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SHOULDER
Comparison of conservative treatment with and without manualphysical therapy for patients with shoulder impingementsyndrome: a prospective, randomized clinical trial
Gamze Senbursa Æ Gul Baltacı Æ Ahmet Atay
Received: 24 September 2006 / Accepted: 9 January 2007 / Published online: 28 February 2007� Springer-Verlag 2007
Abstract The aim of this prospective, randomized
clinical study was to compare the effectiveness of two
physical therapy treatment approaches for impinge-
ment syndrome, either by joint and soft tissue mobili-
zation techniques or by a self-training program. Thirty
patients (Group 1, n = 15; Group 2, n = 15) with
the diagnosis of an outlet impingement syndrome of
the shoulder were treated either by strengthening the
depressors of the humeral head with a guided self-
training program (Group 1, age 49.5 ± 7.9 years), or by
joint and soft tissue mobilization techniques (Group 2,
age 48.1 ± 7.5 years). Group 1 was instructed with
the active range of motion (ROM), stretching and
strengthening exercise program including rotator cuff
muscles, rhomboids, levator scapulae and serratus
anterior with an elastic band at home at least seven
times a week for 10–15 min and Group 2 received a
prescription for 12 sessions of joint and soft tissue
mobilization techniques, ice application, stretching and
strengthening exercise programs and patient education
in clinic for three times per week. All patients were
tested with visual analog scale (VAS) for pain level,
goniometric measurement for ROM and algometry for
the pain threshold. Function was measured with a
functional assessment questionnaire. The VAS (10 cm)
used to measure pain with functional activities and the
functional assessment questionnaire (Neer) were also
measured 3 months after the initiation of treatment.
Subjects in both groups experienced significant de-
creases in pain and increases in shoulder function, but
there was significantly more improvement in the
manual therapy group compared to the exercise group.
For example, pain in the manual therapy group was
reduced from a pre-treatment mean (±SD) of 6.7
(±0.3) to a post-treatment mean of 2.0 (±2.0). In con-
trast, pain in the exercise group was reduced from a
pre-treatment mean of 6.6 (±1.4) to a post-treatment
mean of 3.0 (±1.8). ROM at flexion, abduction and
external rotation in the manual therapy group im-
proved significantly while ROM in the exercise group
did not. There were statistically differences among the
groups in function (P > 0.05). Group 2 showed signif-
icantly greater improvements in the Neer Question-
naire score and shoulder satisfaction score than Group
1. The patients treated with manual physical therapy
applied by experienced physical therapists combined
with supervised exercise in a brief clinical trial showed
improvement of symptoms including increasing strength,
decreasing pain and improving function earlier than
with exercise program.
Keywords Manual therapy � Shoulder �Impingement Syndrome � Exercise
Introduction
The shoulder joint, the most mobile joint in the human
body, is at greater risks for injuries. Shoulder pain is
This study was presented in the 52nd Annual Meeting ofAmerican College of Sports Medicine in Nashville, USA, 2005.
G. Senbursa � G. Baltacı (&)School of Physiotherapy and Rehabilitation,Hacettepe University, 06100 Ankara, Turkeye-mail: [email protected]
A. AtayDepartment of Orthopaedics and Traumatology,Hacettepe University, 06100 Ankara, Turkey
123
Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921
DOI 10.1007/s00167-007-0288-x
second only to low back pain in occurrence, affecting
approximately 16–21% of the population [13]. More-
over, approximately one-fifty of all disability payments
for musculoskeletal disorders are for patients with
shoulder disorders [9].
The most frequent cause of shoulder pain is subac-
romial impingement syndrome, accounting for 44–60%
of all complaints of shoulder pain [17]. Several factors
causing shoulder impingement syndrome include rota-
tor cuff muscle weakness, acromial morphology, muscle
imbalance, capsular laxity or tightness, dysfunctional
glenohumeral and scapulothoracic kinematics, degen-
eration and inflammation of the tendons or bursa [4].
