Author(s): Erika Trovato, DO , Anju Sanchala, DO, Kenia Maldonado Vergara, MD, Abner Vazquez Pabon, MD, Margaret Wilson, DO
Originally published: October 22, 2013 Last updated: April 16, 2026
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Disease/Disorder

Definition

Overuse injuries are typically characterized by the lack of a single traumatic event. Instead, they arise when tissues are exposed to repetitive or excessive loading on musculoskeletal or neural tissues over time, with a mismatch between tissue stress and the body’s ability to repair and adapt, leading to injury of bones, muscles, tendons, or ligaments.1,2

Central nervous system (CNS) disorders (e.g., spinal cord injury (SCI), stroke, traumatic brain injury (TBI), multiple sclerosis) result in mobility impairments that force patients to put a greater burden on unaffected or less affected structures.3

For many individuals with CNS disorders, performing repetitive motions is a vital part of general mobility and activities of daily living (ADL). This can lead to repetitive injuries, resulting in pain-limiting mobility, Overuse injuries impact patients’ functional independence, activities of daily living, and even participation in rehabilitation programs.4

Etiology

The development of overuse injuries in patients after a CNS disorder results from a combination of factors, including biomechanical issues such as malalignment, poor technique, and muscle imbalance. Intrinsic factors such as age, joint laxity, previous injury, level of impairment after a SCI, or severe weakness after a brain injury, may reduce resilience. Extrinsic influences, such as surface conditions, improper equipment setup, slope, ergonomics, and the design of the home, contribute to the strain. Finally, insufficient recovery, including inadequate rest, sleep, or nutrition, limits the body’s ability to heal, thereby increasing its susceptibility to bone, muscle, tendon, and ligament injuries.1,5

The overuse injuries often follow a predictable course: discomfort appears after activity, then during activity without affecting performance, later progressing to pain that limits activity, and in advanced stages, discomfort may be present even at rest.6,7

Individuals with CNS disorders encounter additional challenges, such as muscle weakness, spasticity, reduced motor control, and diminished proprioception that can create imbalances among muscle groups, further increasing injury risk. Research also shows that long-term reliance on assistive devices (wheelchairs, crutches, walkers) is associated with altered joint biomechanics, intra-articular stress, and compensatory movements that contribute to overuse injuries.7,8

Epidemiology including risk factors and primary prevention

Overuse injuries are highly prevalent among people with CNS disorders, especially in patients who sustained a SCI. These injuries often affect the shoulder, elbow, wrist, and hand due to the increased reliance on upper limbs for mobility and activities of daily living.5 Some of the most common injuries include:

  • Shoulder injuries: The main complaint of these patients is shoulder pain, whose etiology is multifactorial. The prevalence of pain symptoms ranges from 70%-80% in spinal cord injury and 20%-50 % of stroke survivors overall.5,9
    • Shoulder pain in paraplegics and tetraplegics is most likely to be orthopedic or musculoskeletal-related (approximately 80%).
    • Rotator cuff (RC) injuries: rates above 60% in manual wheelchair users, with progression over time and risk factors including age, duration of wheelchair use, and wheelchair sports participation.5
    • Impingement syndrome: Incidence as high as 75% in symptomatic shoulder pain patients with SCI.10
    • 5Bicipital tendinitis: The incidence has yet to be described in the literature; however, it remains a common cause of referred shoulder pain in patients with SCI.
  • Elbow injuries:
    • Entrapment mononeuropathies are around 67% with ulnar neuropathy at the elbow (UNE)/cubital tunnel syndrome being around 10%.5
  • Wrist and hand injuries are common, with pain symptom prevalence ranging from 9% to 63%, depending on activity level, time since injury, and other factors. Common conditions include median nerve entrapment, and De Quervain’s tenosynovitis.5
  • Myofascial pain of the neck and low back with incidence over 50% of patients.

