Medical management of musculoskeletal pain in professional wheelchair basketball players: an evidence-based guide

ABSTRACT

Wheelchair basketball (WB) has evolved from a recreational activity to an internationally recognized sport. It is useful in enhancing psychophysical well-being in athletes with disabilities. However, WB professional players’ medical management, especially regarding musculoskeletal pain (MSP), poses unique challenges and the related scientific literature still seems fragmentary. An extensive review of the PubMed, Cochrane, and Embase databases was performed to identify the available evidence regarding the medical management of WB players MSP. It emerges that WB players often face musculoskeletal injuries due to repetitive movements and game-specific actions. The management of these injuries requires a multidisciplinary approach. Firstly, the use of pharmacological treatments like Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) is common, though care must be taken to comply with World Anti-Doping Agency (WADA) regulations. Then, preventive strategies, including tailored rehabilitation and strength conditioning, are essential. Moreover, the use of dietary supplements, while popular for enhancing recovery and performance, carries risks, particularly contamination with prohibited substances. Therefore, medical staff must exercise caution when recommending supplements. Finally, this review highlights that WB players’ MSP management requires balancing effective treatment with adherence to anti-doping rules, limiting the use of traditional drugs where possible and improving the clinical application of non-pharmacological treatments, such as physical and rehabilitation medicine approaches.

Plain Language Summary

Wheelchair basketball is a sport practiced by people with motor impairments and represents an extraordinary opportunity to stay physically active. This sport requires rapid movements, sometimes wheelchairs collide and athletes fall, which can cause injuries and pain in the muscles and joints. Managing these problems requires resolving pain without using drugs which would be considered doping, as they could distort an athlete’s performance. Therefore, anti-inflammatory drugs, physiotherapy and rehabilitation, as well as prevention, are the therapy pillars for wheelchair basketball players who suffer from muscle and skeletal pain.

1. Background

Wheelchair basketball (WB) was born in the United States in the late 1940s, following World War II, as a recreational activity for veterans with spinal cord injuries. Over time, it evolved into a competitive sport, recognized internationally and governed by the International Wheelchair Basketball Federation (IWBF). As a rehabilitation tool, WB plays a vital role in enhancing physical strength, coordination, and psychological well-being in individuals with disabilities [1]. It improves cardiovascular fitness, upper body strength, and functional mobility, while fostering social inclusion, teamwork, and mental resilience, promoting a global recovery [2], especially at a professional level. As in all professional sports, medical management of professional WB players represents an important challenge for healthcare workers in this field. In fact, it is a crucial component for maintaining optimal performance and ensuring long-term health, especially in the context of WB. This is particularly true when addressing injuries, illnesses, and specific challenges such as musculoskeletal pain (MSP), which is common among athletes with disabilities. Athletes in WB are subject to a unique set of physical stresses that can differ significantly from those experienced by able-bodied athletes, necessitating specialized medical care [3]. Effective management requires a multidisciplinary approach, involving not only sports medicine professionals but also physiatrists, dietitians, and physiotherapists.

Injury management in WB is often complicated by the demands of the sport, where players are required to maintain high levels of strength, agility, and coordination despite the use of a wheelchair. The incidence of musculoskeletal injuries, particularly those involving the upper limbs, is notably higher in WB players compared to other sports. These injuries typically result from the repetitive nature of wheelchair propulsion and collisions during play [4]. Preventive strategies, including proper training techniques and equipment modifications, are essential to minimize the risk of these injuries [5,6]. Moreover, the management of these issues requires careful monitoring and individualized treatment plans to ensure that athletes can perform at their best while avoiding complications.

In order to provide comprehensive medical care, it is essential to integrate the latest research on sports medicine and rehabilitation specific to wheelchair athletes. Studies have demonstrated the efficacy of tailored rehabilitation protocols, pharmacological treatments for chronic conditions, and innovative technologies aimed at improving mobility and performance outcomes for WB players [7,8]. Furthermore, understanding the psychological and emotional aspects of dealing with MSP in elite athletes is also critical in promoting both recovery and continued participation in competition [9]. As a consequence, the aim of this perspective article is to bring order to the existing scientific literature in this area and to provide a practical guide to healthcare professionals working in the world of Paralympic sports and WB in particular, allowing effective and safe MSP management of athletes according to the World Anti-Doping Agency (WADA) rules.

