Abstract
Background:
Weightlifting continues to increase in popularity due to its numerous benefits for physical health, performance enhancement, and age-related functional preservation. Although previous studies have investigated injury patterns in strength athletes, few have examined lower extremity injuries among the general population.
Purpose:
To evaluate the epidemiologic trends, injury characteristics, and mechanisms of weightlifting-associated lower extremity injuries in pediatric and adult patients.
Study Design:
Descriptive epidemiologic study.
Methods:
A retrospective cohort study of the National Electronic Injury Surveillance System (NEISS) was conducted to identify emergency department visits for lower extremity injuries related to weightlifting between January 1, 2014, and December 31, 2023. Patient demographic characteristics, injury diagnosis, body part, and mechanism of injury were collected. Patients were stratified into 4 age groups: pediatric (<18 years), young adult (18-39 years), middle-aged (40-64 years), and geriatric (≥65 years). Chi-square tests were used to analyze categorical variables, and temporal trends were evaluated using linear regression models.
Results:
The sample included 6846 cases (national estimate [NE] = 260,704). The mean age was 32.20 ± 30.71 years, with approximately 69.9% of the study population being male. Common diagnoses were contusion/abrasion (n = 1435; NE = 55,722; weighted percent of NE = 21.0%), fracture (n = 1321; NE = 48,344; 19.5%), and nerve injury (n = 348; NE = 15,397; 5.1%). The most commonly affected body parts were lower trunk (n = 2575; NE = 101,480; 37.6%), toe (n = 1697; NE = 60,871; 24.8%), and foot (n = 1389; NE = 52,860; 20.3%). Pediatric patients experienced the highest proportion of injuries to the toe (NE = 22,328, 35.2%) and foot (NE = 18,223, 28.7%), whereas high rates of lower trunk injuries were observed in young adults, middle-aged adults, and geriatric populations (NE = 60,594, 47.0%; NE = 25,559, 46.7%; NE = 4528, 33.7%; respectively). Pediatric patients demonstrated the highest proportion of injuries due to drop/crush injury (NE = 41,625; 65.5%), whereas young and middle-aged adults were commonly injured performing “nonspecific” lifting movements (NE = 46,286, 35.9%; NE = 22,130, 40.4%; respectively).
Conclusion:
The increased risk of foot and toe trauma in pediatric patients and high incidence of injuries due to dropped weights highlight the need for increased supervision, education, and protective equipment. In contrast, adult lifters were commonly injured performing lifting movements, resulting in increased rates of lower trunk injuries. Targeted, age-specific strategies to mitigate injury risk and promote safety regarding lower extremity weightlifting injuries are needed.
Weightlifting has become a widely adopted form of exercise, with recent surveys estimating that >60 million Americans regularly participate in some form of resistance training.18,32 The physical and mental health benefits are well-documented, including improvements in muscle strength, bone density, metabolic function, and overall quality of life.26,46,47 These benefits have contributed to the increasing popularity of resistance training among diverse age groups, ranging from adolescents pursuing performance enhancement to older adults sustaining functional independence and preventing musculoskeletal decline.12,13,26,47 Nonetheless, injury remains a significant concern: Approximately 27% of weightlifters report sustaining an injury within the first 6 months of initiation, and in the United States alone, weightlifting-related injuries account for >25,000 emergency department (ED) visits annually.1,19
Existing literature has contributed some insight into significant injury mechanisms and patterns in strength athletes, particularly among powerlifters, Olympic weightlifters, and CrossFit participants.1,26,44 These studies have consistently identified dropped weights, improper lifting technique, and equipment misuse as leading causes of injury, with the trunk, hip, and lower extremities being the most commonly affected regions.1,9,19,44 Common diagnoses include contusions, sprains and strains, fractures, and lacerations.1,10,19 However, much of the current research has focused on competitive or experienced athletes, limiting its generalizability to the broader, recreational weightlifting population.1,44 Although some epidemiologic studies have evaluated weightlifting-associated injuries in the general public, these analyses failed to evaluate specific mechanisms of injury (MOIs).30,37,38 Pirruccio et al 37 solely focused on shoulder-related injuries, highlighting the need for additional research regarding lower extremity injuries for the development of targeted prevention strategies. Few studies have stratified data by age group, despite well-established physiological differences that may influence injury risk, such as neuromuscular immaturity in pediatric patients and decreased bone density and muscle mass in older adults.11,20,39
Understanding how injury characteristics vary by age is essential for developing age-appropriate education, gym safety protocols, and public health recommendations. Large-scale epidemiologic analyses can fill this gap by identifying injury trends and mechanisms in the general population across the lifespan. Therefore, the purpose of this study was to evaluate the epidemiological trends and characteristics of lower extremity injuries associated with weightlifting using data from the National Electronic Injury Surveillance System (NEISS). We hypothesized that injury mechanisms and subsequent diagnoses would vary greatly among different age demographics.
