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Background: Manual wheelchairs serve as reliable assistive technology devices to improve independence, quality of life and access to environment. Frequent and prolonged reliance on these assistive devices for completion of daily activities and functional mobility contributes to a significant increase in the amount of strain placed on the upper extremities secondary to the natural inefficiency and repetitive nature of wheelchair propulsion. Manual wheelchair configuration includes many components that influence system stability and maneuverability. The purpose of this case report is to highlight the impact of manual wheelchair configuration on propulsion efficiency, user function and mobility, and prevention of secondary shoulder complications in an individual with a spinal cord injury. Case Description: Patient XYZ was a 49-year-old male referred for a wheelchair clinic evaluation with the presenting diagnosis of chronic paraplegia and subjective report of difficulties with community mobility. The wheelchair was determined to be an improper fit, and the appropriate modifications were made to improve efficiency. Outcome Measures: The Wheelchair Use Confidence Scale and Six-Minute Push Test were used to assess the effectiveness of modifications to the manual wheelchair. Discussion: With additional knowledge and understanding of the previously established literature, healthcare providers are in a better position to identify and execute appropriate wheelchair modifications. This case report highlights one scenario of effective modifications to improve efficiency, guided by the literature.