Significant pain has been defined as pain requiring analgesic medication, pain associated with two or more activities of daily living (ADLs), or pain severe enough to result in cessation of activity.1 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 (ADL).2 In addition to mobility and ADLs, sporting activities place increased load and repetitive stress through the shoulders of manual wheelchair users.3 It is important to note that shoulder pain in the wheelchair athlete may have numerous possible causes including rotator cuff pathology, acromioclavicular joint pathology, subacromial impingement, supraspinatus tendinopathy, and biceps tendinopathy.
- Overuse. There have been multiple studies that support the theory that overuse is a major contributor to shoulder pain in wheelchair users and athletes.4-7 Individuals who are dependent upon a wheelchair for mobility use their upper extremities above their shoulder level with regularity and have high loads on their shoulders.
- 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 and anterior capsule as well as compensatory lengthening posteriorly and relative weakness of the scapula thoracic muscles.8 Abnormal positioning of the scapula, disturbances in scapula humeral rhythm, and generalized shoulder dysfunction can result.9
- Forces. The shoulder is subject to a repetitive and continuous load during the push phase of wheelchair propulsion.10 In addition, higher-intensity wheelchair propulsion during many wheelchair sports increases superior shoulder joint forces, which can result in superior translation of the humeral head and subsequent compression of the subacromial structures against the overlying acromion.5
- Muscle imbalances. A previous study found that the shoulders of wheelchair athletes were significantly stronger in abduction, adduction, external rotation, and internal rotation compared to able-bodied athletes. However, the ratio of abduction to adduction strength was 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. Further evidence was provided by the same study, which showed that shoulders of individuals with rotator cuff impingement syndrome were weaker in adduction as well as external and internal rotation compared to individuals without impingement.11
- Trauma/falls. Shoulder pain can also result from direct trauma or falls.
Epidemiology including risk factors and primary prevention
- Prevalence. There is a large range in prevalence of wheelchair athletes with shoulder pain, ranging from 40% to 78%.7,12-16 A recent review including 11 articles found the prevalence of shoulder pain ranged from 38% to 75% among wheelchair basketball players.17
- Risk factors:
- Neurologic level. Several studies have shown a higher prevalence of shoulder pain in patients with tetraplegia compared to paraplegia.1,18 Partial innervation and impaired balance of shoulder, scapular, and thoracohumeral muscles may place individuals with tetraplegia at higher risk for developing shoulder pain, especially during activities such as athletics.However, overuse injuries are more common in persons with paraplegia.19
- Duration of injury. There are conflicting studies regarding the relationship between duration of injury and shoulder pain in wheelchair users.19
- Gender. There is also mixed evidence supporting female gender as a risk factor for shoulder pain.20,21
- Trunk control. Athletes with low trunk control experienced more pain when compared to athletes who had better trunk control.22,23
- 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.13,24-26
- Other. Additional risk factors include higher body-mass index (BMI)27, smoking, diabetes, cardiac disease, and other systemic illnesses.19,28,29
- Primary Prevention. Primary prevention techniques include avoiding excessive overhead maneuvers, proper wheelchair fit, using the lightest wheelchair possible, and performing level or downward transfers.30
Normal shoulder anatomy/physiologic changes in wheelchair athletes
- Normal shoulder anatomy.
- Joints. The shoulder is composed of four joints: the glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), and the scapulothoracic (ST), with most movement occurring at the GH joint.31
- Ligaments. The ligamentous restraints of the glenohumeral joint are the inferior glenohumeral ligament (IGHL), the middle glenohumeral ligament (MGHL), and the superior glenohumeral ligament (SGHL).31
- Innervation. Innervation of the shoulder complex is mainly through the C5 through C7 nerve roots, via the brachial plexus.31
- Vascular. 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.31
- Movement. 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 5:4.31
- Physiologic changes in the wheelchair athlete.