Methods
Study Design
This retrospective cohort study used data from NEISS, an injury surveillance database made publicly available by the US Consumer Product Safety Commission. NEISS collects data on injury-related ED visits across a stratified probability sample of >100 US hospitals, each with ≥6 inpatient beds and 24-hour emergency services. Each entry is assigned a statistical weight based on the hospital region, capacity, and geographic location of the institution providing care, which was paired to corresponding patient cases and allowed for proportional calculation of nationally representative estimates. This method has been used and validated by previous studies. 24 The database includes patient demographic characteristics, injury diagnosis, body part involved, disposition, and narrative descriptions of the injury event. This study used publicly available, de-identified data and was exempt from institutional review board oversight.
All lower extremity injuries assigned a corresponding weightlifting NEISS code occurring between January 1, 2014, and December 31, 2023, were included. Relevant cases were identified using NEISS product codes corresponding with weightlifting codes from the International Classification of Diseases, 10th Revision, and keyword filters applied to injury narratives. The demographic characteristics collected in this study included age, sex, race, and discharge disposition after the encounter. The NEISS database provides diagnosis codes created by the US Consumer Product Safety Commission. The diagnosis categories included the following: contusion/abrasion, fracture, nerve injury, laceration, internal injury, strain/sprain, dislocation, and other. Fractures were defined as any injury with a diagnosis code corresponding to “fracture, avulsion, or crush.” Internal injuries consisted of those with the diagnosis codes “internal injury, hematoma, or hemorrhage.” All other injuries not falling within the aforementioned categories, including amputations, foreign bodies, and punctures, or with unspecified diagnoses, were classified as “other.” Two independent reviewers (C.N. and P.L.) assessed all narratives to confirm inclusion and to categorize the mechanism of injury. Discrepancies were resolved by consensus or consultation with a senior author (D.P.T.). MOIs were classified into 1 of 10 predefined categories: drop/crush injury, impact with floor, impact with equipment, nonspecific lifting movement, squat, deadlift, impact with another person, leg press, primary upper body workout, or dynamic swinging motion. Cases lacking sufficient detail were coded as “unspecified.” Patients were stratified into 4 age groups based on physiologic and biomechanical differences: pediatric (<18 years), young adult (18-39 years), middle-aged adult (40-64 years), and geriatric (≥65 years). The United States defines geriatric patients as those 65 years or older, and this definition was used by previously published studies. 3
Inclusion and Exclusion Criteria
This descriptive epidemiologic study included all patients presenting to the ED with a primary weightlifting-associated injury. Cases were excluded if the injury did not occur during active weightlifting (eg, injuries sustained while walking to or from the gym). Injuries primarily resulting from other activities but exacerbated during lifting were excluded.
Statistical Analysis
All analyses were performed using IBM SPSS software (Version 29.0; IBM Corp). National estimates (NEs) were calculated by multiplying the associated statistical weight of each respective hospital by its raw data point. Descriptive statistics were used to summarize patient demographic characteristics, injury diagnoses, affected body regions, and MOIs. Categorical variables were analyzed using chi-square tests. Temporal trends were evaluated using linear regression models. Post hoc comparisons were adjusted using the Holm method to control for multiple testing. Statistical significance was set at P < .05.
