Shoulder Problems – Pain in the Wheelchair Athlete

Disease/Disorder

Definition

The shoulder is the most common site of musculoskeletal pain among individuals who depend upon their upper limbs for mobility, transfers, and activities of daily living (ADLs). ^1,2 In addition to mobility and ADLs, sporting activities place increased load and repetitive stress through the shoulders of manual wheelchair users leading to rotator cuff pathology, acromioclavicular joint pathology, subacromial impingement, and biceps tendinopathy.

Etiology

• Overuse. There have been multiple studies that illustrate how shoulder overuse is a major contributor to shoulder pain in wheelchair users and athletes, especially with excessive overhead functional movements, increasing overall load.³
• Posture. Typical seated posture in a manual wheelchair user consists of posterior pelvic tilt, increased thoracic kyphosis, and forward head position, which can lead to abnormal shortening of the pectoral muscles, tightening of the anterior capsule of the glenohumeral joint, compensatory lengthening posteriorly, and relative weakness of the scapulothoracic muscles.⁴
• Forces. The push phase of wheelchair propulsion subjects the shoulder to repetitive and continuous load, with increased intensity during sport and faster propulsion.⁵
• Muscle imbalances. While the shoulders of wheelchair athletes are significantly stronger than in sedentary individuals, the ratio of abduction to adduction strength was found to be considerably higher in individuals with paraplegia, indicating relative weakness in shoulder adductors. This imbalance of stronger abductors compared to adductors is thought to create a pull on the humeral head in a cephalad direction, leading to migration of the humeral head and narrowing of the acromiohumeral head distance.⁶
• Trauma/falls. Shoulder pain can also result from direct trauma or falls.
• Metabolic disease. In the general population of people who do not use wheelchairs as a means of propulsion, metabolic disease is a significant risk factor for shoulder pain from a number of defined shoulder conditions. In the ambulatory population, adiposity and diabetes are known risk factor for rotator cuff muscle and tendon changes, as well as shoulder osteoarthritis, implying there are independent direct effects of metabolic disease on development of painful shoulder conditions even in the absence of repetitive loading.

Epidemiology including risk factors and primary prevention

• Prevalence. The prevalence of shoulder pain in wheelchair athletes ranges from 40-78%, as compared to 44% overall in the general wheelchair population. ^2,3,7
• Risk factors
  • Neurologic level. Several studies have shown a higher prevalence of shoulder pain in patients with tetraplegia compared to paraplegia, especially during sport.¹ However, overuse injuries are more common in persons with paraplegia.⁸
  • Duration of injury. Increased duration of injury is associated with upper extremity pain.²
  • Gender. Evidence is mixed supporting gender as a risk factor for shoulder pain.²
  • Trunk control. Athletes with low trunk control experienced more pain when compared to athletes who had better trunk control.¹⁰
  • Level of injury: Patients with SCI at a higher level are more likely to suffer from rotator cuff disorders.²
  • Sport. Participants of certain wheelchair sports, including wheelchair track, road racing, rugby, field events, and wheelchair basketball, have been shown to have a higher incidence of shoulder injuries.²
  • Other. Additional risk factors include higher body-mass index (BMI)², smoking, diabetes, cardiac disease, and other systemic illnesses.^8,12
• Primary Prevention. Primary prevention techniques include shoulder conditioning exercises, avoiding excessive overhead maneuvers, proper wheelchair fit, using the lightest wheelchair possible, control of BMI, and performing level or downward transfers.¹³

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

Wheelchair athletes may develop a variety of acute shoulder injuries including rotator cuff pathology, acromioclavicular joint pathology, subacromial impingement, and biceps tendinopathy.¹⁴ Acute injuries may result from an injury during a transfer, pushing the wheelchair to overcome an obstacle, or from lifting/carrying objects or the wheelchair itself.

Injuries may also be due to overuse, such as with repetitive propulsion or lifting.

