For generations, athlete participation in sport has reflected perceived societal ideologies or norms, with historically underrepresented groups facing large barriers to exercise and disparate health outcomes during activity. One of these historically underrepresented groups is the female athlete. Women participating in sports experience decreased media representation, increased exposure to abuse during sport, higher clinical rates of relative energy deficiency in sport (RED-S), and higher rates of mental health disorders compared to male athletes. These factors increase drop-out rates of nondisabled women in sports, thus widening gender inequity gaps.

The female Para (athlete with disability participating in sport governed by the International Paralympic Committee) or adaptive athlete (athlete with disability) faces even more barriers to sport participation by additional nature of a functional impairment. Based on Paralympic classification, these diagnoses include physical (such as spinal cord injury or SCI, limb loss, short stature, and cerebral palsy or CP), visual (such as acquired or congenital vision disorders), or intellectual impairments (such as Down syndrome or diagnoses affecting cognition prior to the age of 18 years). This dual barrier to sport participation, by nature of both gender and ability status, creates even more disproportionate inequities for female Para and adaptive athletes. Though inclusion of nondisabled women in the Olympics has significantly increased, from the inaugural competition in 1900 with 22 women to achieving gender parity in the 2024 Paris Olympics, the Paralympics have yet to demonstrate full gender parity. ^,

Though female Para and adaptive athletes experience tangible barriers affecting general health and well-being, there is minimal published research on holistic considerations targeting their clinical health. The purpose of this scoping review is to explore current considerations in clinical care of the female Para and adaptive athlete from an organ systems perspective, focusing on recommendations for optimizing management and mitigating health disparities.

This literature review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement. PubMed and CINAHL were searched by a health sciences librarian on July 2, 2025 to identify literature on female adaptive athletes. No date or language filters were applied. The search strategies are included in Box 1 . Cited references of included articles were examined for additional relevant literature.

Citations were uploaded in Covidence, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews, for screening and data extraction. Titles and abstracts were independently screened by 2 researchers to exclude irrelevant abstracts using predetermined inclusion and exclusion criteria. Next, 2 researchers independently reviewed full-text articles for inclusion. Articles focusing on training and kinematics of sport performance or classification were excluded, in addition to those lacking gender analyses or discussion of intersection between gender and disability. Disagreements on inclusion and exclusion decisions were resolved through discussion.

A total of 522 abstracts were retrieved and uploaded in Covidence. From these, 86 articles met criteria for inclusion. A flow diagram of the selection process is shown in Fig. 1 .

Flow diagram of study selection.

(Diagram generated with PRISMA).

In athletes with hearing impairment, women demonstrate decreased cardiorespiratory fitness. In a cohort of 14 female basketball players with hearing impairment, VO ₂ peak, a key measurement of aerobic health in optimizing peripheral uptake of oxygen from skeletal muscles, was significantly lower than VO ₂ peaks from nondisabled athletes. Aerobic activity was considered “low” at 55.9 ± 6.1 mL/min/kg (“low” = VO ₂ peak 56–60 mL/min/kg). Physical working capacity at a heart rate (HR) of 170 beats per minute (PWC ₁₇₀ ) was 20.3 ± 2.0 kg m/min/kg, which was considered “average” (16–20 kgm/min/kg). Low VO ₂ peak and average PWC ₁₇₀ in hearing-impaired populations may stem from decreased vocalization, which diminishes lung expansion and total lung volume, compounded by inherent sex-specific decreases in female cardiovascular health parameters. Given decreased overall myocardial efficiency, female athletes with hearing impairment may benefit from specialized cardiorespiratory training programs.

In athletes with muscular weakness from neurologic injury, comparable results are observed. An analysis of 10 female wheelchair basketball players with polio, multiple sclerosis, or SCI showed that women had lower power outputs and higher velocity fatigue indices (quicker time to fatigue). When fatiguing, women reduced propulsion velocity and increased torque, thus demonstrating decreased anaerobic fitness when compared to men. Case reports show decreased peak aerobic capacity, as well as greater decrement in peak speed (17% drop) across wheelchair sprints when compared to unpublished data from elite wheelchair athletes (within 10%), in a wheelchair tennis player with an incomplete L1 SCI and higher rate of perceived exertion (RPE) at end-of-race in a Paralympian with SCI. Thus, training should be optimized to maximize anaerobic fitness and improve muscular efficiency in female athletes with SCI.

