The Physically Challenged Athlete

General Considerations


  • Physically challenged: combines all groups of athletes competing in international competitions such as Paralympics; such athletes have an impairment that limits their ability to participate in athletic arenas within a manner considered “normal” for defined sport

  • Impairment: any loss or abnormality of psychological, physical, or anatomic structure or function

  • Disability: any restriction imposed from an impairment that limits an individual’s ability to perform an activity within a manner considered “normal” for an able-bodied individual

  • Handicap (as defined by World Health Organization): a disadvantage, resulting from impairment or disability that interferes with a person’s efforts to fulfill a role that is normal for that person; handicap is a social concept, representing social and environmental consequences of a person’s impairments or disabilities


  • Over 56.7 million disabled people in the United States (US); many nonambulatory

  • “Disabled” classification broad; includes nonathletic population

  • Over 200,000 people in the US with spinal cord injury (SCI)

    • Includes traumatic and nontraumatic

    • 11,000 new injuries per year; average age at injury is 32 years

    • 55% tetraplegia, 45% paraplegia

  • Over 1,540,000 million people in the US with limb loss

    • Incidence of congenital limb deficiency is 60 per 100,000 live births.

    • People older than 65 years account for 19.4 per 1000 of those with limb loss.

    • Comorbidities: diabetes, vascular, and malignancy

    • Incidence:

      • Lower extremity amputation (LEA), diabetes, and younger than 30 years: 7.2%

      • LEA, diabetes, and older than 30 years: 9.9%

      • Dysvascular disease: 46.2 per 100,000 with limb loss

      • Trauma: over 5.86 per 100,000 with limb loss (war increases this rate)

      • Malignancy: 0.35 per 100,000 with limb loss

  • Multiple sclerosis: 400,000 cases diagnosed in the US each year

  • Muscular dystrophies: new cases estimated at 250,000 each year in the US; Duchenne muscular dystrophy is 1 of the 9 types of muscular dystrophy


  • First sports event, physically challenged: 1888, Sport Club for the Deaf; Berlin, Germany

  • First international competition for the disabled: International Silent Games, 1924

  • First international sports competition for people with various physical impairments: Stoke Mandeville Games for the Paralyzed, 1948

  • Youth divisions, in addition to adult, for athletes with physical impairment: 1980s

    • Adaptive physical education, hippotherapy (a form of therapy using the characteristic movements of a horse to provide carefully graded motor and sensory inputs), and aquatic therapy: 1980s


  • Interscholastic, collegiate, professional sports: physical impairment cannot require changes in rules of a sport, lowering of standards for achievement, or modification of a defined sport to accommodate athletes

  • Neither adaptive equipment nor physical impairment can impart danger or an advantage to athletes or others competing in that sport.

  • Wrestling

    • Those with hearing loss have successfully competed with normal hearing athletes; if hearing loss is >55 decibels in the better ear, qualifies for physically challenged

    • Limb loss: must weigh in with prosthesis, if used

  • Jim Abbott, professional major league baseball. Congenitally absent right hand

  • Archery

  • Below-knee amputations (BKAs)

    • Allowed in high school football after restrictions removed in 1978; check local competition rules

    • National Federation of State High School Associations’ rules concerning contact sports:

      • Restricted to BKA; no upper extremity or above-knee prosthesis

      • Metal hinges restricted to lateral and medial; require covering

      • No metal in front of knee unless appropriately padded

      • Prosthesis wrapped with minimum of half-inch foam rubber or appropriate polyurethane

      • Approval of physician associated with amputee care recommended

  • Paralympics

    • International competition following Olympics

    • Traditionally includes athletes with limb deficiency, cerebral palsy (CP), visual impairment, SCI, “les autres” (those not fitting into other groups), and intellectual disability

    • Currently, intellectual disability is not a participant group in the International Paralympic Committee (IPC)-sanctioned events. The IPC has asked the International Sports Federation for Persons with an Intellectual Disability (INAS-FID) to develop eligibility and verification processes that are commensurate with other IPC divisions to ensure fair competition.

Classification Systems

  • System used to equalize athletes in competition using objective methods:

    • Medical diagnosis only: e.g., CP, limb deficiency, and muscular dystrophy

    • Functional measurement only: e.g., wheelchair mobility level, above-knee amputation (AKA), and BKA

    • Hybrid: use functional measurements and medical diagnosis; multiple sclerosis with full trunk control and wheelchair mobility

  • May be sports-specific for alpine skiing or cycling

  • Classification systems may differ at international and local competitions.

  • 1996 Paralympics: Of 3500 athletes, the most common impairment was limb deficiency.