Several modifiable and non-modifiable factors contribute to the increased risk of overuse injuries in this population. Non-modifiable risk factors include a higher level of lesion (e.g., thoracic vs. lower levels), as higher lesion levels often indicate less trunk control and increased strain on the arms; longer duration since injury or longer daily wheelchair use time; and older age. Modifiable risk factors include a higher body mass index (BMI), wheelchair propulsion style and frequency, greater use of assistive devices, and transfer techniques.5,11,12

Patho-anatomy/physiology

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, bone, nerve, and cartilage. Physical stressors are thought to be potentiating factors in overuse injuries. This includes the amount of force involved, duration of the stressor, and localization of the stressor. Repetitive forceful action increases risk of injury to tendons especially.13 Furthermore, non-neutral or awkward positions increase the stress on specific structures instead of allowing for distribution of force using proper ergonomics. This, again, leads to increased risk of injury to these targeted structures.13 As overuse injuries eventually lead to an impairment in the tissue’s ability to heal, it is important to prevent these injuries to avoid any decrease in function.14

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 but vary between individuals. Assistive devices, such as wheelchairs, often subject patients to overuse injuries. Poorly fitted backrests lead to poor posture, increased kyphosis, and reduced propulsion efficiency. Over time, manufacturers and prescribers have worked to improve wheelchair ergonomics to reduce the risk of overuse injuries. Wheelchair backs that support spinal curves have shown to improve posture, increase propulsion skills, and increase user comfort and stability.15

Overuse injuries pass through an acute and subacute phase in which ongoing microtrauma occurs. When an injury advances to the chronic phase, 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

In a 2014 prospective cohort study evaluating newly injured persons with SCI, three trajectories of self-reported musculoskeletal shoulder pain were identified: “No or Low pain” (64%, n=148), “High Pain” (30%, n=63), and “Decrease of pain” (6%, n=14). It was found that the two most likely predictors for “high pain” were tetraplegia and limited shoulder range of motion.17

Essentials of Assessment

History

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

Other items to be considered in the history are time elapsed from initial CNS disorder, previous diagnostic evaluations, previous attempted treatment options and efficacy, any recent changes in assistive devices, 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, active and passive range of motion (ROM), and a neurologic exam including manual muscle testing, sensation, and reflexes, are key. It is often helpful to have the individual demonstrate the maneuver 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

  • Rotator cuff tear
    • Supraspinatus: Empty can, Drop arm test
    • Infraspinatus: Hornblower’s test
    • Subscapularis: Lift off test
  • Impingement: Neer’s and Hawkin’s tests
  • Bicipital tendinitis: Speed’s and Yergason’s tests
  • Lateral epicondylitis: Cozen’s test
  • De Quervain’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 are central to identifying risk factors for upper limb overuse injuries. For wheelchair set up, modern motion analysis and wearable sensor studies confirm that rear-axle positioning and maintaining 100–120° of elbow flexion during propulsion are associated with reduced peak shoulder load and improved stroke efficiency, thereby lowering the risk of shoulder pain and injury.18 This degree of flexion is obtained by having the rear axle about 2 inches forward from the shoulders. Routine evaluation by rehabilitation providers is essential, as equipment needs and user biomechanics change over time, and improper setup (e.g., suboptimal axle placement or elbow angle) correlates with higher shoulder pain scores.19 For stroke and brain injury patients, functional assessment should also include scapular kinematics (e.g., increased internal rotation, anterior tilt, reduced upward rotation), and motor control caused by altered muscle recruitment patterns. These maladaptive patterns contribute to shoulder pain, impaired upper limb function, and increased risk of secondary musculoskeletal injury, including impingement and subluxation.20,21

Laboratory studies

Blood tests a are rarely needed unless systemic red flag signs or failure to respond to treatment to suggest alternate pathology.22

Imaging studies

Most overuse injuries can be diagnosed clinically however, imaging may be warranted for persistent pain, or diagnostic uncertainty. Plain radiographs can be used to exclude fractures, malalignment or osteoarthritis.  Musculoskeletal ultrasound is increasingly used as a first-line tool for soft-tissue. Ultrasound or MRI is the next step after inconclusive or negative radiographs when rotator cuff pathology is suspected. Ultrasound offers diagnostic accuracy comparable to MRI for full-thickness tears (90–95% range), though it is more operator-dependent and less reliable for partial-thickness lesions.23 In neurologic populations, it is especially valuable for identifying hemiplegic shoulder pathology in stroke and monitoring overuse syndromes in wheelchair users.

