Sports medicine of athletes with disabilities includes screening, injury prevention, diagnosis, and treatment of the physically and/or intellectually disabled athlete.
Classification of participants varies between governing bodies and is based upon an athlete’s physical or intellectual abilities as to make for fair competition. To participate in Paralympic sports, an athlete must have 1 of 10 permanent impairments: 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 having one of the following conditions: intellectual disabilities, cognitive delays as measured by formal assessment, or significant learning or vocational problems due to cognitive delay that require or have required specially designed instruction. Each sport and eligible impairment are classified in order to maintain a fair playing field.
There are an estimated 56.6 million individuals with disabilities in the United States,2 including approximately two million recreational and competitive athletes with disabilities.3 The Rio 2016 Summer Paralympic Games included 4328 athletes from 160 countries in 22 sports.37 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%), tendonitis (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%).5 During the 2016 Summer Paralympic Games, a total of 510 injuries were reported in 441 athletes, with an injury incidence rate of 10 injuries per 1000 athlete-days.37
As with the able-bodied athlete, repetitive use can cause common overuse conditions, such as tendinopathy and osteoarthritis, as well as sports-specific acute traumatic injuries. However, there are certain chronic/acute injuries which are unique to the use of adaptive equipment in participation.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
In many instances, musculoskeletal injuries manifest themselves in the athlete with disability secondary to overuse and accommodation. Rotator cuff and bicipital tendinopathies, for example, represent common types of pathology seen in the spinal cord injury (SCI) population due to wheelchair usage. Disorders of these tendons typically result from impingement or as an isolated traumatic injury. Given that this population requires their shoulders for mobility, it is common for disease to progress. The presentation over time varies from acute to slowly progressive pain and dysfunction.6
Specific secondary or associated conditions and complications
Following amputation and prosthetic fitting, the skin of the distal portion of the residual limb becomes a weight-bearing surface where it had not previously been, resulting in increased risk for abrasions, blisters, and skin rash.7 Skin breakdown may occur when pressure is applied disproportionately to a pressure-sensitive area of skin on the residual limb. Skin may also develop verrucous hyperplasia; a wart-like lesion at the distal end of the residual limb.8 Sweating with athletic activity can increase moisture at the skin-socket interface and make skin breakdown more likely. Skin breakdown can be particularly disabling in an amputee, who relies on weight bearing through the residual limb for ambulation.8,9
A neuroma may occur at the distal end of a transected nerve in the residual limb of an amputee. When a neuroma is exposed to pressure, it creates paresthesias, dysesthesia, and radiating pain in the phantom distribution of the transected nerve. When a neuroma occurs on a weight-bearing structure, it can create severe pain with ambulation, limiting an athlete’s ability to train and compete. Unwanted socket pressure and irritation in the below-knee amputee can also lead to prepatellar, infrapatellar, and pretibial bursitis.7
Heterotopic ossification (HO) has been reported to develop frequently in joints and muscle adjacent to trauma with the residual limbs of traumatic amputees, which may increase risk of skin breakdown or stimulate pain with weight bearing.10 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.10
Spinal Cord Injury Athlete
Autonomic dysreflexia (AD) is a condition that occurs when sympathetic outflow increases in response to a noxious stimulus that is unregulated. Spinal cord injuries at the level of T6 and above are at risk for AD. Symptoms include paroxysmal hypertension, bradycardia, facial flushing, and headache. If hypertension continues to increase without treatment, stroke or death may occur. Common noxious stimuli that lead to AD include tight clothing, urinary or fecal retention, renal or bladder stones, pressure ulcers, infections, or intra-abdominal pathology.9 When AD is intentionally induced to gain a competitive advantage, it is referred to as “boosting”. Consequently, the subject exhibits increased BP and blood flow to working muscles, thus improving performance.11 Examples of self-induced noxious stimuli may include drinking large amounts of fluids, strapping legs tightly, or clamping their catheters to induce bladder distention.7 Studies have shown that more than 15% of athletes with SCI above T6 have voluntarily induced AD to boost their performance.11 It is important to recognize boosting poses serious health risks for the athlete and is considered an ergogenic aid that is not sanctioned by sports-governing bodies.7
Temperature regulation is impaired in athletes with SCI, especially with lesions above T8.7 Impaired sweating below the lesion level reduces the effective body surface area available for evaporative cooling. This can lead to hyperthermia. Cool temperatures can also pose a risk when there is an inability to sense wet clothing and decreased shiver response below the level of injury. 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.7 Other complications seen in athletes with SCI include pressure skin ulcers, 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 (SCFE), plantar fasciopathy, tendinopathy, and osteoarthritis. Atlanto-axial instability diagnosed with flexion and extension radiographs for instability (>4-5 mm of odontoid-atlas separation), may be present in these individuals. Some individuals may have instability but remain asymptomatic. In individuals with instability, certain sports should be avoided, such as alpine skiing, diving, gymnastics, soccer, and hockey.12,13 Visual disturbances are also common in the intellectually disabled population, including blepharitis, astigmatism, nystagmus, and strabismus, which may lead to increased risk for injury.14
Essentials of Assessment
It is important to conduct a pre-participation exam (PPE) in all athletes with a disability. A comprehensive approach including the evaluation of the athlete’s wheelchair, prosthetics, orthotics, and assistive/adaptive devices should be performed prior to competition.