In athletes with amputation, a case report describes a middle-aged Paralympic cross-country skier with bilateral upper extremity amputations who underwent exercise exhaustion testing on a cycle ergometer 3 times per year over 10 years. Her maximum heart rate (HR _max ) and maximal oxygen intake decreased from first to subsequent evaluation, but her blood lactate also decreased, indicating no appropriate increase in anaerobic activity despite a lower HR _max and equivalent time to exhaustion. However, her VO ₂ max (51.30 mL/kg/min) eventually improved over time and was comparable to those in 3 female athletes with intellectual disability (average VO ₂ max 51.8 mL/kg/min) and 1 with visual impairment (VI; VO ₂ max 56.9 mL/kg/min). ^,,

Despite these sex-specific deficits in cardiorespiratory performance, exercise still plays a large cardioprotective effect in female Para and adaptive athletes. Cardiac dimensions were larger for wheelchair basketball players with SCI (620.3 mL; 9.6 mL/kg) when compared to sedentary women with SCI (477.4 mL; 8.2 mL/kg), and athletes had higher maximal work rate, oxygen consumption, and lactate without accompanying increase in HR. These cardiac dimensions were comparable to sedentary, nondisabled subjects, though those with amputations or poliomyelitis had greater heart volumes than those with SCI. ^, In persons with SCI, dysregulation of sympathetic innervation to the heart precipitates greater pooling of blood in atrophied lower extremities and less muscular work, thus decreasing stroke volume. However, regular physical activity can improve aerobic physiology through improvements in mitochondrial activity and glycolysis. These changes can influence lipid profiles as well, with middle-aged Paralympic women having lower glycemia, higher high density lipoprotein, lower triglycerides, and lower blood pressure than Paralympic men, likely due to effects of estrogen in decreasing rates of atherosclerosis. In addition, higher RPE but stable mean heart rate variability (HRV) was seen with progressive load in a senior Paralympic table tennis player with T12-L1 SCI. Menopause and aging typically increase HRV due to dysregulation of the parasympathetic nervous system, so it was proposed that longitudinal involvement in sport improved expected cardiovascular parameters in an aging, female adaptive athlete.

One case report describes a pediatric 14 year old goalball player found to have left ventricular noncompaction leading to mild biventricular systolic dysfunction. After prophylaxis with acetylsalicylic acid and regular clinical follow-up, she returned to competitive goalball after 1 year, demonstrating the importance of screening for cardiac risk in this population.

In a prospective longitudinal study, 10 professional endurance Para cyclists (5 women and 5 men) with various diagnoses (SCI, neuromuscular disorders, musculoskeletal impairments, and VI) were monitored over 35 weeks. Women had more than a 3 fold increased likelihood of developing a respiratory illness than men (incidence relative risk: 3.66), thus demonstrating sex-specific differences in illness risk regardless of underlying diagnosis.

In athletes with VI, female Paralympic goalball players had lower functional vital capacity (FVC, 3.78 ± 0.56 vs 5.96 ± 0.18), forced expiratory volume in one second (3.22 ±0.38 vs 4.79 ± 0.36), and forced expiratory flow between 25% and 75% of forced vital capacity (3.32 ± 0.67 vs 4.62 ± 1.15 L/s) compared to men. Decreased upper extremity and trunk isometric muscle function in women with VI may affect diaphragm and trunk musculature, thus limiting overall respiratory function.

In athletes with SCI, women with paraplegia had significant decreases in peak oxygen consumption and minute ventilation compared to men with paraplegia. This may occur due to decreased muscle mass and capacity for lung volume expansion in women. Similarly, decreased FVC with increased fatigue was seen during an endurance event in a Paralympian with SCI.

Multiple studies discuss weight and body composition for female Para and adaptive athletes. The distribution of bone mineral, lean mass, and fat mass was assessed in both female wheelchair athletes and a reference group by dual-energy X-ray absorptiometry (DXA) in one study. The transferability of anthropometric equations commonly used in women was examined to establish a field method of body composition assessment. These equations were not as accurate in the wheelchair group, underestimating total percent (%) body fat. Instead, body mass index (BMI) and waist girth showed strong correlations with body fat in the wheelchair group. Utilizing DXA, another study determined that female athletes with physical impairment exhibit a unique body composition profile compared with female nondisabled athletes and male athletes with a physical impairment, identifying a sex-specific pattern of body fat and lean tissue distribution, particularly in the legs. Another study in sitting volleyball players demonstrated significant differences between gender when calculating body fat % and body density using skinfolds (SF) measures, but not when using air-displacement plethysmography.

In a group of elite wheelchair athletes, significantly higher total fat and total fat-free mass was seen in women compared to men. Similarly, another study of wheelchair athletes noted body fat % in female athletes was higher than in male athletes (32.9 ± 6.7% vs 21.1 ± 5.6%). Higher body fat in women may be due to basic gender differences in fat accumulation as well as utilization during sport. Women also tend to take longer to participate in recreational and sporting activities postinjury, which may contribute to this difference.