Results
Patient Demographic Characteristics
After application of inclusion and exclusion criteria, a total of 6846 participants (NE = 260,704) were included for analysis. There were 1981 pediatric patients (NE = 64,079; weighted percent of NE = 28.9%), 3189 young adults (NE = 129,001; 46.6%), 1308 middle-aged adults (NE = 54,775; 19.1%), and 368 geriatric patients (NE = 13,426; 5.4%). The mean age was 32.20 ± 30.71, with a median age of 26 years. The sample was primarily male (n = 4784; NE = 179,112; 69.9%) compared with female (n = 2061; NE = 81,535; 30.1%). The most common races were White (n = 2742; NE = 116,256; 40.1%) and African American (n = 1214; NE = 43,028; 17.7%), and patients were primarily not Hispanic (n = 2121; NE = 79,849; 31.0%). Patients were most commonly discharged home (n = 6511; NE = 249,052; 95.1%) after the encounter.
General Trends in Final Diagnoses, Body Locations, and Mechanisms of Injury
Overall, the most common final diagnoses were contusion/abrasion (n = 1435; NE = 55,722; 21.0%), fracture (n = 1321; NE = 48,344; 19.5%), and nerve injury (n = 348; NE = 15,397; 5.1%). There were 3251 (NE = 122,620; 47.5%) final diagnoses of “other.” The most commonly injured body parts were lower trunk (n = 2575; NE = 101,480; 37.6%), toe (n = 1697; NE = 60,871; 24.8%), and foot (n = 1389; NE = 52,860; 20.3%). The most common MOIs were drop/crush injury (n = 3018; NE = 110,726; 44.1%), deadlift (n = 437; NE = 16,884; 6.4%), and impact with equipment (n = 427; NE = 17,280; 6.2%). There were 2130 (NE = 83,941; 31.1%) unspecific lifting injury mechanisms. Additional information regarding overall distribution of final diagnoses, body locations injured, and MOIs can be found in Tables 1, 2, and 3, respectively.
Most Common Diagnoses of Weightlifting-Associated Lower Extremity Injury Stratified by Age Group a
Data presented as national estimate (%).
Most Common Locations of Weightlifting-Associated Lower Extremity Injury Stratified by Age Group a
Data presented as national estimate (%).
Most Common Mechanisms of Weightlifting-Associated Lower Extremity Injury Stratified by Age Group a
Data presented as national estimate (%).
Injury Patterns When Stratified Among Different Age Groups
Within the pediatric population, the most common final diagnoses were contusion/abrasion (n = 597; NE = 20,516; 32.3%), fracture (n = 515; NE = 15,881; 25.0%), and laceration (n = 106; NE = 3012; 4.7%). There were 664 (NE = 21,091; 33.2%) final diagnoses described as “other.” The most common body locations injured were toe (n = 750; NE = 22,328; 35.2%), foot (n = 520; NE = 18,223; 28.7%), and lower trunk (n = 327; NE = 10,789; 17.0%). The most common MOIs were drop/crush injury (n = 1285; NE = 41,625; 65.5%), nonspecific lifting movement (n = 339; NE = 11,008; 17.1%), and impact with equipment (n = 115; NE = 3268; 5.8%).
Regarding the young adult age group, the most common final diagnoses were contusion/abrasion (n = 546; NE = 23,748; 18.4%) fracture (n = 500; NE = 20,510; 15.9%), and nerve injury (n = 202; NE = 8617; 6.7%). There were 1778 (NE = 69,267; 53.7%) final diagnoses of “other.” The most common body locations injured were lower trunk (n = 1537; NE = 60,594; 47.0%), toe (n = 583; NE = 23,746; 18.4%), and foot (n = 580; NE = 24,465; 19.0%). The most common MOIs were nonspecific lifting movement (n = 1171; NE = 46,286; 35.9%), drop/crush injury (n = 1124; NE = 46,216; 35.8%), and deadlift (n = 313; NE = 12,030; 9.3%).