General Considerations for Treatment of Athlete

  • Cognitive age differences: coping with impairment

    • Adult: potential concurrent medical issues, social isolation

      • Management of comorbid diabetes, arthritis, or other diseases

  • Youth: peer interaction, relationships

    • Missed social/peer opportunities

    • Constant change in size/fit of adaptive equipment

    • Health insurance: have benefit and Medicaid limits

  • Counsel: assist athlete in redesigning athletic or career goals

  • Financial needs: insurance coverage, private funds, or home equity loans

    • Paperwork, appeal process, or funding for equipment needs

  • Physical office facilities: Americans with Disabilities Act (ADA) criteria for accessibility

    • Adjustable-height examination table

    • Appointment scheduling adjustment to allow time to address unique mobility, equipment, or comorbidity issues

  • Establish virtual office with other healthcare professionals (e.g., neurosurgeon, physiatrist, therapist, vocational rehab, psychologist, primary care physician, prosthetics, or orthotist)


  • Several US and international organizations address needs of physically challenged athletes ( Box 14.1 ), e.g., Disabled Sports USA (DS/USA):

    • Founded 1967, by disabled Vietnam veterans

    • Provides opportunities for those with disabilities to gain confidence and dignity through sports, recreation, and educational programs

    • Nation’s largest multisport, multidisability organization, serving >60,000 people

    • Member of the US Olympic Committee

    • Sponsors the Wounded Warrior Project

    Box 14.1

    Resource Organizations



Spinal Cord Injury

Physiologic Changes in Exercise

  • Altered venous return, consequent decreased ability to respond to exercise stress

  • Depending on level of SCI, possible blunting of heart rate response to exercise

  • Vagal withdrawal, not sympathetic drive

    • Decreases reflexive regulation of blood flow

    • Decreased total peripheral resistance (increased vasodilation)

    • Increased peripheral pooling

      • Treatment to minimize: compression garments or abdominal binder

    • Decreased oxygenated blood to exercising muscle

      • Fatigue, limited aerobic endurance

  • Cardiac repolarization abnormalities

  • Decreased lactate threshold

  • Limited pulmonary capacity, generally restrictive type (due to respiratory muscle weakness)

  • Kinetic chain disruption

    • Loss of ground reactive force from lower extremity

    • Stabilizing muscles become prime movers.

  • Greater muscular strength improves aerobic power and endurance.

  • Paraplegics and people with high-level SCI can increase VO 2 max with exercise.

    • Dependent on intensity, frequency, and duration

Medical Concerns in Athletes


  • SCI level: complete or incomplete, type of injury ( Figs. 14.1 and 14.2 )

    Figure 14.1

    Motor impairment related to level of SCI.

    Figure 14.2

    Incomplete spinal cord injuries.

  • Surgeries related to injury: past spinal fusion, surgical muscle transfers for functional improvement, or surgically implanted medical devices

  • Medications: antiepileptics, antispasmodics, tricyclic antidepressants, anticholinergics, baclofen pumps, pain medications, and others for comorbidities

  • Comorbid medical issues; related to:

    • Impairment: e.g., pressure sores, type and success of bowel/bladder management program; recurring urinary tract infection (UTI)

    • Concurrent illness: e.g., traumatic brain injury (TBI), diabetes, visual impairment, amputation, cardiac disease, or seizures

  • Level of functional independence: independent transfers with wheelchair, self-management of personal hygiene

  • Adaptive equipment needs: for sports-specific or general mobility

  • Prior training: environmental conditions, aerobic and anaerobic conditioning, or flexibility

Physical Conditions to Consider

Deep Venous Thrombosis (DVT)

  • Risk greatest in the first 2 weeks after injury

  • Other risk factors: obesity, trauma to pelvis and lower extremities, congestive heart failure, prior malignancy, tight garments below level of lesion, and previous thromboembolism

  • Venous pooling in lower limbs

  • Prevention: passive stretching of limbs, abdominal binder, and functional electrical stimulation (latter needs further research)

Heterotopic Ossification

  • Etiology unclear

  • Symptoms: pain, increased warmth, swelling, and decreased joint motion or contracture

  • Incidence: 16%–53%

  • Locations: hip, followed by knee, shoulder, and elbow

  • Prevention: initial treatment after onset of SCI with nonsteroidal anti-inflammatory drugs (NSAIDs) and passive range of motion (ROM)/mobilization

  • Risk decreases 2–3 times with appropriate treatment

  • Treatment:

    • Stretching and passive ROM exercises

    • Medication: NSAIDs (e.g., indomethacin) and bisphosphonates (e.g., etidronate)

      • Etidronate disodium: blocks aggregation, growth, and mineralization of calcium hydroxyapatite crystals; heterotopic ossification can occur in previously etidronate-treated patients

    • Surgical excision: high reoccurrence rate, lesser if delayed until skeletal maturity/low bone turnover rate

  • Imaging: three-phase bone scan; radiographs often negative during initial phase of symptom presentation; may take 4–5 weeks for findings to appear

  • Laboratory findings: significant elevation in fractionated alkaline phosphatase during bone ossification

Autonomic Dysreflexia (AD)

Jul 19, 2019 | Posted by in SPORT MEDICINE | Comments Off on The Physically Challenged Athlete

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