Shoulder problems – pain in the wheelchair athlete

Author(s): Gaurav Telhan, MD and Daniel Areson, DO

Originally published:09/20/2014

Last updated:09/06/2018

1. DISEASE/DISORDER:

Definition

Pain and discomfort occur within the shoulder(s) of persons who depend upon their upper limbs for wheelchair mobility, transfers and activities of daily living (ADL).1  In addition to the stresses of daily life, wheelchair athletes put increased load and repetitive stress through their shoulders during sporting activities. 2   Increased external load can be broken down into three factors:  the amplitude and direction of the force, frequency of the force, and duration of the force. Deviation from one or more of the factor’s optimal values, results in damaging stress through the shoulder.3 Even every day wheelchair use, including propulsion at a low intensity, has been demonstrated through biomechanical models , to generate large amounts of force in the scapula-humero-thoracic musculature. 4

Etiology

  1. Overuse syndromes may result from the repetitive motion of propulsion. 5,6
  2. In sports that require speed, the increase in strokes per second (i.e., faster cadence) places higher demands on the upper limb.  5,9
  3. The shoulder must maintain a functional balance between stability and mobility. The stability of the joint is mainly dependent on active muscle control, with only a small amount of stability coming from the joint capsule, labrum, and ligaments.8
  4. Muscle strength imbalances within the rotator cuff, deltopectoral girdle and scapular stabilizers result from improper training, poor technique, and repetitive motion. 7,9
  5. Shoulder pain can also result from direct trauma or falls.

Epidemiology including risk factors and primary prevention

  1. There is a large range in prevalence of wheelchair athletes with shoulder pain, ranging from 16%10 to 76%.11
  2. Shoulder pain from all causes is more common in tetraplegia. Overuse injuries are more common in persons with paraplegia and longer duration since injury.9
  3. Increased weight also influence shoulder complaints in manual wheelchair users.12,13
  4. Risk factors include: years spent in wheelchair,14 female gender, higher body-mass index (BMI), older age.9It is also more common in those who smoke, have diabetes, cardiac disease, and other systemic illnesses. 1,9,15
  5. Reduced trunk control can also lead to shoulder pain in wheelchair athletes. Athletes with low trunk control experienced more pain when compared to athletes who had better trunk control. 16,17
  6. Such pain typically affects participants in track events, marathon road racing, basketball and tennis. 18
  7. Prevention techniques include avoiding excessive overhead maneuvers, proper wheelchair fit, using the lightest wheelchair possible, and performing level or downward transfers.  19

Normal shoulder anatomy/ Physiologic changes in wheelchair athletes

The shoulder is composed of four joints: the glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), and the scapulothoracic (ST). 20

The ligamentous restraints of the glenohumeral joint are the inferior glenohumeral ligament (IGHL), the middle glenohumeral ligament (MGHL), and the superior glenohumeral ligament (SGHL). 20

Innervation of the shoulder complex is mainly through the C5 through C7 nerve roots, via the brachial plexus.  20

The major arterial supply to the rotator cuff is derived from the ascending branch of the anterior humeral circumflex artery, the acromial branch of the thoracoacromial artery, as well as the suprascapular and posterior humeral circumflex arteries. Cadaver studies have demonstrated a hypovascular area within the critical zone of the supraspinatus tendon, and it has been suggested that this area of hypovascularity has a significant role in the degeneration of the tendon. 20

Scapulothoracic rhythm – glenohumeral motion is much greater than scapulothoracic motion for the first 30 degrees of abduction (ratio of 4:1 to 7:1). Over the subsequent 30-180 degrees of shoulder abduction, this ratio is closer to 5:4. 20

The high peak force placed on the supraspinatus, infraspinatus, and biceps brachii during the push phase, as well as the start and end of the recovery phase; can lead to fatigue of the rotator cuff muscles. This increased force leads to fatigue of the supraspinatus and infraspinatus which can further lead to excessive superior humeral head translation.21

  1. The rotator cuff musculature allows finely tuned asymmetric contractions to maintain the humeral head in the glenoid during active motions that may otherwise cause subluxation or shoulder instability. 20
  2. Curtis and Black suggest that suboptimal wheelchair driving posture (i.e. suboptimal arm elevation and torso position during propulsion) can lead to biomechanical shoulder dysfunction.22
  3. Jeon and colleagues indicate that abnormal scapular kinematics play a role in the development of shoulder complaints.23Kibler et al further explain that scapular dyskinesis – or the observable alterations in the position of the scapula and the patterns of its motion can be caused by several factors such as: abnormal posture while resting, alteration of muscle activation, and contractures.24 All of which may contribute to early scapular dyskinesis in wheelchair athletes.

