Impact of Myofascial Release Therapy Combined with Isokinetic Training on pain, function, and radiological outcomes in collegiate basketball players with subacromial impingement syndrome: a prospective randomized controlled trial.

Impact of Myofascial Release Therapy Combined with Isokinetic Training on pain, function, and radiological outcomes in collegiate basketball players with subacromial impingement syndrome: a prospective randomized controlled trial - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMC Sports Sci Med Rehabil . 2026 Apr 7;18:258. doi: 10.1186/s13102-026-01680-2 Impact of Myofascial Release Therapy Combined with Isokinetic Training on pain, function, and radiological outcomes in collegiate basketball players with subacromial impingement syndrome: a prospective randomized controlled trial Gopal Nambi 1, ✉ , Mshari Alghadier 1 , Mohammed Moustafa Aldosouki Hegazy 1, 2 , Julie Saji George 1 , Ahmad Khaleel Alomari 3 , Osama R Aldhafian 4 , Alaa Jameel A Albarakati 5 , Shahul Hameed Pakkir Mohamed 6, 7 , Hani Fahad Albalawi 6 , Mohamed Taher Mahmoud Eldesoky 6, 8 , Enas Elsayed Mohamed Abutaleb 6, 8 , Samah Saad Zahran 6, 9 Author information Article notes Copyright and License information 1 Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia 2 Department of Physical therapy for Musculoskeletal Disorders and its Surgery, Faculty of Physical therapy, Cairo university, Giza, Egypt 3 Department of Biomedical Technology, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia 4 Department of Surgery, College of Medicine, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia 5 Department of Surgery, College of Medicine, Umm Al-Qura University, Al-Qunfudah Branch, Makkah, Saudi Arabia 6 Department of Health Rehabilitation Sciences, Faculty of Applied Medical Sciences, University of Tabuk, 71491 Tabuk, Saudi Arabia 7 Saveetha College of Physiotherapy, Saveetha Institute of Medical and Technical Sciences (SIMATS), Thandalam, Chennai, TamilNadu 602105 India 8 Department of Basic Sciences for Physical Therapy, Faculty of Physical Therapy, Cairo University, Cairo, Egypt 9 Department of Musculoskeletal Disorders and their Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt ✉ Corresponding author. Received 2025 Sep 15; Accepted 2026 Mar 30; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13224595  PMID: 41947262 Abstract Background Subacromial impingement syndrome (SIS) is a common condition in overhead athletes, associated with pain, impaired function, and altered shoulder mechanics. Conventional physiotherapy may not fully address underlying myofascial restrictions and neuromuscular deficits. Myofascial Release Therapy (MFR) and Isokinetic Training (IT) are promising interventions; however, their combined effects remain underexplored. Objective This study aimed to evaluate the effectiveness of combining MFR and IT on pain, function, and radiological outcomes in collegiate basketball players with SIS. Methods A prospective randomized controlled trial was conducted over an eight-week intervention period, with additional follow-up assessments performed up to six months after baseline. Sixty basketball players (45 males, 15 females) aged 18–25 years with clinically and radiographically confirmed SIS were randomly assigned to either an intervention group (MFR + IT; n = 30) or control group (conventional physiotherapy; n = 30) through computer-generated allocation method. Primary outcome was pain intensity measured using the Numerical pain rating scale (NPRS). Secondary outcomes included pain pressure threshold measured using an algometer, shoulder range of motion (ROM) assessed with a goniometer, shoulder function evaluated with the Shoulder Pain and Disability Index (SPADI), and radiographic parameters such as the coracohumeral interval and supraspinatus tendon thickness & subacromial space measured through MRI and ultrasound. Due to the nature of the interventions, it was not feasible to blind the participants or therapists. However, the outcome assessors and data analysts were blinded. Results At the 6-month follow-up, the intervention group demonstrated significantly greater improvements compared to the control group across all outcomes. Pain intensity decreased significantly (MD = 2.6; 95% CI: 2.34 to 2.85). Pain pressure threshold increased (MD = − 27.2 kPa; 95% CI: −43.73 to − 10.66). Shoulder range of motion improved significantly in abduction (MD = − 17.2°; 95% CI: −20.05 to − 14.34) and external rotation (MD = − 5.9°; 95% CI: −7.5 to − 4.29). Shoulder function (SPADI, %) improved (MD = 10.5%; 95% CI: 9.35 to 11.64). Radiological outcomes showed significant changes in coracohumeral interval space (MD = − 2.3 mm; 95% CI: −2.63 to − 1.96), supraspinatus tendon thickness (MD = 0.5 mm; 95% CI: 0.26 to 0.73), and subacromial bursa thickness (MD = 0.4 mm; 95% CI: 0.05 to 0.74). Conclusion The combination of MFR and IT is more effective than conventional physiotherapy in reducing pain, improving shoulder function, and increasing the coracohumeral interval space, as well as improving supraspinatus tendon and sub-acromial bursa thickness in athletes with SIS over a 6-month follow-up