Subacromial impingement syndrome is one of the
most common shoulder disorders which characterized
by shoulder pain that is exacerbated with arm elevation
or overhead activities, in adults, with a high socioeco-
nomic impact on working ability [6, 18].
While many treatments have been employed in the
management of shoulder impingement syndromes,
few have been proven to be effective in randomized
controlled trials [20, 26, 31]. Corticosteroid injections
into the glenohumeral joint, non-steroid anti-inflam-
matory drugs, physical therapy modalities, strength
and stretching exercises have been listed non-surgical
approaches to treatment in subacromial impingement
syndrome [18, 27, 30]. One of treatment techniques in
shoulder impingement syndrome is manual therapy
techniques including deep friction massage, exercise
and soft tissue and joint mobilization techniques [6]. The
goals of manual therapy of subacromial impingement
are to decrease subacromial inflammation, to allow
healing and strengthening of a dysfunctional rotator cuff
and to restore pain-free shoulder function [4, 21, 25].
It seems reasonable to suggest that manipulation/
mobilization techniques for joints that exhibit limited
passive accessory motion may be helpful in the man-
agement of shoulder problems that do no respond to
conventional management. Unfortunately, there is lit-
tle evidence on the efficacy of these types of inter-
ventions for patients with subacromial impingement
syndromes not responding to conventional manage-
ment. Thus, the purpose of this study was to compare
the effectiveness of two physical therapy treatment
approaches for impingement syndrome, either by joint
and soft tissue mobilization techniques or by a self-
training program after 4 weeks of treatment.
Materials and methods
The short-term clinical effectiveness of manual physi-
cal therapy compared with usual care was assessed in a
randomized clinical trial. Short-term was defined as the
end of the 4-week treatment period. The study was
conducted at the outpatient clinic of Physiotherapy
and Rehabilitation, Hacettepe University, Ankara,
Turkey. After informed consent was obtained, 30 con-
secutive patients (Group 1, n = 15; Group 2, n = 15)
with the diagnosis of an outlet impingement syndrome
of the shoulder were treated either by strengthening the
depressors of the humeral head with a guided self-
training program (Group 1, age 49.5 ± 7.9 years), or by
joint and soft tissue mobilization techniques (Group 2,
age 48.1 ± 7.5 years).
Assessment
The study population consisted of 30 patients between
30 and 55 years of age. The criteria for inclusion in the
study were shoulder pain with no major shoulder
trauma, taken no treatment another physiotherapy
clinic in the last 2 years, marked loss of active and
passive shoulder motion or painful range of motion
(ROM), magnetic resonance imaging as a reference
standard. Exclusion criteria included a history of fro-
zen shoulder, disorders of the acromioclavicular joint,
degenerative arthritis of the glenohumeral joint, calci-
fying tendonitis, shoulder instability, posttraumatic
disorders, or shoulder surgery and/or elbow, hand,
wrist and cervical spine disorders.
Each patient underwent a history assessment and a
physical examination that tested the shoulder mobility,
tenderness and impingement.
All patients were tested with visual analog scale
(VAS) for pain level [8, 29], goniometric measurement
for ROM [22] and algometry for the pain threshold
[23]. Function was measured with a functional assess-
ment questionnaire. All patients were also evaluated
before and after rehabilitation. The VAS (10 cm) used
to measure pain with functional activities and the
functional assessment questionnaire (Neer) were also
measured 3 months after the initiation of treatment.
