Manual therapy or exercise for shoulder impingement: what the evidence shows

Shoulder pain is a common concern that can affect daily activities. While often described as "shoulder impingement," healthcare professionals now frequently prefer terms like "subacromial pain syndrome" (SAPS) or "rotator cuff related shoulder pain" [2, 3]. This shift reflects a broader understanding of the pain, which can involve rotator cuff tendons, the bursa, and other structures in the subacromial space [2, 3]. The concept of simple mechanical impingement as the sole cause of pain is debated, and these newer terms better reflect the complex nature of the condition. The studies discussed in this article define their participant groups using these various terms, reflecting this classification shift [2, 3].

Physical therapies like manual therapy and exercise are often recommended for shoulder pain. This article reviews what major studies say about their effectiveness, alone or combined, and how they compare to other treatments.

Manual Therapy and Exercise Combined Versus Placebo: A Cochrane Review

A 2016 Cochrane review by Page and colleagues investigated manual therapy and exercise, alone or combined, for rotator cuff disease [1]. It included adults with rotator cuff disease, comparing interventions like mobilisations, manipulations, and supervised or home exercises against placebo, no intervention, or other treatments [1].

The review included 60 trials with a total of 3620 participants, but only 10 addressed the main comparisons of interest [1]. Risk of bias was low in three trials, unclear in 14, and high in 43 [1]. Due to clinical differences between studies or incomplete reporting, the researchers could not combine data from most trials into meta-analyses [1].

The Single High-Quality Trial

Only one trial in the Cochrane review compared combined manual therapy and exercise to a placebo [1]. This high-quality trial involved 120 participants with chronic rotator cuff disease, using inactive ultrasound therapy as placebo [1].

At 22 weeks, the results showed: * Overall pain: Participants receiving placebo reported an average pain change of 17.3 points on a 100-point scale [1]. Those receiving manual therapy and exercise reported an average pain change of 24.8 points [1]. The adjusted mean difference between the groups was 6.8 points (95% confidence interval (CI) -0.70 to 14.30 points) [1]. The authors concluded there were no clinically important differences between the groups for this outcome [1]. * Function: Participants receiving placebo reported an average function change of 15.6 points on a 100-point scale [1]. Those receiving manual therapy and exercise reported an average function change of 22.4 points [1]. The adjusted mean difference was 7.1 points (95% CI 0.30 to 13.90 points) [1]. Again, the authors concluded there were no clinically important differences between the groups for function [1]. * Treatment success: 57% (31 out of 54) of participants in the manual therapy and exercise group reported treatment success, compared to 41% (24 out of 58) in the placebo group [1]. This resulted in a risk ratio (RR) of 1.39 (95% CI 0.94 to 2.03) [1]. * Adverse events: 31% (17 out of 55) of participants in the manual therapy and exercise group reported adverse events, compared to 8% (5 out of 61) in the placebo group [1]. This means adverse events were relatively more frequent with manual therapy and exercise (RR 3.77, 95% CI 1.49 to 9.54) [1]. However, these events were described as mild, typically short-term pain after treatment [1].

The Cochrane review authors concluded that, despite identifying 60 eligible trials, only this one high-quality trial compared a combination of manual therapy and exercise (which reflects common practice) to a placebo [1]. It found no clinically important differences between groups for any outcome [1].

Why Evidence Was Low Quality for Other Comparisons

For other comparisons, the Cochrane review rated the evidence as low or very low quality [1]. This was due to clinical heterogeneity (differences between studies), incomplete outcome reporting, and a high risk of bias in many trials [1].

Manual Therapy and Exercise Compared to Other Treatments (Cochrane Review)

The Cochrane review also looked at how manual therapy and exercise, when combined, compared to other common treatments for rotator cuff disease [1].

