Paraplegia and the Shoulder

Document Type


Publication Date


Publication Title

Physical Medicine & Rehabilitation Clinics of North America Special issue: Shoulder Rehabilitation, Part II


Physical Therapy


Among consumers, families, therapists, physicians, and other rehabilitation professionals, there has been an increasing interest in shoulder pain associated with spinal cord injury (SCI). These disorders primarily affect the soft tissues, including the tendons (eg, rotator cuff tendonitis and bicipital tendinitis), muscles (eg, myalgias and myofascial pain syndromes), and bursae. Disorders of bone and joints also have been of interest (eg, osteoporosis and osteoarthritis of the acromioclavicular and glenohumeral joints).

The interest in shoulder disorders in SCI is relatively recent because long-term survival after SCI occurred during the past 50 years. The current population of individuals with SCI is unique in that people are living into their 70s and 80s for the first time. Using the upper limbs for weight-bearing purposes for 40 to 50 years or more has created biomechanical challenges to limbs that are designed primarily for prehension and mobility. Studying the natural history of these disorders is possible now for the first time.

These disorders represent a continuum—from conditions that are well understood and diagnostically straightforward to cases that are not well defined. Rotator cuff tear has relatively clear pathophysiologic and diagnostic criteria. In contrast, some cases of shoulder and neck pain are not specific. These latter conditions often are defined by the specific location of pain and do not have a clearly defined pathophysiology or diagnosis.

Although there have been clinical reports of lower limb musculoskeletal disorders related to paralysis and wheelchair use from the 1950s, epidemiologic studies of upper limb disorders and the associations with mechanical stressors have been relatively recent. Although similar disorders have been studied in large prospective studies of workers, athletes, performing artists, and hobbyists, most of the studies in SCI have been case series or convenience samples. The generalizability of these studies is more limited.

Several general limitations of the studies to date are apparent. Many reports are small and do not employ statistical analyses. A specific diagnosis or pathomechanism was not established in many cases. Detailed assessments of physical factors using quantitative methods generally are not used. Most studies have not addressed the relationship between age and time since injury. Because many of these same conditions occur with increasing frequency as a function of age in the general population (eg, rotator cuff tendinopathy), carefully designed studies with appropriate controls are necessary to establish differences between people with SCI and people without SCI.

The study of musculoskeletal disorders in people with SCI is in its infancy and beset with difficulties. Imprecise definitions, a paucity of outcome studies, a lack of animal models and tissue availability, and analyses of biomechanical loads all contribute to a level of uncertainty in this field. This insufficiency of data affects aspects of clinical care, particularly the diagnostic assessment, evaluation of contributory factors, identification of cause-and-effect relationships, and development of a dependable treatment program.

In the past few years, scientific literature, textbooks, patient education materials, consumer guides, websites, and manuals have stated that repetitive motion or overuse results in shoulder disorders when living with a SCI. Although a presumptive etiology is implied, little evidence exists that repetitive motion or overuse is responsible for the disorder under study. Regardless of the etiology, if the shoulder disorder is mechanical in nature, modification of biomechanical loads must be a fundamental aspect of the treatment program.