Sports Medicine for Special Groups

Author(s): Brenton Charles Bohlig, MD, Sushil Singla, MD, and David J. Haustein, MD

Originally published:09/20/2013

Last updated:02/13/2018

1. DISEASE/DISORDER:

Definition

Sports medicine of the disabled athlete 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.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 disability is divided in order to maintain a fair playing field. They have created an online interactive tool which can provide a general outline on their website (https://www.teamusa.org/US-Paralympics/Athlete-Classifications).

Etiology

There are an estimated 56.6 million disabled individuals in the United States,2 including approximately two million recreational and competitive disabled athletes.3 Athletic activity may benefit the disabled athlete with increased exercise endurance, muscle strength, cardiovascular efficiency, functionality, life skills, self-esteem, and overall quality of life.1 It is important, however, to be aware of associated injuries that may be uniquely related to the specifics of each sport, and the athlete’s specific disability. One area often neglected in discussion of disabled athletes is the cognitively impaired athlete such as in Down syndrome.  Although these individuals may have impairments in adaptive functioning such as social, domestic, and communication skills, there is a clear benefit to physical activity.

Epidemiology including risk factors and primary prevention

Lower extremity injuries are more common in ambulatory athletes (visually impaired, amputee, cerebral palsy), whereas upper extremity injuries are more frequent in athletes who use a wheelchair.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 This study took into account both Paralympics World Games and Championships, which have a variety of sports.

Patho-anatomy/physiology

As with the able-bodied athlete, repetitive use can cause common overuse conditions such as tendinopathy and osteoarthritis. Additionally, there are similar sports-specific risks for acute traumatic injury in disabled athletes. 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 disabled athlete 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 for mobility.  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.  Overall, many overuse injuries coexist with some degree of bicipital and rotator cuff tendinopathy.  The presentation over time varies from acute to slowly progressive pain and dysfunction.6

Specific secondary or associated conditions and complications

Amputee Athlete

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 months to a year 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 extgension 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

2. ESSENTIALS OF ASSESSMENT

History

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, presence of impairments, cardiopulmonary history, level of functional independence as pertains to activities of daily living, and the individual’s need for adaptive equipment.

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

Physical examination

Examination should be tailored for individuals, 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, and cardiopulmonary assessment. A focus can be made on the common areas of injury for each sub-sect of disabled athletes. 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.

Functional assessment

In the spinal cord injury population, many individuals rely on wheelchairs for mobility, and ultimately their independence.  Injuries can be particularly devastating and rob these athletes of independence as they undergo treatment.  Management of injured disabled athletes of all types include orthotic prescriptions, direct home modifications, possibly psychological counseling, and additional rehab therapy for patients to regain and maintain their maximum function.15

Imaging

As in the case of the able-bodied athlete, imaging is a very important asset to the continued evaluation and monitoring of disabled individuals. X-ray, CT, US and MRI, when appropriate, can be an excellent adjunct 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

Shoulder

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 were 100-165% bodyweight, consequently increasing the risk for muscle damage and shoulder complaints.16  Assessment with ultrasound can be of great value to diagnose tendon pathology.

Wrist

Carpal tunnel represents the most common site of peripheral nerve entrapment in both disabled and able-bodied individuals.  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 testing may help decipher between nerve versus tendon pathology. Ultrasound can also detect nerve entrapment pathology.

Environmental

Thermoregulation

As previously mentioned, following spinal cord injuries there is disruption of neuro-regulatory systems that are 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 two most limiting factors for participation continue to be awareness and access.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 disabled individuals of all the opportunities available to them. Additionally, the disabled athlete requires a social support system, which is critical to their participation and well-being.

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 with the acute new pathology.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

The treatment guidelines for disabled athletes 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

Injuries may be classified as acute, subacute, or chronic, and in most situations should be approached in a similar fashion to those of the able-bodied population.

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 rest, ice, compression, elevation, and immobilization when appropriate, similar to able-bodied athletes.

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.

Coordination of care

The approach to the disabled athlete 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, and orthotics/prosthetics, is essential in order to offer the most comprehensive and efficient management of the injured disabled athlete.

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

Please see ‘Resources’ section below for websites to assist in gathering more information.

Emerging/unique Interventions

Injuries to disabled athletes can be minimized in the future as more knowledge is obtained regarding them.  Currently there are no set outcome measures for disabled athletes and their injuries.  However, there are classification systems that all disabled athletes must go through to be properly paired against athletes of similar abilities. This encourages fair play and also reduces injury.

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

Disabled athletes 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.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

NA

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

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 at this time. As with able-bodied athletes, illegal performance enhancement through drugs and the illegal practice of “boosting” must be watched for and prevented.

Resources

U.S. Paralympics                                           https://www.teamusa.org/US-Paralympics
Special Olympics                                           http://www.specialolympics.org/
National Veterans Wheelchair Games      http://wheelchairgames.org/
Paralyzed Veterans of America                  http://www.pva.org/adaptive-sports
Disabled Sports USA                                    http://www.disabledsportsusa.org/

REFERENCES

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  8. 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.
  9. 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.
  10. Bayley JC, Cochran TP, Sledge CB. The weight-bearing shoulder: the impingement syndrome in paraplegics. J Bone Joint Surg Am. 1987;69:676-678.
  11. 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.
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Original Version of the Topic

Arthur J. De Luigi, DO, Dane C. Pohlman, DO. Sports Medicine for Special Groups. 09/20/2013.

Author Disclosure

Brenton Charles Bohlig, MD
Nothing to Disclose

Sushil Singla, MD
Nothing to Disclose

David J. Haustein, MD
Nothing to Disclose

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