The shoulder impingement syndrome is one of the most common causes of pain and dysfunction in the athletes shoulder. Primary shoulder impingement syndrome can occur in anyone who repeatedly or forcefully uses the upper extremity in an elevated position. The patho-mechanics of this syndrome implicate activities that repetitively place the arm in over head positions. Majority of athletes who manifest this condition participate in baseball, swimming, cricket and tennis, but it is by no means confined to these sports. Repeated compression of the subacromial contents causes micro-pockets of damage which eventually summate as the activity is persisted with. Capsular tightness appears to be a common mechanical problem in primary impingement syndrome. The ensuing inflammatory reaction involves vascular congestion and edema into the tendon or bursa which further reduces the space beneath the coraco-acromial arch. This results in pain that interferes with normal biomechanics of the shoulder by causing muscle impingement and compensatory movements or postures. The importance of its recognition is that impingement is often a progressive condition that, if recognized and treated early, can have a more favorable outcome. Delay in recognition and treatment can allow secondary changes to occur, with resultant limitations in treatment options and functional outcomes.
1.2 THE MAGNITUDE
The magnitude of the problem is attested by the fact that 30 to 60 percent of competitive swimmers and 25 percent of base ball pitchers and tennis players incur this malady at some point during their careers. Recognition of the syndrome and early non-operative intervention are essential for a successful resolution and the return of athletes to their accustomed level of performance.
Most athletes start participating in sports when they are relatively young, by adolescence many would have experienced the symptoms commonly known as "bursitis", "cuffitis", or "supraspinatus syndrome". Impingement syndrome is by far the most common soft tissue injury of the shoulder for which an athlete seeks treatment.
1.3 MECHANICAL FACTORS
Capsular tightness appears to be a common mechanical problem in primary impingement syndrome. The posterior, anterior and inferior portion of the capsule has been reported to be involved in this.
Athletes or individuals who avoid painful overhead activity or who are subjected to motion imbalances as a result of their sports can develop capsular tightness which restricts joint mobility and prevent opposite direction humeral head glide leading to an earlier onset or greater degree of subacromial compression and painful or limited function, particularly in elevated planes of movement.
1.4 OVERUSE INJURIES: AN OUTLINE
Overuse injuries in athletes are more common than traumatic and post surgical injuries to shoulder. The joint by structural default compromises on stability for the sake of mobility. This poses a complex interaction of laxity, rotator cuff injury (Tensile tendinitis) and impingement injuries (Compression tendinitis) leading to syndrome causing functional limitation.
The etiology again is attributed to patho-mechanics and can be classified into primary and secondary causes.
PRIMARY CAUSES
Primary impingement
ï¶ Increased subacromial loading
ï¶ Acromial morphology (A hooked acromion, presence of an osacromiale or osteophyte, and/or calcific deposits in the subacromial space make patients more predisposed for primary impingement.)
ï¶ Acromioclaviculararthrosis (inferior osteophytes)
ï¶ Coracoacromial ligament hypertrophy
ï¶ Coracoid impingement
ï¶ Subacromialbursal thickening and fibrosis
ï¶ Prominent humeral greater tuberosity
ï¶ Trauma (direct macrotrauma or repetitive microtrauma)
ï¶ Overhead activity (athletic and nonathletic)
SECONDARY CAUSES
Secondary impingement
ï¶ Rotator cuff overload/soft tissue imbalance
ï¶ Eccentric muscle overload
ï¶ Glenohumeral laxity/instability
ï¶ Long head of the biceps tendon laxity/weakness
ï¶ Glenoid labral lesions
ï¶ Muscle imbalance
ï¶ Scapular dyskinesia
ï¶ Posterior capsular tightness
ï¶ Trapezius paralysis
1.5 NEED FOR THE STUDY
The use of manual therapy as a part of comprehensive rehabilitation care is still not very popular and there are only few studies done in this particular area and needs more objective findings. It is this paucity my study aims to bridge.
1.6 SIGNIFICANCE OF THE STUDY
The specific hypotheses were that patients diagnosed with primary shoulder impingement syndrome, treated with manual joint mobilization combined with hot packs, active range of motion, physiologic stretching, muscle strengthening exercises, soft tissue mobilization and patient education would experience less pain intensity upon subacromial compression testing and Greater active range of motion. My study aims to outline the benefits of incorporating Manual therapy technique into treatment regimes.