2. Materials and methods

The scientific literature still lacks of solid evidence based on high quality studies totally dedicated to WB players suffering from MSP. As a consequence, this review searched for all the possible useful articles dealing with the medical management of this population, regardless the article type. Three independent authors separately carried out the articles search. The scientific databases used for this research were the following: Pubmed (https://pubmed.ncbi.nlm.nih.gov, accessed on February the 4^th 2025), Cochrane (https://www.cochranelibrary.com, accessed on February the 4^th 2025), and Embase (https://www.embase.com accessed on February the 4^th 2025). The used keywords were “wheelchair basketball,” “wheelchair sports,” “Paralympics,” “pain,” “injuries,” “musculoskeletal,” “therapy,” “treatment*,” “drug*,” “food supplement*,” “rehabilitation,” “return to play,” “medical,” “injection*.” Several synonyms and more in-depth words were searched for each keyword, according to the scientific and clinical experience of the authors, who are all eminent researchers in the field of wheelchair basketball medical management. Then, the following filters were activated: test availability: full text; species: humans; languages: English. The references of the articles were manually examined to find the more relevant publications. Once the potential articles were gathered, they were further filtered based on specific criteria for inclusion or exclusion. The inclusion criteria were the following: all the articles related to medical management for WB players’ MSP, independently from their level of evidence and their design; online full text available; and papers published in the English language. The exclusion criteria were the following: duplicated records and articles which were not specifically focused on WB. Three further investigators separately assessed each title, abstract, and full-text article for eligible studies. As a perspective review, statistical analysis, selection process, and risk of bias assessment were not needed.

3. Managing musculoskeletal pain in professional wheelchair basketball players: insights from scientific literature

MSP is a common concern among athletes, and WB players are no exception. The nature of their sport, combined with the unique biomechanics of wheelchair mobility, presents specific challenges for managing musculoskeletal discomfort. It is essential to understand the mechanisms behind MSP in WB players, explore current management strategies, and highlight the need for an individualized, multidisciplinary approach to care, drawing from existing literature and clinical studies.

3.1. Understanding musculoskeletal pain and injuries in wheelchair basketball

MSP represents a common disorder in many sports, both for able-bodied athletes and for athletes with disabilities [10–16]. Each sport presents peculiarities that can favor its emergence, especially as a consequence of injury due to intense training and matches. WB is a physically demanding sport, requiring players to perform dynamic movements such as quick acceleration, lateral shifts, and abrupt stops. These actions place significant stress on the musculoskeletal system, often leading to MSP and injuries. MSP in WB players is a prevalent issue that can significantly impact performance and overall quality of life. The pain often involves the upper limbs, including the shoulders, elbows, and wrists, due to the high reliance on these areas for wheelchair propulsion, maneuvering, and handling the ball during competition [17].

Particularly, the repetitive use of the upper extremities during wheelchair propulsion and basketball-specific movements leads to strain and fatigue in the shoulder girdle muscles and tendons. The rotator cuff, in particular, is vulnerable to overuse injuries, including tendinopathies and impingement syndromes. Several studies have documented the high incidence of rotator cuff injuries in WB players. A recent review by Karasuyama et al. reported that shoulder pain ranges from 38%-75% among WB players [18]. A clinical trial by Farì et al. highlighted that the supraspinatus tendon is particularly at risk of developing WB-related overuse, and as a consequence, it is crucial to focus on it in any rehabilitation strategy [19]; as a consequence of this tendon overload, a study by Tsunoda et al. reported the high frequency of tenosynovitis of the long head of the biceps in this population of athletes [20].

Elbow and wrist injuries also represent a significant concern for WB players. The repetitive motion of gripping the wheels and pushing the wheelchair can lead to overuse and traumatic injuries. A study by Sakai et al. highlighted the high frequency of triangular fibrocartilage lesions and cysts on the lateral-posterior corner of the capitulum of the humerus in WB players, probably due to overload and falls [21]. Carpal tunnel syndrome is another highly frequent complaint, as the repetitive wheelchair movements can cause compression of the median nerve due to chronic inflammation of wrist tendons [22,23]. These injuries often result in pain, swelling, and decreased function, which can severely limit an athlete’s ability to perform optimally.

Hands are also an anatomical area often suffering injuries in WB. In fact, falls are very frequent because of collisions with other wheelchairs, and the hands represent the first part that comes into contact with the ground [24]. A recent epidemiological study demonstrated that hand fractures are the most common WB-related injury among the traumatic ones [25].

In addition to the upper limbs, the spine is another area of concern in WB. Indeed, WB players experience frequent twisting and bending motions, which place significant stress on the head, cervical spine, and lower back muscles [26]. Poor posture, inadequate seating, or improper wheelchair configuration can result in inefficient force distribution and increased strain on the spinal muscles. Better trunk control seems useful to reduce this risk [27,28]. Overall, it is mandatory to guarantee a perfect athlete’s integration with the wheelchair, since they represent a single unit, and in this sense, the straps are indispensable for improving athletic performance in WB-specific activities [29].