In history-taking, one should include the athletic goals of the individual, pre-disability health, present level of training, sports participation, medication/supplement use, nutrition, cardiopulmonary history, level of functional independence as pertains to activities of daily living, the individual’s need for adaptive equipment, mental health, and sleep history.28,29
It has been suggested that PPE should be conducted by the primary medical team responsible for the athlete’s care in the clinic rather than the mass/station method as these medical professionals are aware of the athlete’s baseline functional status and degrees of disability.7
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. For example, it would be prudent to spend time evaluating a lower limb amputee’s affected and unaffected side, with/without the prosthesis, skin breakdown, stability, flexibility, and strength of the trunk/hip girdle.
In the spinal cord injury population, many individuals rely on wheelchairs for mobility. So, injuries can be particularly devastating to the athlete’s independence. Management of injured athletes with disabilities include orthotic prescriptions, direct home modifications, psychological counseling, and additional rehab therapy for patients to regain and maintain their maximum function.15
An important part of a PPE is baseline concussion evaluations. Recent studies show that up to 43% of wheelchair athletes report a history of concussion. Baseline scores using a modified Graded Symptoms Checklist are higher in patients with a history of a concussion, independent of their disability, but especially in patients with a brain disorder. Assessing these patients at baseline is crucial for comparison if a patient requires assessment for similar symptoms during athletic competition. This is especially important for patients that tend to have concussion-like symptoms at baseline including dysarthria or blurry vision, which makes concussion evaluations more challenging. In this case, it is helpful to discuss with family members and caregivers to assess a patients return-to-play status.30,31
When appropriate, X-ray, CT, US, and MRI can be excellent adjuncts to physical exam in diagnosing common and rare musculoskeletal conditions. Heterotopic ossification can occur in up to half of SCI patients, beginning at a mean of 12 weeks after injury.27 The triple phase bone scan is the most reliable test for diagnosis.
Supplemental assessment tools
The shoulder is the most commonly injured joint in wheelchair sport athletes, with studies reporting a prevalence ranging from 16-76%.32 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.16
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%.17 Wheelchair users are also at increased risk for: nerve entrapment at Guyon’s canal, osteoarthritis, and DeQuervain’s tenosynovitis.15 Electrodiagnostic and ultrasound evaluation may help decipher between nerve and tendon pathology.
As previously mentioned, following spinal cord injuries there is disruption of neuro-regulatory systems involved in control of body temperature. Below the level of the lesion, spinal cord-injured athletes have impaired shivering to produce heat and impaired sweating and vasodilation to dissipate heat. Athletes with tetraplegia are increased risk as compared with paraplegia.18 Paraplegic/tetraplegic athletes are expected to see greater increases in body temperature with exertion and greater decreases in temperature with exposure to cold weather. Frostbite is of particular concern during cold weather events due to impaired sensation in athletes with spinal cord injuries.
Social role and social support system
Technological advance has led to increased possibilities for individuals with disability, however the most limiting factors for participation include awareness, access, and expense.18 Athletic endeavors have shown improved endurance, muscle strength, proprioception, but also psychological benefit such as self-worth and body awareness. It is the responsibility of all health care providers to make an effort to inform individuals with disabilities of all the opportunities available to them. Additionally, the athlete with disability requires a social support system, 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.33
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 with the acute new 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.15
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 similar to able-bodied athletes with protected immobilization, rest, ice, compression, elevation.
Injuries may become subacute secondary to unique increased energy requirements for daily activities, such as wheelchair propulsion, or use of a prosthesis. Given these cases, it may be difficult to completely rest the affected limb.