Chronic injuries may include chronic tendinopathy (tendinosis, tendon tears), chronic labral degeneration, or development of osteoarthritis. Loss of range of motion (ROM) can become more pronounced in patients with chronic shoulder pain, where altered shoulder biomechanics stress the joints adjacent to the shoulder girdle proper.

There are no studies examining the trajectory of shoulder pain in wheelchair athletes over time. However, Eriks-Hoogland et al studied 225 newly injured individuals with SCI over 5 years identifying three distinct shoulder pain trajectories: 64% of participants had low or no pain, 30% had stable high pain, and 6% had decreased pain.¹⁷  

Specific secondary or associated conditions and complications

• Restricted motion of posterior shoulder muscles.⁸
• Rotator cuff tendinitis/shoulder impingement syndrome.⁸
• Bicipital tendinitis.⁸
• Myofascial pain syndrome, trigger points of trapezius and parascapular musculature.¹¹
• AC or GH joint osteoarthritis.⁸
• Acromioclavicular joint injuries.⁸
• Distal clavicle osteolysis.⁸
• Humeral head osteonecrosis.⁸
• Anterior shoulder dislocation.⁸
• Adhesive capsulitis.⁸
• Distal clavicle and first rib stress fractures.⁸

Essentials of Assessment

History

• Pain assessment.²
• For patients with spinal cord injury, identify motor and neurologic level of injury.²
• Treatment to date.
• Current medications.
• Handedness.
• Wheelchair properties.
• Home and athletic environment.
• Past medical history including cardiopulmonary comorbidities.

Physical examination

• Evaluation includes a full neuromuscular examination, including the following¹²
  • Inspection for atrophy, misalignment, or scars.
  • Wheelchair posture and fit.
  • ROM, flexibility, strength, and sensory testing.
  • Palpation of the supraspinatus tendon at its insertion on the greater tuberosity, biceps tendon in the bicipital groove, AC and GH joints, periscapular musculature.
  • Examine the non-affected shoulder to assess symmetry in muscle bulk as well as anatomic positioning.
• Special tests¹²
  • Subacromial impingement: Neer, Hawkins-Kennedy, Yocum, painful arc tests.
  • Rotator cuff muscle integrity: Jobe test, lift-off, resisted internal and external rotation.
  • Tests of glenohumeral instability: Sulcus sign, Cofield test, Jobe relocation test, jerk test.
  • Biceps Tendon, Labrum, and/or AC joint: Speed, Yergason, O’Brien and scarf tests.

Functional assessment

• Assess for pain interference with mobility, transfers, self-care, ADL, cognition, and mood.¹²
• Assessment of patient’s posture, ability to perform pressure relief techniques, transfer capability and techniques for all surfaces, wheelchair set-up and propulsion.¹²
• Review of work, home, community, athletic, and driving environments.¹²

Laboratory studies

• Suspicion for inflammatory arthritis, gout, or infections (such as Lyme disease) may require relevant laboratory workup.
• Laboratory studies may additionally be used to evaluate for a suspected non-musculoskeletal cause for shoulder pain, such as referred pain from acute abdomen or cholecystitis/cholelithiasis, as well as other illness such as diabetes, hypothyroidism, and alcoholism.¹²

Imaging

• Orthogonal shoulder radiographs: Anteroposterior (AP) internal rotation, scapular AP external rotation, and supraspinatus outlet views of both shoulders using standard plain radiographic techniques⁵ to assess bony pathology, (i.e., fractures, degenerative joint changes, rotator cuff outlet narrowing, AC joint, GH joint congruency, acromial type).¹⁴
• CT arthrogram: To assess for labral tears, distinguish partial thickness versus full-thickness rotator cuff tears, and examining patients with hardware that cannot undergo MRI.¹⁴
• Ultrasonography: Operator-dependent. Can evaluate acromioclavicular pathology, partial or full-thickness rotator cuff tears or tendinosis, biceps tendon pathology, subacromial or glenohumeral joint effusions.⁵
• Magnetic resonance imaging (MRI): Main modality used for diagnosis of soft tissue injury such as rotator cuff tendinopathy, bursitis, or ligamentous injury.¹⁴
• MR arthrogram: Can help identify labral injuries or capsular pathology, chondral defects.¹⁴

