178 J I M D C   2 0 1 7  178 

Op e n  Ac c e ss  
F u l l  L e n g t h  A r t i c l e  
 
 

 Effects of Therapeutic Ultrasound and Manual Physiotherapy in 

Shoulder Impingement Syndrome in Volleyball Players  

Muhammad Imran 1, Naveed Arshad 2, Shahbaz Ibrahim 3, Aqeel Ahmed 4, Muhammad Tayyab Minhas 5 

1 Consultant Physiotherapist, DHQ Hospital Sheikhpura 
2 Assistant Professor, Islamabad Medical and Dental College, Islamabad 

3 Assistant Professor, Riphah International University, Faisalabad Campus 
4 Assistant Professor, Isra University Islamabad Campus 

5 Lecturer, Riphah International University, Faisalabad Campus

A B S T R A C T  

Objective: To look into the effectiveness of ultrasound therapy in addition to physical therapy and exercises on relief of 

pain, increase in the range of movements and improvement in muscle power in patients of Shoulder Impingement 

Syndrome (SIS). 

Patients and Methods: A total of 30 patients, aged 18-30 years, of SIS were randomly selected amongst volley ball 

players. They were divided by convenient sampling into two groups of 15 patients each: therapeutic ultrasound manual 

physiotherapy & exercise treatment (TUMPET) Group and manual physiotherapy exercise treatment (MPET) Group; the 

latter served as the control group. Both group were tested twice once before the start of treatment and once after 

completion of treatment. 

Results: The measurement of shoulder Rang of Movement and muscle power show significant results in both control 

and treatment groups at the end of 14th week’s treatment period. In control group (Group MPET) the range of motion 

degree scale has improved from 135.53±10.88 to 136.67±9.94 P-value 0.000 and muscle strength grades has improved 

from 3.33±0.49 to 4.00±0.000. In the interventional group (Group TUMPET) the range of motion degree scale has 

improved from 134.00±6.80 to 164.33±8.42 P-value 0.000 and muscle strength grades has improved from 3.47±0.52 to 

5.60±0.50 P-value 0.000. 

Conclusion: Those individuals who received ultrasound treatment along with manual and exercises therapy showed 

significant improvement at fourteen weeks’ treatment. 

Keywords: Manual therapy, Shoulder exercises, Shoulder impingement syndrome, Therapeutic ultrasound

Author`s Contribution 
1
 Conception, Synthesis and Planning of 

the research, Active participation in data 
collection. 

2
 Active participations in active 

methodology, Interpretation, analysis and 
discussion. 

3 
Data management.  

4
 Analysis 

and discussion. 
5 

Data management 

Address of Correspondence 
Naveed Arshad 

Email. oliajann@gmail.com 

Article info. 
Received: June 12, 2017 
Accepted: August 10, 2017 
 

Cite this article: Imran M, Arshad N, Ibrahim S, Ahmed A, Minhas MT. Effects of Therapeutic  Funding Source: Nil 
 Ultrasound and Manual Physiotherapy in Shoulder Impingement Syndrome in    Conflict of Interest: Nil 
 Volleyball Players..JIMDC. 2017; 6(3):178-181.      
 

I n t r o d u c t i o n  

Various studies have been conducted focusing on the 

clinical problem of Shoulder Impingement Syndrome 

(SIS), especially making an attempt to identify the causes 

of this problem and the damage it causes to a sport man.  

Kibler argued that sportsmen, normally throwing athletes 

and swimmers, who experience the unpleasant effects of 

O R I G I N A L  A R T I C L E  



 

                           179 J I M D C   2 0 1 7  179 

impingement disorder, are shown to have tear of the 

scapulothoracic muscles.1 The dynamic impact of the 

scapular muscles weakening is best shown when the 

serratus anterior muscle is involved.2 The failure of 

stretching the scapula offers ascent to scapula winging 

via raising the upper limb.3 Weak muscles of scapula 

modify the scapulohumeral muscles and spot tension on 

gleno-humeral, which brings about auxiliary muscles 

outward the impingement. 