Manual muscle testing for flexion, abduction, internal
and external rotation strength of the shoulder was as-
sessed. Supraspinatus muscle trigger point tenderness
was determined by Algometry (Commander 1998
JTech Medical Industries) (Fig. 1). The Neer test was
applied to diagnose impingement syndrome [24]. While
scapular rotation was prevented with one hand, the
shoulder of the patient was passively forced to eleva-
tion at an angle between flexion and abduction by the
other hand. Pain in the subacromial was indicative of a
positive test. The ROM of the shoulder was measured
in all planes with a goniometer while the patients were
lying supine as blind pre- and post-treatment. Shoulder
916 Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921
123
flexion was assessed in the sagittal plane with the arm
at the side and the hand pronated, while shoulder
abduction was measured in the frontal plane with
the arm at the side and shoulder externally rotated to
obtain maximum abduction. Shoulder external and
internal rotation were measured in the transverse plane
while the arm was abducted to 90�, the elbow flexed to
90�, the hand pronated and forearm perpendicular to
floor. The measurement of spontaneous pain, at night
pain, pain at rest and pain with motion was conducted
by means of a 100 mm VAS (Tables 1, 2; Fig. 2).
The study was approved by the ethical committee of
the Medical Faculty at the University of Hacettepe. All
patients gave their written consent to participate.
Treatment
Group 1: self-training
Group 1 was instructed with the active ROM,
stretching and strengthening exercise program includ-
ing rotator cuff muscles, rhomboids, levator scapulae
and serratus anterior with an elastic band at home at
least seven times a week for 10–15 min and the exer-
cises were taught by physiotherapist and patients did
the exercises everyday during 4 weeks. Same exercise
program was given to each patient as shoulder exercise
brochure [1].
Group 2: manual therapy
Group 2 received a prescription for 12 sessions of joint
and soft tissue mobilization techniques, ice application,
stretching and strengthening exercise programs and
patient education in clinic for three times per week.
Self-training and manipulative physiotherapy aim at
strengthening rotator cuff muscles, increase tenderness
and pain and, therefore, probably reduce subacromial
impingement. Patients were treated in physical therapy
unit three times per week (12 sessions) for 4 weeks.
The manual therapy included deep friction massage
on supraspinatus muscle tendon (Fig. 3), radial nerve
stretching, scapular mobilization (Fig. 4a, b), glenohu-
meral joint mobilization (Fig. 5a, b) [5], proprioceptive
neuromuscular facilitation techniques including rhyth-
mic stabilization and hold-relax [11]. The self-training
was taught and controlled to patients under the guid-
ance of a physiotherapist. An instruction of the exer-
cise program was given as shoulder exercise brochure
[1]. For self-training at home, an elastic band was used
because this seemed more suitable then dumbbells.
The main advantage of the Thera-Band was the
availability of different levels of resistance, so it could
be adjusted individually to the patient’s level of
strength [11, 28]. The patients with painful disabling
impingement syndrome of the shoulder were random-
ized into two different conservative treatment groups.
Each group was treated over a period of 4 weeks. In
addition to the therapy regimen, the patients were
advised to avoid overhead sports and overhead work.
After the 16-week period, they were told to use their
shoulders normally without any limitation. All patients
agreed to conservative treatment.
Statistical analysis
Statistical analysis was conducted with SPSS Version
10 by using of the Student t-test for results. A signifi-
cant P-value was considered to be <0.05.
Table 1 Comparison of pain at night, rest and with motion before and after treatment in Group 1 and 2 according to VAS
Night pain Pain with motion Pain at rest
Before treatment After treatment P Before treatment After treatment P Before treatment After treatment P
X SD X SD X SD X SD X SD X SD
Group 1 6.1 1.9 1.2 1.6 0.01 6.3 2.7 2.5 1.5 0.01 2.0 2.0 0.9 0.2 0.07Group 2 5.6 2.1 2.2 2.4 0.02 6.0 2.5 3.1 2.0 0.01 3.0 1.8 0.7 1.4 0.02
Fig. 1 Supraspinatus muscle trigger point tenderness measuredby Algometer
Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921 917
123
Results
The statistical analysis of the two therapy groups did
not reveal any significant differences in age, duration of
disease, pain level, and initial result of the Neer score.