Supplemental assessment tools

• Wheelchair User’s Shoulder Pain Index (WUSPI): Self-reported measure of functional activities.¹²
• SF-36: Health-related quality of life.¹²
• Brief Pain Inventory: Assess impact of pain on daily function.¹²
• West Haven-Yale Multidimensional Pain Inventory: Measures impact of chronic pain upon the patients’ lives, responses of others to the patients’ communications of pain, and extent to which patients participate in common activities.¹⁹
• International Spinal Cord Injury Pain Basic Data Set (ISCIPDS): Measures impact of pain upon physical, social/emotional function, and sleep.¹²

Early predictions of outcomes

Early symptom recognition and initiation of treatment predict better patient outcomes. Other factors that improve outcomes include less severe pain, younger age, physical fitness and overall health, fewer medical comorbidities, sound wheelchair propulsion/transfer techniques and fit.^12,13,20

Environmental

• Specifically for wheelchair athletes an analysis of the training environment and training plan is crucial when overuse-type injury is suspected. An analysis of sports wheelchair or other equipment set up is paramount to identify any biomechanical risk factors, as is analysis of training plan for training errors such as sudden increases in intensity or duration of training
• Wheelchair and athletic equipment modifications which reduce forces upon the shoulder, including moving the axle forward and using lightweight materials.^8,12,13,20
• Modification of the work, home, community and driving environments.^8,12,13
• Social role and social support system.

Professional issues

N/A

Rehabilitation Management and Treatments

Available or current treatment guidelines

The recommendations that appear in Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals are applicable to the wheelchair athlete with shoulder pain.¹³

Guideline topics include

• Control of pain and inflammation.
• Rest and activity modification.
• Rehabilitation.
• Evaluation of posture and wheelchair set-up.
• Review of ADLs.
• Education.

At different disease stages

New onset/Acute^12,13

• Oral pharmacologic interventions (non-steroidal anti-inflammatory drugs–NSAIDs, acetaminophen).
• Corticosteroid or ketorolac injections.
• Physical and/or occupational therapy.
• Modalities (ice, transcutaneous electrical stimulation, ultrasound, Extracorporeal Shockwave Therapy).
• Relative rest or activity modification.
• Functional rehabilitation should be initiated to restore shoulder complex flexibility, stability, muscle strength/balance, and endurance.
  • Rehabilitation exercises should be performed with the arms below the height of the shoulder to prevent the risk of shoulder impingement.⁶
  • Stretching with the goal of restoring full painless ROM.
  • Strengthening the following muscle groups:
    • Scapular stabilizers: Restore control of the scapula to position of posterior tilt and external rotation.
    • Rotator cuff strengthening.
    • Shoulder adductors.
  • Primary humeral head movers.
• Endurance training.
• Postural control.

Sub-acute^12,13

• Avoid tasks above shoulder height.
• Provide lightest possible wheelchair.
• Beneficial adjustments include moving the rear axle forward to decrease rolling resistance and increase efficiency.
• Vertically position the rear axle so the hand is placed at top center position on the pushrim with elbow at 100-120^o of flexion.

Chronic/Stable^12,13

• Altering ADLs.
• Adaptive equipment.
• Consider power chair or push-rim-assist for daily use.
• Platelet-rich plasma (PRP) injections.
• Acupuncture.
• Relative rest or activity modification.
• Functional rehabilitation.
• NSAIDs use is controversial; use of NSAIDs for treatment of acute musculoskeletal injuries may impair healing. Use of NSAIDs for overuse injuries that appear to be degenerative rather than an inflammatory may be ineffective.
• Steroid and local anesthetic injection may lead to adverse long-term effects on the joint secondary to known chondrotoxicity, which could result in significant morbidity for a person who uses a wheelchair for mobility. Risk/benefit of injection therapy should be carefully considered.
• Surgery is reserved for failure of a high-quality program of non-operative management.

