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Overuse injury is an injury without a specific event associated with the onset of the injury and mostly results from cumulative tissue damage.  As a result, the musculoskeletal system relies on overload of other structures to avoid rupture and/or further injury.1 The most common of these includes rotator cuff injuries, back injuries and carpal tunnel syndrome.1,2 For many individuals with central nervous system (CNS) disorders, performing repetitive motions is a vital part of general mobility and activities of daily living (ADL). This can lead to repetitive microtrauma of bones, joints and soft tissues and can contribute to pain and worsen functional capacity.3


The development of overuse injuries in patients after a central nervous system disorder is due to a combination of factors such as genetics, trauma history, age of injury, level of impairment after a spinal cord injury or severe weakness after a brain injury as well as environmental factors such as equipment and layout and design of home.2,4

For individuals with CNS disorders the most common cause for these injuries result from altered biomechanics of weight bearing through joints not designed to sustain repetitive motions or significant amounts of weight over time. Examples include upper limb activity with wheelchair propulsion and transferring the body between surfaces. Additionally, the individual in a wheelchair will be required to place joints in mechanically compromising positions, such as with overhead reaching, which over time, contributes shoulder injuries and adds to each other over time. Individuals with CNS disorders are more likely to have muscle weakness or mechanical disadvantages that causes an imbalance between muscle groups that can lead to injury.3 The majority of research in the area of overuse injuries in CNS disorders is with wheelchair users, but long-term reliance on walkers, crutches, and other assistive devices can also contribute to overuse injuries. There continues to be a lack of research regarding specific patterns that these assistive devices contribute to injuries.

Studies have shown altered biomechanics in this specific population includes weakness, spasticity, lack of motor control and affected proprioception. This usually is followed by affected intraarticular pressure in affected joints that result in the overuse injury.5,6

Epidemiology including risk factors and primary prevention

Most of the information on the epidemiology of overuse injuries comes from literature on persons with spinal cord injury (SCI). For patients with brain injuries., epidemiologic studies continue to be limited. Some of the most common injuries include, by region:

  • Shoulder injuries: prevalence of pain symptoms range from up to 81% in spinal cord injury and 26% in patients with stroke.2,5
    • Shoulder pain in paraplegics versus tetraplegics is more likely to be orthopedic or musculoskeletal-related (80% versus 81%, respectively).
    • Rotator cuff (RC) injuries: 20% unilateral, 29% bilateral for paraplegics, with full thickness tears more prevalent than partial thickness7
      • Prevalence of rotator cuff tears 4x higher in paraplegics vs. control with tear of supraspinatus most common.8
      • In brain injury patients with hemipleglic upper extremities, fatty infiltration of the RTC occurs and may affect functional recovery afterwards.9
    • Impingement syndrome: incidence as high as 75% in symptomatic shoulder pain patients with SCI10
    • Bicipital tendinitis: the incidence has yet to be described in literature, however, remains common cause for referred shoulder pain.2
    • Osteoarthritis (OA): glenohumeral OA 14-32%, AC joint 31-42% in spinal cord injury, incidence in brain injury yet to be described 5,8
  • Elbow injuries: prevalence of pain symptoms range from 6-15% with older studies reporting up to 32%.2,3
    • Lateral epicondylitis: 17% in wheelchair users that play sports11
    • Entrapment mononeuropathies have been found to be around 67% with ulnar neuropathy at the elbow (UNE)/cubital tunnel syndrome being around 10%.2
  • Wrist/hand injuries: prevalence of pain symptoms range from 9-63%.2
    • Median nerve entrapment 78%12
    • DeQuervain’s tenosynovitis
  • Myofascial pain of the neck and low back with incidence over 50% of patients.

Risk factors in both spinal cord injuries and brain injuries include age since initial injury, higher body mass index (BMI), wheelchair propulsion style or use of assistive devices and transfer techniques.2,5,7 Primary prevention includes early and comprehensive rehabilitation that teaches adequate and joint-sparing techniques in transfers and effective wheelchair propulsion. Identifying strength disproportion may help the rehabilitation group to target weak or affected muscles for proper rehabilitation.