Subjects in both groups experienced significant de-
creases in pain and increases in shoulder function, but
there was significantly more improvement in the man-
ual therapy group compared to the exercise group. For
example, pain in the manual therapy group was reduced
from a pre-treatment mean (±SD) of 6.7 (±0.3) to a
post-treatment mean of 2.0 (±2.0). In contrast, pain in
the exercise group was reduced from a pre-treatment
mean of 6.6 (±1.4) to a post-treatment mean of 3.0
(+1.8). ROM at flexion, abduction and external rotation
in the manual therapy group improved significantly
while ROM in the exercise group did not. There were
statistically differences among the groups in function
(P > 0.05). Group 2 showed significantly greater
improvements in the Neer Questionnaire score and
shoulder satisfaction score than Group 1.
Discussion
Two groups with a subacromial impingement syn-
drome of the shoulder were treated with two different
conservative methods: self-training (Group 1), and
manual therapy (Group 2).
The patients were treated and followed up for a
period of 4 weeks. The main reason to limit the study
to 4 weeks was that it was impossible to keep stan-
dardized conditions over a longer period. Prescribing
physiotherapy for a longer time is not allowed by the
health insurance system. Also the treatment at hospital
might occasionally be interrupted due to problems of
time and transportation. The Cyriax method requires
fewer hospital visits enabling the patients to proceed in
their daily and sports activities. No special equipment
is needed for the method but only an experienced
physical therapist in the technique. The manipulation
Table 2 The Neer results of patients with subacromialimpingement
Neer 1 Neer 2 P
0 1
Group 10 5 0.0081 8 2
Group 20 1 0.0021 10 4
P 0.169 0.651
60
65
70
75
80
85
90
Ext.Rot.Group I Ext. Rot.Group II Int. Rot. Group I Int.Rot Group II
Before Treatment After treatment
Fig. 2 Comparison of external and internal rotation ROMbefore and after treatments in Group 1 and 2
Fig. 3 Deep friction massage on supraspinatus muscle
Fig. 4 Scapular mobilizationtechniques
918 Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921
123
used during the Cyriax approach is mild and does not
require anesthesia. It provides a health-care advantage
during the active treatment period and this is of major
importance for both the patient and the overloaded
physical therapy clinics of referral hospitals [8]. It
seems reasonable to suspect that some of these indi-
viduals may have decreased passive accessory joint
motion that is not addressed by conventional man-
agement and may benefit from interventions that uti-
lize manipulation/mobilization techniques.
There is little published evidence on the efficacy of
manipulation/mobilization for patients with any diag-
nosis involving the shoulder. Although literature data
lacks a consensus on the non-operative approach for
the treatment of subacromial impingement, it is still
the primary intervention. The abstracts or full reports
of 146 titles with appropriate key words regarding
manual therapy were reviewed in February 2005. Of
these, 105 studies were not primarily studies of manual
therapy and were thus eliminated from review. In the
41 remaining studies, 18 did not utilize statistical
comparisons or report blinded assessment of outcome
measures [7].
Another systematic review examined the evidence
for the efficacy of rehabilitation interventions for
patients with subacromial impingement syndrome via
computerized bibliographic databases of Medline, the
Cumulative Index to Nursing and Allied Health Lit-
erature, and the Cochrane Database of Systematic
Reviews from 1966 to October 2003 [19]. They found
15 randomized clinical trails. The limited evidence
currently suggests that exercise and joint mobilizations
were efficacious for decreasing pain and improving
function for patients with subacromial impingement
syndrome [19].
The efficacy of the treatments for shoulder symp-
toms have rarely been evaluated in randomized com-
parative studies so far [3, 6]. In the last 10 years, many
publications have focused on functional disorders that
may result in subacromial impingement [10, 14, 28, 31].
There is one report on treating subacromial disorders
with manual therapy. Bergman et al. performed a
randomized controlled study in 250 patients with
shoulder symptoms [2]. The patients received standard
treatment and manipulative treatment. The authors
reported a reduction shoulder complaints and an
improvement in the range-of-motion after treatment.