1.7 OBJECTIVE OF THE STUDY
The objective of the study is to evaluate the effect of manual therapy (Mulligan, Maitland) as a component of comprehensive treatment for primary shoulder impingement syndrome in athletic shoulder.
1.8 HYPOTHESIS
The null hypothesis for the study is stated as follows :
"There is no significant difference in reducing pain and improving range of motion and function on using manual therapy techniques in overhead athletes with primary shoulder impingement syndrome"
2. LITERATURE REVIEW
 Lo YP, Hsu YC and Chan KM conducted a study in 372 players and found that 163 persons (43.8%) had shoulder problems and 109 players (29%) had shoulder pain. The prevalence of shoulder pain ranked highest among volley ball players (N= 28) followed by swimmers (N= 22), badminton, basketball and tennis (Br.J.Sports Med,sep 1990)
 Fluerst Ml has stated impingement syndrome to be one among the 10 most common sports injuries and attribute it to unstable design of the joint. He suggests exercise to rotator cuff strengthening to hold the shoulder in place and preventing dislocations (American Health Oct 1994).
 Fu FH, Harner CD and Klein AH classifies impingement into 2 categories Primary and Secondary. Primary being caused by nonathletic injuries of supraspinatus tendon while secondary is caused by athletic injuries due to unstable patterns of movement (stressful and end ranges). This they concluded will enable better clinical approaches. (Clin. Orthop Aug 1991).
 Brox JL, Staff PH, Ljunggren AE & Brevik JL used Neer shoulder score and found that surgery and supervised exercise program definitely had an improved rotation when compared to placebo treatment. (BMJ Oct 1993).
 Blevins FT has suggested classification of rotator cuff injury and dysfunction based on etiology as primary impingement, primary tensile overload and secondary impingement and tensile overload resulting from glenohumeral instability. Arthoscopic examination shows anterior capsular laxity (positive "drive through sign") as well as superior posterior labral and cuff injury typical of internal impingement. If rehabilitation alone is not successful a capsulolabral repair followed by rehabilitation may allow the athlete to return to their previous level of competition. Athletes with acute episodes of macrotrauma to the shoulder resulting in cuff pathology usually presents with pain, limited active elevation and a positive "shrug-sign". Arthroscopy and debridement of thickened, inflamed or scarred subacromial bursa with cuff repair or debridement as indicated is usually successful in those who do not respond to a rehabilitation program. (Sports Med.1997).
 Masala S et al., in their study on "Impingement syndrome of shoulder" have proved that CT and MRI are more reliable and accurate diagnostic methods. CT scan is sensitive to even slight bony changes and MRI detects tendon, bursa and rotator cuff changes. However they suggest plain X-rays to be performed as a first procedure. (Radiol. Med Jan 1995). This idea of MRI being sensitive to diagnose impingement has also been confirmed by Rossi F (Eur.J.Radiol. May 1998). However, Holder J has concluded that differentiation between tendinopathy and partial tears might be difficult using MRI imaging. (Radiologe Dec 1996).
 Corso G has emphasized the use of impingement relief test as an adjunctive procedure to traditional assessment of shoulder impingement Syndrome. This supposedly helps in isolating the primary tissue lesion. Such that conservative management could be addressed to that specific structure (J.ortho. Phys Ther, Nov 1995).
 Brossmann J and colleagues from the veterans administration medical center of California have stated that MR imaging of different shoulder positions may help reveal the pathogenesis of shoulder impingement Syndrome. (AJR Am. J Roentgenol. Dec 1996).
 Deutsch A, Altcheck DW et al., have shown that patients with stage II and stage III impingement had a larger scapulothoracic component than the normal shoulder during abduction movement. The superior migration of humeral head is probably the result of cuff failure, either partial or complete.
 Douglas E. Conroy and Karen W Hayes in their article on "Impingement syndrome in the athlete shoulder" have conclusively stated that the subjects receiving joint mobilization and comprehensive treatment would have improved mobility and function compared to similar patients receiving comprehensive treatment alone. Mobilization decreased 24-hour pain and pain with subacromial compression test in patients with primary impingement Syndrome. (J Orthop Sports Phys. Ther. Mar 1998).
