September 5 is World Spinal Cord Injury Day, an annual observance led by the International Spinal Cord Society. The 2026 theme is “From Awareness to Action: Ten Years Advancing SCI Prevention,” marking the tenth anniversary of the observance.[1]
For an orthopedic practice, the message is especially important because spinal cord injury can overlap with trauma, fractures, bone loss, shoulder overuse, mobility problems, and long-term rehabilitation. At the same time, spinal cord injury is primarily a neurologic emergency and rehabilitation diagnosis. A person with a possible acute spinal cord injury needs emergency medical care, not a routine orthopedic office visit.
The World Health Organization estimates that more than 15 million people worldwide are living with spinal cord injury. Many traumatic spinal cord injuries are related to falls, road traffic injuries, violence, work injuries, and sports injuries, which means prevention remains a major part of reducing the burden of SCI.[2]
This guide focuses on the orthopedic and musculoskeletal side of spinal cord injury: how to reduce preventable trauma, how to recognize emergency warning signs, why bone health matters after SCI, how shoulders can become overloaded, and how rehabilitation helps protect function and independence.
What is a spinal cord injury?
The spinal cord is the main pathway carrying signals between the brain and the rest of the body. It runs through the spinal canal formed by the vertebrae.
A spinal cord injury can occur when the cord itself is damaged. That may happen after trauma, such as a fall, motor-vehicle crash, sports injury, or fracture-dislocation of the spine. It can also occur from nontraumatic causes such as tumors, vascular problems, infection, or other medical conditions.[2]
The effects depend on the location and severity of the injury. Possible problems include:
- Weakness or paralysis
- Numbness or altered sensation
- Loss of balance or coordination
- Changes in bowel or bladder control
- Difficulty breathing
- Pain or spasticity
- Changes in blood pressure regulation and other autonomic functions
Not every neck or back injury causes a spinal cord injury. Likewise, not every spinal cord injury is associated with a visible fracture. That is why the neurologic symptoms after trauma matter so much.
When should you suspect a spinal cord injury after trauma?
After a fall, collision, sports injury, diving injury, or other high-energy event, certain symptoms should be treated as an emergency.
The Hawai‘i Department of Health Neurotrauma Program lists warning signs that include severe neck or back pain, weakness, numbness or tingling, paralysis, loss of bowel or bladder control, difficulty walking, impaired breathing, and an abnormally positioned neck or back.[3]
Call 911 if a spinal cord injury is possible.
Until emergency professionals arrive:
- Keep the injured person as still as reasonably possible.
- Do not ask them to stand, walk, or “test it out.”
- Avoid unnecessary bending, twisting, or lifting of the head, neck, or back.
- Do not remove a helmet unless airway management requires trained intervention.
- Provide basic first aid within your level of training.
- If the person is not breathing normally, follow emergency dispatcher instructions and current CPR guidance.
The Hawai‘i Department of Health and major first-aid organizations emphasize avoiding unnecessary movement when a neck or back injury is suspected because additional motion may worsen an unstable injury.[3][4]
Why prevention matters
The 2026 World SCI Day theme focuses on moving from awareness to action.[1] In practical terms, prevention means reducing the situations in which high-energy trauma reaches the head, neck, or spine.
No prevention strategy can eliminate every spinal cord injury, but several measures reduce risk.
On the road
Use seat belts every trip. Children should use age- and size-appropriate restraints. Avoid driving while impaired, and avoid distracted driving.
Motorcycle, bicycle, and other sport-specific helmets are designed primarily to reduce head injury, but protective equipment is still an important part of reducing serious trauma. Helmets do not make a high-risk activity “safe,” so speed, environment, skill, and judgment still matter.
Around heights and falls
Falls are an important cause of traumatic spinal cord injury, especially as people age.[2]
Useful prevention strategies include:
- Addressing medications or medical conditions that contribute to dizziness
- Improving lower-extremity strength and balance
- Using railings and adequate lighting
- Removing loose rugs and trip hazards
- Using appropriate ladders and fall protection at work
- Treating vision or footwear problems that increase fall risk
For people with recurrent falls or declining balance, a structured rehabilitation plan can be more useful than simply being told to “be careful.”
In sports and recreation
Technique, supervision, conditioning, and appropriate protective equipment all matter.
High-risk mechanisms include axial loading of the head and neck, uncontrolled contact, major falls, and diving into shallow or unknown water.
In Hawai‘i, ocean and water recreation deserve particular respect. Never dive headfirst into water when the depth or underwater terrain is uncertain. Conditions change, including sandbars, reefs, shore break, and wave energy.