Female athletes with and without VI also had higher % body fat than male athletes with and without VI when utilizing foot-to-foot bioelectrical impedance analysis.

In Special Olympics (SO) participants, the BMI of female athletes differed appreciably from their male counterparts in one study. Women in both the younger and older age groups were significantly more obese than men in related age groups. An international survey of SO athletes also showed that adult female athletes were 1.8 times more likely than male athletes to be obese, and female youth were more likely to be obese than male youth.

Low energy availability (LEA) has systemic consequences, as female athletes often restrict energy intake. In elite wheelchair athletes, LEA occurred in 73% of the days in female athletes and in 30% of the days in male athletes. Energy balance was positive in men (+169.1 ± 304.5 kcal) but negative (−288.9 ± 304.8 kcal) in women, and LEA seems to be higher in female wheelchair athletes compared to nondisabled female athletes. Therefore, either female wheelchair athletes are more prone to LEA or the cutoff values to classify a wheelchair athlete with LEA might be different compared to those of nondisabled athletes. In addition, a randomized controlled crossover trial showed lower mean LEA (defined as ≤30 kcal/kg fat free mass or FFM per day in nondisabled women) in women and men. Not unlike other studies, macronutrient intake, EA, and blood biochemical parameters were suboptimal in elite female wheelchair athletes. Similarly, male and female Paralympic sprinters with VI, hemiplegic CP, and distal upper limb deficiency had a lower mean EA of 36 to 39 kcal/kg FFM per day.

These findings pose key considerations for female Para and adaptive athletes, especially regarding diagnosis of RED-S, which involves an interrelated spectrum of EA, menstrual dysregulation, and bone mineral density (BMD) on athlete health, including protein synthesis, reproductive health, and return-to-play. ^, The American College of Sports Medicine demarcates “low BMD” in young female athletes in weight-bearing sports as Z scores between −1.0 and −2.0 with other risk factors. However, there are no current definitions for “low” EA or “low” BMD in female Para athletes.

In a cross-sectional study of Paralympians including 110 women (30.4% with SCI or lower extremity amputation), 3.1% reported a prior eating disorder and 32.4% scored highly on Eating Disorder Examination Questionnaire pathologic behavior subscale scores, putting athletes at risk for RED-S. About 59.5% women wanted modifications to body weight to optimize athletic performance. Almost half of premenopausal women (44%) described oligomenorrhea (6–9 menstrual cycles in 12 months) or amenorrhea (<5 menstrual cycles in 12 months), and 13.4% had delayed menarche (onset >15 years old). About 54.5% of athletes had low BMD and reported bone stress injuries (BSI). Only 13.6% of women were aware of the concept of RED-S. The interplay between menstrual dysregulation and BMD was also seen in another study, in which BMD at the lumbar spine was significantly lower in athletes with amenorrhea compared to those with normal menstruation. This could be partially due to significantly lower rates of brain-derived neurotrophic factor (BDNF) found in amenorrheic women, since BDNF is produced by osteoblasts, induces differentiation of embryonic stem cells, and typically promotes bone density.

Athletes with SCI are at high risk of RED-S. In addition to known nutrient deficiencies, energy expenditure (EE) is reduced 25% to 75% during exercise when compared to nondisabled athletes, with the largest reduction occurring in athletes with tetraplegia or static wheelchair athletes. ^, For example, the mean EA of female Para wheelchair basketball players with SCI or skeletal system disorders was 41.4 kcal/kg lean body mass, which was lower than average. Women with SCI are at higher risk of decreased BMD and osteoporosis due to decreased estrogen over time.

For female athletes with spina bifida, there is an increased risk of developing an eating disorder (8%) compared to the general female population (0.5%–2%), possibly due to rhetoric related to decreasing caregiver burden by decreasing weight. There is also evidence of decreased BMD, especially in the lower extremities, in those who use wheelchairs.

For female athletes with VI, there are higher rates of hip fracture than in men with VI. ^,, The BMD in the weight-bearing proximal femur of women with VI was 8% lower than in age-matched sighted women, which could contribute to this elevated risk of BSI.

For athletes with amputations, there is greater EE due to increased metabolic equivalents for functional gait and typically decreased BMD on the same limb as the amputation, which leads to increased EE.

Nutrition and endocrinologic factors can significantly affect gynecologic health in athletes. In one study of female Para and collegiate athletes, 46.2% of Para athletes with weight loss had irregular menstruation. Menstrual cycle-related negative symptoms that influenced training or competition were reported more frequently by Para athletes than by collegiate athletes (81.5% vs 55.6%). This may be why oral contraceptive use was significantly more frequent among Para athletes than collegiate athletes (14.8% vs 1.8%), though contraceptive use may mask menstrual dysfunction and make it harder to assess for LEA or RED-S among athletes with SCI. Another study showed that 77% of Para athletes reported performance to be impacted by their menstrual cycle, which was higher than the group mean.

