shoulder impingement syndrome is the most frequent cause of pain and overhead reach 
 limitation in the shoulder area . normal shoulder 
 functions are dependent on the scapular humeral rhythm and rotator cuff muscles control2 . disruption of the scapular humeral rhythm 
 synergistic relationship may occur because imbalance in the shoulder muscles34 . restriction of shoulder movement in most cases results from muscle spasm , which also 
 restricts the flow of blood , lymph , and nerve signals in the area4,5,6 . some studies have shown that manual therapy and soft tissue mobilization may 
 promote restoration of joint functions after an injury through elongation of shortened 
 structures , which helps the restoration of range of motion6 , 7 . manual therapy may promote 
 proper restoration of joint function after an injury . as a treatment for shoulder 
 impingement syndrome , physical therapists often used subscapularis trigger release ( str ) 
 combined with proprioceptive neural facilitation ( pnf ) procedures , both of which are used to 
 induce changes in myofascial length . contract - relax pnf ( crpnf ) procedures have been shown 
 to be effective in increasing shoulder range of motion ( rom)8,9,10 . the hold - relax technique is also called the contract - relax 
 technique and is a technique in which the muscle is stretched isometrically , contracted for 
 715 seconds , briefly relaxed for 23 seconds , and then immediately subjected to a passive 
 stretch that stretches the muscle even further than the initial passive stretch . the muscle is then relaxed for 20 seconds before 
 the pnf technique is performed11,12,13 . few studies on glenohumeral external rotation and overhead , reach exist that prove which 
 treatments are best for immediately minimizing pain in patients with shoulder impingement 
 syndrome5 , 6 . the aim of this study was to evaluate the effects of subscapularis 
 soft tissues and contract - relax pnf techniques on minimization of pain and improving of 
 glenohumeral external rotation at 45 of abduction and overhead reach activity in patient 
 with shoulder impingement syndrome . the subjects were assigned randomly into two groups by lot method : group a ( n=15 ) and group 
 b ( n= 15 ) . the inclusion criteria included a clear diagnosis of shoulder impingement 
 syndrome and age between 40 and 60  years . in addition , the criteria negative results in the 
 capsule stretch test , visual analog scale ( vas  5 ) , external rotation = 35  5 , overhead 
 reach of 155 10  cm , no use of analgesics , and anti - inflammatory drugs and muscle relaxants 
 within 24 hours before the participation in the study , and positive results in the neer 
 impingement test . the subjects with following problems were excluded ; open wounds , 
 infection , acute injuries or fractures , recent surgeries , swelling , rheumatoid arthritis , 
 reflex sympathetic syndrome , or adhesive capsulitis . subjects were assessed for pain with vas , range of motion with a goniometer , and overhead 
 reach with an inch tape . measurements of pain , external rotation and overhead reach were 
 made for all subjects before and after receiving either the experimental or control 
 intervention . glenohumeral external rotation was measured 
 with the subjects lying supine on a treatment table with a pillow under their knees . reference lines 
 for abduction were drawn on the skin over the midline of the sternum and the anterior aspect 
 of the midline of the humerus . a reference point was also drawn on the skin over the 
 anterior aspect of the acromion . in addition , a reference line was drawn on the skin over 
 the ulnar aspect of the forearm . overhead reach was measured with the subjects in a standing 
 position facing a wall , with the tips of their toes aligned with a pre marked line on the 
 floor 30.50  cm from the wall . the subjects were asked to actively walk their fingers up the 
 wall to reach as far as they could . overhead reach was measured as the distance in 
 centimeters from the floor to the tip of the middle finger using a tape measure . the subjects in the treatment group received soft tissue mobilization ( stm ) of the 
 subscapularis , followed by pnf . the subjects were positioned with the humerus abducted to 
 45 with elbow flexed to 90 , and the humerus was externally rotated to a midrange position , 
 typically about 20 to 25 of external rotation . the subscapularis was palpated in the 
 axilla to identify areas of myofascial mobility restrictions , taut bands , or trigger points . identified restrictions were treated with stm utilizing a combination of sustained manual 
 pressure , and slow deep strokes to the subscapularis myofascia for 7 minutes . the stm was 
 followed by contract - relax pnf for the subscapularis and other glenohumeral medial rotators , 
 beginning in the same position used for the stm . the patients were instructed to perform 
 maximal glenohumeral internal rotation against an opposing , isometric , manual resistance 
 applied by the treating physical therapist for 7 seconds . this 7-second internal rotation contraction against resistance followed by full 
 active external rotation was repeated 5 times . subjects were then instructed to actively 
 move through the pnf flexion - abduction external - rotation diagonal pattern for 5 repetitions 
 with manual facilitation . the arm was 
 abducted to 45 and the forearm was rested on the pillow for support . ultrasound ( us ) therapy 
 was given to the subscapularis muscle insertion at the shoulder region . the intensity used 
 was 0.5 watt/ cmsq , frequency used is 3  mhz and the time of the treatment was 10 
 minutes . immediately after the treatment post reading for pain , external rotation of shoulder and 
 overhead reach were recorded . the data are expressed as mean sd . the probability value less than 0.05 ( p value  0.05 ) 
 was considered significant by using spss software ( v.16.0 ) . paired t test and independent t 
 test was used for those variables that are normally distributed ( table 1table 1.mean and standard deviation values for vas , shoulder external rotation and 
