Author(s): Stephen Luebbert, MD, FAAPMR, CAQSM, Raquel Johnson, MD, Brenton Bohlig, MD, FAAPMR, CAQSM
Originally published: September 20, 2013 Last updated: April 24, 2025
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Disease/Disorder

Definition

Sports medicine of athletes with disabilities includes screening, injury prevention, diagnosis, and treatment of the physically and/or intellectually impaired athlete.

Classification of participants varies between governing bodies to ensure fair competition. The International Paralympic Committee recognizes 10 permanent impairments within three domains (physical, visual, intellectual): hypertonia, ataxia, athetosis, loss of muscle strength, loss of range of movement, loss of limb, limb deficiency, short stature, low vision, or intellectual impairment.1  For the intellectually disabled athlete, the Special Olympics defines its allowed participants as being at least 8-years-old and identified by an agency or professional as meeting these three criteria: IQ below 70, significantly limited adaptive behaviors in conceptual, social, or practical skills, and condition manifestation before age 22.2 Each sport and eligible impairment are classified in order to maintain a fair playing field.

Etiology

In the U.S., 44.7 million individuals have disabilities,3 with about 2 million participating in sports.4 The Paris 2024 Summer Paralympic Games included 4,400 athletes from 160 countries in 22 sports.5 Athletic activity may benefit this population with increased exercise endurance, muscle strength, cardiovascular efficiency, functionality, life skills, self-esteem, and overall quality of life.1

Epidemiology including risk factors and primary prevention

Lower extremity injuries are more common among ambulant para-athletes (visually impaired, amputee, cerebral palsy), whereas upper extremity injuries are more frequent in non-ambulant athletes.4 A six-year longitudinal study on reported injuries from disabled sports organizations revealed medical illnesses (29.8%) were the most common, followed by muscular strains (22.1%), tendinopathy (9.5%), sprains (5.8%), contusions (5.6%), and abrasions (5.1%). The body part most commonly injured was the thorax/spine (13.3%), followed by the shoulder (12.8%), the lower leg/ankle and toes (12.0%), and the hip/thigh (7.4%).6 During the 2020 Summer Paralympic Games, a total of 386 injuries were reported in 352 athletes, with an injury incidence rate of 5.8 injuries per 1000 athlete days.7 Sled hockey, as well as Para swimming, have been found to have a higher incidence of sports-related concussions (SRC) when compared to similar able-bodied athletes. SRC incidence is similarly increased in Para athletes with visual impairments as well as in women.8

Patho-anatomy/physiology

As with the able-bodied athlete, repetitive use can cause common overuse conditions as well as sports-specific acute traumatic injuries. Additionally, there are certain conditions and which are unique to the adaptive athlete and their use of adaptive equipment.

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

Musculoskeletal injuries frequently manifest in athletes with disability secondarily to overuse and accommodation. Rotator cuff and bicipital tendinopathies represent common pathologies seen in the spinal cord injury (SCI) population due to wheelchair usage. These tendinopathies typically result from impingement, causing shoulder pain and dysfunction. Since this population requires their shoulders for mobility, it is common for shoulder disease to progress into pain and dysfunction throughout the entire arm. This can be detrimental in the wrists where overuse presents potential for carpal tunnel syndrome.9

Specific secondary or associated conditions and complications

Amputee Athlete

Following amputation and prosthetic fitting, the skin of the distal portion of the residual limb (RL) becomes a weight-bearing surface where it was not previously, resulting in increased risk for abrasions, blisters, and skin rash. Skin breakdown may occur when pressure is applied disproportionately to a pressure-sensitive location on the RL. Skin may also develop verrucous hyperplasia, a wart-like lesion at the distal end of the RL. Sweating with athletic activity can increase moisture at the skin-socket interface, increasing risk of skin breakdown. Amputees are also at increased risk for fungal skin infections (especially during warmer seasons), bacterial skin infections, and contact dermatitis.10,11 Skin breakdown can impede RL weight-bearing during ambulation, which can significantly hinder the amputee’s functional mobility.12

A neuroma may occur at the distal end of a transected nerve in the RL of an amputee. When pressure is added to neuromas, it creates paresthesias, dysesthesia, and radiating pain in the phantom distribution of the transected nerve. A neuroma on a weight-bearing structure can create severe pain with ambulation, limiting an athlete’s ability to train and compete. Unwanted socket pressure and irritation in below-knee amputees can also lead to prepatellar, infrapatellar, and pretibial bursitis.12

