preventative methods. Sports Med
1993;16:57–63
9. Garrett WE Jr. Muscle strain injuries. Am J Sports Med
1996;24(6 suppl):S2–S8
10. Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Spriggins
A. Clinical risk factors for hamstring muscle strain injury: a
prospective study with correlation of injury by magnetic
resonance imaging. Br J Sports Med 2001;35:435–439
11. Verrall GM, Slavotinek JP, Barnes PG, Fon GT. Diagnostic
and prognostic value of clinical findings in 83 athletes with
posterior thigh injury: comparison of clinical findings with
magnetic resonance imaging documentation of hamstring
muscle strain. Am J Sports Med 2003;31:969–973
12. Heiss DG, Shields RK, Yack J. Balance loss when lifting a
heavier-than-expected load: effects of lifting technique. Arch
Phys Med Rehabil 2002;83:48–59
13. Garrett WE Jr, Califf JC, Bassett FH. Histochemical
correlates of hamstring injuries. Am J Sports Med 1984;12:
98–102
14. Yu JS, Petersilge C, Sartoris D, Pathria M, Resnick D. MR
imaging of injuries of the extensor mechanism of the knee.
Radiographics 1994;14:541–551

15. Noonan TJ, Garrett WE Jr. Injuries at the myotendinous
junction. Clin Sports Med 1992;11:783–806
16. Shellock FG, Fukunaga T, Mink JH, Edgerton VR. Acute
effects of exercise on skeletal muscle: concentric vs eccentric
actions. AJR Am J Roentgenol 1991;156:765–768
17. El-Khoury GY, Brandser EA, Kathol MH, Tearse DS,
Callaghan JJ. Imaging of muscle injuries. Skeletal Radiol
1996;25:3–11
18. Garrett WE Jr. Muscle strain injuries: clinical and basic
aspects. Med Sci Sports Exerc 1990;22:436–443
19. Palmer WE, Kuong SJ, Elmadbouh HM. MR imaging of
myotendinous strain. AJR Am J Roentgenol 1999;173:703–
709
20. Greco A, McNamara MT, Escher RMB, Trifilio G, Parienti
J. Spin-echo and STIR MR imaging of sports-related muscle
injuries at 1.5T. J Comput Assist Tomogr 1991;15:994–
999
21. Ferretti A, Ippolito E, Mariani P, Puddu G. Jumper’s knee.
Am J Sports Med 1983;11:58–62
22. Towers JD, Russ EV, Golla SK. Biomechanics of tendons
and tendon failure. Semin Musculoskelet Radiol 2003;7:59–
65
23. Kannus P, Jozsa L. Histopathological changes preceding
spontaneous rupture of a tendon. A controlled study of 891
patients. J Bone Joint Surg Am 1991;73:1507–1525
24. Kannus P, Natri A. Etiology and pathophysiology of tendon
ruptures in sports. Scand J Med Sci Sports 1997;7:107–
112
25. Steinbach LS, Fleckenstein JL, Mink JH. Magnetic
resonance imaging of muscle injuries. Semin Musculoskelet
Radiol 1997;1:127–141
26. Fleckenstein JL, Weatherall PT, Parkey RW, Payne JA,
Peshock RM. Sports-related muscle injuries: evaluation with
MR imaging. Radiology 1989;172:793–798
27. Zarins B, Ciullo JV. Acute muscle and tendon injuries in
athletes. Clin Sports Med 1983;2:167–182
28. Deutsch AL, Mink JH. Magnetic resonance imaging of
musculoskeletal injuries. Radiol Clin North Am 1989;27:
983–1002
29. De Smet AA. Magnetic resonance findings in skeletal muscle
tears. Skeletal Radiol 1993;22:479–484
30. Keeves RK, Laskowski ER, Smith J. Weight training
injuries. Part 1: diagnosing and managing acute conditions.