In the tendon of supraspinatus and sub acromial bursa, 

the painful condition is sub acromial impingement 

syndrome (SIS) in the arch of coracoacromial and 

humeral head; this is a common cause of pain.4 The pain 

is felt severely and is caused by micro trauma, misuse or 

repetitive movements of the overhead position of the arm 

which is leading to deltoid and biceps area. It is presumed 

that the stiffness of coracoacromial ligament, the long 

head of biceps lesion, rotator cuff tear, partial or full 

thickness and sub acromial bursitis and abnormal 

biomechanical movements of scapula are the main 

causes of sub acromial impingement disorder.5 The 

literature shows the effectiveness of different physical 

therapy movements and manual therapy procedures on 

the management outcome.6 Effectiveness of the use of 

ultrasound therapy for the management of SIS is still 

inconclusive. Several researches show that ultrasound for 

SIS do not provide an extra advantage7; others show the 

usefulness of ultrasound in SIS.8 

Sub acromial impingement might be treated by means of 

traditional treatment.9 For range of motion and muscular 

power to restore the mobility and stability of shoulder 

perform specific supervised exercises. Therapeutic 

ultrasound is more common in physical therapy treatment 

and other electrotherapy treatments like TENS and 

stimulator are also used. 

Mulligan's theory on manuals therapy is that damage of 

joint or loss in function result in a chronic misaligns inside 

the joint and the procedures are used to straighten joint or 

re-establishing its alignment for decrease in pain, improve 

utility and improve dynamic range of movement in 

shoulder abduction.10 The rationale of this study was to 

evaluate, firstly, the impact of ultrasound treatment for 

impingement disorder in athletes and coaches. We are 

interested to increase muscle strength of shoulder joint by 

different shoulder exercises. 

    P a t i e n t s  a n d  M e t h o d s  

A randomized control trial was done. A total of 30 male 

volley ball players with SIS were enrolled in the study 

from different universities of Lahore. They were allocated 

into two groups of 15 individuals each by non-probability 

convenience sampling; these groups were named as 

therapeutic ultrasound manual physiotherapy & shoulder 

exercise treatment (TUMPET) Group and manual 

physiotherapy shoulder exercise treatment (MPET) 

Group. Both group were tested twice once before the start 

of treatment and once after completion of treatment. The 

participants were separated into two assemblies via 

convenience sampling. The duration of the study was 14 

weeks. 

The following two procedures were used for evaluation of 

the patients: 

Abduction range of motion which was measured by the 

degree of range of motion and assessed by a goniometer. 

It consists of 4 degrees of shoulder abduction range of 

motion i.e., 40 – 60 degree, 61 – 100 degree, 101 – 150 

degree and 151 – 180 degrees.12 Muscle power which 

was measured by grading system of muscle power and 

assessed by using the 3 kg weight.12 It consists of 6 

grades and has response as (Grade 0: refers to non- 

contractile and non-sensory in palm of the person.  

Grade 1: The individual presently feels a contraction 

lacking the capability of hands to move.  

Grade 2: The patient devoid of burdens raises hands by 

means of half of the range. Grade 3: The person only with 

no weights can raise hands with full range.  

Grade 4: person can lift weight up to three kg to partial 

range, 90 degrees.  

Grade 5: The person can lift three kg with full range). 

Demographic data included the following information: 

ages of the participants and difficulties in overhead 

activities. 

All participants completed the study and were included in 

the analysis. 15 individuals from MPET group completed 

the study that expected manual therapy and executed the 

exercises of shoulders. Whereas 15 individuals of 

TUMPET group as well completed the study that 

acknowledged ultrasound therapy, exercises of shoulders 

and manual therapy. The protocol for both the MPET and 



 

                           180 J I M D C   2 0 1 7  180 

TUMPET groups involved the application of manual 

physical therapy and shoulder exercises for a total of 14 

treatment sessions of 30 minutes, over a period of 14 

consecutive weeks. At the beginning of the treatment, all 

participants were given a brief explanation of anatomy 

and biomechanics of the shoulder complex and a short 

description of the etiology and pathology of SIS.The 

treatments aimed to prevent further damage and 

consisted of manual therapy techniques such as joint 

mobilization techniques and transverse friction massage 

and shoulder pendulum exercises. The treatments aimed 

at restoring the functional level by increasing ROM, 

muscle strength and flexibility and consisted of ROM 

exercises with rope and pulley, L bar exercises, self-

capsular stretching exercises, joint mobilization 

techniques and strengthening exercises with weights, 

therapeutic bands, springs and push-ups. The standard 

exercise protocol and manual therapy were given in order 

to restore muscular deficits in strength, mobility, and 

coordination of the rotator cuff and the shoulder girdle 

muscles to unload the subacromial space during active 

movements. And the participants were expected to return 

to their functional level without recurrence at the end of 

the treatment. Participants in the TUMPET group received 

continuous ultrasound for 5 minutes with a device that 

was operated at a frequency of 1.5 MHz, and an intensity 

of 1 W/cm2, the treating physical therapist, using the 

technique of slow circular movements, applied the 

transducer head over the superior and anterior 

periarticular regions of the participant's glenohumeral joint 

and on the shoulder trigger points. The treatment was 

continued from the first treatment session over the 15th 

treatment session period. 