Heterotopic ossification (HO) develops frequently in joints and muscles adjacent to trauma with the RL of traumatic amputees. HO can increase the risk of skin breakdown or stimulate pain with weight bearing.12 HO typically develops within the first 6-12 months after amputation, often while an amputee is beginning prosthetic training. This allows for modifications of the socket prior to athletic competition.12

Spinal Cord Injury Athlete

Autonomic dysreflexia (AD) occurs when unregulated sympathetic outflow increases in response to a noxious stimulus, affecting individuals with SCI at the T6 level and above. Symptoms include paroxysmal hypertension, bradycardia, facial flushing, and headache, with untreated hypertension potentially leading to stroke or death. Common triggers include tight clothing, urinary or fecal retention, renal or bladder stones, pressure injuries, infections, or intra-abdominal pathology. “Boosting” refers to intentionally inducing AD for a competitive advantage by increasing blood pressure and blood flow to muscles.12 Methods may include drinking large amounts of fluids, strapping legs tightly, or clamping their catheters to induce bladder distention. Over 15% of athletes with SCI above T6 have voluntarily induced AD to boost performance. It is important to recognize boosting poses serious health risks for the athlete and is considered an ergogenic aid that can also lead to disqualification.13

Athletes with SCI, especially above the T8 level, have impaired temperature regulation due to reduced sweating below the lesion, limiting evaporative cooling and increasing hyperthermia risk. Cold temperatures can also be dangerous due to increased shivering and inability to sense wet clothing. Impaired vasomotor and sudomotor neural control, decreased muscle mass below the lesion, and possible impaired central temperature regulating mechanisms all contribute to the development of hypothermia and potentially frostbite.14 Other complications seen in athletes with SCI include skin pressure injuries, increased spasticity, and stress fractures.

Cognitively impaired athlete

Common musculoskeletal issues in the Down Syndrome population include joint laxity, poor muscle tone, scoliosis, pes planus/cavus, hallux varus/valgus, patellofemoral syndrome, slipped capital femoral epiphysis, plantar fasciopathy, tendinopathy, and osteoarthritis. Atlanto-axial instability can be diagnosed with flexion and extension radiographs for instability (>4-5 mm of odontoid-atlas separation). 98% of these cases are asymptomatic.15  Some Special Olympic pre-participation forms do include some guidance for assessment of atlanto-axial instability in Down syndrome, and, if atlanto-axial instability is present, counsel on restriction from any sport with particular risk of increased axial pressures or extreme range of motion demands at the head and neck.16 Visual disturbances are also common in those with intellectual disability and may lead to increased risk for injury.17

Essentials of Assessment

History

It is important to conduct a pre-participation exam (PPE) in all athletes with a disability. A comprehensive evaluation includes the athlete’s wheelchair, prosthetics, orthotics, and assistive/adaptive devices, and should be performed pre-competition.

In history-taking, one should include the athletic goals of the individual, pre-disability health, current training level, sports participation, medication/supplement use, nutrition, cardiopulmonary history, level of functional independence pertaining to activities of daily living, the individual’s adaptive equipment needs, mental health, and sleep history.18

Physical examination

Examination should be tailored to the individual, including evaluation of focal neurologic deficits, joint stability/flexibility/range of motion (ROM), muscle strength, skin integrity (especially at pressure-sensitive sites), adaptive equipment needs, cardiopulmonary assessment, and to the common areas of injury for each sub-sect of para-athlete.  

In the spinal cord injury population, many individuals rely on wheelchairs for mobility. As such, injuries can be particularly devastating to the athlete’s independence. Management of injured athletes with disabilities include orthotic prescriptions (which can be enhanced by a prosthetist/orthotist on the team), direct home modifications, psychological counseling, and additional rehab therapy for patients to regain and maintain maximum function.18

An important part of a PPE is baseline concussion evaluations. Recent studies suggest up to 9.3% of parasport athletes reported at least one sports-related concussion over the course of a year.19 Assessing these athletes at baseline is crucial for comparison, especially important for those with concussion-like symptoms at baseline including dysarthria or blurry vision. Discussion with family members and caregivers can aid in guiding return-to-play status.

Imaging

When appropriate, X-ray, CT, US, and MRI can be excellent adjuncts to physical exam in diagnosing common and rare musculoskeletal conditions.  Currently, screening radiographs are not routinely recommended for asymptomatic atlantoaxial instability, but there are 3 questions that should be assessed in those with Down syndrome (adapted from the British Gymnastics program):

  1. Does the person show evidence of progressive myopathy/myelopathy?
  2. Does the person have poor head/neck muscular control?
  3. Does the person’s neck flexion allow the chin to rest on their chest?