Physician Sportsmed 1998;26:67–83
31. Keeves RK, Laskowski ER, Smith J. Weight training
injuries. Part 1: diagnosing and managing chronic condi-
tions. Physician Sportsmed 1998;26:54–63
32. Brady TA, Cahill BR, Bodnar LM. Weight training–related
injuries in the high school athlete. Am J Sports Med 1982;
10:1–5
33. Cahill BR. Osteolysis of the distal part of the clavicle in male
athletes. J Bone Joint Surg Am 1982;64:1053–1058
34. de la Puente R, Boutin RB, Theodorou DJ, Hooper A,
Schweitzer M, Resnick D. Post-traumatic and stress-
induced osteolysis of the distal clavicle: MR imaging findings
in 17 patients. Skeletal Radiol 1999;28:202–208
35. Kaplan PA, Resnick D. Stress-induced osteolysis of the
clavicle: a case report. Radiology 1986;158:139–140
36. Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis
in weight lifters. Am J Sports Med 1992;20:463–467
37. Slawski DP, Cahill BR. Atraumatic osteolysis of the distal
clavicle: results of open surgical excision. Am J Sports Med
1994;22:267–271
COMMON INJURIES RELATED TO WEIGHTLIFTING/YU, HABIB 299
38. Yu YS, Dardani M, Fischer RA. MR observations of post-
traumatic osteolysis of the distal clavicle after traumatic
separation of the acromioclavicular joint. J Comput Assist
Tomogr 2000;24:159–164
39. Haupt HA. Upper extremity injuries associated with
strength training. Clin Sports Med 2001;20:481–490
40. Wadhwa SS, Mansberg R, Fernandes VB, Qasim S. Forearm
splints seen on bone scan in a weightlifter. Clin Nucl Med
1997;22:711–712
41. Hamilton HK. Stress fracture of the diaphysis of the ulna in
a body builder. Am J Sports Med 1984;12:405–406
42. Van der Wall H, McLaughlin A, Bruce W, Frater CJ,
Kannangara S, Murray IPC. Scintigraphic patterns of injury
in amateur weight lifters. Clin Nucl Med 1999;24:915–
920
43. Gumbs VL, Segal D, Halligan JB, Lower G. Bilateral distal
radius and ulnar fractures in adolescent weight lifters. Am J
Sports Med 1982;10:375–379
44. Cholewicki J, McGill SM. Mechanical stability of the in vivo
lumbar spine: implications for injury and chronic low back
pain. Clin Biomech (Bristol, Avon) 1996;11:1–15
Downloaded by: University of Connecticut. Copyrighted material.
45. Bach BR Jr, Warren RF, Wickiewicz TL. Triceps rupture. A
case report and literature review. Am J Sports Med
1987;15:285–289
46. Kelly DW, Carter VS, Jobe FW, Kerlan RK. Patellar and
quadriceps tendon ruptures—jumper’s knee. Am J Sports
Med 1984;12:375–380
47. Fees M, Decker T, Snyder-Mackler L, Axe MJ. Upper
extremity weigh-training modifications for the injured
athlete. Am J Sports Med 1998;26:732–742
48. Kretzler HH Jr, Richardson AB. Rupture of the pectoralis
major muscle. Am J Sports Med 1989;17:453–458
49. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the
pectoralis major muscle. An anatomic and clinical analysis.
Am J Sports Med 1992;20:587–593
50. Connell DA, Potter HG, Sherman MF, Wickiewicz TL.
Injuries of the pectoralis major muscle: evaluation with MR
imaging. Radiology 1999;210:785–791
51. Miller MD, Johnson DL, Fu FH, Thaete FL, Blanc RO.
Rupture of the pectoralis major muscle in a collegiate football
player: use of magnetic resonance imaging in early diagnosis.
Am J Sports Med 1993;21:475–477
52. Ohashi K, El-Khoury GY, Albright JP, Tearse DS. MRI of
complete rupture of the pectoralis major muscle. Skeletal
Radiol 1996;25:625–628
53. Lee J, Brookenthanl KR, Ramsey ML, Kneeland JB,
Herzog R. MR imaging assessment of the pectoralis major
myotendinous unit: an MR imaging–anatomic correlative
study with surgical correlation. AJR Am J Roentgenol 2000;
174:1371–1375
54. Carrino JA, Chandnani VP, Mitchell DB, Choi-Chinn K,
DeBerardino TM, Miller MD. Pectoralis major muscle and
tendon tears: diagnosis and grading using magnetic reso-
nance imaging. Skeletal Radiol 2000;29:305–313
55. McEntire JE, Hess WE, Coleman SS. Rupture of the
pectoralis major muscle: a report of eleven injuries and review
of fifty-six. J Bone Joint Surg Am 1972;54:1040–1046
56. Robertsen K, Kristensen O, Vejen L. Manubrium sterni
stress fracture: an unusual complication of non-contact sport.