 Hawkins RJ and Hobeika PE in their article on "Impingement syndrome in the athlete shoulder" have conclusively stated that the impingement syndrome may spill over at any time to involve the adjacent biceps tendon, subacromical bursa and acromio-claviular joint and as a continuum, with the passage of time, may eventuate in degeneration and partial, even complete thickness, rotator cuff tears later in life. They also recommend careful warm-up exercises, occasional rest by avoiding offending movement and local modalities of ice, ultrasound and transcutantaneous stimulation along with pharmacotherapy. They also state surgical decompression and definitive acromioplasty could be performed. (Cl. Sports. Med. Jul 1983).
 Bak K and Magnusson SP have emphasized that internal rotation might be much more affected than the external rotation which might cause superior migration of humeral head. They also state that range of motion in shoulder need not correlate with the occurrence of shoulder pain. (Am. J. Sport Med, Jul 1997).
 Homes CF and associates of University of Arkansas have concluded that intensive patient education, home program, therapeutic exercises and specific manual mobilization has better patient compliance and lesser abnormalities on objective examination after 1 year.(J.Orthop. Sports. Phys. Ther. Dec 1997).
 McCann PD and Bigliani LU in their article on "Shoulder pain in tennis players" has emphasized rotator cuff and scapular muscle strengthening and surgical stabilization of the capsulo-labral complex for patients who fail rehabilitation program. Prevention of injury in tennis players seem to depend upon flexibility, strength and synchrony among the gleno-humeral and scapular muscles. (Sports Med. Jan 1994).
 Carpenter JE et al., in their article in MDX health digest have found out that there is an increase in threshold for movement proprioception by 73%. This decrease in proprioceptive sensation might play a vital role in decreasing athletic performance and in fatigue related dysfunction. Thought it is still doubtful if training improves the perception, this is an important finding that has farfetched implications in the treatment of shoulder impingement syndrome as fatigue might be quite common with the decrease vascularity and trauma to the structure of rotator cuff. (Am. J. Sports Med Mar 1998).
 Scheib JS from university of Tennessee Medical Center has stated that overuse sydromes mandate rest and control of inflammation through drugs and physical modalities. He prescribed a gradual progression of strengthening program and any return of symptoms should be adequately and promptly appraised and treated. He emphasized that proper conservative treatment alone prevents progression of impingement syndromes. (Rheum. Dis. Clin. North.Am Nov 1990).
 Morrrison DS and colleagues have shown that non operative treatment of shoulder impingement syndrome resulted in significant improvements. In their study of 413 patients 67% had a good recovery while 28% had to go for arthroscopic procedures. Further age, gender and concomitant tenderness of acromio-clavicular joint did not affect the outcome significantly. (J.Bone and Joint Surg. Am. May 1997).
 Brewer BJ has documented a morphologic change of the greater tuberosity and progressive degeneration of all elements of the tendinous structures that is age related with progressive
(1) osteitis of the greater tuberosity, cystic degeneration, and irregularity of the cortical margin; (2) degenerative sulcus between the greater tuberosity and the articular surface;
(3) disruption of the integrity of the attachment of the tendon to the bone by Sharpey's fibers; (4) loss of cellularity, loss of staining quality, and fragmentation of the tendon;
(5) diminution of the vascularity of the tendon; and
(6) dimmunition of fibrocartiage.(Am J Sports Med, Mar-Apr 1979).
 Kinger A et al., stated that volleyball players have a different muscular and capsular pattern at the playing shoulder compared to the opposite shoulder. Their playing shoulder is depressed, the scapular lateralized, the dorsal muscles and the posterior and inferior part of the shoulder capsule shortened. These differences were of more significance in volleyball players with shoulder pain than in volleyball players without shoulder pain. Muscular balance of the shoulder girdle is very important in this sport. It is therefore imperative to include adequate stretching and muscular training program for the prevention, as well as for therapy, of shoulder pain in volleyball players. (Br J Sports Med, Sep 1996).
 Jobe FW,Kvitne RS,Giangarra CE in their article "shoulder pain in the overhand or throwing athlete- the relationship of anterior instability and rotator cuff impingement", shoulder pain in the overhand or throwing athlete can often be traced to the stabilizing mechanisms of the glenohumeral joint.