In conclusion, MSP in WB players is a common and significant issue, with the upper limbs, particularly the shoulders, being the most frequently affected areas. A combination of preventative measures, early intervention, and tailored rehabilitation is essential to ensure the well-being of these athletes and maintain their competitive performance [5,30].

3.2. Managing musculoskeletal pain: current approaches

The management of MSP in WB players requires a multifaceted approach. These strategies can be divided into pain management techniques, physical therapy, ergonomic adjustments, and strength and conditioning programs. However, an essential aspect to consider when managing MSP in athletes is adherence to the WADA regulations, especially regarding the use of certain medications like corticosteroids. WADA’s rules are critical in ensuring fair play and athlete safety, making it crucial to carefully navigate pain management approaches that align with both the therapeutic needs and the regulatory requirements for competitive athletes. In this sense, the need for treating chronic diseases is saved by TUEs, which grant the use of prohibited drugs for athletes who require them, providing well described medical diagnosis, respecting a specific assumption timing and clearly declaring all these data to the competent agency.

3.2.1. Pain management techniques: drugs

Pain management strategies play a significant role in both acute and chronic MSP. As mentioned, WADA regulations do not allow the use of steroids in professional athletes, neither orally nor for local use, such as through injections, in order to avoid potential performance-enhancing effects. Firstly, pharmacological options include NSAIDs, which are commonly used to manage acute inflammation and pain. These medications are effective for treating pain associated with inflammation, but their long-term use can lead to side effects, including gastrointestinal issues, kidney damage, and increased risk of cardiovascular problems. Additionally, long-term reliance on NSAIDs can contribute to dependency or masking of injuries, delaying proper diagnosis and recovery [31]. As a consequence, NSAIDs are a valid extemporaneous option for treating pain during official competitions [32]. Similarly, for mild to moderate pain, paracetamol, alone or with NSAIDs, is usually useful for rapid pain relief, avoiding significant side effects [33]. To conclude the discussion on oral drugs, it is necessary to remember that WADA provisions have established that opiates and cannabis are prohibited substances for athletes because they could modify their performance.

3.2.2. Biological injections

Injections give physicians the possibility to put a drug directly into a specific anatomical target, reducing the risks of systemic side effects and enhancing its efficacy. In the field of sport medicine, a possible option to reduce acute MSP could be injections of lidocaine alone. In this regard, however, there is no specific scientific literature relating to athletes with disabilities, and even the literature on able-bodied athletes seems conflicting about the use of lidocaine injections in competition [32]. Nevertheless, injected lidocaine seems to be a good option for myofascial syndrome [34], which is very frequent in WB players at the neck and shoulder level due to biomechanical overload [35].

Other possible infiltrative solutions involve the use of PRP, collagen, and stem cells. PRP is an innovative technique that uses autologous blood to improve the healing of various musculoskeletal tissues, exploiting the regenerative potential of the growth factors contained in the alpha granules of platelets [36]. There is a growing interest in using these products for treating musculoskeletal disorders, particularly athletic injuries such as tendinopathies, ligament, and muscle strains [37]. PRP is easy to prepare and inject, safe, and it seems effective in providing both short- and long-term pain relief, proving even more effective than steroids [38].

Mesenchymal stem cells, although promising in MSP management, particularly joint pain, remain a solution that is difficult to apply in practice for professional players, as the sampling procedure is complicated and the pain resolution times may not be sufficiently rapid [39]. Among injectable biologic agents, collagen also appears promising in its ability to reduce pain and improve joint function [40], but supporting scientific literature is still sparse regarding the use of this drug in athletes.

3.2.3. Non-pharmacological therapies: the role of physiotherapy and rehabilitation

Physiotherapy, encompassing physical therapies and rehabilitation techniques, plays a critical role in the management of MSP in WB players. A comprehensive assessment is the first step. Specialized medical doctors and physiotherapists evaluate the athlete’s musculoskeletal system by conducting physical examinations, taking a detailed history of symptoms, and identifying any contributing factors. The assessment includes testing range of motion, muscle strength, joint stability, and overall function. In fact, this sport is extremely physically demanding [3]. It is a contact sport, during which players are required to make intense efforts such as sudden changes of direction, receiving and throwing the ball, but above all collisions with other wheelchairs with frequent falls [41–43]. Consequently, both training and matches expose the musculoskeletal system as a whole, and in particular upper limbs and trunk, to significant biomechanical loads [44]. For athletes dealing with acute pain due to injury, immediate physiotherapy interventions aim to alleviate symptoms, reduce inflammation, and promote tissue healing. Firstly, techniques commonly used include manual therapy. Mobilization and manipulation of joints can help reduce stiffness and improve joint function [45]. In fact, WB players usually suffer from mechanical pain hypersensitivity due to many active myofascial trigger points that cause cervical and shoulder pain [17]. In this sense, soft tissue techniques, such as massage or myofascial release, can be used to relieve muscle tension, similarly to what is traditionally done for other sports [46,47].

