Manual therapy is done utilizing skilled, hands-on techniques, including but not limited to manipulation/mobilization for the diagnosis and treatment of soft tissue and joint pathologies. The ultimate goals of this treatment technique include reducing pain and inflammation, increasing the range of motion (ROM), assisting the body in repairing joints and soft tissue, decreasing myofascial restrictions to improve muscle length, improving extensibility and/or stability, and facilitating movement to improve function (Bernard, 2016). In shorter terms, manual therapy is an umbrella technique covering many specific hands-on approaches including but not limited to massage, functional mobilization, myofascial release, active release, soft tissue mobilization, joint mobilization, and traction. In the environment of a sport medicine clinic placement, this treatment technique is used roughly 90% of the time. The importance of this topic is that many treatment sessions for the Women’s Volleyball team at McMaster University consist of soft tissue and joint manual therapy alone, and may be combined with other treatment techniques every few visits depending on injury status. This technique has been used most with the team to flush out calves, hamstrings, quadriceps, and mostly shoulders. Shoulder impingement, also known as shoulder impingement syndrome (SIS), painful arc syndrome, subacromial impingement (SAI), or supraspinatus syndrome, is recognized by “the mechanical encroachment of subacromial soft tissue into the subacromial space, resulting in narrowing of the subacromial space” (Stuyf, De Hertogh, Gulinck, & Nijs, 2012). Impingement is the most common diagnosis of shoulder dysfunction and can be described as shoulder pain that is exacerbated by overhead activities (Kachingwe, Phillips, Sletton, & Plunkett, 2008). Shoulder injuries, and more specifically shoulder impingement injuries are the most common injury seen on the volleyball team due to their constant repetitive overhead use of the arm, and this is where manual therapy comes in handy. The objective of this paper is to determine if manual therapy is a valid and effective technique for the treatment and management of shoulder impingement.
Research by Hawkins and Kennedy (1980) showed the early start of the discussion of what shoulder impingement is, how it affects athletes, and what can be done about it by considering the three main stages of the disease, associated problems, and thoughts on appropriate treatment. Stage I of impingement includes edema and hemorrhage, is most common with competitive teams and can be treated with anti-inflammatories, ultrasound, ice, strengthening, and potentially surgery. Stage II of impingement includes fibrosis and tendonitis, is similar to stage I, but additionally includes ROM exercises daily to help in treatment. Stage III of impingement includes tendon degeneration, bony changes, and potential tendon ruptures, and there is a high emphasis on maintaining ROM with exercises and specific manual therapy of shoulder muscles (Hawkins & Kennedy, 1980). Overall, this started a trend of using exercises, strengthening programs, and special manual treatment as preventative and treatment measures for shoulder impingement in young athletes.
Manual therapy is widely used as a treatment modality in isolation for athletes requiring treatment or management for shoulder impingement. A study by Stuyf et al. (2012) examined the evidence-based methods for treatment of patients with SIS that are most commonly used among Physiotherapists (PT’s). Online questionnaires were put out to thousands of PT’s for them to report the interventions they most commonly use for treatment of SIS. Of those that responded, manual mobilization was the most frequently reported for the treatment of SIS at 96.6%, followed by exercise therapy at 94.1%, then postural focused training and other interventions at lower percent usage rates. Manual mobilizations were shown to be most often used for the treatment of SIS and included glenohumeral (GH) and scapular mobilizations, joint mobilization, and soft tissue mobilization through massage, friction and kneading (Stuyf et al., 2012). Due to the fact that this study was conducted through online questionnaires, and was geared towards Dutch PT’s, we cannot use this evidence and generalize it to Canadian PT’s. A separate study by Heredia-Rizo, Lopez-Hervas, Herrera-Monge, Gutierrez-Leonard, and Pina-Pozo (2013), provided a comparison of manual therapy to shoulder mobilization on individuals with SAI. After three weeks of intervention, whether mobilization or manual therapy (soft tissue techniques on upper back, trapezius, and shoulder), the change in active and passive ROM as well as the self-perceived functionality of the upper limb were measured. The experimental group showed significantly greater improvement in both active and passive ROM than the conventional group, showing a positive effect of manual therapy on improving ROM (Heriedia-Rizo et al., 2013). In addition to this evidence, Delgado-Gil et al. (2015) compared immediate effects of mobilization with movement (MWM) to a sham technique in patients with SIS. MWM was used on half of the subjects (twenty-one) by maintaining a posterior-lateral manual glide on the humeral head at the same time as active shoulder flexion. This was compared to twenty-one subjects receiving a sham technique without any movement, and the outcomes captured included pain intensity, pain during active ROM and maximal active ROM. Overall, those receiving MWM experienced a significantly greater reduction in the intensity of pain during shoulder flexion, greater pain-free shoulder flexion, greater max shoulder external rotation and greater max shoulder flexion than those receiving the sham intervention. In addition to these findings, Delgado-Gil et al. (2015) also discussed future directions, which introduced the idea that in typical physical therapy sessions, a multimodal treatment approach is often used and may be the most useful approach. Although throughout placement in a sport med clinic with the Women’s Volleyball team, manual therapy in isolation is most commonly used and we have seen a plethora of benefits, a multimodal approach is discussed further in the next section.