Decreased muscle strength especially in the shoulder adductors and low physical activity have been shown to be weak predictors of shoulder pain development over a 3-year period.13 Mulroy, et al. speculated that weaker shoulder adductors may be unable to unload the rotator cuff effectively leading to injury. Interestingly, higher UE weight-bearing activities were not found to be risk factors for development of shoulder pain whereas low activity was associated to the development of shoulder pain.14


Overuse injuries involve repetitive motions that most commonly affect the musculotendinous unit resulting in tendinopathy, tenosynovitis, and/or muscle soreness. Other tissues that can be involved include bursae (bursopathy), bone (stress fractures), nerve (compression neuropathies), and cartilage (OA). As a consequence of repetitive microtraumatic overuse, injuries eventually lead to an impairment in the tissue’s ability to self-repair. As a result, there occurs limited function associated to the involved structure.15 Physical stressors thought to be potentiating factors in overuse injury include level of force, posture, duration, contact stress, vibration and temperature.10 Examples of highly repetitive activities that require increase in intra-articular forces include transfers, pressure relief maneuvers, and wheelchair propulsion.5,6

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

In general, overuse injuries develop over several months to years after the CNS injury or disorder but vary by individual and situation. Several conditions related to using a wheelchair and other assistive devices result in the development of overuse syndrome. Over time, these devices have progressed to be lighter and have had ergonomic adjustments that prevent poor postures that may contribute to injuries (posterior pelvic tilt, excessive neck flexion, prolonged shoulder abduction, internal rotation and extension).

Overuse injuries pass through an acute and subacute phase in which ongoing microtrauma occurs and when it advances to chronic phases, maladaptive tissue forms and prevents further recovery. The prevalence of carpal tunnel syndrome has been noted to be higher in patients with longer periods since initial CNS insult which supports the scarring and tissue maladaptation associated with overuse.16

Three pain trajectories of self-reported musculoskeletal shoulder pain (0=No Pain, 1=very mild, 2=mild, 3=moderate, 4=severe, 5=very severe) over 5 years were identified in one prospective cohort study of 225 newly injured persons with SCI: “No or Low pain” (64%, n=148), “High Pain” (30%, n=63), and “Decrease of pain” (6%, n=14). The authors hypothesized that a fourth trajectory “Increase of pain” could be identified if a follow-up time of >5 years was used, which would hypothetically show pain problems in shoulders due to overuse. The trajectories were identified using latent class growth mixture modeling (LCGMM), which are contemporary statistical techniques that aim to identify unique trajectories of data, and in this case three trajectories optimally showed data. Two significant predictors of a “High Pain” trajectory were tetraplegia and having limited shoulder ROM at the beginning of active rehabilitation.17

Essentials of Assessment


Initial history should include a comprehensive evaluation of pain symptoms (onset, location, radiation, character, severity, alleviating/aggravating factors, typical activities or sports that bring on pain). Special attention should be paid to history surrounding inciting injury (as in spinal cord injury or brain injury), as concomitant musculoskeletal injuries are often overlooked.

Other items to be considered in the history are level of SCI (if present), time elapsed from initial CNS disorder, previous diagnostic evaluations, previous attempted treatment options and whether or not they were efficacious, any recent changes in wheelchair use, the presence of spasticity, and changes in body mass index (BMI). Additionally, a review of the functional impact of injury on ADLs, work, community activities, and recreation should be completed.

Questions guided to differentiate between types of pain (neuropathic, referred and mechanical) can be helpful. In this specific population, it is important to screen for potential non-musculoskeletal sources of the pain (e.g., new or changing neurologic symptoms, symptoms of an inflammatory process, etc.).

Physical examination

As with any general musculoskeletal exam, inspection of the region in question for deformity and atrophy, palpation for point tenderness, range of motion (ROM) (both passive and active), and neurologic exam including manual muscle testing, sensation and reflexes, are key. It is often helpful to have the individual demonstrate the maneuver or activity that reproduces the pain. Evaluation of spasticity and muscle imbalances are special considerations in this population.

Selected provocative maneuvers by potential diagnosis include the following:

  • RC tear:
    • Supraspinatus: Empty can, Drop arm test
    • Infraspinatus: Hornblower’s
    • Subscapularis: Lift off test
  • Impingement: Neer’s and Hawkin’s tests
  • Bicipital tendinitis: Speed’s and Yergason’s tests
  • Lateral epicondylitis: Cozen’s test
  • DeQuervain’s tenosynovitis: Finkelstein’s test
  • Carpal tunnel syndrome (CTS): Phalen’s, median nerve compression, and Tinel’s test

Functional assessment

Exploring mechanics of transfer technique and wheelchair propulsion can be helpful, as well as evaluation of equipment, including wheelchair set-up and seating arrangement. At times, symptoms may be associated with these daily activities. Routine evaluation by rehabilitation providers may help identify ergonomic improvements and/or patient preferences for different activities. Boninger et al suggested that the optimal position of a wheelchair’s rear axle is 2 inches forward of the shoulder which helps maintain 100-120 degree of elbow flexion to maximize stroke patterns.18

Laboratory studies

Blood tests are usually not necessary but in patients without proper response to treatment or red flags such as fever and others may help rule out less likely causes. Electrodiagnostic studies may be considered to evaluate for entrapment injuries, radiculopathies or a more generalized process if pertinent (e.g., neuropathy).