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

In acute injury, pain is usually associated with decreased range of motion and positioning the shoulder to avoid pain; the affected arm is held in a dependent posture at the side. A visible or palpable deformity, edema or effusion may be present. Mid-deltoid pain is indicative of conditions such as inflammation or tears of the rotator cuff, degenerative arthritis, calcific tendinitis, labral tearing, avascular necrosis of the humeral head, localized bursitis, or adhesive capsulitis.20

The main contributing factors to shoulder pain in the wheelchair athlete are overuse, weakness in shoulder adduction, internal and external rotation.  Decreased trunk control is also associated with increased complaints of shoulder pain in wheelchair athletes.25

Patients with chronic history of shoulder pain can be more diagnostically challenging. The loss of ROM becomes more pronounced. Due to the lack of glenohumeral mobility, altered biomechanics of the shoulder would require a greater contribution from the scapulothoracic joint in order to perform activities of daily living. The patient may also stress the joints adjacent to the shoulder girdle proper; for example, greater and more frequent motion in the elbow may result in an epicondylitis. 20

Specific secondary or associated conditions and complications

  1. Restricted motion of posterior shoulder muscles 9
  2. Rotator cuff tendinitis/shoulder impingement syndrome 9
  3. Bicipital tendinitis 15
  4. Myofascial pain syndrome, trigger points of trapezius and parascapular musculature6
  5. AC or GH joint osteoarthritis 9
  6. Acromioclavicular joint injuries 9
  7. Distal clavicle osteolysis 9
  8. Humeral head osteonecrosis 9
  9. Anterior shoulder dislocation 9
  10. Adhesive capsulitis 9
  11. Distal clavicle and first rib stress fractures 9

2. ESSENTIALS OF ASSESSMENT

History

  1. Pain assessment (onset, duration, quality, intensity, location, radiation, aggravating or alleviating factors)
  2. For patients with spinal cord injury, identify motor and neurologic level of injury
  3. Treatment to date, current medications
  4. Handedness
  5. Wheelchair type (manual, power-assist, power) and set-up
  6. Home and athletic environment
  7. Review of systems
  8. Past medical history which should review any cardiopulmonary comorbidities.

Physical examination

  1. Evaluation includes a full neuromuscular examination, including the following:1
    • Inspection for atrophy misalignment or scars.
    • Seating posture in the wheelchair and wheelchair 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.
  2. Special tests:1
    • 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.
    • Speed, Yergason, O’Brien and scarf tests.

Functional assessment

  1. Assess for pain interference with mobility, transfers, self-care, ADL, cognition, and mood1
  2. Assessment of patient’s posture, ability to perform pressure relief techniques, transfer capability and techniques for all surfaces, wheelchair set-up and propulsion1
  3. Review of work, home, community, athletic, and driving environments1

Laboratory studies

  1. Laboratory studies ordered would depend on other suspected non-musculoskeletal cause for shoulder pain, such as referred pain from acute abdomen or cholecystitis/cholelithiasis.1
  2. Lab studies can check for diabetes, hypothyroidism, alcoholism and other risk factors for rotator cuff tendinopathy but are typically not needed1

Imaging

  1. Orthogonal Shoulder Radiographs – Views such as anteroposterior (AP) internal rotation, scapular AP external rotation, and supraspinatus outlet views of both shoulders using standard plain radiographic techniques 26 will help assess bony pathology, (i.e., fractures, degenerative joint changes, rotator cuff outlet narrowing, AC joint, GH joint congruency, acromial type).  20
  2. CT Arthrogram – labral tears, distinguish partial thickness vs. full-thickness rotator cuff tears, examining patients with hardware that cannot undergo MRI.  20
  3. Ultrasonography – operator-dependent. Can evaluate acromio-clavicular pathology, partial or full-thickness rotator cuff tears or tendinosis, biceps tendon pathology, subacromial or glenohumeral joint effusions27 20
  4. Magnetic Resonance Imaging (MRI) – radiographic study of choice for diagnosis of soft tissue injury such as rotator cuff tendinopathy, bursitis or ligamentous injury.  20
  5. MRI-Arthrogram – can help identify labral injuries or capsular pathology, chondral defects.  20

Supplemental assessment tools

  1. Wheelchair User’s Shoulder Pain Index (WUSPI) – self-reported measure of functional activities (transfers, wheelchair mobility, self-care, work/school activities, driving, household chores, sleeping).1,28
  2. SF-36 – health-related quality of life1,29
  3. Brief Pain Inventory – nine questions measuring interference with activity, sleep, mood, relationships, walking, work, enjoyment of life, pain on that day, and location.1
  4. West Haven-Yale Multidimensional Pain Inventory – impact upon the patients’ lives, responses of others to the patients’ communications of pain, and extent to which patients participate in common activities. 30
  5. International Spinal Cord Injury Pain Basic Data Set (ISCIPDS) – clinically relevant information concerning SCI-related pain. Impact of pain upon physical, social/emotional function, and sleep.1,31

Early predictions of outcomes

Early symptom recognition and initiation of appropriate treatment will predict better patient outcomes. Other factors that improve outcomes include less severe pain, younger age, better physical fitness and overall health, fewer medical comorbidities, sound wheelchair propulsion/transfer techniques, and using a wheelchair with proper ergonomic fit. 1,4,19,32

Environmental

  1. Modification of the work, home, community and driving environments. 1,9,19
  2. Wheelchair modifications which reduce forces upon the shoulder, including moving the axle forward and using lightweight materials. 1,9,19,32
  3. Modifying athletic equipment: e.g., in tennis, looser string tension will provide more stroke power and reduce forces on the shoulder. 33
  4. Social role and social support system

Shoulder pain can decrease the level of independence and increase the burden of care, with the patient requiring assistance with transfers, ADLs and wheelchair propulsion. Sports participation decreases and may affect the patient psychologically. This in turn can influence body habitus, affecting self-image. Education regarding shoulder pain and prevention involves the patient, family, friends, providers, vendors, teammates and coaches.