In addition to its effectiveness and validity when used in isolation for athletes with a shoulder impingement, manual therapy is more widely used in combination with multiple other treatment options and may be proven more effective this way. Heriedia-Rizo et al. (2013) was helpful in explaining the benefits of manual therapy in isolation over mobilization, however also provided insight on using manual therapy in combination with alternate treatment options. When combined with electrotherapy and postural hygiene, manual therapy shoulder showed a greater improvement on shoulder mobility, active and passive ROM as well as overall upper limb functionality, demonstrating a clear combined, and additive benefit (Heredia-Rizo et al., 2013). Since electrotherapy and postural hygiene lack availability in the clinic, this combination would not be suitable to adapt into the McMaster Women’s Volleyball shoulder impingement treatment programs. Page et al. (2016) synthesized evidence regarding the benefits and harms of manual therapy and exercise alone or in combination for treatment of individuals with rotator cuff disease. Fifty-two trials they reviewed demonstrated no difference in outcomes between manual therapy alone, therapeutic ultrasound, ice, or kinesiotaping, and we can therefore infer that these treatments in combination may provide a more optimal treatment program (Page et al., 2016). Due to the lack of conclusive evidence, future trials should compare manual therapy and exercise with a realistic placebo and future trials of manual therapy or exercise alone for rotator cuff disease should be based on a strong rationale. A case report looking at manual therapy and rehabilitation for SAI by Bennett, Macfarlane, and Vaughan (2017), showed manual therapy having a positive effect on pain and function over a six week period demonstrated by reduced pain with Hawkins-Kennedy, Neer’s Impingement, empty can, and lift-off special tests. A further conclusion is that when combined with therapeutic exercise (rotator cuff muscle strengthening while stretching the pectorals), manual therapy (cross fibre massage, direct myofascial release, and GH traction) appeared to provide better outcomes for functionality as well as pain than therapeutic exercise or manual therapy alone (Bennett et al., 2017). Additionally, when four physical therapy interventions (supervised exercise, supervised exercise with GH mobilizations, supervised exercise with MWM, and physicians advice) effectiveness’ were compared for use on SIS in a study by Kachingwe et al. (2008), outcome measures included 24hr pain, pain with Near and Hawkins-Kennedy special tests, active ROM, and shoulder function. Results were comparable to previous studies in that all of the mobilization and manual therapy techniques proved valid and effective in the outcomes measured, however, that performing GH mobilizations and MWM in combination with a supervised exercise program resulted in the greatest pain decrease and largest function improvement in those with SIS. These studies are important in the sport medicine placement since a clinic setting requires familiarity and use of many different modalities, and with tight time constraints, treatment times must be used wisely. With this knowledge of the benefit of combined modalities, many athletes can be “receiving treatment” simultaneously if we plan well, and have these alternative treatment methods available.
Since the aims of SIS/SAI rehab programs are to reduce pain and inflammation, improve shoulder mobility, strengthen weak surrounding muscles, and correct postural problems, any treatment that shows effectiveness in these domains can be considered valid and effective in the management of the pathology (DeBerardino, 2017). Based on research, manual therapy techniques should continue to be used as a treatment tool in the clinic with the McMaster Women’s Volleyball team. The importance of this paper is that not only can overhead athletes benefit from the modality, but also it can be generalized to all generations and a wide range of the population as there’s little to no risk involved, and clear benefits have been shown. Manual therapy seems to be chosen over other modes of treatment for shoulder impingement syndrome more often and, in isolation, has been shown to improve ROM, reduce pain, and increase functionality in those with SAI. Continuing with the plethora of benefits of manual therapy, there is an abundance of information provided about manual therapy in combination with other techniques, which demonstrate more conclusive effects on improving mobility, ROM, functionality, and overall SIS/SAI management and treatment. Manual therapy is an extremely valid and effective treatment option, and evidence shows that it can provide even greater benefit when used in combination with other treatment options including supervised exercise programs, ice, local modalities, as well as isolated mobilizations. What may be missing from the literature, are studies examining and discussing the specific effects inside the body of different treatment modalities for SAI to see specifically what is changing internally, to result in improved symptoms.