Subacromial impingement syndrome effectiveness of physiotherapy and manual therapy


Some of our Elf friends who are regular swimmers have been suffering from sore shoulders. One of them has been diagnosed as having subacromial impingement syndrome (SIS). This term involves different structures in the shoulder such as the rotator cuff, tendonitis and bursitis of the shoulder.

Treatment of SIS can include surgery but our friend is wondering what the effectiveness of non-surgical treatment is. So we searched the literature and found a review that explored effectiveness of physiotherapy and manual therapy.

Here’s what they did

The authors searched the Cochrane Library, PubMed, EMBASE, PEDro and CINAHL  for relevant systematic reviews and randomised clinical trials (RCTs) up to March 209. There were no language restrictions.

The studies were to include only those where SIS was not caused by an acute trauma or any systemic disease and results on pain, function or recovery were reported at a follow-up period of ≥2 weeks.

Two reviewers independently extracted data and assessed the methodological quality of each RCT using Furlan’s 12 criteria. A best-evidence synthesis was used to summarise the results. The article was included in the best-evidence synthesis only if a comparison was made between the groups and the level of significance was reported.

Here’s what they found

  • Two reviews and 10 RCTs (5 high quality) reporting on pain, function or recovery were included.
  • One RCT studied manual therapy as an add-on therapy to self-training.
  • All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field.
  • Hyperthermia (heat) compared to exercise therapy or ultrasound: moderate evidence was found for the effectiveness of hyperthermia in the short term, no midterm or long-term results were studied.
  • Hyperthermia (heat) and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence).
  • Exercise therapy gave the best results (moderate evidence) in the midterm compared to placebo or controls.
  • Other interventions, conflicting, limited or no evidence was found.

The authors concluded

Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.


Hyperthermia is effective in the short term

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

This review considered the effectiveness of physiotherapy and manual therapy on pain, function or recovery. The interventions included in this review were varied and included; pulsed electromagnetic field (PEMF), laser, accupuncture, ultrasound, ultrasound plus ionthophoresis, corticosteriod injections, mobilisation as an add-on therapy to exercise, manual therapy as an add-on therapy to self-training, workplace-based hardening, clinical-based hardening, exercise, physiotherapy, and shoulder braces.

The authors found difficulty comparing these interventions and thus pooling of data and meta-analyis was not possible and they had to report a best evidence synthesis.

What do you think?

  • Do you use any of these interventions to treat subacromial impingement syndrome?
  • Do you have a standard protocol? If so would you like to share it with us?
  • How do you measure effectiveness of your interventions?

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community. Post your comment below, or get in touch via social media (FacebookTwitterLinkedInGoogle+).

Do you know that there is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses? This is called the Preferred Reporting Items for Systematic Reviews and Meta-Analyses or PRISMA statement and can be accessed through the website of the EQUATOR Network. The Elves use the PRISMA statement for critical appraisal of systematic reviews, although it is not a quality assessment instrument to gauge the quality of a systematic review.


  • Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM Subacromial impingement syndrome–effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014 Aug;48(16):1202-8. doi: 10.1136/bjsports-2012-091802. Epub 2013 Nov 11. [abstract]
  • PRISMA statement
  • EQUATOR Network
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Tracey Howe

Hi I am Tracey Howe. I am a Professor of Rehabilitation Sciences at Glasgow Caledonian University, UK and Deputy Chair of Glasgow City of Science. I am also an editor for the Cochrane Musculoskeletal Review Group and a convenor for the Cochrane Health Care of Older People Field. I am a Trustee of the Picker Institute Europe. I started my career as a physiotherapist in the National Health Service in England. I have extensive experience of assessing the quality of research in Universities in the UK and internationally. I enjoy strategic visioning, creative problem-solving, and creating vibrant, multi-disciplinary environments, through collaboration, partnerships, and relationships, that empower others to succeed.

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