- Rotator cuff. Given that only 25-30% of the humeral head is in contact with the glenoid fossa at one time, the muscles and ligaments surrounding the GH joint are tantamount in maintaining stability.32 The rotator cuff complex is comprised of the supraspinatus, subscapularis, teres minor, and infraspinatus muscles. The rotator cuff produces a downward force on the humeral head, counterbalancing the upward migration of the humeral head by the deltoid muscles during humeral elevation and wheelchair propulsion.11 The middle deltoid, acting as a shoulder flexor, is the main contributor to total mechanical power during the initial third of the push phase. The pectoralis major, anterior deltoid, and infraspinatus muscles generate the majority of total mechanical power for the remainder of the push phase. At the end of the push phase, the middle deltoid, subscapularis, and latissimus dorsi muscles act to absorb the arm’s power. The infraspinatus muscle contributes the most to hand-rim propulsion power compared to any other muscles, but it is also responsible for GH joint stabilization. Given the dual role of the infraspinatus muscle, it may be more susceptible to fatigue compared to other rotator cuff muscles.33
- Muscles imbalances. Discussed previously in “Etiology” section.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Due to the factors discussed in previous sections, wheelchair athletes are increased risk for development of acute shoulder pain secondary to multiple causes including rotator cuff pathology, acromioclavicular joint pathology, subacromial impingement, supraspinatus tendinopathy, and biceps tendinopathy.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.31
Loss of ROM can become more pronounced in patients with chronic shoulder pain. 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.31
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 to identify distinct trajectories of musculoskeletal shoulder pain and to determine possible predictors of these trajectories. The authors identified three distinct shoulder pain trajectories: 64% of participants had low or no pain during the duration of the study, 30% had stably high pain throughout the duration of the study, and 6% had decreased pain over the duration of the study. Having tetraplegia and having limited shoulder ROM were the two significant predictors for the high pain group. Somewhat surprisingly, no group was found to have worsening pain over the first five years post-SCI.34
Specific secondary or associated conditions and complications
- Restricted motion of posterior shoulder muscles.19
- Rotator cuff tendinitis/shoulder impingement syndrome.19
- Bicipital tendinitis.29
- Myofascial pain syndrome, trigger points of trapezius and parascapular musculature.27
- AC or GH joint osteoarthritis.19
- Acromioclavicular joint injuries.19
- Distal clavicle osteolysis.19
- Humeral head osteonecrosis.19
- Anterior shoulder dislocation.19
- Adhesive capsulitis.19
- Distal clavicle and first rib stress fractures.19
Essentials of Assessment
- Pain assessment (onset, duration, quality, intensity, location, radiation, aggravating or alleviating factors such as repetitive movement, uphill WC propulsion, overhead activities, and transfers).35
- For patients with spinal cord injury, identify motor and neurologic level of injury.36
- Treatment to date, current medications.
- Wheelchair type (manual, power-assist, power) and set-up.
- Home and athletic environment.
- Review of systems.
- Past medical history which should review any cardiopulmonary comorbidities.
- Evaluation includes a full neuromuscular examination, including the following:28
- 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.
- Special tests:28
- 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.
- Assess for pain interference with mobility, transfers, self-care, ADL, cognition, and mood.28
- Assessment of patient’s posture, ability to perform pressure relief techniques, transfer capability and techniques for all surfaces, wheelchair set-up and propulsion.28
- Review of work, home, community, athletic, and driving environments.28
- Laboratory studies ordered would depend on other suspected non-musculoskeletal cause for shoulder pain, such as referred pain from acute abdomen or cholecystitis/ cholelithiasis.28
- Lab studies can check for diabetes, hypothyroidism, alcoholism, and other risk factors for rotator cuff tendinopathy but are typically not needed.28
- 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 techniques37 will help assess bony pathology, (i.e., fractures, degenerative joint changes, rotator cuff outlet narrowing, AC joint, GH joint congruency, acromial type).31
- 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.31
- Ultrasonography: Operator-dependent. Can evaluate acromioclavicular pathology, partial or full-thickness rotator cuff tears or tendinosis, biceps tendon pathology, subacromial or glenohumeral joint effusions.38
- Magnetic resonance imaging (MRI): Main modality used for diagnosis of soft tissue injury such as rotator cuff tendinopathy, bursitis, or ligamentous injury.31
- MR arthrogram: Can help identify labral injuries or capsular pathology, chondral defects.31
Supplemental assessment tools
- 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).28,39
- SF-36: Health-related quality of life.28,40
- Brief Pain Inventory: Nine questions measuring interference with activity, sleep, mood, relationships, walking, work, enjoyment of life, pain on that day, and location.28
- 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.41
- International Spinal Cord Injury Pain Basic Data Set (ISCIPDS): Clinically relevant information concerning SCI-related pain. Measures impact of pain upon physical, social/emotional function, and sleep.28,42
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.28,30,43-45
- Modification of the work, home, community and driving environments.19,28,30
- Wheelchair modifications which reduce forces upon the shoulder, including moving the axle forward and using lightweight materials.19,28,30,44
- Modifying athletic equipment: e.g., in tennis, looser string tension will provide more stroke power and reduce forces on the shoulder.46
- 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.