 Flatow EL and associates of Orthopaedic Research Laboratoty, New York Orthopaedic Hospital, on the biomechanics of humerus with acromion states that contact starts at the anterolateral edge of the acromion at 0 degrees of elevation, it shifts medially with arm elevation. On the humeral surface, contact shifts from proximal to distal on the supraspinatus tendon with arm elevation. When external rotation is decreased, distal and posterior shift in contact is noted. Acromial undersurface and rotator cuff tendons are in closest proximity between 60 degrees and 120 degrees of elevation; contact was consistently more pronounced for type III acromions. Mean acromiohumeral interval was 11.1 mm at 0 degrees of elevation and decreased to 5.7 mm at 90 degrees, when greater tuberosity was closest to the acromion. Contact centers on the supraspinatus insertion, suggesting altered excursion of the greater tuberosity may initially damage this rotator cuff region. Conditions limiting external rotation or elevation may also increase rotator cuff compression. Marked increase in contact with Type III acromions supports the role of anterior acromioplasty when clinically indicated, usually in older patients with primary impingement. ( Am J Sports Med, Nov-Dec 1994).
 Hawkins RJ, Abrams JS in "Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2)" lay emphasis on prophylaxis in high-risk populations, such as pitchers and swimmers. Once symptoms occur, the majority can be successfully managed with nonoperative measures. Prolonged failure of conservative care prior to rotator cuff tear requires surgical decompression with predictable success in most. (Orthop clin North Am, Jul 1994).
 Hjelm R, Draper C, spencer S supported the concept that capsular ligament not only provide restraint, but are specifically oriented to guide and center the humeral head on the glenoid during shoulder movements. Glenohumeral ligament length insufficiency can be the primary cause of shoulder pain, ranging from frozen shoulder to impingement like symptoms.Proper capsular ligament length can be restored with manual techniques. All patients with shoulder pain should have capsular ligament assessment to ensure proper glenohumeral mechanics. (J Orthop Sports Phys Ther, Mar 1996).
 Frogameni AD,Woodworth P in their study on "Non- operative treatment of subacromial impingement syndrome"performed a retrospective study of 616 patients and have shown that non-operative treatment of subacromial impingement syndrome resulted in significant improvement.Overall,413 patients had a satisfactory result while others had to go for arthroscopic procedures. Also, shoulder dominance, gender and concomitant tenderness of the acromioclavicular joint did not affect the result significantly.(Arthroscopy;16(1):35-40).
 Pink MM et al in their article "Arthroscopic findings in the overhand throwing athlete:evidence for posterior internal impingement of the rotator cuff" supported the concept of impingement of the posterior cuff undersurface with the posterosuperior glenoid rim in the overhand throwing athlete with shoulderpain. (J Shoulder Elbow Surg;8(2):102-111).
 Gjengedal E et al in their study on "Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome):a prospective, randomized controlled study in 125 patients with a two-and-half year follow-up" found that the success rate was higher for patients randomized to surgery(26 of 38) and exercises (27 of 44) compared with the placebo group(7 of 28).(Clin J Sport Med 2003 May;13(3):176-182.)
 Claude HC,Pierre Freemont in their article "Therapeutic exercise and orthopedic manual therapy for impingement syndrome :a systematic review" suggested that therapeutic exercise or manual therapy benefited more when compared with other treatments such as acromioplasty, placebo or no intervention. Studies were included if (1) they were a randomized controlled trial;(2) they were related to impingement syndrome, rotator cuff tendinitis or bursitis;(3) one of the treatments included therapeutic exercise or manual therapy.(J Orthop Sports Phys Ther.1998 Jul;28(1):3-14.
 Greenbaum BS,Einhorn A in their article "Shoulder impingement" has stated that impingement rehabilitation focuses on strengthening the humeral head depressors while ignoring the deltoid and supraspinatus muscles. Later treatment includes specific retraining of scapular balancing muscles. The final phase of treatment includes strengthening the prime humeral movers in positions that avoid further stress to the injured rotator cuff tendons and last of all specifically strengthening the supraspinatus muscle.(Orthop Clin North Am.1997 Jan;28(1):69-78.
 Roberts et al(2002) used MRI to identify and measure the changes in anatomic structures in the subacromial space as the arm was moved from complete rest to 160 degree of forward flexion during the Hawkin's and Neer impingement manoeuvres. They concluded that a clinically positive Hawkin's sign is consistent with external shoulder impingement.
 Andy Finn in his article "Shoulder impingement physical therapy to stop the pain and recover fast" has conclusively stated that shoulder impingement disorder can be resolved effectively with a professional program of rehabilitation which is based on specific exercises for the rotator cuff can cut down recovery times from months to weeks, reducing pain, inflammation and the need for medicines, naturally.