period. Trial registration The trial was registered in the clinical trial registry with registration number CTRI/2020/06/025602 on 04/06/2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13102-026-01680-2. Keywords: Shoulder Impingement Syndrome, Myofascial Release, Exercise Therapy, Basketball, Randomized Controlled Trial Introduction Subacromial impingement syndrome (SIS) is a common shoulder pathology in overhead athletes, particularly in sports such as basketball that require repetitive and forceful shoulder movements. The prevalence of SIS in overhead athletes varies depending on the population and sport, with estimates suggesting that 5–36% of athletes’ experience shoulder impingement symptoms during their careers [ 1 , 2 ]. Imaging studies report rotator cuff abnormalities in up to 93% of symptomatic throwers, while partial-thickness tears are also observed in approximately 40% of asymptomatic elite athletes [ 3 ]. In basketball players, repetitive actions such as shooting, rebounding, blocking, and passing impose substantial mechanical demands on the shoulder, often involving repeated elevation and rotation under load [ 4 ]. Over time, cumulative micro-trauma from these movements may lead to inflammation, soft-tissue thickening, and mechanical compression within the subacromial space, resulting in pain and reduced range of motion [ 5 ]. In many athletes, exposure to repetitive loading begins early in adolescence, and structural adaptations may accumulate over time before symptoms manifest clinically. Thus, in collegiate players, SIS may reflect the cumulative effects of prolonged overuse rather than acute injury. If left untreated, SIS can impair performance, increase injury recurrence, and lead to long-term functional limitations [ 6 ]. Despite its widespread clinical use, the concept of SIS has recognized limitations. Notably, there is a lack of consistent correlation between radiological findings and clinical symptoms, as structural abnormalities are frequently observed in asymptomatic individuals, while symptomatic patients may present with minimal imaging changes. This discrepancy suggests that SIS is a multifactorial condition involving not only structural factors but also neuromuscular control deficits, altered movement patterns, and soft tissue dysfunction. Contemporary evidence supports a biopsychosocial model in which pain is influenced by the interaction of biological, psychological, and social factors. Neurophysiological mechanisms, including altered central pain processing and peripheral sensitization, may contribute to persistent symptoms even in the absence of clear structural pathology [ 7 ]. Traditional management strategies for SIS focus on pain relief and functional restoration through pharmacological and physiotherapeutic interventions. Corticosteroid injections and non-steroidal anti-inflammatory drugs are commonly used to reduce inflammation but often provide only short-term benefits [ 8 ]. Exercise-based rehabilitation, particularly targeted strengthening and stretching programs, is considered a cornerstone of treatment. Evidence indicates that structured exercise programs improve pain and function more effectively than non-exercise interventions, and that combining manual therapy with exercise may provide additional short-term benefits [ 9 ]. However, these approaches may not fully address underlying myofascial restrictions or neuromuscular deficits associated with chronic SIS [ 10 ]. There is increasing interest in multimodal rehabilitation approaches that integrate different therapeutic strategies. Myofascial Release Therapy (MFR) and Isokinetic Training (IT) have emerged as promising interventions in shoulder rehabilitation. MFR involves the application of sustained, gentle pressure to soft tissues; however, this pressure is distributed across multiple underlying structures, including muscles, fascia, and connective tissues [ 11 ]. Its effects are unlikely to be explained solely by localized mechanical changes. Previous assumptions that MFR alters tissue elasticity or reduces muscle stiffness are not strongly supported, particularly given the limitations in objectively measuring such changes in vivo [ 12 ]. Instead, current evidence suggests that MFR operates primarily through neurophysiological mechanisms. These include modulation of central and peripheral pain processing, increased pressure pain thresholds, and activation of descending inhibitory pathways [ 7 , 11 ]. Such neuroplastic responses may contribute to improvements in pain and function without necessarily producing measurable structural changes in soft tissues. In the context of SIS, this perspective supports the use of MFR as part of a comprehensive rehabilitation strategy targeting both mechanical and neurophysiological factors [ 13 ]. However, evidence examining the effects of MFR in overhead athletes with SIS remains limited [ 14 ]. IT (IT) is a controlled exercise modality that involves movement at a constant speed against accommodating resistance. It is widely used in sports rehabilitation to improve muscle strength, endurance, and joint stability while minimizing injury risk [ 15 ]. In shoulder