All Data was entered and analyzed carried out with SPSS 

statistical software (version 21). Distributions of frequency 

and also standard deviations and means were utilized for 

expressive reasons. Paired sample T-test to assess the 

difference of Mean values, ± Std. deviation and P value 

or not in 1st week range of motion and power of muscle 

and 14th-week range of motion and power of muscle 

within each group. Independent sample T-test to assess 

dissimilarity of Mean values, ± Std. deviation and P value 

for significant or not in 1st-week range of motion and 

power of muscle and 14th-week range of motion and 

power of muscle in between groups. The P value was 

considered statically significant 0.05. 

R e s u l t s  

The mean range of ages and sports experience was 

calculated by mean values. The average age of both 

groups (MEPT and TUMPET) was 24.57±2.54 and sports 

experience was 3.58±1.73 (Table 1). Paired sample t-test 

was applied for change in (Group MPET & TUMPET), 1st 

week range of motion and muscle power and 14th week 

ROM and muscle power (Table 2) compare the mean 

significant values in between the groups, independent 

sample t-test was used that indicated highly significant 

difference in ROM and muscle power in impingement 

syndrome. It was hypothesized that ultrasound, manual 

therapy and physical therapy exercises are more effective 

in shoulder impingement syndrome in volleyball players. 

D i s c u s s i o n  

In this study, ‘the range of movements (ROM) and muscle 

power’ in shoulder impingement syndrome were looked 

into before and after subjecting the affected joint to 

ultrasound therapy, manual therapy and physical 

exercises in an attempt to reduce the signs and 

symptoms and to increase the ROM and muscle power of 

the shoulder joint. 

Previously, a randomized control study has been 

published from Turkey; it emphasized on the 

effectiveness of ultrasound versus physical therapy 

treatments and other measures in the management of 

shoulder problems.13 The study was conducted on 40 

patients who had been recognized with the help of 

ultrasonography or MRI to have a periarticular tender 

ailment of the shoulder and had been randomly selected. 

Of these patients, one group obtained proper ultrasound 

(n=20, mean time and standard deviation=8.7±8.8 

months and the range was 1 – 36) and the other group 

received fake ultrasound (n=20, imply time=8.1±10.8 

months, and range=1-42). Both groups were treated in 5 

days a week with real or fake ultrasound for 10 minutes, 

superficial heat for 10 mins, electrical stimulation for 15 

minutes, and exercise program for15 to 30 minutes for 3 

weeks. The groups showed a reduction of pain, improved  

ROM, shoulder incapacity annexure ratings, and fitness 

assessment rankings with treatment, but the changes 



 

                           181 J I M D C   2 0 1 7  181 

were not statistically significant between the groups. After 

findings finally they determined that the results cautioned 

that proper ultrasound as compared with fake ultrasound 

deliver in addition gain whilst implemented to different 

physical therapy treatment within the control of shoulder 

problems. 

Different studies have determined that manual and 

exercise therapy appear to have a role in shoulder 

impingement.14 It is observed that a 4-week program 

along with motor management and strengthening 

exercises reduced shoulder pain and improved feature of 

individuals with shoulder impingement syndrome. The 

efficacy of ultrasound, laser, and exercises of shoulder 

impingement syndrome have been emphasized.4 

In another study, a management plan of manual and 

exercise therapy was looked into for the efficacy of 

placebo treatment which was implemented through 

physical therapists to the patients with persistent rotator 

cuff syndrome. Patients were selected randomly and 

blinded, placebo controlled trial was conducted. A 

program of manual therapy and domestic workout was no 

longer advised; further, instantaneous treatment for pain 

and functional ability was found to have benefits as 

compared with a practical placebo treatment that was 

given by therapists’ in elderly patients with chronic rotator 

cuff syndrome.15 Some authors investigated and 

concluded that ultrasound is a diagnostic tool with high 

precision, safe and affordable, dynamic, and conservative 

treatment after two months resulted in improved treatment 

outcome.12 

In the present study, the individuals who were subjected 

to manual and physical exercises therapy of shoulder as 

well as those who were subjected to ultrasound treatment 

in addition to manual and exercises therapy had 

significant improvement after fourteen weeks treatment. 

However, in the latter group, there was the statistically 

highly significant difference in the degree of range of 

motion of shoulder joints. There was also observed a 

significant difference in term of muscle strength grades in 

impingement syndrome.  

 

 

C o n c l u s i o n  

It is concluded that ultrasound therapy has benefit as 

compared to physical exercises of shoulder in treatment 

of shoulder impingement syndrome to reduce pain, 

increase ROM and muscle power. 

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