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.30
The American Academy of Orthopaedic Surgeons issued a guideline for optimizing the management of rotator cuff problems.47
Future treatment guidelines should 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.28
Topics that should be addressed in future treatment guidelines include:
- Control of pain and inflammation.
- Rest and activity modification.
- Evaluation of posture and wheelchair set-up.
- Review of ADLs.
At different disease stages
- Oral pharmacologic interventions (non-steroidal anti-inflammatory drugs–NSAIDs, acetaminophen).
- Corticosteroid injections.
- Physical and/or occupational therapy.
- Modalities (ice, transcutaneous electrical stimulation, ultrasound).
- Relative rest or activity modification.
- Targeted therapy to muscles that stabilize the shoulder joint.
- Functional rehabilitation should be initiated to restore shoulder complex flexibility, 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.11
- 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 muscles: Focused cuff strengthening.
- Shoulder adductors.
- Primary humeral head movers.
- Endurance training.
- Postural control.
- Avoid tasks above shoulder height.
- Manual wheelchair propulsion is associated with vertically-oriented forces that increase during fast and inclined propulsion, as well as with fatigue.
- Provide lightest possible wheelchair.
- Proper set-up ensures fluid motion.
- 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 100-120o of flexion.
- Altering ADLs.
- Adaptive equipment.
- Consider power chair or push-rim-assist for daily use.
- NSAIDs are controversial since overuse injuries appear to be degenerative rather than an inflammatory tendinitis.
- Steroid injections may compromise healing potential, weaken tissue, and predispose an individual to further injury.
- Relative rest or activity modification.
- Functional rehabilitation.
To address injuries resulting from repetitive stroke pattern of wheelchair propulsion and the related subacromial pain, Curtis et al proposed a rehabilitation regimen involving three exercises for strengthening the posterior shoulder and two stretches for the anterior shoulder based.12 Van Straaten et al proposed a 12-week, high-dose scapular stabilization and rotator cuff strengthening program via telehealth, which was shown to decrease shoulder pain at 12- and 24-week follow-ups in wheelchair users with spinal cord injury.48 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. This could be done in a clinic appointment, practice session or during play.
Patient & family education
- Early identification of overuse problems may allow intervention before the condition becomes chronic.
- 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.49
Heyward et al emphasized the need to balance physical activity with the need to avoid overloading the shoulder girdle complex. The authors proposed investigating structured strength training regiments designed to counterbalance the strains of the repetitive wheelchair stroke pattern.21
Tools to track performance related shoulder pain in wheelchair athletes
Wheelchair User’s Shoulder Pain Index (WUSPI)14,39
Shoulder Pain and Disability Index (SPADI)50
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.3,28
Use of proper equipment that promotes better biomechanics and fits the athlete well.28,30,44
Cutting Edge/ Emerging and Unique 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.28,30,44 Functional stimulation assisted rowing has been demonstrated to significantly reduce chronic shoulder pain in manual wheelchair users with spinal cord injury.51
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.28,29,44,52 As mentioned earlier, there are no studies examining the trajectory of shoulder pain in wheelchair athletes over time.
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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. 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
Nothing to Disclose
Kelsey Gliesing, PT, DPT
Nothing to Disclose