There are an estimated 54.4 million disabled people in the United States (27).

There are approximately two million recreational and competitive disabled athletes in the United States (20).

Among those with disabilities, as many as 60% never participate in any physical activity or sports.

Although many opportunities exist for individuals with disabilities, the two most limiting factors for participation in athletics are awareness and access (30). Health care practitioners should make every effort to inform these individuals of the multiple opportunities and encourage their safe participation.

Athletes with disabilities demonstrate increased exercise endurance, muscle strength, cardiovascular efficiency, and flexibility; improved balance; and better motor skills compared with individuals with disabilities who do not participate in athletics.

In addition to physical benefits, psychological benefits of exercise include self-image, body awareness, motor development, and mood.

Disabled athletes have fewer cardiac risk factors and higher high-density lipoprotein cholesterol and are less likely to smoke cigarettes than those who are disabled and nonactive (7).

Individuals with amputations who participate in athletics have improved proprioception and increased proficiency in the use of prosthetic devices (29).

Athletes with paraplegia are less likely to be hospitalized, have fewer pressure ulcers, and are less susceptible to infections than nonactive individuals with paraplegia (26).

Injury patterns for disabled athletes are similar to those for athletes without disabilities; however, location of injuries appears to be disability and sport dependent. Lower extremity (LE) injuries are more common in ambulatory athletes (visually impaired, amputee, cerebral palsy), whereas upper extremity (UE) injuries are more frequent in athletes who use a wheelchair (12).

A 3-year, cross-disability prospective study found the injury rate of disabled athletes to be 9.30/1,000 athlete exposures (10) — an injury rate less than what has been reported in college football (12.0-15.0/1,000) and college soccer (9.8/1,000), but higher than that reported in men’s and women’s college basketball (7.0/1,000 and 7.3/1,000, respectively) (4,5).

A 6-year longitudinal study on reported injuries from disabled sports organizations revealed that illnesses (29.8%) were the most common, followed by muscular strains (22.1%), tendonitis (9.5%), sprains (5.8%), contusions (5.6%), and abrasions (5.1%). The body part most commonly injured was the thorax/spine (13.3%), followed by the shoulder (12.8%), the lower leg/ankle and toes (12.0%), and the hip/thigh (7.4%) (11).

Wheelchair users are at a significant increased risk of UE entrapment neuropathies, like carpal tunnel syndrome (CTS), with a reported prevalence rate of between 50% and 73%; however, it appears that wheelchair athletes have a lower prevalence than nonathletes (2,6).

With regard to winter sports, studies have shown that disabled athletes have a lower incidence of injuries than able-bodied skiers (19).

Preparticipation assessments (PPA) should be performed in a systematic comprehensive fashion similar to that performed for able-bodied athletes.

Sports medicine practitioners should not be overly focused on the athlete’s impairment/disability and miss common medical issues.

Careful evaluation of the athlete’s wheelchair, prosthetics, orthotics, and assistive/adaptive devices should also be performed prior to competition. This is usually facilitated by consultation with the individual’s orthotist, prosthetist, or other health care specialists with experience in this area.

Sports medicine practitioners who are not familiar with certain impairments should solicit assistance from practitioners with more experience. This often requires a team approach. For example, a physician specializing in sports medicine may have little experience in spinal cord injuries (SCIs), whereas an SCI specialist may have even less experience in sports medicine. Together, however, they can jointly assess an individual and clear him or her safely for participation.

Practitioners should avoid mass screening stations for individuals with disabilities in favor of private office setting visits.

It is recommended that the PPA be performed by a medical team that is involved in the longitudinal care of the disabled athlete, because knowledge of baseline functioning is essential.

The specific elements required in the PPA are determined by the sport, the level of participation, the athletic organization, the clinical indications, and the athlete. The PPA should provide information to guide the athlete, trainer, coach, and team physician toward safe participation, activity limitations, and disability-specific training.

The objectives of the examination include the following:

In addition to the standard components of a history, the elements of the history for an athlete with a disability also should include athletic goals, predisability health, present level of training, sports participation, medications and supplements used, presence of impairments, past and family cardiopulmonary history, level of functional independence for mobility and self-care, and needs for adaptive equipment.

The elements of the disability and sports-specific physical examination are tailored for the individual. Sensory deficits, neurologic deficits, joint stability and range of motion (ROM), muscle strength, flexibility, skin integrity, medications, and adaptive equipment needs must be assessed. During the musculoskeletal examination of an athlete who uses a wheelchair, evaluate the stability, flexibility, and strength of the commonly injured sites (e.g., shoulder, hand and wrist, and LEs) as well as the trunk.

Special attention should be paid during the PPA to skin breakdown on insensate pressure areas as well as sites that come in contact with orthotics/prosthetics. Also, a careful history of heat/cold injuries and changes in neurologic function should be solicited.

During the musculoskeletal examination of an individual who has had an LE amputation, assess the stability, flexibility, and strength of the trunk, as well as the hip girdle and the unaffected and affected LE with or without the prosthesis.

For individuals with UE amputations, the stability, flexibility, and strength of the shoulder girdle must be assessed in the unaffected and affected extremity with and without prosthesis, in addition to a trunk and LE evaluation.

For the athlete with brain injury, stroke, or multiple sclerosis, it is prudent to assess the limitations of the unaffected and affected areas based on mobility and sports-specific tasks.

Cardiovascular and pulmonary examinations can identify conditions that can cause cardiopulmonary collapse or disease progression. Suggested guidelines for cardiovascular screening of the athlete are available from the American College of Sports Medicine, American Heart Association, and American College of Cardiology.

A PPA is performed upon entry into sports and should be repeated at least every 2-3 years. An interim examination prior to each sport season may be necessary if the athlete’s health condition changes.

Disabled athletes are subject to many of the same injuries and complications from physical exertion as the able-bodied population.

In addition, some specific diagnoses that result in disability also lead to increased risk of particular injuries and complications. These will be discussed here.

There is certainly overlap between the categories of diagnoses resulting in disability. For example, many patients with SCIs are wheelchair users. For the purposes of this discussion, the following conditions will be considered: SCI, major limb loss, and wheelchair use.

Given the degree to which wheelchair users rely on their upper limbs for mobility and activities of daily living, the importance of recognizing, treating, and preventing upper limb injuries is magnified when compared with the able-bodied population. Because relative rest of the upper limb may be impossible or nearly impossible in this population, other measures should be considered. These may include splinting and orthotic prescriptions, admission to an inpatient setting if rest is required, or home modifications or additional assistance (21).