Spinal cord injury and bone health
One of the less obvious long-term orthopedic consequences of spinal cord injury is loss of bone density below the level of injury.
Reduced weight bearing, changes in muscle loading, and neurologic factors can accelerate bone loss. The World Health Organization specifically lists osteoporosis among important secondary conditions associated with SCI.[2]
The 2022 Consortium for Spinal Cord Medicine clinical practice guideline on bone health after spinal cord injury was developed to help prevent fractures and fracture-related complications in adults living with SCI.[5]
Why does this matter?
A person with SCI may sustain a fracture from a lower-energy event than expected. Depending on the level of sensation, the injury may not produce the same pain pattern that would normally trigger an immediate evaluation.
Possible clues to a fracture may include:
- New swelling
- Bruising
- A change in limb position
- New spasticity
- Reduced ability to transfer or function
- Unexplained autonomic symptoms
- A new pressure area
- A change in wheelchair positioning or sitting tolerance
If a person with SCI develops new swelling, deformity, loss of function, or concern for a fracture, prompt evaluation is appropriate.
Pacific Bone & Joint’s bone health and osteoporosis services focus on identifying skeletal risk and reducing preventable fractures. Patients with SCI may need individualized assessment because bone-loss patterns after neurologic injury can differ from typical age-related osteoporosis.
Fractures after spinal cord injury can be different
Orthopedic fracture care in someone with SCI may require different decisions than fracture care in someone with normal sensation and muscle function.
Important factors can include:
- Baseline mobility
- Whether the person stands or walks
- Transfer technique
- Skin condition and pressure-injury risk
- Bone quality
- Spasticity
- Sensation
- Existing contractures
- Wheelchair fit
- Caregiver needs
- The effect of immobilization on independence
A cast or brace that is perfectly reasonable in another patient may create skin, positioning, or transfer problems in someone with impaired sensation. Surgery also has its own risks and should be chosen for clear functional reasons.
The goal is not simply to make an X-ray look normal. It is to restore safe function while protecting skin, alignment, mobility, and independence.
Why rehabilitation matters after spinal cord injury
Rehabilitation is a central part of spinal cord injury care. The World Health Organization emphasizes rehabilitation and ongoing health care as essential to reducing disability and secondary complications.[2]
Rehabilitation can address:
- Strength and conditioning
- Transfers
- Wheelchair skills
- Standing or walking when appropriate
- Balance
- Range of motion
- Contracture prevention
- Equipment needs
- Pressure-relief strategies
- Shoulder protection
- Return to work, recreation, and community activity
A 2023 systematic review of rehabilitation interventions for bone health after SCI found that multicomponent rehabilitation may contribute to bone-health management, although the evidence remains heterogeneous and no single exercise approach eliminates fracture risk.[6]
That distinction matters. Exercise is important, but it is not a substitute for individualized bone-health evaluation in a person at high fracture risk.
Protecting the shoulders after spinal cord injury
For many wheelchair users, the shoulders become weight-bearing joints in a practical sense.
They may be used repeatedly for:
- Wheelchair propulsion
- Transfers
- Pressure relief
- Bed mobility
- Reaching
- Dressing
- Lifting
- Sports and recreation
Over time, repetitive loading can contribute to rotator-cuff pain, tendinopathy, weakness, and loss of independence.
One randomized trial in people with paraplegia and chronic shoulder pain found that a program combining shoulder strengthening, stretching, and movement optimization reduced pain and improved function compared with an education-only control program.[7]
The broader lesson is not that every person with SCI needs the same exercise program. It is that shoulder pain should not automatically be accepted as an unavoidable price of wheelchair use.
A rehabilitation assessment can look at:
- Transfer technique
- Wheelchair setup
- Propulsion mechanics
- Rotator-cuff and scapular strength
- Range of motion
- Repetitive loading
- Equipment that may reduce strain
Pacific Bone & Joint physical therapy can help evaluate musculoskeletal limitations, shoulder overload, strength, balance, and movement strategies when outpatient orthopedic rehabilitation is appropriate.
What about joint pain in someone with SCI?
Joint pain still deserves a diagnosis.
Depending on the level of injury and sensation, a person with SCI may experience typical orthopedic problems such as:
- Rotator-cuff disease
- Shoulder arthritis
- Carpal tunnel syndrome
- Tendon irritation
- Hip or knee arthritis
- Fractures
- Heterotopic ossification
- Contractures
- Overuse injuries
The challenge is that symptoms may present differently. A person may notice loss of transfer ability, swelling, reduced motion, or a change in function before they notice conventional pain.