If any of the above questions are in the affirmative, especially acutely, the athlete’s cervical spine should be immobilized with same day cervical x-ray and MRI with neurosurgical consultation.20

Heterotopic ossification (HO) can occur in both amputees and those with SCI. The triple phase bone scan can be a more sensitive modality than conventional X-ray for capturing HO.12

Supplemental assessment tools

Shoulder

The shoulder is the most commonly injured joint in wheelchair sport athletes, with studies reporting a prevalence ranging from 16-76%.21 Repetitive motions involved in wheelchair propulsion require high levels of energy and activity which may cause tendons to weaken or break down. Peak glenohumeral contact forces can reach 100-165% of bodyweight, consequently increasing the risk for muscle damage and shoulder complaints.22 Seating position should be assessed, as some sources suggest a straight seat position may be associated with more shoulder injury and pain, as opposed to an angled position. Targeted exercise has also been found to be beneficial for those with shoulder impingement symptoms and SCI.23 The evidence is currently mixed with regards to the association between musculoskeletal pain, daily physical activity, and participation in sport.23,24

Wrist

Median neuropathy at the wrist represents the most common site of peripheral nerve entrapment in athletes with disability. Chronic wheelchair use offers a prevalence of carpal tunnel syndrome of 49-73%. Wheelchair users are also at increased risk for: nerve entrapment at Guyon’s canal, osteoarthritis, and De Quervain’s tenosynovitis.12 Electrodiagnostic and ultrasound evaluation may help decipher between nerve and tendon pathology.

Social role and social support system

Technological advancements have led to increased possibilities for para athletes, however the most limiting factors for participation include awareness, access, and expense. Athletic endeavors have shown improved endurance, muscle strength, proprioception, but also psychological benefit such as improved self-worth. Additionally, these athletes require strong social support, which is critical to their participation and well-being. While it is imperative to be patient-centered, it is also vital that providers remain family-centered and acknowledge the support that caregivers may need from health care providers.25

Professional issues

Multidisciplinary approach to these athletes is beneficial due to the potential complexity of injuries mixed with pre-existing conditions. Utilization of the skills of the different physician subspecialties provides the best management of injuries and illnesses inherent to their primary (disabling) pathology in addition to any new, acute pathology.

Rehabilitation Management and Treatments

Available or current treatment guidelines

The treatment guidelines for athletes with disability and their unique injuries include activity and ergonomic modifications, orthotics, special prosthetics, multidisciplinary approach to treatments and unique surgeries if needed.12

At different disease stages

Acute injuries, including muscle strains, ligamentous sprains, and bone fractures, may be more prevalent in certain individuals with specific disabilities due to overuse or biomechanical accommodation. These injuries should be treated with protected immobilization, rest, ice, compression, elevation. Be aware that rest of an affected limb may be difficult with wheelchair or prosthetic use.

Chronic repetitive injuries, such as shoulder pathology and nerve entrapments, are common in this population, particularly with the upper extremity in wheelchair users.12 Therefore, it is important to assess the equipment with these athletes, such as socket fitting in the amputee to positioning and cushioning in the wheelchair athlete.

Best practice begins with the most conservative and least invasive interventions. For amputee athletes, this includes adjusting sock ply or consulting the prosthetist for socket modifications (e.g., pad insertion). A full socket replacement should only be considered after all minor adjustments fail. Similarly, in wheelchair athletes, optimizing seat positioning can help reduce shoulder pain,23 but other adjustments can also include camber angle and seat heat.

Physical therapy, as well as coordination with the athlete’s athletic trainers, should remain a core component throughout rehabilitation to preserve strength, mobility, and function. Topical analgesics can be used early, while oral medications like NSAIDs should be reserved for acute flares to avoid long-term side effects.

If conservative measures—adjustments, ergonomics, therapy, and medications—are inadequate or too painful, obtain imaging (X-ray, MRI, or ultrasound) to assess for conditions that may contraindicate certain types of injections (e.g., full-thickness tears, fractures, or avascular necrosis). In the absence of such findings and with no major risk factors (e.g., infection, uncontrolled diabetes, allergy to injectates), injections may be considered for therapeutic and diagnostic benefit.

Injections can be diagnostic (primarily with anesthetic) or in the form of corticosteroids, and orthobiologics (such as but not limited to platelet-rich plasma (PRP), microfragmented adipose tissue (MFAT), and bone marrow aspirate (BMAC)). Limit repeated injections to the same area, and consider surgical referral if efficacy declines.

Return-to-play protocols vary by injury type, location, severity, and sport, often requiring a coordinated, multidisciplinary approach for optimal care.