Br J Sports Med 1996;30:176–177
57. McCurdie I, Etherington J, Buchanan N. Sternal fracture
in a female army officer cadet. Br J Sports Med 1997;31:
164
300 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 9, NUMBER 4
58. Neviaser TJ. Weight lifting. Risks and injuries to the
shoulder. Clin Sports Med 1991;10:615–621
59. Yu JS, Ashman CJ, Jones G. The POLPSA lesion: MR
imaging findings with arthroscopic correlation with posterior
instability. Skeletal Radiol 2002;31:396–399
60. Cresswell TR, Smith RB. Bilateral anterior shoulder
dislocations in bench pressing: an unusual cause. Br J Sports
Med 1998;32:71–72
61. Heggland E, Parker RD. Simultaneous bilateral glenoid
fractures associated with glenohumeral subluxation/
dislocation in a weightlifter. Orthopedics 1997;20:1180–
1183
62. Maffulli N, Mikhail H. Bilateral anterior glenohumeral
dislocation in a weightlifter. Injury 1990;21:254–256
63. Mair SD, Zarzour RH, Speer KP. Posterior labral injury in
contact athletes. Am J Sports Med 1998;26:753–758
64. Amadio PC. Epidemiology of hand and wrist injuries in
sports. Hand Clin 1990;6:379–381
65. Wood MB, Dobyns JH. Sports-related extraarticular wrist
syndromes. Clin Orthop Relat Res 1986;(202):93–102
66. Farooki S, Seeger LL. MR imaging of sports injuries of the
shoulder. Semin Musculoskelet Radiol 1997;1:51–63
67. D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW.
Repair of distal biceps tendon ruptures in athletes. Am J
Sports Med 1993;21:114–119
68. Fitzgerald SW, Curry DR, Erickson SJ, Quinn SF, Fried-
man H. Distal biceps tendon injury: MR imaging diagnosis.
Radiology 1994;191:203–206
69. Falchook FS, Zlatkin MB, Erbacher GE, Moulton JS, Bisset
GS, Murphy BJ. Rupture of the distal biceps tendon:
evaluation with MR imaging. Radiology 1994;190:659–
663
70. Pearl ML, Besso K, Wong K. Strength deficits related to
distal biceps tendon rupture and repair: a case report. Am J
Sports Med 1998;26:295–296
71. Andrews JR, Whiteside JA. Common elbow problems in the
athlete. J Orthop Sports Phys Ther 1993;17:289–295
72. Sherman OH, Snyder SJ, Fox JM. Triceps tendon avulsion
in a professional body builder. A case report. Am J Sports
Med 1984;12:328–329
73. Sollender JL, Rayan GM, Barden GA. Triceps tendon
rupture in weight lifters. J Shoulder Elbow Surg 1998;7:151–
153
74. Tarsney FF. Rupture and avulsion of the triceps. Clin
Orthop Relat Res 1972;83:177–183
75. Farrar ELI, Lippert FGI. Avulsion of the triceps tendon.
Clin Orthop 1981;161:242–246
76. Michna H. Organization of collagen fibrils in tendon:
changes induced by anabolic steroid. II: a morphometric and
stereologic analysis. Virchows Arch B Cell Pathol Incl Mol
Pathol 1986;52:75–86
77. Michna H. Tendon injuries induced by exercise and anabolic
steroids in experimental mice. Int Orthop 1987;11:157–
162
78. Wood TO, Cooke PH, Goodship AE. The effect of exercise
and anabolic steroids on the mechanical properties and crimp
morphology of the rat tendon. Am J Sports Med 1988;16:
153–158
79. Stannard JP, Bucknell AL. Rupture of the triceps tendon
associated with steroid injections. Am J Sports Med 1993;21:
482–485
80. Fritz RC. MR imaging in sports medicine: the elbow. Semin
Musculoskelet Radiol 1997;1:29–49
2005
81. Herrick RT, Herrick S. Ruptured triceps in a powerlifter
presenting as cubital tunnel syndrome. A case report. Am J
Sports Med 1987;15:514–516
82. Klemme WR, Petersen S. Avulsion of the triceps brachii
with selective radial neuropathy. Orthopedics 1995;18:285–
287
83. Tiger E, Mayer DP, Glazer R. Complete avulsion of
the triceps tendon: MRI diagnosis. Comput Med Imaging
Graph 1993;17:51–54
84. Russell PJ, Phillips SJ. A preliminary comparison of front
and back squat exercises. Res Q Exerc Sport 1989;60:201–
208
85. Agre JC. Hamstring injuries. Proposed aetiological factors,
prevention, and treatment. Sports Med 1985;2:21–33
86. Kujala UM, Orava S, Jarvinen M. Hamstring injuries.
Current trends in treatment and prevention. Sports Med
1997;23:397–404
87. Orava S, Kujala UM. Rupture of the ischial origin of
the hamstring muscles. Am J Sports Med 1995;23:702–
705
88. Kerr R. MR imaging of sports injuries of the hip and pelvis.
Downloaded by: University of Connecticut. Copyrighted material.
Semin Musculoskelet Radiol 1997;1:65–82
89. Brandser EA, El-Khoury GY, Kathol MH, Callaghan JJ,
Tearse DS. Hamstring injuries: radiographic, conventional
tomographic, CT, and MR imaging characteristics. Radi-
ology 1995;197:257–262
90. Pomeranz SJ, Heidt RS Jr. MR imaging in the prognostica-
tion of hamstring injury. Work in progress. Radiology 1993;
189:897–900
91. Kingzett-Taylor A, Tirman PF, Feller J, et al. Tendinosis
and tears of gluteus medius and minumus muscles as a cause
of hip pain: MR imaging findings. AJR Am J Roentgenol
1999;173:1123–1126
92. Cvitanic O, Henzie G, Skezas N, Lyons J, Minter J. MRI
diagnosis of tears of the hip abductor tendons (gluteus
medius and gluteus minimus). AJR Am J Roentgenol 2004;
182:137–143
93. Waters PM, Millis MB. Hip and pelvic injuries in the young
athlete. Clin Sports Med 1988;7:513–526
94. El-Dieb A, Yu JS, Huang GS, Farooki S. Pathologic
conditions of the ligaments and tendons of the knee. Radiol
Clin North Am 2002;40:1061–1079
95. Zeiss J, Saddemi SR, Ebraheim NA. MR imaging of the
quadriceps tendon: normal layered configuration and its
importance in cases of tendon rupture. AJR Am J
Roentgenol 1992;159:1031–1034
96. El-Khoury GY, Wira RL, Berbaum KS, Pope TL, Monu
JUV. MR imaging of patellar tendonitis. Radiology 1992;
184:849–854
97. Reiff DB, Heenan SD, Heron CW. MRI appearances of the
asymptomatic patellar tendon on gradient echo imaging.
Skeletal Radiol 1995;24:123–126
98. Davies SG, Baudouin CJ, King JB, Perry JD. Ultrasound,
computed tomography, and magnetic resonance imaging in
patellar tendonitis. Clin Radiol 1991;43:52–56
99. Starok M, Lenchil L, Trudell D, Resnick D. Normal
patellar retinaculum: MR and sonographic imaging with
cadaveric correlation. AJR Am J Roentgenol 1997;168:
1493–1499
100. Yu JS, Popp JE, Kaeding CC, Lucas J. Correlation of MR
imaging and pathologic findings in athletes undergoing
surgery for chronic patellar tendonitis. AJR Am J Roentgenol
1995;165:115–118

101. Popp JE, Yu JS, Kaeding CC. Recalcitrant patellar
tendonitis: MRI, histological evaluation and surgical treat-
ment. Am J Sports Med 1997;25:218–222
102. Munshi NI, Mbubaebu CE. Simultaneous rupture of the
quadriceps tendon with contralateral rupture of the patellar
tendon in an otherwise healthy athlete. Br J Sports Med
1996;30:177–178
COMMON INJURIES RELATED TO WEIGHTLIFTING/YU, HABIB 301
103. Nance EP, Kaye JJ. Injuries of the quadriceps mechanism.
Radiology 1982;142:301–307
104. Siwek CW, Rao JP. Ruptures of the extensor mechanism of
the knee joint. J Bone Joint Surg 1981;63-A:932–937
105. Quinn SF, Brown TR, Demlow TA. MR imaging of patellar
retinacular ligament injuries. J Magn Reson Imaging 1993;3:
843–847
Downloaded by: University of Connecticut. Copyrighted material.