Episode 31 | Ask the Expert | Guest: Samantha Williams BSc, HCPC, MSCP, AACP – Specialist MSK Physiotherapist and Founder, Form 360 Physiotherapy
Strength sports carry an undeserved reputation. The image of catastrophic injury – a barbell drop, a televised elbow dislocation – looms large in the public imagination, but the evidence tells a different story. According to Samantha Williams, Olympic weightlifter and founder of Form 360 Physiotherapy, these sports actually sit among the lower-risk activities at elite level, and when injuries do occur, they are almost always the result of identifiable, manageable factors.
In this episode of the London Bridge Sports Medicine podcast, Lucie sits down with Samantha – who has appeared on the podcast previously to discuss strength training for women – for a focused conversation on injury specifically. What follows is a clear-eyed guide to the four main injury categories in strength sports, the anatomy behind them, and the clinical approach to getting people back on the platform.
The four injury categories
Samantha groups injuries in strength sports into four main categories: tendon-related issues, impingement, compression, and sprains and strains. The first three account for the vast majority of clinical presentations.
1. Tendon problems: tendonitis versus tendinopathy
Tendons are dense bundles of collagen fibre that attach muscle to bone. When they become overloaded, two distinct conditions can develop – and understanding the difference matters for treatment.
Tendonitis is the acute version: sudden onset, clearly sore to touch, with a noticeable reduction in strength and power output. Patellar tendonitis (just below the kneecap) and quadriceps tendonitis (just above it) are the most common presentations in strength sports. Tennis and golfer’s elbow also appear across both weightlifting and powerlifting.
Tendinopathy is the longer-term version, typically developing from unresolved tendonitis. Under ultrasound, the tendon shows disorganised collagen, thickening, and increased vascularity. The symptom pattern is characteristic: stiffness first thing in the morning that eases with warm-up, dull niggling pain after training rather than during it, and a sense of restriction rather than sharp pain. “Can you do a single leg knee bend without warming up?” is Samantha’s quick clinical test. In tendinopathy, the answer is usually no.
The underlying mechanism for both is a mismatch between the loading tissue (muscle) and the loaded tissue (tendon). When muscle strength or conditioning can’t absorb the demands being placed on it, excess stress is transferred to the tendon. It’s not the weight that’s the problem; it’s the disparity.
Management
For acute tendonitis, the priority is offloading – reducing the volume or intensity of the aggravating movement rather than stopping altogether. Manual therapy, acupuncture, and massage can improve blood flow and reduce tension in the surrounding loading muscles. Anti-inflammatories are generally avoided unless symptoms are significantly limiting daily function.
For established tendinopathy, the cornerstone of treatment is progressive loading. Tendons respond to load – the right amount, applied consistently, drives the collagen remodelling that restores healthy tissue. Shockwave therapy is a well-regarded adjunct for chronic cases, applied alongside physiotherapy rather than instead of it. Samantha is candid that it can be uncomfortable, particularly over sensitive areas, but its effect on both pain and tissue quality makes it genuinely useful.
2. Hip impingement and labral tears
This is the category Samantha finds most clinically interesting – and one of the most common in strength sports. Femoroacetabular impingement (FAI) occurs when the ball of the femur makes contact with the rim of the hip socket (acetabulum) at the end ranges of hip movement. In the deep squat positions central to both weightlifting and powerlifting, this contact is inevitable for many people.
Two anatomical variants increase susceptibility:
- Cam impingement – the ball of the femur is slightly irregular in shape, creating a bony contact point against the socket rim as the hip flexes. The labrum – the ring of cartilage lining the socket – is what gets pinched.
- Pincer impingement – the acetabulum has an overgrowth or extended lip, causing the same contact in a slightly different way.
Repeated impingement can progress to a labral tear. Many presentations that are diagnosed as hip flexor strains or hip bursitis are, on closer examination, labral injuries. The body is highly adaptive – “it’s not a problem until it’s a problem,” says Samantha – but that ceiling eventually arrives.
Management
Control around the hip and pelvis is the clinical focus – ensuring the glutes, hip flexors, and adductors are all working effectively, and that core engagement is supporting the hip through deep loaded positions rather than the hip compensating alone. Hip mobility is equally important, particularly internal rotation, which is the movement most commonly restricted.
Proprioception through the whole lower limb – the ability to maintain stable, controlled single-leg positions – is something Samantha feels is under-assessed. Strength in a specific muscle and functional stability in a dynamic movement are not the same thing, and both need to be addressed.
3. Compression: back injuries in context
Back injuries in strength sports are far less common than the sport’s reputation suggests. “Strength sports will make your back probably the most robust it’s ever been, if done correctly,” says Samantha. But compression-related issues do occur, and the most common is facet joint irritation rather than the disc injuries most people fear.
When disc injuries do occur, Samantha’s first priority is education. Many people come to clinic believing that a disc injury ends their involvement in the sport. It rarely does. Discs do heal. Understanding what the injury actually is, and what the realistic trajectory looks like over months and years, changes the psychological landscape of recovery significantly.
Her clinical approach involves early movement in all directions – deliberately avoiding the guarding and restriction that tends to compound and prolong back pain – alongside spinal flexion under load, which creates decompression and strengthens the structures that protective behaviour leaves weak. Manual therapy, while debated in the literature, consistently produces immediate improvements in perceived range of motion and pain that enable patients to engage with the rehabilitation that actually drives recovery.
4. Sprains and strains: less common than you’d think
Ligament sprains and muscle tears are the injuries most associated with strength training in the public imagination, but Samantha sees them relatively rarely in her specialist practice. In competitive weightlifting and powerlifting, progressive programming and coaching keep loads well within what the body is prepared to handle. The catastrophic events – elbow dislocations, quad tendon ruptures – are disproportionately visible because they tend to be televised, not because they are common.
In recreational strength training, where technique and programming are less supervised, bicep strains, pectoral strains, and occasional tears are more likely. Bodybuilding training – with its very high volumes targeting specific muscle groups – carries higher strain risk than the compound, progressive loading of the strength sports.
Samantha’s key principles
- Never rush. Progressive overload and periodisation exist for a reason. Lifting a weight well for eight to ten weeks before progressing is not holding back – it’s how the body adapts safely.
- Spines like movement. Even after a spinal injury, moving in all directions – carefully and progressively – is almost always the right approach. Protective avoidance compounds and prolongs the problem.
- Load your injuries. Particularly with tendon problems, appropriate loading during recovery is what drives the tissue remodelling that prevents recurrence. Resting until it feels better and returning to full load is not a rehabilitation plan.
- Understand your injury. Knowing what has happened, why, and what recovery looks like removes much of the fear that otherwise makes injuries worse. Education is a clinical tool, not an afterthought.
- Movement is always the goal. “Movement in any form is always going to be key, even if it feels a bit scary initially.”
The bottom line
Strength sports are not the injury minefield they are often portrayed as. The injuries that do occur follow predictable patterns, respond well to evidence-based physiotherapy, and are in most cases preventable with good programming, coaching, and early intervention. If you are training in the strength sports – whether competitively or recreationally – and something is not settling, the sooner it is properly assessed the more straightforward the path back will be.
Samantha Williams (BSc, HCPC, MSCP, AACP) is a Specialist MSK Physiotherapist, Rio 2016 Olympian in weightlifting, and founder of Form 360 Physiotherapy, with clinics in Spitalfields and Victoria, London. Find out more at form360.co.uk or follow her on Instagram at @physio_rio.
To book an appointment with the LBSM team, visit lbsm.co.uk/booking
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