Coordination of care

Coordination of care involves the patient, family, friends, physician, physical and occupational therapists, wheelchair vendors and coaches.

Patient & family education

Early identification and appropriate training, form, conditioning, gear/wheelchair fit, and propulsion technique should be emphasized.

Return to play protocol

A general decision-based return to play (RTP) protocol should be considered for wheelchair athletes with shoulder pain. An ideal RTP criteria should be comprised of little/no pain, subjective satisfaction of the treatment by the patient, near normal ROM and strength, and normal functional ability and sport-specific skills.¹⁷

Tools to track performance related shoulder pain in wheelchair athletes

Wheelchair User’s Shoulder Pain Index (WUSPI)¹²

Shoulder Pain and Disability Index (SPADI)²¹

Translation into practice: practice “pearls”/performance improvement in practice (PIPs) / changes in clinical practice behaviors and skills

Promotion of appropriate preventative exercise program for wheelchair users to decrease shoulder injury, resulting in more functional pain-free years.¹²

Use of proper equipment that promotes better biomechanics and fits the athlete well.^12,13,20

Cutting Edge/Emerging and Unique Concepts and Practice

Lighter wheelchair materials such as aluminum, titanium, carbon fiber, and fiberglass frames decrease the loading forces on the shoulder joints and allow for higher speed, acceleration, and maneuverability.^12,13,20 Functional stimulation assisted rowing has been demonstrated to significantly reduce chronic shoulder pain in manual wheelchair users with spinal cord injury.²² Rotator cuff repair has been shown to demonstrate improvements in pain and functional outcomes in wheelchair users with rotator cuff tears.²³

Gaps in the Evidence-Based Knowledge

There are few studies of how changing a wheelchair configuration can prevent future shoulder injuries in a wheelchair athlete, and no studies examine the trajectory of shoulder pain in wheelchair athletes over time.^12,13

