Six Common Wheelchair Setup Issues that Lead to Chronic Shoulder Pain – Erik Kondo

It is well established that many wheelchair users suffer from shoulder pain. It has also been shown that Shoulder Impingement Syndrome is a likely source of this pain for a high percentage of people. While there are a number of movements that cause impingement, excessive internal rotation of the shoulder is a major cause among wheelchair users. Interior shoulder rotation can be the result of improper wheelchair propulsion posture and repetitive movements which are frequently the result of improper setup of the person’s wheelchair.

“Shoulder impingement, also known as shoulder impingement syndrome, is a condition where the tendons in the shoulder joint become pinched or compressed against the bone, causing pain, particularly when lifting the arm overhead, due to inflammation and irritation from rubbing against surrounding tissues; this often occurs due to repetitive motions or overuse, and can be caused by wear and tear over time.” – Google AI

Improper wheelchair setup leads to poor propulsion in the form of excessive internal rotation of the shoulder which creates shoulder impingement which causes chronic shoulder pain. Whereas a properly set up wheelchair leads to efficient propulsion with a neutral shoulder position which does not (necessarily) cause impingement and associated pain.

It is important to recognize that there are sources of shoulder pain other than propulsion related impingement.

When propelling a wheelchair, internal shoulder rotation is created when the person’s wrists are turned into the body and their elbows are pointed outward. Typically, there is also hunching of the shoulders and neck. Whenever you are in this position, your shoulders are internally rotated and therefore subject to impingement.

There are seven common improper wheelchair setups that produce this poor propulsion technique.

1.??????? Backrest is too high (may also be reclined) and/or has high armrests.

2.??????? Wheelchair seat is too wide.

3.??????? Rear wheels are situated too far back.

4.??????? Seat position is too high relative to the wheels for the person’s level of trunk stability.

5.??????? Footrest that is not sufficiently supportive.

6.??????? Intrusive high mount wheel-locks that cause shortened push strokes when leaning forward and force pushrim only propulsion.

#1. A backrest that is too high will cause the user to propel with their elbows out in order to not hit the backrest during propulsion. Too high armrests will have the same effect. The user will have to turn their wrists inward in order to grasp the pushrims creating internal rotation. This position also prevents the user from incorporating the powerful muscles of their back for propulsion and stability.

Ideally, the user’s elbows are close and parallel to the body and their wrists are neutral with their thumbs pointed forward.

#2. An overly wide wheelchair extends the wrists and elbows out from the body. This is a weak body position that can easily turn into Internal Rotation if the user lets their elbows drift outward.

#3. When the rear wheels are too far back, the user tends to sit in a slumped position to position their shoulders backward to get them closer to the wheels. When the wheels are too far back, they provide minimal support for upper body stability. Therefore, users with minimal or no trunk control will slump (recline) in order to create upper body stability to reduce the risk of falling forward. This slumped position tends to create the outward elbows and inward wrists of Internal Rotation.

The wheelchair is also more difficult to propel and maneuver due to increased weight on the front casters and the position of the center of mass. Thus, requiring more muscular effort and amplifying the effect of Internal Rotation.

#4. When a user lacking in trunk control is seated too high up, their feeling that they might fall, many times leads to slumping (for stability). Drive wheels provide arm support. When the wheels are low, less support is provided. This is less of an issue for people with full trunk control. As a rule, people with more trunk control will sit relatively higher and vice versa.

A smaller diameter wheel has the same effect as a low wheel. It provides less arm support. Everything else being equal, a person with less trunk control will be more stable with a 25” rather than a 24” wheel. Hence, they are less likely to slump and thus less likely to engage in Internal Rotation while propelling.

#5. A footrest that is not supportive creates a less stable lap platform which reduces upper body stability. Insufficient dump given a person’s level of trunk control has the same effect. In both these cases, the lack of stability leads to slumping then to Internal Rotation.

#6. When intrusive high mount push locks are positioned on the front of the wheelchair, the user must only use the pushrim when pushing in order to avoid striking their thumb on the mechanism. When pushing with high force such as on a hill or on soft terrain, the user’s elbows tend to point outward creating Internal Rotation. On the other hand, when the entire wheel (including the tire) is grabbed, the user’s wrists then stay in a neutral position.

Additionally, users tend to shorten their push strokes due to the presence of the wheel-locks which reduces overall propulsion efficiency and increases the effort required.

?The above list illustrates that poor wheelchair seating posture has many sources. It is imperative for users with impaired trunk control to sit in a manner that enhances their upper body stability by providing full access to the rear wheels for support. This will reduce slumping and improve propulsion technique.

The physical setup of their wheelchair greatly affects the wheelchair user’s body position which determines their propulsion movements. By sitting in a manner that reduces internal shoulder rotation, the wheelchair user can propel (more) properly and reduce the likelihood of chronic shoulder pain.

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