The application of ice or heat and functional rest can reduce inflammation, swelling, and pain in the initial stages of an injury. Nevertheless, during official competitions, the need to play more matches in close proximity limits the possibility of rest and requires quicker solutions. Therefore, physical modalities could represent a great ally for athletes and medical staff [48]. Modalities such as TENS or ultrasound therapy can help manage pain by stimulating nerves or promoting tissue healing through sound waves, obtaining rapid pain relief [49]. PEMFs and ESWT are available treatments for joint degeneration and pain in athletes [50]. Finally, considering the above-mentioned high frequency of hand fractures from falls, it is necessary to underline the usefulness of PEMFs in promoting bone healing [51].

Rehabilitation based on therapeutic exercise remains the best treatment for relieving chronic pain and preventing musculoskeletal injuries. A study by Farì et al. suggests the importance of rehabilitation for treating shoulder pain in WB players [52]. The authors found that therapeutic exercise is useful for joint range of motion recovery and pain reduction, and that these goals can be achieved more rapidly and effectively if rehabilitation is carried out using a superficial electromyograph to monitor the exercise protocol in real time. Similarly, García-Gómez et al. stated that a home-based exercise program could be a tool to maintain shoulder health and prevent injuries in elite WB players [53]. Also, Wilroy et al. highlighted the importance of physical and therapeutic exercise as a prevention tool and suggested that a 6-week strengthening and stretching intervention program may decrease risk factors for shoulder injury in WB players [54]. In competition, warm-up and stretching exercises serve to activate the myotendinous structures both for preventive purposes and for reducing MSP when it is already present and related to muscle strain [55].

All these non-pharmacological approaches to pain management not only help manage pain but are also consistent with WADA’s regulations, as they do not involve banned substances or performance-enhancing drugs. Given WADA’s strict guidelines, athletes must carefully consider alternative pain management strategies to ensure they comply with anti-doping rules.

4. What about dietary supplements?

Dietary supplements have become increasingly popular in many medical fields, including pain medicine [56]. Nutraceuticals containing supplements such as terpenes, creatine, collagen peptides, and taurine have become a common practice among athletes to enhance performance, accelerate recovery, and meet nutritional demands [57–60]. These products are marketed as a quick solution to improve endurance, muscle mass, or overall athletic performance, also in WB players [61,62]. They are often considered a convenient and efficient means to ensure rapid MSP relief. However, the use of these substances is not without risks [63].

One major concern is the potential contamination of supplements with prohibited substances [64]. Despite regulations in place to ensure safety, some dietary supplements have been found to contain banned substances that are prohibited by the WADA [65]. These substances may not always be listed on the label, posing a significant risk to athletes, particularly those who are subject to drug testing. Contamination can occur at various stages, including during manufacturing, storage, or packaging, and it can be difficult for athletes to discern whether the supplement is truly free of prohibited compounds. The use of such contaminated products can lead to unintentional doping violations, resulting in suspensions, reputational damage, and career setbacks [66].

The problem is further compounded by the lack of rigorous regulation in the supplement industry. Some companies may fail to adhere to good manufacturing practices or use substandard ingredients, increasing the risk of contamination. Furthermore, the absence of independent testing of products before they hit the market means that even seemingly reputable brands can unknowingly distribute supplements containing banned substances. As a result, WB players are exposed to a substantial risk of ingesting substances that could impair their competitive standing, even if they have not consciously chosen to cheat. Therefore, athletes have to be extremely cautious and to involve their medical staff have before taking any food supplement [67].

In conclusion, while dietary supplements can offer benefits for athletic performance and recovery, athletes must exercise caution and be aware of the potential dangers. It is crucial for WB players to only use supplements that have been certified by third-party testing organizations and to prioritize obtaining nutrients through a well-balanced diet. Overall, the medical staff of a professional WB team must always be consulted before taking any substance, including dietary supplements, with respect to which doctors in the sector are asked to pay extreme attention. Awareness and vigilance are key to safeguarding against the unintended use of prohibited substances in competitive sports.