Coordination of care

A multidisciplinary approach to managing these individuals in conjunction with colleagues in physical /occupational therapy, nursing, psychology, nutrition, and orthotics/prosthetics, is essential to offer the most comprehensive and efficient management of return to sport for the injured adaptive athlete.

Patient & family education

Patient and family education on the vast opportunities for participation in adaptive sports is paramount. It is important to inform families of the physical health benefits of adaptive sports, but also the psychological benefits of exercise, including enhanced self-image, body awareness, motor development, and mood.12

Emerging/unique interventions

A study of 2016 US Paralympians revealed only 24% of responding athletes participated in a consistent injury prevention program.26 Several new assessment tools are in development for wheelchair athletes, including the Wheelchair Error Scoring System (WESS) for concussion-related balance testing, and the Wheelchair User Shoulder Pain Index (WUSPI), Shoulder Pain Scale for Wheelchair Basketball (SPS-WB), and Shoulder Pain Index for Wheelchair Basketball (SPI-WB) for evaluating shoulder pain. While the WESS is being used for pre- and post-injury concussion assessments, a recent study found low to very-low quality evidence supporting the psychometric properties of the WUSPI, SPS-WB, and SPI-WB, indicating they should be used with caution.27,28

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

Athletes with disability should be thought of and cared for in terms of their “ability,” not “disability.”  It is what they can do, not what they cannot do, that makes them a special population and so much fun to care for at any level.

Cutting Edge/Emerging and Unique Concepts and Practice

Emerging technology in adaptive equipment allows for greater comfort, better ergonomics, and hopefully prevention of injury. Custom fitting adaptive equipment with 3-D scanning and printing enables the creation of customized solutions tailored to the user’s specific limb shape and volume as well as the specific demands of their sport.29 Pressure-sensing systems are being utilized with 3D-printed limbs, which have a variety of applications including testing the structural integrity of the prosthesis as well as improved fit with optimized pressure distribution at the limb-prosthesis interface.30

Gaps in the Evidence-Based Knowledge

Further research is needed on the illegal practice of “boosting” and strategies for its prevention and monitoring. For Paris 2024, the International Paralympic Committee (IPC) and  the World Anti-Doping Agency (WADA) collaborated through an Anti-Doping Taskforce, issuing testing guidelines and educational efforts for athletes and coaches. The IPC conducted 1,988 doping control tests, collecting 2,677 samples—a 25% increase from Tokyo. Despite improved testing, gaps remain in the ongoing prevention and monitoring of boosting.31

Long-term studies are needed to evaluate shoulder complications in para athletes, including surgery rates and impact on mobility and ADLs, compared to non-athlete wheelchair users. These findings could support injury prevention through targeted conditioning programs. Additionally, clearer nutritional guidelines are needed to help prevent overtraining syndrome, which increases the risk of bone stress injuries. This is especially important given the unique metabolic demands of athletes with amputations or spinal cord injuries.32

References

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  16. https://www.specialolympicswisconsin.org/wp-content/uploads/2015/04/Athletes-with-Down-Syndrome-Special-Examination-Form.pdf
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  20. Tomlinson, Christopher BM BS, MSc SEM*; Campbell, Alastair MBBCh BaO, FRCR†; Hurley, Alison MB BCh NUI, FFRRCSI‡; Fenton, Eoin MB BCh NUI§; Heron, Neil MBChB, BSc (Hons), MRCGP, F.FSEM, PhD¶,║,**,††. Sport Preparticipation Screening for Asymptomatic Atlantoaxial Instability in Patients With Down Syndrome. Clinical Journal of Sport Medicine 30(4):p 293-295, July 2020. | DOI: 10.1097/JSM.0000000000000642
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Original Version of the Topic

Arthur J. De Luigi, DO, Dane C. Pohlman, DO. Sports Medicine for Special Groups. 9/20/2013

Previous Revision(s) of the Topic

Brenton Charles Bohlig, MD, Sushil Singla, MD, and David J. Haustein, MD. Sports Medicine for Special Groups. 2/13/2018

Brenton C. Bohlig, MD, FAAPMR, CAQSM, Stephen Luebbert, MD, MS, Aaron Brown, BS, David J. Haustein, MD. Sports Medicine for Special Groups. 6/1/2022

Author Disclosure

Stephen Luebbert, MD, FAAPMR, CAQSM
Nothing to Disclose

Raquel Johnson, MD
Nothing to Disclose

Brenton Bohlig, MD, FAAPMR, CAQSM
Nothing to Disclose