Imaging is often not needed initially, as the majority of diagnoses can be made by history and physical examination. Plain radiographs of the area in question can be considered to rule out fracture or to evaluate for degenerative changes. With the ongoing development of musculoskeletal ultrasound, diagnostic ultrasound may be of use as well. Further imaging options such as CT and MRI may be helpful if planning for a surgical procedure or to rule out other potential causes.

Supplemental assessment tools

  • Constant Murley Score (CMS): 100-point score; components include degree of pain patient experiences subjectively, ability to perform ADLs, objective testing of ROM and shoulder power.
  • Wheelchair Users Shoulder Pain Index (WUSPI): 15-item self-report questionnaire on effect of shoulder pain on ADLs
  • Klein and Bell ADL index: 170 items assessing six domains: dressing, mobility, elimination, hygiene, eating and emergency communication; score can range from 0-313. Predictive validity obtained by correlating score to number of attendant hours needed.19


Details on the layout of the individual’s home, automobile and/or work environment, can be helpful when considering activity modifications to take into account the frequency and amount of transfers and overhead activities the patient performs.

Social role and social support system

Strong social support and access to resources will be important when prescribing relative rest from likely essential activities, or in case of referral for surgery with long recovery times and periods of immobility.

Professional Issues

Shoulder pain intensity was inversely related to quality of life, social integration and physical activity scores.20,21 Ergonomic assessments of the workplace environment may offer alternative equipment or set-up that will decrease the particular overuse activity in question.

Rehabilitation Management and Treatments

Available or current treatment guidelines

A useful algorithm for assessing pain after spinal cord injury, including musculoskeletal pain from overuse was developed in the early 2000’s.22

  • New onset/acute
    • Goal at this stage is to control pain and inflammation while limiting further tissue damage.
      • PRICE treatment (protection, relative rest, ice, compression, elevation)
      • +/- oral or topical non-steroidal anti-inflammatory drugs.
      • Use of splints where appropriate.
      • Physical modalities such as ultrasound, iontophoresis, paraffin baths.
      • Targeted corticosteroid injections to the affected area can be considered.
    • Subacute
      • Focus at this stage is preventing exacerbations and new injury by addressing modifiable factors.
        • The clinician should reiterate proper posture and optimize static alignment rather than relying on muscular strength.
        • Ensure proper wheelchair fit (positive seat plane, perpendicular, low backrest, appropriate seat depth, adequate seating system).
        • Targeted therapeutic exercise program focusing on strengthening, stretching
          • Reduction in shoulder pain was found in seven studies of therapeutic exercise after spinal cord injury (three randomized controlled trials and 4 cohort studies) and was determined by reduction in WUSPI score (outlined above).23
          • Norrbrink, et al described an intensive exercise program to reduce musculoskeletal and neuropathic pain: subjects trained on a double-poling ergometer three times per week during a 10-week period, in small, supervised groups. Each session lasted 50 min. and included a warm-up, four intervals of 6-7 min, followed by a cool-down. Improvements in both neuropathic and musculoskeletal pain complaints were seen.24
        • Activity modification
    • Chronic/stable
      • One option in this stage may be transitioning to a pushrim-activated power-assisted wheelchair to prolong a person’s ability to use a manual wheelchair (MWC).25
        • Power-assisted wheelchair reduced potential risk factors of overuse injuries in one pilot study.26
      • At the point where pain becomes too severe or limits function in a way that makes it unsafe to perform certain activities, transitioning from a MWC to power mobility to preserve current function should be considered.
      • For certain diagnoses (e.g., CTS, RC tears), surgery may be an option when conservative treatment has failed but can have significant morbidities. Recovery times with periods of absolute or relative non-weightbearing could mean the difference between the patient being able to live independently and not.
    • Pre-terminal or end-of-life care
      • NA

Coordination of care

Concomitant evaluation with physical therapy and occupational therapy, especially in regard to functional transfers, push mechanics, adaptive equipment and wheelchair fit, can be helpful. Workplace assessments if available can also be considered to review set-up and suggest equipment/workplace modifications to minimize joint stresses and injury.

