Torn muscles. Physical exhaustion. Pressure sores.
Emerging research suggests that disabled athletes experience higher rates of certain injuries, and experts said they need more time to recover from muscle overuse. Sometimes it’s because of the nature of their disability. Another factor is that these athletes often rely on the same limited muscle groups they use in sports to function in their day-today lives — so they can’t always get the rest they need for a speedy recovery.
One study of about 300 Team USA athletes led by the United States Olympic & Paralympic Committee found that Paralympic athletes had a 1.79 times greater risk of injury and 2.44 times greater risk of illness than Olympic athletes. Ongoing survey data from the International Paralympic Committee also suggests that injury rates among Paralympians are higher than among Olympians.
“The issue with Paralympic athletes I’ve noticed in clinical practice is that it’s not so much the injury but it’s the recovery with the ongoing activity of daily living,” said Yetsa A. Tuakli-Wosornu, founding director of the Stanford Center for Sports Equity, an interdisciplinary program that drives positive change in and through sports.
She is one of many researchers who have investigated injuries in para sports and are calling for more education and awareness on how various disabilities and medical conditions affect injury recovery. There is a lack of knowledge among many physicians on how to work with para athletes, Tuakli-Wosornu said.
“Despite the increased risk, they have decreased resources — so there’s a mismatch,” she said.
Why recovery is more challenging for para athletes
For disabled athletes, especially those who bear weight through their arms, injuries are more common on the upper body, particularly the shoulders, elbows and wrists. That’s different from non-disabled athletes who are more likely to experience injuries on the lower body.
Paralympians may be more prone to overtraining and overuse of certain muscles, experts said. Recovering from arm or shoulder injuries becomes a lot harder, for example, when an athlete relies on their arms to get in and out of bed or move around.
This was the case for Justin Phongsavanh, 27, of McDonough, Ga., who is a Paralympic javelin thrower for the United States. Phongsavanh was shot by a stranger in a parking lot when he was 18 years old, resulting in a spinal cord injury that left him paralyzed from the chest down. As both a javelin thrower and a wheelchair user, Phongsavanh puts enormous strain on his shoulders.
In early 2021, he injured his left shoulder during a training session. Then, while that was still healing in summer 2021, he injured his right shoulder. Suddenly, he found himself unable to even get in and out of bed without assistance.
“I literally could not leave my bed except to use the bathroom or eat for 10 days,” he said.
With bed rest, he recovered enough to compete in the Tokyo Paralympics later that summer, nabbing a bronze medal, but afterward, he was forced to stop throwing a javelin for several months. He has since healed, he said, but his shoulders still feel sore most days.
In the future, if he experiences a shoulder injury that requires any type of surgery, Phongsavanh said he plans to “immediately” retire from sports.
“The integrity of my body is more important than obtaining a medal,” he said. “It’s just not realistic. I have to live with this body.”
The issue can become even more pronounced for Paralympians such as Oksana Masters, who compete in both the Summer and the Winter Games, leaving a shorter amount of time for rest and recovery in between.
Masters, 35, of Champaign, Ill., is a double leg amputee who has competed in rowing, skiing, biathlon and hand cycling. She said she uses the same muscles for competition and daily living activities, such as pushing herself up onto her prosthetic legs.
“When you think about Olympians, there are ways they can recover entirely in their sport where they’re not using their arms over and over,” she said. “The hardest part for Paralympians is the day in and day out of life and not pushing yourself in between.”
Another challenge for recovery and rest can be side effects of the disability itself, said Sara Szabo, a sports scientist at the University of Alberta.
Sleep is part of the basic foundation for health in any athlete, she said, but for disabled athletes, especially those with visual impairments or chronic pain, “there can be big challenges with sleep.”
Other disabilities such as spinal cord injuries or amputations are also associated with a higher prevalence of sleep disorders and insomnia., said Milan Milosevic, an occupational and sports medicine specialist at the University of Zagreb. “Amputees, lots of them, they have problems with sleep because of pain, like phantom pain. But there’s no explanation for why they feel this pain,” Milosevic said.
