Effects of Tele-rehabilitation With and Without Self-Mulligan Technique on Pain Range of Motion and Functional Disability in Subacromial Pain Syndrome

Subacromial pain syndrome (SAPS), often used almost the same as subacromial impingement syndrome, is counted among the most common reasons of shoulder pain and in many primary care or orthopedic clinics it usually makes around 44-65% of all shoulder issues. It actually covers a wide range of problems like rotator cuff tendinopathy, partial or sometimes full-thickness rotator cuff tears, subacromial bursitis and even calcific tendinopathy in some cases. The condition mostly happens because of repeated mechanical compression of the rotator cuff tendons and the subacromial bursa between humeral head and the acromion, which slowly leads to inflammation, micro- trauma and then degenerative type changes over time. The usual presentation is pain in overhead activities and a kind of reduced ROM and gradually people also struggle with day-to-day and work-related movements.

The overall burden of SAPS is quite high, not only due to pain and disability in the person but also in the wider community since it affects productivity and increases health- care use. Management is mostly done with a mix of medications, physiotherapy and in some cases surgery too. Conservative management like physiotherapy-based rehab is still the main approach because it is non-invasive and generally works well. Inside this, manual therapy methods such as the Mulligan Mobilization with Movement (MWM) have gained a lot of attention since they seem to help joint movement, reduce pain and show improvement in function.

Subacromial Pain Syndrome (SAPS) is a multifactorial musculoskeletal condition characterized by pain and functional limitation in the shoulder, primarily arising from structures located within the subacromial space, including the rotator cuff tendons (especially supraspinatus), subacromial bursa, and the long head of the biceps tendon. The pathophysiology of SAPS is complex and involves a combination of mechanical, degenerative, and inflammatory processes that evolve over time. Traditionally described as "impingement syndrome," the condition was thought to result mainly from mechanical compression of soft tissues between the humeral head and the acromion during shoulder elevation. However, contemporary understanding recognizes that intrinsic tendon degeneration plays an equally, if not more, significant role. Repetitive overhead activities, poor scapular kinematics, and altered glenohumeral biomechanics lead to microtrauma within the rotator cuff tendons, resulting in tendinopathy characterized by collagen disorganization, neovascularization, and increased ground substance. This degenerative process weakens the tendon structure, making it more susceptible to partial or full- thickness tears. Additionally, inflammation of the subacromial bursa contributes to pain and reduced range of motion, further exacerbating functional disability.

Biomechanically, the shoulder joint relies on a delicate balance between mobility and stability. The coordinated action of the rotator cuff muscles and scapular stabilizers is essential for maintaining proper alignment of the humeral head within the glenoid fossa. In SAPS, this balance is disrupted due to muscle imbalances, weakness, or neuromuscular control deficits, particularly involving the serratus anterior and lower trapezius. These alterations result in abnormal scapular movement patterns, commonly referred to as scapular dyskinesis, which reduces the subacromial space during arm elevation and increases stress on soft tissues. Over time, this leads to cumulative tissue damage and persistent pain. Furthermore, postural abnormalities such as forward head posture and rounded shoulders contribute to altered scapular positioning, compounding the problem by promoting anterior tilt and internal rotation of the scapula, thereby narrowing the subacromial space.

The etiology of SAPS is multifactorial and can be broadly categorized into intrinsic and extrinsic factors. Intrinsic factors include age-related degenerative changes, decreased vascularity of the rotator cuff tendons, and genetic predisposition to tendon pathology. With aging, there is a natural decline in tendon elasticity and healing capacity, making individuals more prone to tendinopathy and tears. Extrinsic factors, on the other hand, involve mechanical compression and include anatomical variations such as acromial shape (e.g., hooked acromion), thickening of the coracoacromial ligament, and osteophyte formation at the acromioclavicular joint. Occupational and recreational activities that involve repetitive overhead movements, such as painting, swimming, or throwing sports, significantly increase the risk of developing SAPS. Additionally, lifestyle factors such as physical inactivity, obesity, and smoking may impair tissue healing and contribute to the progression of the condition.(7) Pain in SAPS is primarily nociceptive in nature, arising from inflamed and mechanically stressed tissues. However, chronic cases may also involve central sensitization, where the nervous system becomes hypersensitive, leading to amplified pain perception even in response to minimal stimuli. This chronic pain state often results in protective muscle guarding, reduced movement, and further functional decline, creating a vicious cycle of pain and disability. Range of motion is typically limited, particularly in shoulder abduction and external rotation, due to both pain inhibition and structural restrictions. Functional disability manifests as difficulty performing daily activities such as dressing, grooming, or lifting objects, significantly impacting quality of life.