 MacDonald et al., compared the diagnostic accuracy of the Neer and Hawkin's impingement sign to arthroscopic findings and stated that both tests were similar for finding rotator cuff disease but the Hawkin's sign was more sensitive for subacromial bursitis. They concluded that when both the tests are negative there is a high level of prediction that rotator cuff tendinopathy, tearing or bursitis can be ruled out.
 Aimie F.Kachingwe et al., found that MWM in combination with a supervised exercise program resulted in a higher percentage of change (but not statistically significant) from pre- to post-treatment in decreasing pain and improving function compared to the supervised exercise only and control groups.
 Pappas GP et al. ,in their article "In vivo anatomy of the Neer and Hawkins sign positions for shoulder impingement" has stated that the Neer and Hawkins impingement signs are commonly used to diagnose subacromial pathology. It was found that the Hawkins position resulted in significantly greater subacromial space narrowing and subacromial rotator cuff contact than the Neer position though both the maneuvers significantly decreased the distance from the supraspinatus insertion into the acromion and posterior glenoid and from the subscapularis insertion to the anterior glenoid. The intraarticular contact of the supraspinatus with the posterosuperior glenoid was observed in all subjects in both positions, which they stated that internal impingement may play a role in the Neer and Hawkins signs. (J Shoulder Elbow Surg 2006 Jan-Feb;15(1):40-49).
 Valadie et al., in a study described that there is consistent contact between the soft tissues and the coraco-acromial ligament and between the articular surface of the rotator cuff and the anterior superior glenoid during the Hawkin's and Kennedy test.Edelson and Teitz reported contact between the lesser tuberosity and antero-superior glenoid in the Hawkin's and Kennedy test position.
 MacDermid JC et al., in their article "The shoulder Pain and Disability Index demonstrates factor, construct and longitudinal validity" concluded that the SPADI is a valid measure to assess pain and disability in community-based patients reporting shoulder pain due to musculoskeletal pathology. The SPADI is a self-report questionnaire to measure the pain and disability associated with shoulder pathology.Based on their study the internal consistencies of the SPADI subscales were high.(BMC Musculoskeletal Disorders 2006,7:12 do1:10.1186/1471-2474-7-12)
3. MATERIALS AND METHODOLOGY
This study is designed to involve Manual therapy as a component of comprehensive treatment for primary shoulder impingement in athletic shoulder. The study was carried out for one year.
3.1 STUDY DESIGN
The study is conducted in the format of experimental pre test, post test study design.
3.2 STUDY SETTING
This study is conducted on athletes of Coimbatore sports club, when they had come to Sri Ramakrishna hospital for shoulder pain treatment. Informed consent was obtained from all the subjects to carry out my thesis work after prior referral from the physician in-charge.
3.3 SAMPLING
Random sampling
A total of 20 athletes with primary shoulder impingement were divided into 2 groups of 10 each.
Group A
10 athletes: - Mulligan mobilization combined with Stretching and Strengthening exercises.
Group B
10 athletes: - Maitland mobilization combined with Stretching and Strengthening exercises.
3.4 CRITERIA FOR SAMPLE SELECTION
Eligibility
Age eligibility for study : 18 Years to 35 Years
Genders eligibility for study : Male
Accepts Healthy Volunteers : No
CRITERIA
Inclusion Criteria
 Reproduction of symptoms with impingement test: either Hawkins-Kennedy or Neer test.
 Pain about the superolateral shoulder region.
 Pain during active shoulder elevation at or above 60o.
 Active range of motion deficit in humeral elevation.
 Limited functional movement patterns in elevated positions.
 Positive clinical signs indicating subacromial impingement symptoms (SIS): pain aggravating with overhead activity; a painful arc, etc.
Exclusion Criteria
 History of capsular, ligament, tendon and labrum injuries.
 Any recent surgeries carried out in and around shoulder joint.
 Traumatic shoulder dislocation within the past 3 months.
 Previous rehabilitation for this episode of shoulder pain
 Severe degeneration bony or ligament changes.
 Primary scapula thoracic dysfunction.
 Reproduction of shoulder pain with active or passive cervical motion.
 Systemic inflammatory joint disease.
 Unstable fracture of humerus, scapula and clavicle.
 Any neurovascular co-morbidities of the involved upper extremity.
 Any pathology around the shoulder like Periarthritis, Calcified tendinitis, Frozen shoulder, AC arthritis etc.
 Global loss of passive shoulder ROM, indicative of adhesive capsulitis.
