Francesca Galiano
21/09/2022 - Last update 28/12/2022

Sam Bennett, Chris Macfarlane, Brett Vaughan | Year 2017

The use of osteopathic manual therapy and rehabilitation for subacromial impingement syndrome, a aase report


Subacromial impingement syndrome

Type of study:

Case report

Date of publication of the study’:



Purpose of the study

  • Objective: to report the effect of OMTh in a patient with subacromial impingement syndrome
  • Measured outcomes: report of the symptoms, disability and ability to carry out specific activities using the Disabilities of the Arm, Shoulder & Hand (QuickDASH) questionnaire, the Upper Extremity Functional Index (UEFI) and pain intensity through the Visual Analog Scale (VAS)


  • Number: 1
  • Description: 24-year-old man, with a 7-year history of right side shoulder pain, inferior to the acromioclavicular joint, and a feeling of instability in the glenohumeral joint (the specific episode for which he presented at the clinic had begun 6 weeks before). The pain would intensify when lifting the arm over the head, with an intensity of 6 out of 10 on VAS, and it was described as the worst ever experienced since the condition onset 7 years earlier. The man worked as a tennis instructor and personal trainer, as well as competing as a tennis player once a week.

The shoulder pain started after an Australian football match during which he had fallen heavily on his right acromion. Two months later an MRI revealed supraspinatus tendinosis and reduced subacromial space. In the following years and months, due to the interventions of osteopaths and physiotherapists, there were periods of exacerbation and remission, the latter immediately after the treatments which would favor a reduction in pain intensity and an increase in range of motion (ROM), effects that would anyway disappear once the shoulder was put under stress again.

The musculoskeletal evaluation highlighted on the right side: alteration in the position of humerus and scapula; hypertonicity and tenderness of the rotator cuff; hypertonicity of the pectoralis minor and major and of the trapezius; familiar pain reproducible through active and passive movements; the tests of Hawkins-Kennedy, Neer and Jobe and Lift off were positive. A strength asymmetry and a ROM reduction in the T1-4 region. Following the positive orthopedic tests, the condition was defined as supraspinatus tendinosis and secondary subacromial impingement.

Interventions and evaluations

  • At baseline and during the study, evaluation of disability and capacity to perform activities using QuickDASH and UEFI
  • 6 weekly sessions of OMTh
  • Personalized OMTh with techniques of cross fiber massage applied to pectoralis and myofascial release applied to the trapezius, high-velocity low-amplitude to the thoracic vertebrae, rotator cuff inhibition, ligamentous tension balancing to the glenohumeral joint
  • Advice to avoid activities that would exacerbate pain and definition of a rehabilitation program (with the support of elastic bands) in order to strengthen the muscles and redefyne a correct posture


After having played tennis during the first two weeks of treatment, with consequent worsening of the situation, the patient showed a good level of compliance to the therapy, especially with regard to the rehabilitation program, followed for 5 to 7 times a week. After 6 weeks, the pain at the supraspinatus muscle decreased and the Hawkins-Kennedy and Neer’s tests came out negative, whereas the Jobe’s test produced a mild complaint. The muscle strength became symmetrical and the internal rotation ROM was recovered.

The UEFI score showed a decrease of 11 points (from 77/80 to 66/80), thus showing a clinically significant change (the minimum change threshold is 9 points). Likewise, the QuickDASH reported a decrease from 34.09 to 6.82, also suggesting a substantial clinical improvement (as higher than 40%). The maximum pain intensity reported on the VAS was 1 out of 10. After two weeks the boy went back to play tennis and at the 5-months follow-up reported to be practically free of pain, able to play tennis once a week and to teach at the same level as before the consultation.


L’OMTh in combinazione con un programma di riabilitazione ha favorito un sostanzialmente miglioramento clinico in questo caso di tendinosi e sindrome da impingement sub-acromiale. In effetti, la letteratura mostra come l’integrazione fra terapie manuali ed esercizi strutturali come quelli applicati in questo caso possa indurre risultati importanti in situazioni di dolore e alterata funzionalità della spalla e delle strutture annesse. Questo è stato tuttavia il primo studio a mostrare le potenzialità di unire l’esercizio fisico all’osteopatia in caso di sindrome da impingement sub-acromiale.

The review of Osteopedia

By Marco Chiera

Strengths:accurate description of evaluation and treatment; use of validated evaluation instruments and results analyzed on the basis of threshold of clinical significance; use of OMTh integrated with a rehabilitation program for an effective therapy; significant results from a clinical point of view; good discussion of the usefulness of an integrated approach involving manual therapies and exercises.

Limits: It is not possible to understand which intervention has had the greater impact, if the OMTh or the rehabilitation program. In the same way, although the authors wanted to evaluate the usefulness of balanced ligamentous tension, it is difficult to understand whether or not it was useful as a technique within such a complex intervention.
Since the boy had already tried OMTh, it would have been interesting to collect data on previous treatments. In fact, missing this information and given that the pain had started 7 years earlier and the man had experienced various highs and lows despite a number of physiotherapy and OMT visits, it is difficult to assess whether a 5-months follow-up was sufficient to understand the effectiveness of the OMTh implemented in this study (a relapse may have occurred shortly afterwards).

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