Among middle-aged adults, the most common final diagnoses were fracture (n = 224; NE = 9304; 17.0%), contusion/abrasion (n = 207; NE = 8691; 15.9%), and nerve injury (n = 124; NE = 5902; 10.8%). There were 672 (NE = 27,179; 49.6%) final diagnoses of “other.” The most common body locations injured were lower trunk (n = 606; NE = 25,559; 46.7%), toe (n = 249; NE = 11,108; 20.3%), and foot (n = 207; NE = 7804; 14.2%). The most common MOIs were nonspecific lifting movement (n = 521; NE = 22,130; 40.4%), drop/crush injury (n = 414; NE = 16,857; 30.8%), and impact with equipment (n = 123; NE = 5483; 10.0%).
Within the geriatric population, the most common diagnoses were contusion/abrasion (n = 85; NE = 2766; 20.6%), fracture (n = 82; NE = 2649; 19.7%), and nerve injury (n = 25; NE = 672; 5.0%). There were 137 (NE = 5664; 42.4%) final diagnoses of “other.” The most common body injury locations were toe (n = 115; NE = 3689; 27.5%), lower trunk (n = 105; NE = 4528; 33.7%), and foot (n = 82; NE = 2369; 17.6%). The most common MOIs were drop/crush injury (n = 195; NE = 6027; 44.9%), nonspecific lifting movement (n = 99; NE = 4289; 31.9%), and impact with equipment (n = 27; NE = 1113; 8.3%).
Post Hoc Analyses in Evaluating Differences in Proportions
One-way analysis of variance demonstrated that pediatric patients had the highest proportion of contusion/abrasion compared with all other age groups. Additionally, pediatric athletes had the highest proportion of foot and toe injuries compared with all other age groups. In comparison, the proportion of lower trunk injuries in young, middle-aged, and geriatric patients was greater than that in the pediatric cohort. Differences observed between groups were found to be statistically significant (P < .05).
Discussion
Our study demonstrated that pediatric patients had the highest incidence of drop or crush injuries, with subsequently high rates of foot and toe injuries. In contrast, young and middle-aged adults commonly experienced contusion/abrasion or fracture, with injuries often localized to the lower trunk and toes. These patients, in contrast to the pediatric population, were most often injured performing nonspecific lifting movements. Finally, the geriatric population accounted for a notably smaller proportion of injuries in the total population compared with the other age categories. Among these patients, injuries due to dropped weight or while performing nonspecific lifts were the most prevalent mechanisms, with injuries more commonly affecting the toes and lower trunk.
Pediatric patients in this study exhibited the highest proportion of foot and toe injuries, most commonly resulting from drop or crush mechanisms. These injuries are often linked to mishandling of free weights or poor spatial awareness in younger individuals who lack motor control, maturity, or supervision.12,29 Contusion and fracture were the most frequent diagnoses in this group, consistent with other studies noting a higher risk of direct trauma during resistance training among unsupervised or improperly trained youth. 31 Despite long-standing evidence supporting the safety and benefits of resistance training in pediatric populations when properly supervised,28,41 these findings suggest that young lifters may still be engaging in training environments without adequate oversight. Additionally, the increased rates of pediatric injuries may potentially be attributed to inexperience and adolescents engaging in riskier behavior, making them more susceptible to injury. 45 Strategies to reduce injury risk include providing education for athletes, parents, and coaches; improving supervision; and encouraging the use of protective equipment such as steel-toed shoes or reinforced flooring surfaces. 15
Among young and middle-aged adults, injuries were most frequently localized to the lower trunk (48.3% and 46.3%, respectively), with squats and deadlifts as significant contributions toward overall MOIs. Additionally, the true incidence of deadlift or squatting injuries is likely higher than reported, with some potentially designated into the “nonspecific lifting movement” category, which constituted a large proportion of this population. These dynamic movements place substantial axial load on the lumbar spine and sacroiliac joints, requiring not only proper technique but also appropriate programming and fatigue management.16,42 Previous biomechanical studies have demonstrated that poor form under high loads can result in increased lumbar shear and compressive forces, predisposing athletes to lumbar strain or disc herniation.4,8 Programs emphasizing movement assessment, individualized load progression, and technique refinement may reduce risk. Additionally, alternative exercises that target similar musculature, such as trap bar deadlifts or single-leg variations, may offer a safer profile for some athletes. Furthermore, the use of supportive accessories, such as lifting belts, has been shown to provide a potential advantage at reducing lower back stress by increasing intra-abdominal pressure and reducing peak muscle strain.21,22,40,43