3.5 MAIN STUDY
Procedure
Athletes were randomly assigned to two groups according to the block randomization method Group 1- Mulligan mobilization combined with Stretching and strengthening exercises. Group 2- Maitland mobilization combined with Stretching and strengthening exercises. Block randomization was used to ensure that an equal number of athletes were assigned to each treatment group and informed of their treatment protocol. Pre and post-treatment assessment measurements were taken, the initial assessment session occurred on the first day of the week of the physician examination.
The effect of treatment was assessed based on the following dependent variables: -
1. Pain-free active ROM measured with a standard goniometer for flexion and scaption.
Pain-free shoulder fexion and scaption active ROM was measured with a universal goniometer according to a standard procedure. Scaption was measured in standing by aligning the goniometer axis over the coracoid process, the stationary arm parallel to the thorax and the moving arm midline of the humerus with the medial epicondyle as a guide. Standardized goniometric measurements of glenohumeral motion have been shown to have good intrarater reliability and validity.
2. Measurement of shoulder function assessed with the shoulder pain and disability index (SPADI).
The numerically- scaled SPADI, a 13-item self-administered instrument measuring shoulder functional and pain status, has been shown to have good test-retest reliability, responsiveness, and/or validity. The SPADI used in this study was modified to facilitate subject understanding by including equal-distanced hashed lines marked 0-10, with zero labeled no pain/no functional limitations and 10 labeled worst pain/unable to perform. If a subject chose to mark between the hashed lines, the question was scored to the nearest 0.25.
3. Hawkins- Kennedy test
The Hawkins-Kennedy test is performed by positioning the arm passively at 90° of shoulder fexion followed by the therapist forcibly internally rotating the arm-a maneuver that also directs the critical zone against the coracoacromial ligament. The sensitivity of this maneuver has also been found to be good.
4. Neer test
The Neer impingement test, conducted by passive forward elevation and internal rotation of the humerus with the scapula stabilized, is deemed positive if the patient reports pain, usually above 120° of shoulder elevation when the critical zone of the rotator cuff tendon is compressed against the subacromial arch. The Neer test has been found to have fair to good sensitivity for determining the presence of shoulder impingement.
All subjects in the treatment groups (Groups 1-2) received physical therapy for one hour each for three times per a week for four weeks according to the following protocols, and each session ended with subjects receiving a cold pack for 10-15 minutes to decrease potential inflammation and delayed muscle soreness. Participants were instructed to perform a home exercise program once a day, Participants were also educated in the etiology of shoulder impingement syndrome and the importance of proper posture, and they were instructed to modify overhead activities.
Participants in Group 1, the exercise plus MWM group received the standard exercise protocol as per showed in Appendix (No.5) plus glenohumeral joint MWM technique as described by Mulligan.
This technique involved the therapist applying a sustained posterior accessory glide to the glenohumeral joint while the subject simultaneously actively flexed the shoulder to the pain-free endpoint and applied a gentle overpressure force using the contralateral arm (Figure 3) in Appendix (No.4). Total abolition of pain during the technique was mandatory; if the patient started to experience pain during active motion; the therapist would investigate different force planes and/or grades of force until pain-free motion was restored. This procedure was repeated for a total of 3 sets of 10 repetitions as long as pain-free motion was sustained; if pain commenced during any repetition of any set, the technique was terminated.
Participants in Group 2, the exercise plus mobilization group received the standard exercise protocol as per showed in Appendix (No.5) with addition of glenohumeral joint mobilization techniques as described by Maitland.
Anterior, posterior, inferior glides, or long-axis distraction grade I-IV joint mobilizations were applied accordingly (Figure 2) in Appendix (No.4). For situations where there was reactivity within the capsular ROM, grade I-II mobilizations were applied. For situations where there was no reactivity but capsular hypomobility, grade III-IV accessory motions were applied. Each mobilization was applied for 30 seconds at a rate of approximately one mobilization every 1 to 2 seconds, followed by a 30-second rest. The 30-second mobilization and resting sessions were repeated 2 additional times for a total of 3 sets of 30- second mobilizations.
3.6 MATERIALS USED
 Treatment couch
 Orthopedic Evaluation Chart.
 Shoulder Pain And Disability Index (SPADI)
 Goniometer.
 Handheld weights (Dumbbells).
 Flexible rubber tubing, a bungee cord, or a large rubber band.