 overhead reach , before and after treatment in both groups ( t - test)parametergroupsmeansdafterbeforevasgroup a6.23.80.79*group b6.075.230.72external rotationgroup a 36.652.44.9*group b36.4740.335.6overhead reachgroup a162.5173.19.07*group b163.6165.38.4 ) . the mean value of pre - test vas score 
 in group a is 6.20 and the mean value of post - test vas score in group a is 3.80 . the mean 
 value of pre - test vas score in group b is 6.07 and the mean value of post - test vas score in 
 group b is 5.33 . there is significant difference between groups in external rotation range of motion at 
 glenohumeral external rotation of 45 of shoulder abduction . in group a pre - test was 36.60 
 and the mean value of post - test was 52.4 . the mean value of pre - test in group b was 36.47 
 and themean value of post - test in group b was 40.33 . the mean 
 value of pre - test overhead reach in group a is 162.5 and the mean value of post - test 
 overhead reach in group a is 172.1 . the mean value of pre - test overhead reach in group b is 
 163.63 and the mean value of post - test overhead reach in group b is 165.3 . the purpose of the study was to determine whether soft tissue mobilization ( stm ) with 
 proprioceptive neuromuscular facilitations ( pnf ) are effective in producing an immediate 
 improvement in glenohumeral external rotation , at 45 of shoulder abduction and overhead 
 reach in patients with shoulder impingement syndrome . the results of this study proved that the stm with pnf is more effective in improving the 
 glenohumeral external rotation and overhead reach . the subjects of group a , who underwent 
 the treatment of stm with pnf were assessed for immediate changes in pain , glenohumeral 
 external rotation and overhead reach . the study shows significant improvement in pain with 
 2.8 levels in the vas and overhead reach up to 12  cm in average . when compared with group b , 
 who underwent the treatment of ultrasound therapy . the results of this study was in agreement with the results was obtained by the research 
 work done by joseph j. godges , et al5 . the 
 main reason for the increase in the range of motion and the overhead reach is that the stm 
 helps in reducing the tightness and it promotes changes in myofascia allowing the elongation 
 of the shortened structures . pnf is effective in increasing the range of motion and its reciprocal activation of agonist 
 and antagonist provides the greatest potential for muscle tendon as it lengthens the golgi 
 tendon organ which stimulates relaxing the antagonist muscles . when pnf is applied and the 
 patient is told to contract the muscle in internal rotation against the resistance and the 
 muscle tension develops , the gto fibers inhibits alpha motor neurons activity and decreases 
 tension in the muscle tendon , so for the neuromuscular system , inhibition is the state of 
 decreased neuronal activity and altered synaptic potential which reflexively diminishes the 
 capacity of a muscle to contract . as the capacity of muscle to contract decreases the arm is 
 moved to external rotation , the antagonists are contracted and antagonist muscles are 
 relaxed and again tension is developed in the agonist muscles this gto monitors the 
 excessive tension during muscle contraction and thus inhibits the excessive 
 contractions67 . the shoulder rotation at the position of 45 of abduction was adopted for soft tissue 
 mobilization and proprioceptive neuromuscular facilitation because at this position 
 subscapularis muscle flexibility deficit is major cause than any capsular restrictions which 
 is mainly the cause of restriction at 90 of glenohumeral external rotation34 . while performing the stm , the subscapularis was palpated in the 
 axilla to identify the areas of myofascial mobility restrictions , taut bands or trigger 
 points identified restrictions were treated with stm utilizing a combination of sustained 
 manual pressure and slow deep strokes to the subscapularis myofascia for 7 minutes . in group b ( control group ) also there was decrease in the pain level , increase in the range 
 of motion and overhead reach but it is comparatively less than that of group a. our results is in agreement with yildirim ma , et al . where their results have indicated 
 that ultrasound therapy reduces pain and increases the mobility and functional status if 
 used for many sessions on painful area . the results shows us is statistically less 
 significance in pain reduction when used for one session on glenohumeral external reduction 
 and overhear reach . our study confirmed the immediate effect of stm with pnf and significant values for 
 reduction in pain , increased glenohumeral external rotation and overhead reach were 
 obtained .
[ purpose ] the aim of this study was to evaluate the effects of soft tissue mobilization 
 and pnf on pain level , and shoulder rom in patients with shoulder impingement syndrome . 
 [ subjects and methods ] thirty patients with painful and limited glenohumeral rom 
 activities were selected . 
 the subjects were randomly assigned to an experimental group 
 ( n=15 ) , which received treatment consisting of soft tissues mobilization and the pnf 
 technique . 
 the control group received an ultrasound treatment . 
 pain level , glenohumeral 
 external rotation and overhead reach were measured before and after the intervention in 
 groups . 
 [ results ] the experimental group showed a significant reduction in pain level in 
 comparison with the control group . 
 the values for shoulder external rotation showed a 
 significant improvement . 
 the mean value for overhead reach in the experimental group 
 significantly increased . 
 [ conclusion ] the combination of soft tissue mobilization for the 
 subscapularis for 7 minutes and 5 repetitions of the contract - relax pnf technique for the 
 shoulder internal rotator muscles followed by 5 repetitions of a pnf facilitated abduction 
 and external rotation diagonal pattern was found to be effective in reducing pain and 
 improving glenohumeral external rotation and overhead reach during a single intervention 
 session .