Despite the well-established benefits that resistance training offers to older adults, including improvements in bone mineral density, muscle strength, and fall prevention, geriatric patients were severely underrepresented in this study.5,17,46 The lower proportion of geriatric athletes compared with pediatric, young adult, and middle-aged participants likely reflects a lower participation rate in weightlifting among older individuals, although it also underscores a missed opportunity for public health intervention. Osteoporosis is highly prevalent among postmenopausal women, and weightbearing resistance exercises have been shown to slow bone loss and reduce fracture risk.6,23 Given the aging population in the United States, greater efforts should be made to encourage safe strength training in this demographic. Community programs, primary care counseling, and accessible gym infrastructure can all play a role in promoting age-appropriate resistance training among older adults. 2
Drop and crush injuries were consistently the most common mechanism of injury across all age groups, highlighting the need for systemic solutions. These injuries often result from preventable factors such as improper equipment handling, overcrowded gym environments, or insufficient user awareness. Implementing structured gym orientation programs for new lifters, enforcing proper equipment storage protocols, and using spatial separation strategies (eg, lifting platforms, dead zones) may reduce the likelihood of accidental trauma. 7 Further, simple equipment upgrades, such as padded flooring or protective footwear, may reduce the severity of injuries when accidents occur. 14
Guidelines from professional organizations such as the American Academy of Orthopaedic Surgeons recommend gradual progression, use of proper form, and adequate warm-up to reduce musculoskeletal injury risk. 2 However, current guidelines are often general and lack age-stratified recommendations based on national injury data. The National Strength and Conditioning Association has emphasized the importance of long-term athletic development, advocating for structured and age-appropriate resistance training beginning in youth and continuing throughout adulthood. 27 These developmental frameworks support the need for early injury education and progressive skill acquisition aligned with the individual’s physical and cognitive maturity. This study highlights the need for development of nuanced, population-specific protocols informed by real-world injury patterns. Future research should explore longitudinal outcomes of different lifting exposures and incorporate biomechanical analyses that link training behaviors to specific injury mechanisms.
This study has several limitations. First, the NEISS database captures only injuries that result in ED visits, potentially underrepresenting the true incidence of weightlifting-related injuries, particularly those treated in urgent care or outpatient clinics or managed at home. Second, several cases had unspecified final diagnoses or narrative fields that were brief or vague, which limited the ability to comprehensively identify corresponding MOIs. However, the percentage of “unspecified” final diagnoses and MOIs in this study is consistent with existing NEISS studies.25,33-36 Moreover, based on the limited granularity of narrative fields, we were unable to stratify weightlifting injuries by type of exercise, including powerlifting, Olympic lifting, and CrossFit, which may have presented with distinct injury patterns. Third, although the database provides excellent information regarding epidemiologic trends over time, it lacks information about the severity of injury, definitive management, and medical comorbidities, which would provide valuable clinical insight into optimal management strategies for weightlifting-associated injuries. These limitations should be considered when interpreting the findings and designing future research.
Conclusion
The increased risk of foot and toe trauma in pediatric patients and the high incidence of injuries due to dropped weights highlight the need for increased supervision, education, and protective equipment. In contrast, adult lifters were commonly injured performing lifting movements, resulting in high rates of lower trunk injuries. Targeted, age-specific strategies to mitigate injury risk and to promote safety regarding lower extremity weightlifting injuries are needed.
Footnotes
Final revision submitted October 26, 2025; accepted October 28, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: D.P.T. has received education payments from Arthrex, Gotham Surgical Solutions & Devices, Peerless Surgical, and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval was not sought for the present study.