Patient & family education

Proper body and push mechanics should be reviewed with family and caregivers, so that it can be reinforced with the patient at home.

Cutting Edge/ Emerging and Unique Concepts and Practice

Cutting edge concepts and practice

Over time, assistive devices’ user’s needs will change, requiring regular input from providers regarding adjustment; however, a new smart pattern recognition system is currently being developed to adapt to each user’s individual needs. The aim is to “provide the adjustable elements which can be used to improve the user’s own input quality.” 27

Regenerative alternatives have been increasingly studied with mixed results regarding upper extremity injuries such as platelet-rich plasma and stem cell injections for chronic overuse injuries.  The use of these regenerative medicine techniques continues to expand secondary to the need for minimally invasive alternatives for chronic overuse injuries as well as potential regeneration.28,29 For certain specific pathologies, such as lateral epicondylitis and calcific tendonitis, extracorporeal shockwave has also emerged as a potential alternative for chronic injuries that do not resolve with typical treatment alternatives.30,31

Gaps in the Evidence-Based Knowledge

Further research is needed to evaluate for outcomes and compare patients with CNS disorders and compare them to the general population. These may help guide for specialized treatment options and/or ergonomic modifications. Studies evaluating chronic overuse injuries in patients with stroke or brain injuries are also limited.


  1. Francoa MF, Madalenoa FO, de Paulaa TM , Ferreira TV , Pinto RF, Resende RA. Prevalence of overuse injuries in athletes from individual and team sports: A systematic review with meta-analysis and GRADE recommendations. Brazilian Journal of Physical Therapy. 2021. 500-513
  2. Vives Alvarado JR, Felix ER, Gater DR Jr. Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2021;27(1):68-74. doi: 10.46292/sci20-00061. PMID: 33814884; PMCID: PMC7983631.
  3. Bonninger ML, Koontz AM, Sisto S, Dyson-Hudson TA, Chang M, Cooper RA. Pushrim biomechanics and injury prevention in spinal cord injury: Recommendations based on CULP-SCI investigations. J Rehabilitation Research and Development. 2005;42(3) (Supp I): 9-20.
  4. Pentland WE, Twomey LT. Upper limb function in persons with long-term paraplegia and implications for independence: Part II. Paraplegia. 1994;32:219-224.
  5. Kendall, R. (2010). Musculoskeletal Problems in Stroke Survivors. Topics in Stroke Rehabilitation, 17(3), 173–178. doi:10.1310/tsr1703-173
  6. Ferrero G, Mijno E, Actis MV, Zampa A, Ratto N, Arpaia A, Massè A. Risk factors for shoulder pain in patients with spinal cord injury: a multicenter study. Musculoskelet Surg. 2015 Sep;99 Suppl 1:S53-6. doi: 10.1007/s12306-015-0363-2. Epub 2015 May 23.
  7. Akbar M, Brunner M, Balean G, et al. A cross-sectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients. J Shoulder Elbow Surg. 2011;20:1108-1113.
  8. Akbar M, Balean G, Brunner M, Seyler TM, Bruckner T, Munzinger J, Grieser T, Gerner HJ, Loew M. Prevalence of Rotator Cuff Tear in Paraplegic Patients Compared with Controls. J Bone Joint Surg Am. 2010;92:23-30
  9. Beom J, Jang HJ, Han TR, Oh BM, Paik NJ, Yang EJ, Lee SU. Fatty replacement of rotator cuff in brain-injured patients is associated with hemiplegic arm function, but not with tendon tear: A multicenter study. NeuroRehabilitation. 2015;37(2):213-9. doi: 10.3233/NRE-151254. PMID: 26484513.
  10. Hastings J, Goldstein B. Paraplegia and the shoulder. Phys Med Rehabil Clin N Am. 2004;5(3):vii, 699-718.
  11. Apple DF Jr, Cody R, Allen A. Overuse syndrome in the upper limb in people with spinal cord injury. In: Sowell TT, ed. RRDS Physical Fitness: A Guide for Individuals with Spinal Cord Injury. Washington DC. Veterans Health Administration. 1996:97-107.