Chronic repetitive injuries such as shoulder pathology and nerve entrapments are common in this population, particularly with the upper extremity in wheelchair users.15-17 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. Biomechanical optimization is also an important consideration for injury prevention and improved athletic performance.34
Coordination of care
The approach to the athlete with disability is partially similar to that for able-bodied athletes, in that the goal is return to sport. However, the approach differs, in that the injury truly can impair function, and functional restoration is of primary interest for the treating physician. 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 the injured athlete with disability.
Patient & family education
Awareness is a major obstacle. The patient and family need to be educated in the vast opportunities for participation in adaptive sports through therapeutic recreation programs that increase their function and well-being. It is important to inform families of the physical health benefits, but also the psychologic benefits of exercise, including enhanced self-image, body awareness, motor development, and mood.19
Injuries to athletes with disability may be minimized in the future as more knowledge is obtained. Currently there are no set outcome measures for athletes with disability and their injuries. A study of 2016 US Paralympians revealed only 24% of responding athletes participated in a consistent injury prevention program.35 However, there are classification systems that all athletes with disability must go through to be properly paired against athletes of similar abilities. This encourages fair play and reduces injury.
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
With the advent of COVID-19, the face of sports has changed significantly. The pandemic has affected accessibility to training facilities, with athletes having decreased programming opportunities. The United States Olympic and Paralympic Training facilities’ (USOPTF) has released standards to reduce incidence of COVID-19 infection, including isolation guidelines and return to sport protocols.36
Gaps in the Evidence-Based Knowledge
The emerging field of regenerative medicine may offer an intriguing area of focus for future practice. However, there exists a lack of significant prospective studies currently. As with able-bodied athletes, illegal performance enhancement through drugs and the illegal practice of “boosting” must be monitored and prevented.
- Herman, Daniel, et al. “The Para-Athlete.” DeLee & Drez’s Orthopaedic Sports Medicine, 4th ed., Elsevier Saunders, 2015, pp. 356–364.
- U.S. Census Bureau, Survey of Income and Program Participation, June–September 2005 and May–August 2010.
- Micheo WF. Concepts in sports medicine. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, PA. Elsevier. 2007:1021-1046.
- Ferrara MS, Peterson CL. Injuries to athletes with disabilities: Identifying injury patterns. Sports Med. 200l;30(2):137.
- Ferrara MS, Palutsis GR, Snouse S, et al: A longitudinal study of injuries to athletes with disabilities. Int J Sports Med. 2000;21:22.
- Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007; 89(8):1001-1009.
- Patel, Dilip R., and Donald E. Greydanus. “Sport Participation by Physically and Cognitively Challenged Young Athletes.” Pediatric Clinics of North America, vol. 57, no. 3, 2010, pp. 795–817., doi:10.1016/j.pcl.2010.03.002.
- Huang ME. Kuiken TA, Miller L, Lipschutz Rehabilitation and prosthetic restoration in lower limb amputation. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, PA. Elsevier. 2011; 277-316.
- Fitzpatrick K, De Luigi AJ, Pasquina PF. The disabled athlete. In: O’Connor F, ed. ACSM’s Sports Medicine: A Comprehensive Review. Philadelphia PA. Lippincott Williams & Wilkins. 2012.
- Bayley JC, Cochran TP, Sledge CB. The weight-bearing shoulder: the impingement syndrome in paraplegics. J Bone Joint Surg Am. 1987;69:676-678.
- Mazzeo, Filomena, et al. “‘Boosting’ in Paralympic Athletes with Spinal Cord Injury: Doping without Drugs.” Functional Neurology, vol. 30, no. 2, 2015, pp. 91–98., doi:10.11138/fneur/2015.30.2.091.
- Birrer RB. The Special Olympics athlete: evaluation and clearance for participation. Clin Pediatr. 2004;43(9):777-782.
- Pueschel SM, Scola FH. Atlantoaxial instability in individuals with Down syndrome: epidemiologic, radiographic, and clinical studies. Pediatrics. 1987;80(4): 555-560.
- Woodruff ME, Cleary TE, Bader D. The prevalence of refractive and ocular anomalies among 1242 institutionalized mentally retarded persons. Am J Optom Physiol Opt. 1980;57(2):70-84.
- Paralyzed Veterans of America 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.
- Veeger HE, Rozendaal LA, van der Helm FC. Load on the shoulder in low intensity wheelchair propulsion. Clin Biomech. (Bristol). 2002;17(3):211-218.
- Price MJ, Campbell IG. Effects of spinal cord lesion level upon thermoregulation during exercise in the heat. Med Sci Sports Exerc. 2003;35(7):1100-1107.
