In the sports of discus, javelin, and shot put, the goal is to hurl, throw, or put an object as far as possible. In the adaptive form of these sports, the distance is then converted to a score based on the athlete’s classification, thus allowing for fair competition among athletes with differing levels of impairment. Athletes participating in all field events, including discus, javelin, and shot put, are classified in the F10s through F50s. The “F” stands for “field,” and the number that follows signifies level of disability. The F10s are athletes with visual impairments; the F20s are athletes with intellectual impairment; the F30s are athletes with varying degrees of motor dysfunction, including cerebral palsy; the F40s are athletes with short stature, limb deficiencies, or amputations; and the F50s are wheelchair athletes, including tetraplegics and paraplegics [2]. As previously mentioned, the lower the classification number within each grouping, the greater the degree of disability. For more details on the classifications, see Table 24.2.

Boccia is the adaptive sport equivalent of bocce. It was originally developed for athletes with cerebral palsy but is now inclusive of athletes of other impairment groups including stroke, traumatic brain injury (TBI), spinal cord injury (SCI), muscular dystrophy, and multiple sclerosis. It is played indoors on a flat, smooth surface and features individual as well as team play. Each individual, or team, has six leather balls (either red or blue), and the purpose is to land the ball as close as possible to the “Jack” or white target ball. To begin the game, or match, the red individual (or team) throws the Jack out onto the court. Athletes, depending on their impairments, are permitted to throw, kick, or use an assistive device known as a pointer to propel the ball from a designated throwing area. After throwing the Jack, that same player then throws his or her first red ball toward the Jack. Blue then throws their first ball. Whichever ball is closer to the Jack identifies the “in team.” The “in team” watches as the other team throws their balls one by one until they either displace the “in team” or run out of balls, after which the other team resumes throwing. A round, or “end,” is completed after all balls are thrown. At this point, the score is tallied. The individual, or team, that is closest to the Jack will score as many points as they have balls closer to the Jack than their opponent’s closest ball [1, 6].

Each match consists of four to six ends depending on the number of players per team (individuals and pairs play four ends, teams of three play six ends). Each player, or team, throws six balls per end (i.e., an individual throws six balls, pairs throw three each, and teams of three throw two each). The winning individual, or team, is the one with the most points at the end. If there’s a tie, a tie-breaker end is played. If at any time during an end the Jack is pushed or rolls out of bounds, the Jack gets placed in the center of the court and the closest ball determines the new “in team” [1, 6].

Individual and team play is comprised of seven different divisions, four divisions of individual play and three divisions of team play (two for pairs and one for teams of three). For a description of each division, please see Table 24.3. The actual boccia balls weigh 275 ± 12 g with a circumference of 270 ± 8 mm [6].

Depending on the athlete’s impairment(s), adaptive equipment may include prosthetic limbs or wheelchairs. Beyond these, the adaptive equipment is more sport specific. As previously mentioned under the field events, seated athletes, specifically F31–34 and F51–58, utilize a throwing frame in discus, javelin, and shot put. The throwing frame is secured to the ground and the seat height cannot exceed 75 cm. Holding bars may be present which can be held by the hand of the non-throwing arm to assist in maintaining balance and generating greater force. There may also be footplates present for added support and stability. Straps can be placed over the thighs and/or pelvis. The use of gloves as an adaptive device to improve grip is permitted for classes F51–53 only [2].

For boccia, specific adaptive equipment may include ramps and pointers, as previously mentioned. BC 3 athletes who cannot throw or kick the boccia ball are eligible to use ramps and pointers. Ramps are slide-like structures that the boccia ball can be “launched” from, and pointers are devices fixed to the athlete’s head, mouth, or arm to push the ball down the ramp [6].

Like all athletes, adaptive throwers are subject to injury. Many adaptive throwers have unique medical issues related to their underlying health conditions. It is important to be aware of these issues first and foremost. In addition to underlying medical issues, adaptive athletes are at risk for injuries related to both their disability and sport-specific activity.