Professional Issues

N/A

3. 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. 34

The American Academy of Orthopaedic Surgeons issued a guideline for optimizing the management of rotator cuff problems. 35

There must be a focus on finding ways to strengthen and optimize shoulder function through training, without causing worsening damage to the shoulder through overuse

Treatment should focus on decreasing acute pain, addressing any secondary disabilities that may be caused by pain, and prevention.1

  1. Control pain and inflammation
  2. Rest and activity modification
  3. Rehabilitation
  4. Evaluation of posture and wheelchair set-up
  5. Review of ADLs
  6. Education

At different disease stages

New onset/Acute1,1819

  1. Oral pharmacologic interventions (non-steroidal anti-inflammatory drugs–NSAIDs, acetaminophen)
  2. Corticosteroid injections
  3. Physical and/or occupational therapy
  4. Modalities (ice, transcutaneous electrical stimulation, ultrasound)
  5. Relative rest or activity modification
  6. Targeted therapy to muscles that stabilize the shoulder joint
  7. Functional rehabilitation should be initiated to restore shoulder complex flexibility, muscle strength/ balance, and endurance
  8. Rehabilitation exercises should be performed with the arms below the height of the shoulder to prevent the risk of shoulder impingement. 36
  9. Stretching – goal: restore full painless ROM.
  10. Strengthening the following muscle groups
    • Scapular stabilizers – restore control of the scapula to position of posterior tilt and external rotation
    • Rotator cuff muscles – focused cuff strengthening
    • Shoulder adductors
    • Primary humeral head movers
  11. Endurance training
  12. Postural control

Sub-acute1,18,19

  1. Avoid tasks above shoulder height.
  2. Manual wheelchair propulsion is associated with vertically-oriented forces that increase during fast and inclined propulsion, as well as with fatigue.
  3. Provide lightest possible wheelchair.
  4. Proper set-up ensures fluid motion.
  5. Beneficial adjustments include moving the rear axle forward to decrease rolling resistance and increase efficiency.
  6. Vertically position the rear axle so the hand is placed at top center position on the pushrim, elbow 100-120 flexion.

Chronic/Stable1,18,19

  1. Altering ADLs
  2. Adaptive equipment
  3. Consider power chair or push-rim-assist for daily use.
  4. NSAIDs are controversial since overuse injuries appear to be degenerative rather than an inflammatory tendinitis.
  5. Steroid injections may compromise healing potential, weaken tissue and predispose an individual to further injury.
  6. Modalities
  7. Acupuncture
  8. Relative rest or activity modification
  9. Functional rehabilitation
    1. To address injuries resulting from repetitive stroke pattern of wheelchair propulsion and the related subacroimal pain, Curtis et al propose a rehabilitation regimen involving three exercises for strengthening the posterior shoulder and two stretches for the anterior shoulder based.37
  1. Surgery – 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. This could be done in a clinic appointment, practice session or during play.

Patient & family education

  1. Early identification of overuse problems may allow intervention before the condition becomes chronic.
  2. Appropriate training, form, conditioning, gear and 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.38

Heyward et al emphasize the need to balance physical activity with the need to avoid overloading the shoulder girdle complex.  Heyward et al propose investigating structured strength training regiments designed to counterbalance the strains of the repetitive wheelchair stroke pattern.39

Tools to track performance related shoulder pain in wheelchair athletes

Wheelchair User’s Shoulder Pain Index (WUSPI) 28

Shoulder Pain and Disability Index (SPADI) 35

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

Promotion of appropriate exercise for wheelchair users is encouraged to decrease shoulder injury, resulting in more functional pain-free years.1,2\

Use of proper equipment that promotes better biomechanics and fits the athlete well.1,19,32

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Lighter wheelchairs allow for higher top speeds and acceleration and increased maneuverability. This includes aluminum, titanium, carbon fiber and fiberglass frames. Lighter wheelchair materials decrease the loading forces on the shoulder joints, reducing the risk of injury.1,19,32

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

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. .1,15,32,40 There are few if any studies specific and transferable to athletes competing in  wheelchair sports.16

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Original Version of the Topic

Jennifer Marie J. Yang, MD, Juan Carlos Ortiz Maldonado, MD. Shoulder problems – pain in the wheelchair athlete. Original Publication Date: 09/20/2014.

Author Disclosure

Gaurav Telhan, MD
Nothing to Disclose

Daniel Areson, DO
Nothing to Disclose

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