All two methods led to a significant improvement in
function and a significant decrease in pain levels over a
period of 4 weeks. The findings of Bergmanet al. con-
firm our results with regard to reduced pain as well as
improvement in mobility and muscle strength [2]. Our
results confirm the efficacy of a manipulative therapy
described by Cyriax in the early phase of the treatment
in subacromial impingement. Patients in the manual
therapy group demonstrated a significant reduction in
pain and increased function compared to the control
group both immediately after treatment and at a 1-
month follow-up. Although there are limitations in
Bergman study’s methodology, the results seem to
support the use of manipulation in patients with per-
sistent symptoms after an impingement syndrome.
Soft tissue (muscle, ligaments, tendons, joint cap-
sules, articular surfaces, skin and fascia) injuries such
as joint sprains or muscle damage are often treated by
manual therapy [16]. Normal tissue regeneration and
remodeling depend on mechanical stimulation during
the repair process [16]. This may help improve the
tissue’s overall mechanical and physical behaviors,
such as tensile strength and flexibility. Manipulation
was seen to have some effect in this study. Soft tissue
and joint mobilization and deep friction massage
Fig. 5 Glenohumeral joint mobilization techniques
Knee Surg Sports Traumatol Arthrosc (2007) 15:915–921 919
123
techniques stimulated the more superficial level of
proprioception, whereas manual techniques using joint
movement, stretching or deep kneading would stimu-
late the deep level of proprioception. Comparing the
results of the different studies, there is no clear supe-
riority of a particular method. After 3 months, half of
the patients improved by 50% or more.
The therapeutic exercise programs within the liter-
ature related to impingement syndrome generally
consisted of stretching the anterior and posterior
shoulder girdle, muscle relaxation techniques, motor
learning to normalize dysfunctional patterns of motion,
and strengthening the rotator cuff and scapular muscles
[9–12]. It is unclear what the optimal exercise regime is
or the frequency and intensity of an exercise program.
In our experience, many clinicians avoid manipula-
tion in acute and sub-acute injuries of the periphery
because of a belief that tissue damage has occurred,
and the notion that manipulation will contribute to
further tissue damage. In other areas, such as lumbo-
pelvic region, the literature generally supports the use
of manual therapy techniques in the management of
acute injuries [15]. Perhaps the pathoanatomical model
that is currently utilized to determine the severity of
shoulder problems biases clinicians inappropriately
assume that manual therapy may be harmful, when in
fact some individuals with impingement syndromes
may exhibit decreased passive accessory joint motion
that, if adequately addressed, will lead to dramatic
improvements in pain and function. It is interesting to
note that a pathoanatomical model based on a ‘‘tissue
damage’’ model has been largely unsuccessful in
explaining pain and disability in low back pain. Despite
the limited number of clinical trials that assess the
efficacy of manual therapy in the management of
impingement syndrome, this form of intervention
seems to have some benefit for patients with subacro-
mial impingement syndromes. We believe it may have
the most benefit for patients who are not responding to
conventional treatment, and who demonstrate limita-
tions in passive accessory motion.
Conclusion
Considering the effect of manipulative therapy, one
can speculate that the proprioceptive feedback trans-
mitted by deep level of receptors. This might improve
neuromuscular control in the movement patterns of the
shoulder girdle and scapular motions. Manual physical
therapy applied by experienced physical therapists
combined with supervised exercise in a brief clinical
trial might better and earlier than exercise alone for
increasing strength, decreasing pain, and improving
function in patients with shoulder impingement syn-
drome. The findings are interesting and motivate fur-
ther studies, including long-term follow-up of large
groups, randomized studies and the comparison of this
treatment model with other treatment models.
A faster program with fewer hospital visits not only
enables the patients to proceed with most of their daily
activities but also decreases the costs of the treatment.
A manipulative therapy might also be an alternative to
conventional physiotherapy in the treatment of the
subacromial impingement.
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