rehabilitation, IT is particularly valuable for strengthening the rotator cuff and associated musculature, which play a critical role in dynamic stabilization during overhead activities [ 16 ]. Studies have demonstrated that IT can improve muscle balance, rotational torque, and endurance, contributing to enhanced functional performance in athletes [ 17 ]. By enabling controlled loading across a defined range of motion, IT supports safe and progressive rehabilitation. Although both MFR and IT have demonstrated benefits independently, there is limited research investigating their combined effects in SIS rehabilitation [ 11 , 17 ]. Evidence from related conditions, such as subacromial pain syndrome, suggests that combining manual therapy with exercise may produce superior outcomes in pain reduction and functional improvement compared with exercise alone [ 18 ]. It is therefore plausible that integrating MFR with IT may provide synergistic benefits, with MFR facilitating improved tissue tolerance and pain modulation, thereby enhancing the effectiveness of subsequent strengthening exercises. Furthermore, most studies evaluating rehabilitation interventions for SIS rely primarily on clinical outcomes, such as pain and functional measures, with limited use of radiological assessments [ 11 , 17 ]. Incorporating imaging-based evaluation may provide additional insights into structural adaptations within the shoulder complex and contribute to a more comprehensive understanding of treatment effects [ 19 ]. The aim of this study was to evaluate the effectiveness of combining MFR with IT on pain, shoulder function, and radiological outcomes in collegiate basketball players with SIS. It was hypothesized that adding MFR and IT to standard rehabilitation would produce greater improvements in pain, shoulder function, and radiological outcomes compared with exercise alone in collegiate basketball players with SIS. Methods Study design This study was designed as a prospective, parallel-group randomized controlled trial conducted over an eight-week intervention period with follow-up assessments at six months. The study was designed and reported following the CONSORT 2022 guidelines for randomized trials. The study was approved by the Departmental Ethical Committee (DEC) of Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia, under approval number RHPT/020/023. The committee evaluated and authorized the informed consent document, treatment procedures, and outcome measures used in the study. Written informed consent was obtained from all participants before enrollment, and participants were informed about their right to withdraw from the study at any point without consequences. Data confidentiality was strictly maintained, and all data were anonymized during analysis. This study was conducted in accordance with the principles of the Declaration of Helsinki (revised 2013). Additionally, the study was prospectively registered in the Clinical Trials Registry of India (CTRI) on June 4, 2020, with the registration number CTRI/2020/06/025602. Participants were randomized in a 1:1 ratio to the Intervention (MFR combined with IT; n = 30) or control group (Conventional physiotherapy; n = 30) using a computer-generated randomization sequence (Random Allocation Software v2.0) software. The randomization was performed by an independent researcher who was not involved in the study’s conduct or data analysis. To ensure allocation concealment, sequentially numbered, opaque, sealed envelopes (SNOSE) were used, prepared by an investigator not involved in recruitment or assessment. Envelopes were opened only after baseline assessments were completed, keeping group assignments concealed from participants and assessors until allocation. Due to the nature of the interventions, it was not feasible to blind the participants or therapists. However, the outcome assessors and data analysts were blinded to group assignments to minimize bias in data collection and analysis. Sample size The sample size was calculated using G*Power software (version 3.1.9.7) for a two-group parallel design. The calculation aimed to detect a 20% improvement in the primary outcome (shoulder pain intensity) between the intervention and control groups. The estimated effect size (Cohen’s d) was derived from previous studies evaluating similar interventions for shoulder pain [ 20 ]. The calculation was set to achieve 80% statistical power (β = 0.20) with a 5% significance level (α = 0.05, two-tailed). Based on these parameters, a total of 60 participants (30 per group) was required to reliably detect the expected difference, accounting for the anticipated variability in pain scores. Participants Participants were recruited from university basketball teams through advertisements, referrals by team physicians, and posters displayed in sports centers. The study was conducted at the Physiotherapy clinic, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia. Inclusion criteria were university basketball players aged 18 to 25 years with a clinical diagnosis of SIS diagnosed by an orthopedic surgeon. They were diagnosed based on a combination of clinical history and standardized