Shoulder Pain in a Manual Wheelchair User
A 34-year-old woman with T6 complete paraplegia (ASIA A) from a motorcycle crash 6 years ago presents with 3 months of right shoulder pain. She is a full-time wheelchair user, transfers independently, and drives a manual chair. Pain is 6/10 at rest, 8/10 with transfers and overhead reaching, and worse at night when lying on the right side. Exam: painful arc 70–110° of abduction, positive Neer and Hawkins tests, tenderness over the greater tuberosity, and 4+/5 right supraspinatus. She wants to "push through it" because she is training for a wheelchair race. She has no imaging yet.
1. What is your working diagnosis and differential, and what workup do you order?
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Working diagnosis: rotator cuff tendinopathy/impingement, likely with subacromial bursitis, in a shoulder chronically overloaded by wheelchair propulsion and transfers. The painful arc, positive Neer/Hawkins, and night pain fit.
Differential: partial- or full-thickness rotator cuff tear (supraspinatus 4+/5 raises concern), AC joint arthropathy, biceps tendinopathy, glenohumeral osteoarthritis, and - importantly in SCI - cervical radiculopathy and syringomyelia if there are sensory changes, plus complex regional pain syndrome.
Workup:
- Plain radiographs of the shoulder.
- MRI or ultrasound of the shoulder to assess cuff integrity given the strength deficit and chronicity.
- Screen the cervical spine if any new upper-extremity sensory or motor findings.
- Assess wheelchair setup (seat width, axle position, tire pressure) and transfer technique.
2. She wants to continue racing. How do you balance activity modification against her goals, and what does your initial rehab prescription look like?
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Do not simply tell her to stop - that harms adherence and function. Negotiate a relative rest plan:
- Reduce provocative load for 2–4 weeks: limit overhead reaching, modify transfers (use a sliding board or higher surface), and temporarily reduce race training volume while keeping cardiovascular work via an arm ergometer at lower resistance.
- Optimize mechanics: review wheelchair fit, axle position, and push technique; consider a lighter chair or power-assist for training.
- Exercise: isometric rotator cuff and scapular stabilization early, progressing to eccentric cuff loading and posterior cuff/scapular retractor strengthening. Avoid painful arcs initially.
- Modalities/adjuncts: relative rest, ice, and a short course of NSAIDs if not contraindicated; consider a subacromial corticosteroid injection if pain limits participation.
- Reassess in 4–6 weeks; escalate to orthopedics if a full-thickness tear is confirmed or strength does not improve.
3. How do you counsel her about the long-term risk to her shoulders, and what monitoring do you build in?
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Frame shoulders as her "weight-bearing joints" - in a manual wheelchair user, every transfer and push loads the shoulder, and overuse injury is a leading cause of lost independence. Counseling points:
- Rotator cuff disease is common and recurrent in long-term manual chair users; early treatment preserves independence.
- Maintain strength and scapular control as a lifelong habit, not just during pain.
- Watch for warning signs: night pain, weakness, dropping objects, or pain that persists at rest.
- Consider equipment strategies (power-assist wheels, lighter chair) as she ages to reduce cumulative load.
Monitoring: periodic shoulder strength and range-of-motion checks at follow-up, repeat exam if symptoms recur, and annual review of wheelchair fit and transfer technique. Document her functional goals so the plan stays goal-directed.