- Wu SK, Williams T. Factors influencing sport participation among athletes with spinal cord injury. Med Sci Sports Exerc. 2001; 33(2):177.
- Harrast, Mark A., et al. “Sports Medicine and Adaptive Sports .” Braddom’s Physical Medicine & Rehabilitation, Elsevier, 2016, pp. 851–881.
- Wilson, Pamela E., and Gerald H. Clayton. “Sports and Disability: Focused Review.” Pm&r, vol. 2, no. 3, 2010, pp. S46–S54. doi:10.1016/j.pmrj.2010.03.003.
- Brose SW, Boninger ML, Fullerton B, et al. Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury. Arch Phys Med Rehabil. 2008;89(11):2086-2093.
- Caird MS, Wills BP, Dormans JP. Down syndrome in children: the role of the orthopaedic surgeon. J Am Acad Orthop Surg. 2006;14(11):610-619.
- Ferrara MS, Palutsis GR, Snouse S, et al: A longitudinal study of injuries to athletes with disabilities. Int J Sports Med. 2000;21:22.
- Mik G, et al. Down syndrome: orthopedic issues. Curr Opin Pediatr. 2008;20(1):30-36.
- Milbrandt TA, and Johnston 2nd CE. Down syndrome and scoliosis: a review of a 50-year experience at one institution. Spine. 2005;30(18):2051-2055.
- Yang J, Boninger ML, Leath JD, Fitzgerald SG, Dyson-Hudson TA, Chang MW. Carpal tunnel syndrome in manual wheelchair users with spinal cord injury: a cross-sectional multicenter study. Am J Phys Med Rehabil. 2009;88(12):1007-1016.
- Schuetz, P, et al. “Amino-Bisphosphonates in Heterotopic Ossification: First Experience in Five Consecutive Cases.” Spinal Cord, vol. 43, no. 10, Mar. 2005, pp. 604–610., doi:10.1038/sj.sc.3101761.
- Swartz L, Hunt X, Bantjes J, Hainline B, Reardon CL. “Mental health symptoms and disorders in Paralympic athletes: a narrative review.” Br J Sports Med. 53(12):737-740, 2019 June.
- Roberts IE, Murphy CJ, Goosey-Tolfrey VL. “Sleep disruption considerations for Paralympic athletes competing at Tokyo 2020.” Journal of Sports Medicine & Physical Fitness. 61(8):1159-1172, 2021 Aug
- Harper MW, Lee J, Sherman KA, Uihlein MJ, Lee KKK. “Wheelchair Athlete Concussion Baseline Data: A Pilot Retrospective Analysis.” Am. J. PM&R. 100(9):895-899, 2021 09 01.
- Fudge JR. “Improving Concussion Care for Athletes with Intellectual Disabilities.” Current Sports Medicine Reports. 19(4):131-132, 2020 Apr.
- Heyward OW, Vegter RJK, de Groot S, van der Woude LHV. “Shoulder complaints in wheelchair athletes: A systematic review.” PLoS ONE [Electronic Resource]. 12(11):e0188410, 2017.
- Raheb J. “Health Care Delivery, Patient Resources, and Community Reintegration.” PM&R Clinics of North America. 32(3):581-589, 2021 08.
- Fletcher JR, Gallinger T, Prince F. How Can Biomechanics Improve Physical Preparation and Performance in Paralympic Athletes? A Narrative Review. Sports (Basel). 2021 Jun 24;9(7):89. doi: 10.3390/sports9070089.
- Harrington SE, McQueeney S, Fearing M. Understanding Injury and Injury Prevention in Para Sport Athletes. J Sport Rehabil. 2021 May 25;30(7):1053-1059. doi: 10.1123/jsr.2020-0477. PMID: 34034232.
- Shah AB, Nabhan D, Chapman R, et al. Resumption of Sport at the United States Olympic and Paralympic Training Facilities During the COVID-19 Pandemic. Sports Health. 2021;13(4):359-363. doi:10.1177/19417381211002761
- Pinheiro LSP, Ocarino JM, Madaleno FO, et al. “Prevalence and incidence of injuries in para athletes: a systematic review with meta-analysis and GRADE recommendations.” Br J Sports Med. 2021:55:1357-1365.
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
Nothing to Disclose
Stephen Luebbert, MD, MS
Nothing to Disclose
Aaron Brown, BS
Nothing to Disclose
David J. Haustein, MD, MBA
Nothing to Disclose