Injuries in the Wheelchair Athlete

Wheelchair propulsion loads the upper limb repeatedly and heavily. Each push drives force through the hand and wrist, along the forearm and across the shoulder, and a racing or court athlete may complete many thousands of push cycles in a single session. The shoulder is the most vulnerable joint, because its small stabilising muscles and mobile ball-and-socket design are not built for repeated weight-bearing, so the rotator cuff and subacromial structures are prone to overload and tendinopathy, giving rotator cuff-related shoulder pain, also called subacromial pain. At the wrist, repeated extension and gripping raise pressure in the carpal tunnel and compress the median nerve, and carpal tunnel syndrome (CTS) is common in manual wheelchair users. At the elbow, the ulnar nerve can be compressed at the cubital tunnel, particularly with sustained elbow flexion and direct pressure. Transfers add further high loads through the shoulder and wrist. Poor propulsion technique, a wheelchair that is too heavy or badly configured, and a rearward axle position all increase the force and the injury risk, while smooth, long strokes that let the hand drift low reduce it.

Shoulder pain is the commonest complaint, felt over the top and outer arm, worse with overhead reach, propulsion and transfers, and often disturbing sleep, with a painful arc and pain on resisted movement pointing to a rotator cuff problem. Carpal tunnel syndrome gives tingling and numbness in the thumb, index, middle and the radial (thumb-side) half of the ring finger, often worse at night, with a positive Tinel or Phalen test and, when advanced, weakness and wasting of the thumb muscles. Ulnar nerve compression at the elbow causes tingling in the little finger and the ulnar half of the ring finger and, later, weakness of grip and key pinch, a positive Froment's sign, and wasting of the intrinsic hand muscles, notably the hypothenar eminence and the first dorsal interosseous. The hands take a beating from the push rims, with calluses, blisters and skin splits, and contact sports such as wheelchair rugby and basketball add finger and thumb injuries, abrasions and falls from the chair.

Most of these problems are diagnosed clinically. Shoulder assessment is by history and examination, and most rotator cuff-related pain needs no initial imaging. Where imaging is indicated, current UK guidance favours a plain radiograph first, with ultrasound or magnetic resonance imaging (MRI) arranged through agreed specialist pathways to show tendinopathy or a tear. Carpal tunnel syndrome and ulnar neuropathy are usually clinical diagnoses, and nerve conduction studies (NCS) are reserved for uncertain cases or when surgery is being considered, confirming the site and severity of nerve compression. Blood tests are added only when the picture is unclear or a red flag is present.

Management starts with load and technique rather than the clinic. Reducing aggravating load and correcting the propulsion technique towards smooth long strokes with a low hand recovery lower the force on the shoulder and wrist, as does a lighter frame. Moving the rear axle forwards also reduces propulsion load, but it reduces rearward stability, so it is adjusted with the wheelchair service only as far as individual stability allows, not done blindly. For rotator cuff pain, a progressive rotator cuff and scapular strengthening programme is the mainstay, with simple analgesia and, where pain limits rehabilitation, a subacromial corticosteroid injection; image guidance offers no advantage over a landmark-guided injection. Steroid injections are used sparingly in a manual wheelchair user, since the shoulder cannot be rested from transfers and daily mobility, so each is paired where possible with a temporary cut in heavy overhead loading and transfers, given the risk of tendon softening or an iatrogenic cuff tear in a limb that keeps weight-bearing. Carpal tunnel syndrome is managed with a neutral night splint, activity and technique modification, and a carpal tunnel corticosteroid injection for persistent symptoms, following current NICE guidance on the condition. Ulnar nerve symptoms respond to avoiding sustained elbow flexion and direct pressure, with padding and technique change. Referral is considered when symptoms are severe or constant, when there is progressive weakness or wasting, or when conservative measures fail, for a specialist opinion and, in nerve entrapment, possible decompression. The wheelchair service and an occupational therapist or rehabilitation engineer are key partners in adjusting the chair, alongside physiotherapy and the wider team.

Rehabilitation rebuilds the shoulder and protects it for the long term. A rotator cuff and scapular stabiliser programme, progressed gradually, restores strength and control, and flexibility work keeps pain-free range while avoiding end-range positions that aggravate cuff pain. Propulsion is retrained towards an efficient, low-force pattern, and the wheelchair is set up to support it. Return to sport is graded, watching training load and technique as volume climbs, since a sudden rise in intensity or duration is a common trigger. The same principles protect the wrist and elbow: neutral positioning, sensible load and good equipment. Because the upper limb is needed for independence as well as competition, athletes are taught to spot early shoulder or hand symptoms and act on them before they cost training or function. Classification is covered in the companion para-sport topic.

• •Guidance on preserving upper limb function in wheelchair users recommends efficient propulsion, an optimised lightweight wheelchair and load management to reduce shoulder and wrist injury.
• •Current UK guidance treats most rotator cuff-related shoulder pain clinically, with exercise-based conservative treatment first, no initial imaging in most cases, and referral for red flags or failed treatment.
• •Current NICE guidance on carpal tunnel syndrome supports a clinical diagnosis, night splinting and injection before surgery, with nerve conduction studies for uncertainty or before an operation.
• •Rotator cuff overload is the commonest and most disabling wheelchair injury, so shoulder preservation is a priority.
• •Wheelchair configuration and propulsion technique are modifiable risk factors that sit at the centre of prevention.

• •The weight-bearing upper limb makes shoulder rotator cuff overload the commonest wheelchair injury.
• •A painful arc and pain on resisted movement point to a rotator cuff problem, which usually needs no initial imaging.
• •Carpal tunnel syndrome is common in manual wheelchair users and is mainly a clinical diagnosis.
• •Nerve conduction studies are for uncertain cases or before surgery, not routine.
• •A lighter chair and moving the rear axle forward, as far as stability allows, reduce force on the shoulder and wrist.
• •Progressive weakness or wasting in the hand is a red flag, not something to monitor.