Electrodiagnostic testing

Electrodiagnostic studies may be considered to evaluate for entrapment injuries, radiculopathies or a more generalized process if pertinent (e.g., neuropathy). In a multicenter cross-sectional study, Yang et al. found that 78% of manual wheelchair users with spinal cord injury had electrophysiologic evidence of median mononeuropathy, highlighting the high prevalence and functional impact of carpal tunnel syndrome in this group. EMG and NCS are valuable for differentiating peripheral entrapments from central motor deficits, quantifying severity, and guiding surgical decision-making.22

Supplemental assessment tools

A variety of standardized assessment tools are available to evaluate shoulder pain, function, and the impact on daily living, particularly in populations with SCI. These tools can include both clinician-administered and patient-reported measures, offering complementary perspectives on impairment, activity limitation, and participation restriction.

  • 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. It is the most used instrument in spinal cord injury (SCI) populations. It is reliable, low burden, and sensitive to intervention effects, though less detailed for pain type/frequency.
  • 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.
  • Patient-Reported Outcome Measures (PROMs): Standardized questionnaires that ask patients report their symptoms, functional limitations, and quality of life. PROMs provide valuable insight into the patient’s perspective and help track treatment response over time however, should always be used in combination with objective measures, since self-report alone not be an accurate assessment of functional ability.
    • DASH (Disabilities of the Arm, Shoulder, and Hand): Broad upper-extremity measure capturing difficulty with daily activities and symptom severity.
    • SPADI (Shoulder Pain and Disability Index): Focuses specifically on pain and shoulder-related disability.
    • SST (Simple Shoulder Test): A quick 12-question self-report tool on functional capacity in common tasks (e.g., lifting, reaching).24

Environmental

Regular review of the layout of the individual’s home, automobile and/or work environment support safer function and long-term independence. Guidelines recommend minimizing overhead activity, optimizing transfers with assistive devices and seating adjustments, and incorporating ergonomic strategies such as adaptive driving controls. For stroke, lowering storage, using one-handed tools, and avoiding overhead pulley exercises help reduce hemiplegic shoulder pain.25

Social role and social support system

The recovery and prevention of overuse injuries in individuals with CNS disorders are heavily moderated by their social environment. Their social support systems, including family caregivers, peer mentors, and formal community resources, help these patients to adhere to rest periods, modify activity patterns, utilize assistive technologies appropriately, and persist with rehabilitation regimens. Studies indicate that for individuals with SCI, factors such as caregiver skills training, community-based support services, social connectedness, and the use of constructive coping mechanisms play a vital role in maintaining caregiving capacity and enhancing overall quality of life. Conversely, lack of support, fragmented care, and caregiver strain increase the risk of non-adherence, delayed recovery, and potentially a higher likelihood of injury due to overcompensation or misuse.26

Strong perceived social support has also been found to buffer against negative psychological outcomes post-injury. For instance, in neurological populations (e.g., acquired brain injury, cerebral palsy, spina bifida), peer support interventions have been associated with improvements in quality of life, reduction in social isolation, and better engagement with self-management strategies. These interventions help patients share strategies for pacing activity, recognizing early symptoms of overuse, and preventing progression of injury. Thus, social role and support are integral to preventing, managing, and recovering from overuse injuries in CNS disorders.27

Professional issues

Shoulder pain intensity was inversely related to quality of life, social integration and physical activity scores. Ergonomic workplace assessments of the workplace environment can identify alternative equipment or modified setups to minimize repetitive strain and reduce overuse demands.

Rehabilitation Management and Treatments

Available or current treatment guidelines

A widely accepted pain assessment algorithm in SCI, including musculoskeletal pain from overuse, was initially developed in the early 2000s. However, recent literature continues to build on its principles with evidence-based strategies.28

New onset/acute

The primary goal during this phase is to control inflammation and pain while avoiding further tissue damage. Management includes the PRICE protocol—Protection, Relative rest, Ice, Compression, and Elevation. NSAIDs, either oral or topical, may be used short-term to control inflammation. Splinting is recommended when indicated to provide joint protection and rest. Physical modalities that may be helpful include therapeutic ultrasound, iontophoresis with corticosteroids, and paraffin baths, particularly for upper limb overuse. Corticosteroid injections can be used judiciously for targeted pain relief, and the development of ultrasound-guided techniques has improved the accuracy and safety of these procedures.