Imaging should be selected based on the suspected problem. X-rays are often the first study for suspected fracture or arthritis. Ultrasound can be useful for selected tendon and soft-tissue problems. MRI may be useful when the diagnosis remains unclear or when deeper structures need evaluation.
Red flags that need urgent evaluation
People living with SCI can develop complications that go beyond routine orthopedic care.
Seek urgent or emergency medical attention for:
- New weakness or paralysis
- New loss of sensation
- New bowel or bladder dysfunction
- Severe neck or back pain after trauma
- Difficulty breathing
- New rapidly increasing swelling after an injury
- A visibly deformed limb
- An open fracture
- A pale, blue, or cold extremity
- Fever with a hot, swollen joint or concern for infection
- Severe headache, sweating, flushing, or blood-pressure symptoms concerning for autonomic dysreflexia in a person at risk
If there is any concern for a new spinal cord injury, call 911.
Can people with spinal cord injury stay active?
Yes. Activity can support cardiovascular health, strength, participation, and quality of life. The right program depends on injury level, neurologic function, bone health, skin integrity, equipment, and personal goals.
For one person, that may mean wheelchair sports. For another, it may mean standing, adaptive cycling, upper-extremity conditioning, pool-based exercise, gait training, or a home exercise program.
The safest plan is individualized.
Before starting aggressive weight-bearing or high-load exercise, people with chronic SCI and significant bone loss may need a bone-health assessment because osteoporosis can increase fracture risk.[5]
A World SCI Day message for Hawai‘i
Hawai‘i’s geography and lifestyle make prevention especially relevant.
We drive, bike, hike, surf, paddle, dive, work at heights, climb on roofs, use ladders, and spend a great deal of time around water. None of those activities should be viewed as inherently unsafe, but all deserve respect for mechanism of injury.
The practical message is:
Protect the head and neck, prevent avoidable falls and crashes, never ignore neurologic symptoms after trauma, and protect the bones and joints that support long-term independence.
For people already living with SCI, musculoskeletal care is not an afterthought. Bone health, fracture prevention, shoulder preservation, equipment, and rehabilitation can all affect function.
When can an orthopedic evaluation help?
An orthopedic evaluation may be useful for a person with SCI who has:
- Suspected fracture
- New limb deformity or swelling
- Shoulder pain affecting transfers or wheelchair use
- Hip, knee, hand, wrist, or other joint problems
- Loss of motion or contracture concerns
- Bone-health questions
- Recurrent falls
- A musculoskeletal problem that is limiting rehabilitation
An orthopedic clinic is not the right destination for a suspected acute spinal cord injury. New neurologic deficits after trauma require emergency evaluation.
For non-emergency musculoskeletal problems, the goal is to coordinate care around function, mobility, bone quality, skin protection, and the patient’s rehabilitation plan.
If you are living with spinal cord injury and a bone, joint, fracture, or rehabilitation problem is limiting your function, request an orthopedic or physical therapy evaluation so the musculoskeletal issue can be assessed in context.
Sources and Further Reading
- International Spinal Cord Society. World SCI Day 2026: From Awareness to Action: Ten Years Advancing SCI Prevention. https://www.iscos.org.uk/page/SciDay
- World Health Organization. Spinal cord injury. Updated April 16, 2024. https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury
- Hawai‘i Department of Health, Neurotrauma Program. Spinal Cord Injury: When to Seek Immediate Medical Attention. https://health.hawaii.gov/nt/spinal-cord-injury/
- American Red Cross. First Aid for an Unresponsive and Breathing Person / suspected head, neck, or back injury guidance. https://www.redcross.org/take-a-class/resources/learn-first-aid/unresponsive-and-breathing-person
- Consortium for Spinal Cord Medicine. Bone Health and Osteoporosis Management in Individuals with Spinal Cord Injury. 2022. https://pva.org/wp-content/uploads/2022/05/CPG_Spinal-Cord-Medicine_2022_FINAL.pdf
- Lippi L, Folli A, Turco A, et al. The impact of rehabilitation in bone loss management of patients with spinal cord injury: A systematic review. J Back Musculoskelet Rehabil. 2023. doi:10.3233/BMR-230006.
- Mulroy SJ, Thompson L, Kemp B, et al. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Phys Ther. 2011;91(3):305-324. doi:10.2522/ptj.20100182.
This article is educational and does not replace emergency care or individualized medical advice. Suspected spinal cord injury, new weakness or numbness after trauma, or new bowel or bladder dysfunction requires urgent medical evaluation.