Because it’s so hard to rest, both Milosevic and Szabo said some para athletes never fully recover, becoming more susceptible to repeated injuries or chronic issues.
A lack of knowledgeable doctors
Kristina Fagher, an associate professor in physiotherapy at Lund University in Sweden, who works with para athletes, is one of many researchers who say there is a need for more doctors and sports medicine specialists to know how to work with para athletes.
While Phongsavanh, the U.S. Paralympic javelin thrower, said the medical staff at the Olympic training center were very competent, it was harder for him to find doctors he could consult at home.
“When you try to find a doctor that’s knowledgeable in spinal cord injuries and sports injuries, now it’s tough, now you’re getting specific,” he said.
Because of his spinal cord injury, Phongsavanh takes a variety of medications, such as blood thinners to prevent potential clots, which can have different side effects. He also is at a higher risk for urinary tract infections and overheating, he said, because he lacks control over his lower body and does not sweat below the area where he was injured.
In interviews with practitioners, coaches and exercise physiologists who do have this expertise, Szabo found that the injury prevention, diagnostic and recovery principles used for non-disabled athletes can’t be universally applied to para athletes.
Understanding how to treat an athlete with disabilities is more complex, Szabo said, because even within one type of disability, such as cerebral palsy, there may be different ways that the disability affects each person. However, there are relatively few injury prevention programs in para sports, and many existing programs are not adapted specifically for para athletes.
The U.S. Olympic & Paralympic Committee has recognized the need for a more customized approach, said Travis Anderson, a research scientist for the committee’s department of sports medicine.
The USOPC is interested in developing a concussion assessment tool specific to Paralympic athletes because the current tool — which includes a recommendation to assess walking ability — is not applicable to all disabled athletes.
The USOPC is also researching sleep, Anderson said. It has been studying jet lag mitigation techniques for blind athletes specifically, he said, because one tip for decreasing jet lag in most people is to increase light exposure, which does not work for blind athletes. Instead, the USOPC is exploring strategies related to the timing of exercise or meals.
Further study is needed
Anderson said that the USOPC is seeking to understand athletes’ injury rates better, as well as what causes them and which sports carry the highest risk. Studying these further could lead to rule or equipment changes that would make athletes safer, Anderson said.
“We’re still somewhat in the discovery phase of all of this,” he said.
For the Summer Games, goalball, para cycling and wheelchair rugby — a high-speed, full-contact sport that has sometimes been called “murderball” — seem to have the highest rates of injury, he said.
While wheelchair rugby athletes have plenty of stories about mangled, bleeding fingers and broken bones from their high-impact collisions, Chuck Aoki, 33, the co-captain of the U.S. team, said simple overuse injuries are more common.
“Our shoulders were not meant to do what we do to them, they were not meant to have this repeated strain on them,” said Aoki, of Ann Arbor, Mich.
A balancing act
Because of his disability, Daniel Romanchuk, a wheelchair racer, frequently deals with pressure sores, which can progress to life-threatening injuries.
Romanchuk, 26, of Champaign, Ill., was born with spina bifida, a condition where the spine and spinal cord don’t form properly, which can lead to lower limb weakness or paralysis. Because of the way his body rubs against his regular wheelchair, he can get pressure sores on his hips, which have sometimes been so bad that he had to drop out of competitions.
To prevent sores, Romanchuk now uses a cushion for his chair that is customized to relieve pressure based on a scan of how he sits. When he does get a pressure sore, he must cover it and completely remove pressure from the area.
When he travels, Romanchuk usually drives to avoid a flight. If a flight is unavoidable, sometimes he buys a first or business class ticket so he can lie down to avoid exacerbating his wounds.
“There’s a lot to balance,” he said. “Even a disability alone can be a lot to handle at times.”