Subacute

The focus in this phase is on preventing further injury and addressing contributing biomechanical and ergonomic factors. Ergonomic re-evaluation is essential, including ensuring proper wheelchair fit in terms of seat depth, backrest height, and cushion angle, as well as optimizing handrim access and push mechanics. Posture and alignment should be optimized to reduce reliance on muscular compensation, and interventions such as spine bracing or posture feedback technology may be considered. Targeted therapeutic exercises aimed at strengthening and increasing flexibility, particularly in the rotator cuff and scapular stabilizers, are supported by evidence. Specifically, shoulder pain has been shown to decrease, with reductions in the WUSPI score demonstrated across multiple studies (8 RCTs, 9 cohort studies).29 Activity modification strategies include training in joint protection, task pacing, and using adaptive tools. High-intensity aerobic exercise, such as modified double-poling ergometry, performed three times per week for 10 weeks, has been shown to reduce both neuropathic and musculoskeletal pain.

Chronic/stable

The goal in this phase is to preserve function, minimize long-term musculoskeletal degeneration, and support independence. Wheelchair upgrades, such as pushrim-activated power-assist wheelchairs (PAPAW), can reduce the metabolic and biomechanical demands of manual wheelchair propulsion.30 When pain limits function or safety, transitioning to powered mobility should be considered, especially for individuals with irreversible joint damage. Surgical management may be appropriate for certain conditions such as carpal tunnel syndrome or rotator cuff tears, but careful pre-operative planning is necessary to avoid compromising the individual’s independence during recovery. Regenerative techniques may also be considered prior to surgery. These include treatments such as platelet-rich plasma (PRP), which has shown mixed but potentially beneficial outcomes in improving tendon function and reducing pain.31 Extracorporeal shockwave therapy (ESWT) has also proven effective in cases such as calcific tendinitis and lateral epicondylitis, and may play a role in reducing pain and improving function.32

Pre-terminal or end-of-life care

At this stage, pain management should prioritize comfort through multimodal strategies. Interventions that increase the burden without offering clear benefit should be avoided.

Coordination of care

It is beneficial to coordinate evaluation with physical and occupational therapy, particularly concerning functional transfers, push mechanics, use of adaptive equipment, and proper wheelchair fitting. When available, workplace assessments can provide valuable insights into work environment setup and allow for recommendations regarding ergonomic or equipment modifications that may reduce joint strain and injury.

Patient and Family Education

Education on proper body mechanics, push mechanics, and joint protection strategies should be extended to caregivers and family members. This enables them to help reinforce these practices with the patient at home. Proper training can be effectively delivered through coordinated efforts by the rehabilitation team.

Cutting Edge/Emerging and Unique Concepts and Practice

There are ongoing developments in smart assistive technologies, including adaptive control systems that use AI and machine learning to dynamically adjust wheelchair settings based on user performance.33 Regenerative medicine is an expanding field offering non-surgical options for treating chronic overuse injuries. Although SCI-specific data is limited, early pilot trials are underway. Neuromodulation techniques—such as transcutaneous spinal cord stimulation (tSCS) and vagal nerve stimulation—are also being explored for their potential to modulate chronic pain.

Gaps in the Evidence-Based Knowledge

Several gaps remain in the literature. CNS disorders are underrepresented, as most overuse injury data comes from SCI populations, with limited information available for stroke, traumatic brain injury (TBI), multiple sclerosis (MS), or cerebral palsy (CP). Longitudinal studies tracking overuse patterns and long-term functional outcomes are also lacking. There is a clear need for tailored treatment guidelines, given the differences in biomechanics, pain physiology, and neuroplasticity between CNS and musculoskeletal populations. Additionally, preventive strategies such as early wheelchair prescription, orthotic support, and load-reducing interventions remain underutilized.

References

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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

Christian Lopez-Aponte, MD, Manuel F Mas, MD. Overuse Injuries in Disorders of the Central Nervous System. 9/1/2022

Author Disclosure

Erika Trovato, DO
Nothing to Disclose

Anju Sanchala, DO
Nothing to Disclose

Kenia Maldonado Vergara, MD
Nothing to Disclose

Abner Vazquez Pabon, MD
Nothing to Disclose

Margaret Wilson, DO
Nothing to Disclose