3.7 TREATMENT DURATION
Group A: - Mulligan mobilization combined with Stretching and strengthening exercises for one hour each for three times per week.
Group B: - Maitland mobilization combined with Stretching and strengthening exercises for one hour each for three times per week.
3.8 DURATION
Duration of study is 12 months.
Treatment Duration is 4weeks/ alternative days/one hour a day.
3.9 OUTCOME MEASURES
 Pain and Shoulder disability were assessed using Shoulder Pain and Disability Index (SPADI).
 Active Range of Motion (AROM): Flexion and Scaption were assessed using Goniometer.
3.10 STATISTICAL ANALYSIS
Two tailed, Independent't' test was used to compare between groups on all descriptive and dependent variables. This will delineate the significance of improvement between the two groups.
The t-test was calculated using the formula:
t =
S =
n1= number of athletes in first sample group.
n2= number of athletes in second sample group.
x1= mean difference of first sample group.
x2= mean difference of second sample group.
s = combined standard deviation.
4. DATA ANALYSIS AND INTERPRETATION
The study was conducted in two groups
GROUP 1
Athletes were treated with Mulligan mobilization combined with Stretching and Strengthening exercises.
GROUP 2
Athletes were treated with Maitland mobilization combined with Stretching and Strengthening exercises.
Pre -test and post -test values were taken and the outcome was evaluated by using the following tools
Goniometer (Active Range of Motion)
Shoulder pain and disability index (SPADI)
The independent't' test was used for statistical analysis
Table No. 4.1
RANGE OF MOTION OF FLEXION , ABDUCTION FOR
GROUP I ( Mulligan Mobilization)
S.NO.
Flexion
Abduction
Pretest
Post test
Pretest
Post test
1
133
167
80
174
2
128
155
92
150
3
120
166
87
164
4
136
169
90
173
5
138
167
79
175
6
123
154
77
164
7
127
154
90
170
8
134
164
95
170
9
120
165
87
166
10
117
158
93
170
RANGE OF MOTION OF FLEXION - GROUP I
( Mulligan Mobilization)
RANGE OF MOTION OF ABDUCTION - GROUP I
(Mulligan Mobilization)
Table No. 4.2
RANGE OF MOTION OF FLEXION , ABDUCTION FOR
GROUP II ( Maitland Mobilization)
S.NO.
Flexion
Abduction
Pretest
Post test
Pretest
Post test
1
132
152
94
140
2
136
145
83
150
3
142
140
87
144
4
130
142
90
146
5
135
153
75
157
6
117
137
86
137
7
132
150
98
145
8
123
147
90
146
9
130
148
96
139
10
127
139
80
137
RANGE OF MOTION OF FLEXION - GROUP II
(Maitland Mobilization)
RANGE OF MOTION OF ABDUCTION - GROUP II
(Maitland Mobilization)
Table No. 4.3
SPADI PAIN , DIABILITY, TOTAL SCORE - GROUP I (Mulligan Mobilization)
S.NO.
Pain
Disability
Total Score
Pre test
Post test
Pre test
Post test
Pre test
Post test
1
45
10
56
16
101
26
2
40
10
48
24
88
34
3
35
5
56
16
91
21
4
40
10
40
8
80
18
5
45
15
48
8
93
23
6
30
5
56
8
86
13
7
45
10
40
24
85
34
8
40
15
40
24
80
39
9
35
10
48
16
83
26
10
40
15
32
8
72
23
SPADI PAIN - GROUP I (Mulligan Mobilization)
SPADI DIABILITY - GROUP I (Mulligan Mobilization)
SPADI PAIN , DIABILITY, TOTAL SCORE - GROUP I (Mulligan Mobilization)
Table No. 4.4
SPADI PAIN , DIABILITY, TOTAL SCORE - GROUP II (Maitland Mobilization)
S.NO.
Pain
Disability
Total Score
Pre test
Post test
Pre test
Post test
Pre test
Post test
1
40
15
40
24
80
39
2
30
10
56
8
86
18
3
45
10
32
8
77
18
4
40
15
48
16
88
31
5
35
5
40
24
75
29
6
40
5
32
16
72
21
7
30
10
56
16
86
26
8
40
15
48
24
88
39
9
45
10
40
8
85
18
10
35
20
56
24
91
44
SPADI PAIN GROUP II (Maitland Mobilization)
SPADI DIABILITY - GROUP II (Maitland Mobilization)
SPADI PAIN , DIABILITY, TOTAL SCORE - GROUP II (Maitland Mobilization)
Table 4.5
SUMMARY OF DATA ANALYSIS FOR TWO GROUPS OF PRIMARY SHOULDER IMPINGEMENT SYNDROME
S.No.