  12. Asheghan M, Hollisaz MT, Taheri T, Kazemi H, Aghda AK. The prevalence of carpal tunnel syndrome among long-term manual wheelchair users with spinal cord injury: a cross-sectional study. J Spinal Cord Med. 2016;39(3):265-271.
  13. Mulroy SJ, Hatchett P, Eberly VJ, Haubert LL, Conners S, Requejo PS. Shoulder Strength and Physical Activity Predictors of Shoulder Pain in People With Paraplegia From Spinal Injury: Prospective Cohort Study. Phys Ther. 2015;95(7): 1027-1038.
  14. Mulroy SJ, Thompson L, Kemp B, Hatchett PP, Newsam CJ, Lupold DG, Haubert LL, Eberly V, Ge T, Azen SP, Winstein CJ, Gordon J. Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Chronic Spinal Cord Injury: A Randomized Controlled Trial. Phys Ther. 2011;91(3):305-324.
  15. Cleveland Clinic. Overuse Syndrome. https://my.clevelandclinic.org/health/diseases/4706-overuse-syndrome-of-the-hands-and-arms. Accessed on 6/18/22
  16. Asheghan M, Hollisaz MT, Taheri T, Kazemi H, Aghda AK. The prevalence of carpal tunnel syndrome among long-term manual wheelchair users with spinal cord injury: A cross-sectional study. J Spinal Cord Med. 2016 May;39(3):265-71. doi: 10.1179/2045772315Y.0000000033. Epub 2015 Jul 16. PMID: 26182184; PMCID: PMC5073759.
  17. Eriks-Hoogland IE, Hoekstra T, de Groot S, Stucki G, Post MW, van der Woude LH. Trajectories of musculoskeletal shoulder pain after spinal cord injury: Identification and predictors. J Spinal Cord Med. 2014;37(3):288-298.
  18. Boninger ML, Baldwin M, Cooper RA, Koontz A, Chan L. Manual wheelchair pushrim biomechanics and axle position. Arch Phys Med Rehabil. 2000;8(1):608-613.
  19. Samuelsson KAM, Tropp H, Gerdle B. Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users. Spinal Cord. 2004;42:41-46.
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  22. Siddall PJ, Middleton JW. A proposed algorithm for the management of pain following spinal cord injury. Spinal Cord. 2006;44:67-77.
  23. Cratsenberg KA, Deitrick CE, Harrington TK, Kopecky NR, Matthews BD, Ott LM, Coeytaux RR. Effectiveness of Exercise Programs for Management of Shoulder Pain in Manual Wheelchair Users With Spinal Cord Injury. J Neurol Phys Ther. 2015;39:197-203.
  24. Norrbrink C, Lindberg T, Wahman K, Bjerkefor A. Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury results from a seated double-poling ergometer study. Spinal Cord. 2012;50:457-461.
  25. Chow JW, Levy CE. Wheelchair propulsion biomechanics and wheelers’ quality of life: an exploratory review. Disability and Rehab Asst Tech. 2011;6(5):365-377.
  26. Kloostermann MGM, Buurke JH, de Vries W, Van der Woude LHV, Rietman JS. Effect of power-assisted hand-rim wheelchair propulsion on shoulder load in experienced wheelchair users: A pilot study with an instrumented wheelchair. Med Eng Phys. 2015;37:961-968.
  27. Gillham M, Pepper M, Kelly S, Howells G. Feature determination from powered wheelchair user joystick input characteristics for adapting driving assistance. Wellcome Open Res. 2017;2(93):1-40.
  28. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014;4: Art. No. CD010071.
  29. Im G-I. Clinical Use of Stem Cells in Orthopaedics. Eur Cell Mater. 2017;33:183-196.
  30. Louwerens JKG, Sierevelt IN, Kramer ET, Boonstra R, van den Bekerom MPJ, van Royen BJ, Eygendaal D, van Noort A. Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial. Arthroscopy. 2020 Jul;36(7):1823-1833.e1. doi: 10.1016/j.arthro.2020.02.027. Epub 2020 Feb 28. PMID: 32114063.
  31.  Yao G, Chen J, Duan Y, Chen X. Efficacy of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis: A Systematic Review and Meta-Analysis. Biomed Res Int. 2020 Mar 18;2020:2064781. doi: 10.1155/2020/2064781. PMID: 32309425; PMCID: PMC7106907.

Original Version of the Topic

Wei-Han Tan, MD, Felicia Skelton, MD. Overuse Injuries in Disorders of the Central Nervous System. 10/22/2013

Previous Revision(s) of the Topic

Ryan Lirette, LSUHSC-NO, Stephen Kishner, MD. Overuse Injuries in Disorders of the Central Nervous System. 9/5/2018

Author Disclosure

Christian Lopez-Aponte, MD
Nothing to Disclose

Manuel F Mas, MD
Nothing to Disclose