Nose-Ogura conducted several studies including Para athletes’ gynecologic issues. One survey of 94 Para athletes indicated that 4% of athletes had amenorrhea and 24% had menstrual irregularities. In a survey of 37 Paralympians from Rio 2016, 27% took measures for menstruation with oral contraceptives or low-dose estrogen-progestin. A similar survey was conducted with 24 athletes with disabilities who experienced pregnancy and childbirth. About 25.6% of elite athletes and 62% of Para athletes with dysmenorrhea replied that their dysmenorrhea affected performance. Eighty-four percent of Para athletes also had premenstrual syndrome. Many Para athletes responded that their condition was best for a few days immediately after menstruation. Lastly, the incidence of urinary incontinence was higher in female Para athletes than nondisabled female athletes (25% vs 5.5% prior to first pregnancy, 54.2% vs 40.4% after childbirth).

Investigation of BSI is key to discussing musculoskeletal considerations in female athletes. In a cross-sectional study analyzing 260 Paralympians, with most common impairments of SCI (30.4%) and lower limb amputations (25.8%), half noted a prior history of fracture, with 53 athletes reporting a previous history of BSI. Though there was no statistically significant difference in BSI rate between sex, female Paralympians had BSIs in different, sometimes uncommon, locations, including the inner sesamoids, wrist, and ribs, which can preclude participation in sport. Thus, rehabilitation post-BSI in the female Para and adaptive athlete is essential and may have unique considerations based on impairment biomechanics.

From a rehabilitation standpoint, sex-specific strength asymmetry is observed in female Para athletes. Para female sitting volleyball players had less muscle strength in bilateral arms, with significant differences in internal rotation at 180° per second velocity, but less muscle asymmetry in bilateral shoulders compared to male players. These biomechanical findings suggest the importance of muscular training and rehabilitation programs for female overhead Para athletes, who may develop asymmetric rotational strength profiles. Similarly, Para female sitting volleyball players scored significantly lower than men in agility, speed, and endurance testing, in addition to seated chest pass. Since women may not perform as well in upper limb tasks, rehabilitation should focus on developing upper extremity strength through power-based exercises.

In athletes with VI, a cross-sectional study of Paralympic judo athletes showed women with VI had a high prevalence of injury, including 73% of the study population, and among athletes who sustained an injury, 80% of injuries to women occurred from direct contact versus 69.4% of men. Another study of 18 judo athletes with VI showed that women had less bilateral upper and lower extremity muscle strength and more interlimb asymmetry than men. This was also seen in goalball athletes, in which women had decreased isometric muscle strength in most upper extremity, core, and pelvic maneuvers when compared to men. Sex-specific differences in strength and symmetry may affect task completion, such as lower rates of completion and slower 1 mile run or walk tests, in elite female goalball players versus male players. Female athletes with VI performed worse on this test than sighted female athletes.

In athletes with neurologic weakness from SCI, spina bifida, or polio, a pilot study showed that shoulder and hand grip/pinch strength were significantly lower in nondisabled women than in wheelchair athletes. This shows a protective effect of sport participation for improving upper extremity strength in wheelchair athletes.

In athletes with CP, a study of Para footballers showed that women had a slower 10 m sprint time and slower change of direction time compared to men. This could be attributed to increased spasticity and coordination-related deficits noted in the female athletes, but also poses considerations on differences in gender impacting performance.

In the SO population, a higher incidence of foot pathology from structural (ie, pes planus/cavus) or infectious etiologies (ie, plantar warts and tinea pedis) was seen in female versus male participants, but was not statistically significant. Differences in anatomic foot structure in women, including weaker ligaments contributing to less structural stability, were purported to contribute to this higher incidence. In another study of SO, men were significantly stronger than women in upper extremity exercises such as chest press, seated row, overhead press, seated dip, and biceps curl. These findings could be related to women having decreased average body weights, muscle mass, and upper extremity strength in the SO population.

Case reports describe other etiologies of musculoskeletal pain, including lumbar radicular pain treated with a transforaminal full-endoscopic discectomy with thermal annuloplasty in a 28 year old Paralympian wheelchair basketball player and phantom knee pain in a collegiate track and field athlete with a transfemoral amputation treated with gait retraining. In addition, premorbid medical conditions affecting musculoskeletal health, including McCune Albright syndrome in a Paralympic archer necessitating early hip arthroplasty due to recurrent femoral neck fractures, is described.

Periodic Health Evaluation Recommendation

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