Group
Parameter
Mean
Sd.
't' value
1.
Group I
Flexion
ROM
34.3
6.79
6.21
Group II
15.3
6.16
Group I
Abduction ROM
80.6
10.17
4.93
Group II
56.2
10.83
2.
Group I
SPADI
PAIN
29
3.74
0.975
Group II
26.5
6.73
3.
Group I
SPADI DISABILITY
31.2
10.4
0.65
Group II
28
10.28
4.
Group I
Total SPADI SCORE
60.2
10.97
1.223
Group II
54.5
8.65
MEAN IMPROVEMENT BETWEEN RANGE OF MOTION OF FLEXION - GROUP I AND GROUP II
MEAN IMPROVEMENT BETWEEN RANGE OF MOTION OF ABDUCTION - GROUP I AND GROUP II
MEAN IMPROVEMENT BETWEEN PAIN-
GROUP I AND GROUP II
MEAN IMPROVEMENT BETWEEN DISABILITY
- GROUP I AND GROUP II
MEAN DIFFERENCE OF SPADI TOTAL SCORE -
GROUP I AND GROUP II
5. DISCUSSION
This study shows the effectiveness of Manual therapy as a component of comprehensive treatment for primary shoulder impingement syndrome in athletic shoulder.
The data analysis shows that there has been significant reduction in pain, increase in ROM and functional ability of shoulder joint, in values of group 1 and group 2.
Pain and shoulder disability is measured by SPADI, the total SPADI shows that mean improvement of group 1 is 60.2 and group 2 is 54.5 with standard deviation of 10.97 and 8.65 respectively. The independent 't' value calculated for SPADI is 1.223 at 18 degree of freedom. This calculated 't' value is less than the table value of 2.101 at 0.05 level of significance. Hence, we accept the null hypothesis. Therefore, there is no significant difference in reducing pain and improving function on using Manual therapy technique in over head athletes with primary shoulder impingement syndrome. Regarding pain, the mean improvement of group 1 is 29 and group 2 is 26.5 with standard deviation of 3.74 and 6.73 respectively and for disability the mean improvement of group 1 is 31.2 and group 2 is 28 with standard deviation of 10.4 and 10.28 respectively. For pain the independent 't' value is 0.975 and for disability is 0.65. Since the values are less than the table values of 2.101 at 0.05 level of significance we are accepting the null hypothesis.
ROM is measured by goniometer, it shows that mean improvement of flexion in group 1 is 34.3 and group 2 is 15.3 with standard deviation of 6.79 and 6.165 and for abduction the mean improvement in group 1 is 80.6 and group 2 is 56.2 with standard deviation of 10.17 and 10.83.
The 't' value calculated for flexion is 6.21 and for abduction is 4.93. Since both the values are more than the table value of 2.101 at 0.05 level of significance, we reject the null hypothesis. Therefore, there is a significant difference in improving ROM of flexion and abduction on using Manual therapy technique in over head athletes with primary shoulder impingement syndrome.
Statistical analysis showed that,
The group 1 who underwent Mulligan mobilization combined with Stretching and strengthening exercises has more consistent improvement than the other group in increasing ROM. There was no significant difference between the groups on reducing pain and improving disability.
LIMITATIONS
The duration of the study could not be extended for more than 12 months due to time constraint.
This study did not include the athletes in stage 3 primary shoulder impingement syndromes therefore the results of this study cannot be generalized to all patients with various stages of primary shoulder impingement syndrome.
6. CONCLUSION
In this study the effectiveness of Manual therapy as a component of comprehensive treatment for primary shoulder impingement syndrome in athletic shoulder, shows that Mulligan mobilization combined with Stretching and Strengthening exercises is effective in increasing mobility. However, athletes improved significantly with all the two treatment strategies.
From this study it is suggested that Manual therapy techniques (Mulligan and Maitland) can be effectively used as a component of comprehensive treatment program.
6.1 RECOMMENDATION
Since it is a time bound study, a study with a large sample size and long term follow up can be done in future.
Studies can be compared with other manipulation techniques.
Studies can be carried out in bilateral primary shoulder impingement syndrome.
