Pectoralis Minor Release in Patients With Subacromial Impingement Syndrome

假比较器：traditional group

Thirty patients will receive traditional physical therapy treatment (Postural correction exercises and scapular stabilization exercises) at the painful shoulder, Treatment sessions will be two times per week for six weeks

其他：conventional physical therapy

Physiotherapy treatment included passive manual joint mobilization, home-based strengthening exercises and advice on posture, twice a week.

So, we will apply this conventional physical therapy to control group

1. Postural correction exercise

   • Patient can apply this exercise on prone lie position for against a wall as in figure 10.
   • patient will start with chin in exercise, will asked to pull his chine in and push the wall, then hold for 15 seconds and repeat for 3 times.
   • Patient will try to touch both shoulders to the wall and hold for 15 seconds.
   • Patient will be asked to straight all spine against the wall and hold for 15 seconds.
2. Scapular stabilization exercise Patient will lie prone with elbow extended, start to move his arm away from his body (horizontal abduction), with wait or without according to Lafayette muscle test results. Apply 2 cycle and each cycle will have 10 times repetitions

实验性的：Experimental Group

Thirty patients will receive traditional treatment plus pectoralis minor stretching and release, Treatment sessions will be two times per week for six weeks.

其他：conventional physical therapy

Physiotherapy treatment included passive manual joint mobilization, home-based strengthening exercises and advice on posture, twice a week.

So, we will apply this conventional physical therapy to control group

1. Postural correction exercise

   • Patient can apply this exercise on prone lie position for against a wall as in figure 10.
   • patient will start with chin in exercise, will asked to pull his chine in and push the wall, then hold for 15 seconds and repeat for 3 times.
   • Patient will try to touch both shoulders to the wall and hold for 15 seconds.
   • Patient will be asked to straight all spine against the wall and hold for 15 seconds.
2. Scapular stabilization exercise Patient will lie prone with elbow extended, start to move his arm away from his body (horizontal abduction), with wait or without according to Lafayette muscle test results. Apply 2 cycle and each cycle will have 10 times repetitions

其他：Experimental group therapy

Treatment will be conventional treatment with pectoralis minor release and stretch.

• Pectoralis minor stretch The subject lying in a supine position with a towel roll running the length of the thoracic spine. The subject's shoulder at 90° of abduction and external rotation and the elbow at 90° flexion while therapist applying a posterior force to the coracoid process, in this study stretch will be performed for two sequential repetitions, holding the stretches for 30 seconds with 30 second break
• Pectoralis minor release the subject in a supine position with the test arm at his side while the therapist palpated medially into the proximal axilla, followed by proceeding superiorly towards the coracoid process then applied pressure in the anterior direction, similar to attempting to lift the muscle, therapist applying tensile force directly to the pectoralis minor. The opposite therapist hand will stabilize the scapula and humeral head maintain for 30 seconds and repeat 2 times

Subacromial space will be measured by X-ray image

The radiograph will be done to measure acromio-humeral distance, which is considered the shortest distance between the inferior cortex of acromion and the top of humeral head. In normal shoulders, the sub acromial space was between 9 and 10 mm. The space was significantly greater in men, with a slight reduction with age. In middle age, a sub-acromial space less than 6 mm is pathological

Pectoralis minor length will be measured by tape measurement

Participants will be asked to remain in a relaxed posture with the arms at the side in a neutral position, avoid postural correction, and exhale just before the measurement.

A tape measure was used to measure the linear distance between the origin and insertion of the muscle. The primary investigator of the study performed all measurements. The origin was defined as the inferior aspect of the 4th rib, which was one finger width lateral to the sternum, just lateral to the sternocostal junction. The insertion was defined as the medial-inferior aspect of the coracoid process .

Shoulder joint ROM (flexion, abduction, internal and external rotation) will be measured by inclinometer

Shoulder flexion, abduction, internal and external rotation movements will be measured with the individual seated upright on a non-reclining high-back chair, to limit trunk compensation. The chair was the same for all movements performed by one individual, but different for each individual, to provide support up to the middle of the scapula.

Shoulder movements will be actively and passively evaluated for flexion in supine and seated positions, abduction, external rotation in a neutral position with 0° abduction (ERN), external rotation with the arm at 90° of abduction (ER90), and internal rotation with the arm at 90° of abduction (IR90) using an Acumar digital inclinometer .

Pain intensity will be measured by using VAS ( visual analog scale)

The patients' pain severity will be evaluated using a visual analog scale (VAS). The visual analog scale (VAS) is a validated, subjective measure for acute and chronic pain. Scores are recorded by making a handwritten mark on a 10-cm line that represents a continuum between 0 "no pain" and 10 "worst pain

Identification of Functional Ability of the shoulder joint using Q-DASH questionnaire with Arabic version

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed as a measure of self-rated upper extremity disability and symptoms The use of the DASH questionnaire as an outcomes instrument in patients with upper-extremity complaints. The main part of the Quick-DASH is a 14-item disability/symptom scale concerning the patient's health status during the preceding week. The items ask about the degree of difficulty in performing different physical activities as well as the problem's impact on social activities, work, sleep, and self-image. Each item has five response options. The scores for all items are then used to calculate a scale score ranging from 1 (no difficulty) to 5 ( unable).