• Versus Glucocorticoid Injection: Five trials (low-quality evidence) found no important differences between manual therapy and exercise and glucocorticoid injection for overall pain, function, active shoulder abduction (lifting the arm away from the body), and quality of life over periods ranging from four weeks to 12 months [1]. However, global treatment success was more common up to 11 weeks in people who received glucocorticoid injections [1].
• Versus Arthroscopic Subacromial Decompression Surgery: One trial (low-quality evidence) found no important differences between manual therapy and exercise and arthroscopic subacromial decompression surgery [1]. This applied to overall pain, function, active range of motion, and strength at six and 12 months, and global treatment success at four to eight years [1]. You can learn more about this comparison in our resource on exercise versus surgery for rotator cuff problems.
• Versus Acupuncture, Dietary Counselling, and Supplements: One trial (low-quality evidence) suggested manual therapy and exercise might be less effective than acupuncture combined with dietary counselling and a Phlogenzym supplement for overall pain, function, active shoulder abduction, and quality of life at 12 weeks [1].
• Other Comparisons: The review authors were uncertain if manual therapy and exercise improved function more than oral non-steroidal anti-inflammatory drugs (NSAIDs), or if combining manual therapy and exercise with a glucocorticoid injection added benefit over the injection alone [1]. This was due to very low-quality evidence from two trials [1].

Effects of Manual Therapy Alone or Exercise Alone (Cochrane Review)

The Cochrane review also examined the effects of manual therapy or exercise when used on their own [1]. Fifty-two trials investigated manual therapy alone or exercise alone, but the evidence for these comparisons was mostly of very low quality [1].

• Manual Therapy Alone: There was little or no difference in patient-important outcomes when manual therapy alone was compared to placebo, no treatment, therapeutic ultrasound, or kinesiotaping [1]. However, manual therapy alone was found to be less effective than glucocorticoid injection [1].
• Exercise Alone: Compared to surgical repair for rotator cuff tear, exercise led to less improvement in overall pain, but not in function [1]. Little or no difference in patient-important outcomes was found between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression, or a functional brace [1].
• Combining Interventions: Manual therapy or exercise provided few or no additional benefits when combined with other physical therapy interventions [1]. Furthermore, one type of manual therapy or exercise was rarely more effective than another [1].

The authors concluded that future trials of manual therapy alone or exercise alone for rotator cuff disease need a strong rationale and should consider if they would change the review's conclusions [1].

What the Steuri Meta-analysis Found

A 2017 systematic review and meta-analysis by Steuri and colleagues examined the effectiveness of various conservative treatments for pain, function, and range of motion in adults with "shoulder impingement" [2]. It included randomised controlled trials (RCTs) comparing conservative interventions to sham treatments or other therapies [2].

The review found the following effects for pain, noting overall very low quality evidence [2]:

• Exercise: Exercise was superior to non-exercise control interventions (standardised mean difference (SMD) -0.94, 95% CI -1.69 to -0.19) [2]. Specific exercises were also superior to generic exercises (SMD -0.65, 95% CI -0.99 to -0.32) [2].
• Corticosteroid Injections: These injections were superior to no treatment (SMD -0.65, 95% CI -1.04 to -0.26) [2]. Ultrasound-guided injections were also superior to non-guided injections (SMD -0.51, 95% CI -0.89 to -0.13) [2].
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs showed a small to moderate effect compared with placebo (SMD -0.29, 95% CI -0.53 to -0.05) [2].
• Manual Therapy: Manual therapy was superior to placebo (SMD -0.35, 95% CI -0.69 to -0.01) [2].
• Manual Therapy Combined with Exercise: When manual therapy was combined with exercise, it was superior to exercise alone, but this effect was observed only at the shortest follow-up period (SMD -0.32, 95% CI -0.62 to -0.01) [2].
• Other Treatments: Laser therapy was superior to sham laser (SMD -0.88, 95% CI -1.48 to -0.27) [2]. Extracorporeal shockwave therapy (ECSWT) was superior to sham (SMD -0.39, 95% CI -0.78 to -0.01) [2]. Taping was also superior to sham taping (SMD -0.64, 95% CI -1.16 to -0.12), with small to moderate SMDs [2].

The Steuri review concluded that, despite very low-quality evidence, exercise should be considered for shoulder impingement symptoms [2]. Tape, ECSWT, laser, or manual therapy might be added to treatment plans [2]. While NSAIDs and corticosteroids were found to be superior to placebo, their comparison to exercise remained unclear [2].

The Haik Review on Subacromial Pain Syndrome

A 2016 systematic review by Haik and colleagues focused on physical therapy treatments for "clearly defined subacromial pain syndrome (SAPS)" [3]. This review summarized current evidence on pain, function, and range of motion from 64 high-quality randomised controlled trials (RCTs) [3].

