My Shoulder Hurts! My Wrist Aches! Upper Limb Pain in Spinal Cord Injury
By Deborah Crane, MD, MPH, Assistant Professor, Rehabilitation Medicine, University of Washington
- Pain and SCI
- Shoulder pain
- Arm and hand pain
- Back and neck pain
- How can I avoid upper limb pain?
- I already have pain—what can I do?
Pain is an unfortunate but common reality for people living with spinal cord injury (SCI). Persons with SCI may suffer with musculoskeletal pain (affecting the muscles, bones or joints), neuropathic (“nerve”) pain, or both. Musculoskeletal pain is typically described as dull or achy, occurs above the level of injury, and is usually triggered by specific movements of a joint or body region. In contrast, neuropathic pain usually occurs at or below the level of injury, is often described as burning or stabbing, and does not have specific triggers.
People understandably worry about developing shoulder pain after SCI because it is such a common problem and can be so disabling. Surveys have found that it affects 30-60% of the SCI population. It is thought that using the arms for propelling a wheelchair or performing transfers over time leads to injuries and arthritic changes in the shoulders. Tears to the rotator cuff (tendons of the muscles that support the shoulder) are a common culprit, but other causes of shoulder pain after SCI include impingement (pinching of the tendons), arthritis (inflammation of the joint), biceps tendonitis (pain in the tendon that attaches the biceps muscle to the shoulder), and bursitis (inflammation of the bursa sac that cushions the joint). In addition, muscular shoulder pain may occur when a person is forced to use his or her shoulder muscles to maintain posture or has muscle imbalances due to the SCI.
The shoulder is not the only upper limb joint at risk for injury. Elbow pain is present for 5-16% of those with SCI. It is commonly caused by tennis elbow, ulnar nerve injury, bursitis, and arthritis.
It is likely that more than 10% of persons with SCI have hand and wrist pain. Carpal tunnel syndrome (when increased pressure in the wrist puts pressure on the median nerve) is overwhelmingly the most common cause of pain in this region. The risk for developing carpal tunnel syndrome increases the longer a person has been living with SCI. Extreme wrist extension (bending the hand back)—a position often used when transferring or propelling a wheelchair—is the likely cause of carpal tunnel syndrome. Arthritis, ulnar nerve injuries, and tendinopathies (injuries or degenerative changes to tendons) also cause hand and wrist pain in the SCI population.
Many people with SCI also have back and neck pain. Depending on level of injury, this may be neuropathic or “nerve” pain, musculoskeletal pain, or both. After SCI, individuals may develop spine deformities that can cause pain, including scoliosis (curving of the spine) or kyphosis (“hump back”). Frequently, people with SCI complain of a “ring of fire” or “iron corset” around their shoulders or torso, which typically occurs at the level where their sensation changes from normal to abnormal. This can be very painful and, at times, very difficult to treat.
For those with relatively new SCIs hoping to prevent upper limb pain, there are some things you can do.
- Try to maintain a healthy body weight. As you gain weight, transferring and propelling your wheelchair become more difficult and puts greater strain on your shoulders, arms and wrists.
- Make sure your wheelchair fits you properly. For manual wheelchair users, check that the wheel axle position and seat height are correct for you. For all wheelchair users, your seating system should provide enough trunk support so you don’t rely on your shoulder muscles to keep you upright.
- Maintain good technique for transfers and wheelchair propulsion.
- If you walk using canes or crutches, a physical therapist can show you how to use good biomechanics so you don’t harm your upper body joints.
- See a physical therapist to make sure your wheelchair still fits you properly. Improper wheelchair fit can cause or worsen pain and injury to the shoulders and arms.
- Review safe transfer and wheelchair propulsion techniques with a physical therapist.
- Consider how many times each day you are transferring, how far each day you are pushing your wheelchair, how you disassemble and store your wheelchair in the car, and what sorts of activities you do for work and fun. Could any of these activities be causing you harm? What can you do to reduce the stress you are putting on your body? Talk to your SCI doctor and therapists about changes you can make in your daily life to reduce harm and pain.
Treatment options for upper limb pain may include therapeutic exercise, weight loss, heat or ice, medications, injections, or surgery. This will depend on the cause of your pain and what you and your doctor decide is the most appropriate treatment for you.
Rest is often the best thing for musculoskeletal pain. Unfortunately, it is very difficult to rest your upper limbs if you have an SCI because you rely on your arms to transfer, push a wheelchair, walk with crutches, etc.
If pain and injury are severe enough, you may need to consider switching to a power wheelchair, at least for part of the time. Power wheelchairs will help to reduce repetitive strain and overuse, conserve energy, and improve speed and ease of travelling over different distances and types of terrain. Of course, there are downsides to using a power wheelchair, and you will need to discuss the pros and cons with your health provider.
Finally, keep in mind that recovery from an upper limb injury or surgery may take a long time. Even after relatively minor surgery, you may need to stay in the hospital for a while so you can adequately rest your upper limbs to allow for healing, prevent skin break down, and get help accomplishing basic daily activities.
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