5. Conclusions

This literature overview highlights that the management of WB players’ health requires a comprehensive, multidisciplinary approach that addresses the unique challenges posed by the sport. MSP, especially in the upper limbs, is a common issue for WB players and significantly impacts their performance and well-being. Effective strategies for managing MSP involve a combination of pharmacological treatments, physical therapy, ergonomic modifications, and individualized rehabilitation plans. The adherence to WADA guidelines is essential to ensure fair play and protect athletes’ health, particularly when managing pain with medications. Given the high risk of injury in WB, preventive measures and early intervention are crucial for maintaining long-term health and optimal performance. Furthermore, the importance of a tailored rehabilitation protocol cannot be overstated, as these factors contribute to holistic recovery. Lastly, while dietary supplements can be beneficial for performance enhancement, strict caution is necessary due to the risk of contamination with banned substances. Maintaining a balance between effective treatment and adherence to anti-doping regulations is vital for the success and safety of WB players.

6. Current literature gaps and future perspectives

This review collects some important aspects of WB players’ MSP management, but it also highlights the limitations of the current scientific literature concerning this specific field. In fact, despite the great and growing attention reserved to WB-related injuries, there is still the need to further deepen treatment, rehabilitation and prevention protocols for MSP management totally dedicated to this specific population. Further high-quality studies, particularly RCTs, are mandatory to better assess the effectiveness of pharmacological and non-pharmacological therapies for MSP in wheelchair athletes, whose characteristics and requests are different from able bodies athletes. Moreover, literature still lacks of studies involving WB women and young athletes, despite the further peculiarities of this specific populations. As a consequence, this review has tried to mix the clinical and on field experience of the authors with the current evidence, hoping that it could represent the starting point for new high-quality RCTs, systematic reviews and meta-analysis aimed at improving the evidence supporting a safer WB practice. Indeed, the extraordinary success of the last Paralympics Games held in Paris in 2024 in terms of general audience and worldwide visibility suggest us that this sport will certainly become more and more popular in the next years. Consequently, a better knowledge in this field will be necessary to ensure that WB could represent an even greater occasion for physical rehabilitation and social inclusion.

Funding Statement

This paper was not funded.

Article highlights

• Wheelchair Basketball (WB) originated as a rehabilitation activity for veterans and has evolved into a competitive Paralympic sport with significant physical, psychological, and social benefits for people with disabilities.

• Musculoskeletal pain (MSP) is a common issue among WB athletes, particularly affecting the upper limbs and trunk due to repetitive propulsion, frequent collisions, and overuse during training and competition.

• Medical management of WB players with MSP must strictly comply with World Anti-Doping Agency (WADA) rules. Therapeutic use exemptions (TUEs) may be necessary for chronic conditions requiring prohibited substances.

• Pharmacological treatments, including Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and paracetamol, remain first-line options for acute pain but have limitations in long-term use due to potential side effects. Steroids and opioids are restricted by WADA regulations.

• Biological injections, such as platelet-rich plasma (PRP), collagen, and lidocaine, show promise in treating MSP, though more evidence is needed in the WB context.

• Physiotherapy and rehabilitation are essential components of MSP management. Effective strategies include manual therapy, myofascial release, physical modalities, such as Transcutaneous electrical nerve stimulation (TENS), Pulsed Electromagnetic Fields (PEMFs), Extracorporeal Shock Wave Therapy (ESWT), and therapeutic exercise tailored to the demands of WB. Exercise programs, especially those monitored in real-time (e.g., with surface electromyography), aid in pain reduction, range of motion recovery, and injury prevention.

• Dietary supplements are frequently used but may pose doping risks due to potential contamination. Athletes are advised to use only certified products under medical supervision.

• There is the need for a multidisciplinary approach involving sports medicine physicians, physiatrists, physiotherapists, and dietitians to ensure comprehensive care and optimal return-to-play. Despite growing research interest, literature gaps persist, particularly regarding high-quality Randomized Controlled Trials (RCTs), female and youth athletes, and prevention strategies specific to WB. This perspective article aims to guide clinical practice while calling for more robust scientific evidence.

Author contributions

The authors contributed to the manuscript as follows: GF contributed to conceptualization, methodology, investigation, writing review & editing. DD and RT contributed to methodology, resources, validation. SB, GP and MF contributed to conceptualization, methodology, resources, writing – original draft. GR, FQ and AB contributed to data curation, writing – review and editing, project administration.

Disclosure statement

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Data sharing statement

The data that support the findings of this study are available from the corresponding author [G.F.], upon reasonable request.