Athletes that compete in adaptive sports often have unique medical issues based on the very health conditions that precipitate their impairments and disabilities, particularly the athletes with spinal cord injuries. Regardless of what sport they are participating in, athletes with spinal cord injuries are at varying risk, based on the level of lesion, for developing urinary stones, bladder infections, respiratory infections, pressure sores, and autonomic dysfunction [7–10]. While insensate individuals are at higher risk of pressure sores/ulcers at baseline, there are added risk factors which are pertinent to adaptive athletes that include increased moisture from sweating and repeated movements during sport activity [7, 11]. All athletes competing in wheelchairs are potentially subjected to this risk. Therefore, it is important for the athletes to have adequate cushioning of the buttocks, frequent pressure reliefs, high-performance moisture-wicking clothing, and optimal nutrition [10, 11]. Autonomic dysfunction, in the form of poor vasoregulation and impaired innervation of sweat glands, places the athlete at risk of hyperthermia, dehydration, and intolerance of environmental extremes, emphasizing the need for proper fluid hydration before, during, and after competition [7, 9, 10]. Another unique medical issue worth noting is the increased seizure risk associated with cerebral palsy. Athletes with cerebral palsy may be at higher risk as the seizure threshold may be lowered through stress encountered during competition, fatigue from training, or dehydration [7]. It is important to keep these underlying health issues in mind when caring for adaptive athletes.

Underlying disability can predispose the adaptive athlete to specific injury patterns. Generally speaking, upper extremity injuries are more common in wheelchair athletes, while lower extremity injuries are more common in ambulatory disabled athletes [8, 12–14]. More specifically, a study that looked at the 1996 Paralympics found that among US competitors with soft tissue injuries, wheelchair athletes had a predilection for shoulder, arm-elbow, and forearm-wrist injuries; visually impaired athletes a predilection for hip-thigh, cervicothoracic region, and shoulder injuries; and cerebral palsy athletes a predilection for lumbar region, foot-toe, and ankle injuries [14]. A separate study that looked at the 2004 Paralympic Games found that injury occurrence was different based on classification, with more injuries occurring among track/field (T/F) 11–13, followed by T/F 40–46, T/F 51–58, T/F 32–38, and finally BC 1–4 [15].

Among disabled athletes, the wheelchair athlete warrants special mention because of the factor of wheelchair use and the unique risk factor for injury from the wheelchair. Repeated contact with the wheelchair push rims for purposes of propulsion increases the risk of blister formation on the hands and fingers, though this is more common in wheelchair racers. To prevent further irritation, blisters should be treated with petroleum jelly and a tape or gauze dressing, while the use of gloves may prevent blister formation from occurring [10, 11].

In addition to blisters, soft tissue injuries and skin lacerations/abrasions are the most prevalent injuries sustained by wheelchair athletes, with estimates of 33% of all injuries being soft tissue injuries [10, 11, 16]. Soft tissue injuries, including strains, sprains, bursitis, tendinopathies, and peripheral nerve entrapments, are most likely to affect the shoulders, elbows, wrists, and hands, with the shoulders being the most commonly affected [11, 17]. The risk of shoulder pathology, including rotator cuff impingement, rotator cuff tears, glenohumeral instability, and biceps tendonitis, is unusually high among wheelchair users. Though this risk is essentially the same for wheelchair athletes in general compared to nonathletic wheelchair users, wheelchair athletes competing in overhead sports appear to be at increased risk [10, 17–19]. Many of these injuries are the result of overuse and correlate with duration of impairment, duration of wheelchair use, and more training hours per week [16–18]. Muscle imbalances of the shoulder girdle may be correlated with wheelchair-related overuse injuries. Training programs should therefore focus on shoulder flexibility and strengthening of the shoulder adductors, internal and external rotators, supraspinatus, pectoralis major, triceps, and anterior deltoid muscles [17, 20].