The key findings from the Haik review include:

• Exercise Therapy: This review found high evidence that exercise therapy is as effective as surgery and better than no treatment or placebo for improving pain, function, and range of motion in the short, mid, and long terms [3].
• Combination of Mobilisation and Exercises: There was high evidence that combining mobilisation with exercises can decrease pain and improve function in the short term [3].
• Isolated Manual Therapy: For manual therapy applied on its own, there was limited evidence for improvements in outcomes [3].
• Physical Resources (Modalities): The review synthesized a high level of evidence regarding the lack of beneficial effects from physical resources such as low-level laser, ultrasound, and pulsed electromagnetic field (PEMF) for pain, function, or range of motion in treating SAPS [3].
• Other Modalities: There was limited evidence for microwave diathermy and transcutaneous electrical nerve stimulation (TENS) [3]. Taping showed moderate evidence of no benefits in the short term [3]. The effects of diacutaneous fibrolysis and acupuncture were not yet well established [3].

The Haik review concluded that exercise therapy should be the first-line treatment for pain, function, and range of motion [3]. Adding mobilisations to exercises might accelerate short-term pain reduction [3]. Based on their findings, low-level laser therapy, PEMF, and taping were not recommended [3].

Comparing the Reviews and Key Takeaways

These three major reviews offer different perspectives and levels of certainty regarding manual therapy and exercise for shoulder pain.

• Exercise as a Foundation: All three reviews highlight the importance of exercise. The Steuri review suggests exercise should be considered [2], and the Haik review states that exercise therapy should be the first-line treatment, with high evidence supporting its effectiveness [3]. The Cochrane review found that exercise alone led to less improvement in overall pain compared to surgical repair, but not in function [1].
• The Role of Manual Therapy:
  • The Cochrane review found that in the single high-quality trial comparing combined manual therapy and exercise to placebo, there were no clinically important differences in pain or function [1]. It also noted that manual therapy or exercise provided few or no additional benefits when combined with other physical therapy interventions [1].
  • The Steuri meta-analysis suggested that manual therapy was superior to placebo [2]. Crucially, it found that when manual therapy was combined with exercise, it was superior to exercise alone, but only at the shortest follow-up [2]. This finding was based on very low-quality evidence [2].
  • The Haik review found high evidence that combining mobilisation with exercises can decrease pain and improve function in the short term [3]. However, for isolated manual therapy, the evidence for improvements was limited [3].

These differences in findings, particularly regarding the added benefit of manual therapy to exercise, can be attributed to several factors: * Definitions and Populations: The reviews focused on slightly different populations (rotator cuff disease, shoulder impingement, subacromial pain syndrome) [1, 2, 3]. * Quality of Evidence: The Cochrane review struggled with the overall low quality and heterogeneity of trials, leading to very few strong conclusions for many comparisons [1]. The Steuri review explicitly stated its findings were based on "very low quality evidence" [2]. In contrast, the Haik review reported including 64 "high-quality RCTs" and found "high evidence" for certain combinations [3]. This highlights the ongoing challenge in synthesizing research on complex conditions. * Effect Sizes and Clinical Importance: While some reviews found statistically significant differences (e.g., Steuri's SMDs), the Cochrane review emphasized whether these differences were clinically important to patients [1].

Overall, while exercise consistently appears as a valuable component of treatment, the evidence for manual therapy adding significant, long-term benefits to exercise is more nuanced across these reviews.

What this means for you

If you are experiencing shoulder pain, it is important to have it assessed by a regulated healthcare professional. A licensed physiotherapist or other healthcare provider can evaluate your specific situation, determine the potential causes of your pain, and help you understand the best treatment options for you.

A physiotherapist can work with you to create a personalized exercise program tailored to your needs and abilities. They can also discuss whether manual therapy, either alone or in combination with exercise, might be a suitable part of your treatment plan, taking into account the current evidence and your individual circumstances.

You can discuss the findings of these studies with your healthcare provider to make informed decisions about your care. To find a regulated professional, such as a physiotherapist, you can check with their provincial regulatory body, like the College of Physiotherapists of Alberta [4]. You can also explore physiotherapy clinics in Calgary and other areas. For more general information about shoulder pain, you can refer to our patient guide to rotator cuff and shoulder impingement pain.