References

1. Sie IH, Waters RL, Adkins RH, Gellman H. Upper extremity pain in the postrehabilitation spinal cord injured patient. Arch Phys Med Rehabil. 1992; 73:44-48. 
2. Liampas A, Neophytou P, Sokratous M, et al. Musculoskeletal Pain Due to Wheelchair Use: A Systematic Review and Meta-Analysis. Pain Ther. 2021;10(2):973-984. doi:10.1007/s40122-021-00294-5 
3. Escobedo EM, Hunter JC, Hollister MC, Patten RM, Goldstein B. MR imaging of rotator cuff tears in individuals with paraplegia. AJR Am J Roentgenol. 1997; 168:919-923. 
4. Aytar A, Zeybek A, Pekyavas NO, Tigli AA, Ergun N. Scapular resting position, shoulder pain and function in disables athletes. Prosthet Orthot Int. 2015; 39(5):390-396. 
5. Blauwet CA, Chakraverty J, Derman W, Idrisova G, Martin P, Miller SC, Morrissey D, Webborn N. Shoulder Pain, Function, and Ultrasound-Determined Structure in Elite Wheelchair-Using Para Athletes: An Observational Study. Med Sci Sports Exerc. 2022 Jun 1;54(6):896-904. 
6. Burnham RS, May L, Nelson E, Steadward R, Reid DC. Shoulder pain in wheelchair athletes: the role of muscle imbalance. Am J Sports Med. 1993; 21(2):238-242. 
7. Curtis KA, Tyner TM, Zachary L, Lentell G, Brink D, Didyk T, Gean K, Hall J, Hooper M, Klos J, Lesina S, Pacillas B.. Effect of a standardized exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord. 1999; 37:421-429. 
8. Dyson-Hudson TA, Kirshblum SC. Shoulder pain in chronic spinal cord injury, part 1: epidemiology, etiology, and pathomechanics. J Spinal Cord Med. 2004; 27(1):4-17. 
9. Heyward OW, Vegter RJK, de Groot S, van der Woude LHV. Shoulder complaints in wheelchair athletes: a systematic review. PLoS ONE. 2017;12:1-20. 
10. Yildirim NU, Comert E, Ozengin N. Shoulder pain: a comparison of wheelchair basketball players with trunk control and without trunk control. J Back Musculoskelet Rehabil. 2010; 23:55–61. 
11. Boninger ML, Souza AL, Cooper RA, Fitzgerald SG, Koontz AM, Fay BT. Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion. Arch Phys Med Rehabil. 2002 May; 83(5):718-23. 
12. Scelza WM, Dyson-Hudson TA. Neuromuscular Complications of Spinal Cord Injury. In: Campagnolo, et al. Spinal Cord Medicine. Lippincott Williams & Wilkins (Wolters Kluwer Health), 2011: Kindle edition. Location 14247-14520. 
13. Consortium for Spinal Cord Medicine. Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2005; 28(5):434-470. 
14. Modarresi S, Jude CM. Radiologic evaluation of the painful shoulder. In: UpToDate, Ramirez MP (Ed), UpToDate, Waltham, MA. (Accessed on October 10, 2022). 
15. Soo Hoo J. Shoulder pain and the weight-bearing shoulder in the wheelchair athlete. Sports Med Arthrosc Rev. 2019; 27:42-47. 
16. Patel, RM, Gelber JD, Schickendantz MS. The weight-bearing shoulder. J Am Acad Orthop Surg. 2018; 26:3-13. 
17. Eriks-Hoogland IE, Hoekstra T, de Groot S, Stucki G, Post MW, van der Woude LH. Trajectories of musculoskeletal shoulder pain after spinal cor injury: identification and predictors. J Spinal Cord Med. 2014; 37(3):288-298. 
18. Jeon I-H, Kochhar H, Lee J-M, Kyung H-S, Min W-K, Cho H-S, Wee H-W, Shin D-J, Kim P-T. Ultrasonographic evaluation of the shoulder in elite wheelchair tennis players. J Sport Rehabil. 2010; 19(2):161–172. 
19. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain. 1985; 23(4):345-356. 
20. Mason BS, van der Woude LH, Goosey-Tolfrey VL. The ergonomics of wheelchair configuration for optimal performance in the wheelchair court sports. Sports Med. 2013; 43(1):23-38. 
21. Breckenridge JD, McAuley JH. Shoulder pain and disability index. J Physiother. 2011; 57(3):197. 
22. Wilbanks SR, Rogers R, Pool S, Bickel CS. Effects of functional electrical stimulation assisted rowing on aerobic fitness and shoulder pain in manual wheelchair users with spinal cord injury. J Spinal Cord Med. 2016; 39(6):645-654. 
23. Valiquette AM, Graf AR, Mickschl DJ, Zganjar AJ, Grindel SI. Rotator cuff repair in upper extremity ambulators: an assessment of longitudinal outcomes. JSES International. 2022 6(6):942-947

Original Version of the Topic

Jennifer Marie J. Yang, MD, Juan Carlos Ortiz Maldonado, MD. Shoulder problems – pain in the wheelchair athlete. 9/20/2014.

Previous Revision(s) of the Topic

Gaurav Telhan, MD, Daniel Areson, DO. Shoulder problems – pain in the wheelchair athlete. 9/6/2018.

Shawn Song, MD, Kelsey Gliesing, PT, DPT. Shoulder Problems – Pain in the Wheelchair Athlete, 12/14/2022

Author Disclosure

Anup Dupaguntla
Nothing to Disclose

Ziva Petrin, MD
Nothing to Disclose