orthopedic tests. Symptom duration was required to be at least 2 months but less than six months, including activity-related shoulder pain and discomfort during overhead movements. Clinical confirmation of SIS was established by positive findings in at least two of the following tests: Neer impingement test, Hawkins–Kennedy test, and painful arc test [ 21 ] and reduced subacromial space width (≤ 10 mm) [ 22 ]. Individuals were excluded if they had history of previous injury around shoulder, a large full-thickness rotator cuff tear, severe labrum or capsular tear, history of shoulder instability, fractures, or dislocations, moderate to severe glenohumeral or acromioclavicular joint osteoarthritis, systemic inflammatory diseases, neurological deficit of the upper limb, patient with radiating pain, severe pain around the shoulder or neck, skin infections, prior shoulder surgeries or corticosteroid injections in the past six months. The large full-thickness rotator cuff tears and moderate to severe glenohumeral or acromioclavicular joint osteoarthritis was based on clinical examination findings (e.g., significant weakness, marked restriction of active range of motion, and positive orthopedic tests) and, where applicable, radiographic evidence (X-ray). Labral and capsular tears were inferred clinically based on the signs of shoulder instability, mechanical symptoms (e.g., locking or catching), or severe dysfunction. The details of participant screening, enrollment, randomization, intervention allocation, outcome assessments, and follow-up evaluations are illustrated in the study flowchart (Fig. 1 ). The flowchart specifies the timing of all evaluation points, including baseline assessment (week 0), mid-intervention evaluation (week 4), post-intervention evaluation (week 8), and the long-term follow-up assessment conducted six months after baseline. Fig. 1. Open in a new tab Flow chart showing the study details Interventions Intervention group Participants in this group received MFR combined with IT. MFR was administered by two certified physiotherapists who each have more than fifteen years of experience in treating shoulder conditions. They followed a standardized protocol targeting the soft-tissue restrictions commonly associated with SIS. The treatment focused on the upper trapezius, levator scapulae, pectoralis major and minor, infraspinatus, and posterior shoulder capsule. Each session began with superficial warming strokes, followed by sustained myofascial release techniques applied using slow, controlled pressure along identified taut bands and trigger points. Cross-hand fascial stretching and longitudinal deep-release strokes were performed for 60–90 s per region, with pressure adjusted to remain within patient tolerance. Scapular mobilization and posterior shoulder gliding techniques were added to modulate pain and improving functional outcomes through neurophysiological mechanisms, including alterations in pain perception, increased pressure pain thresholds, and activation of endogenous inhibitory pathways [ 23 ]. Each session lasted 30 min and was performed five times per week for eight weeks. The myofascial release intervention was applied consistently across all 8 weeks using a standardized manual technique. No specialized equipment was used; all therapy was delivered manually by a trained physiotherapist. IT was conducted using an isokinetic dynamometer (Cybex Norm, Humac, CA, USA), focusing on concentric–concentric protocol targeting shoulder abduction–adduction and internal–external rotation. Participants were positioned with the trunk and scapula stabilized, and the dynamometer axis aligned with the glenohumeral joint. Training was performed within a pain-free range, typically 0–90° of abduction and neutral to 45° of rotation. Each session consisted of three sets of 10 repetitions at angular velocities of 60°/s and 120°/s, with 60–90 s of rest between sets. Training intensity and velocity were progressively increased based on participants’ tolerance, with eccentric loading incorporated in later stages. All sessions were conducted three times per week for eight weeks, with periodic re-evaluation of pain, strength, and range of motion to ensure safe progression. The training protocol was adapted from prior studies showing its efficacy in improving muscle strength and joint function [ 24 ]. The summary of MFR and IT were shown in Table 1 . Table 1. Summary of MFR and IT interventions Intervention Target/Focus Procedure Frequency & Duration Progression & Monitoring Myofascial Release (MFR) Upper trapezius, levator scapulae, pectoralis major & minor, infraspinatus, posterior shoulder capsule Superficial warming strokes → sustained myofascial release along taut bands/trigger points → cross-hand fascial stretching and longitudinal deep-release strokes (60–90 s per region) → scapular mobilization and posterior gliding 5 sessions/week, 30 min/session, 8 weeks Pressure adjusted to participant tolerance; technique consistency ensured by trained physiotherapist; session adherence monitored Isokinetic Training (IT) Shoulder abduction–adduction, internal–external rotation Concentric–concentric protocol on isokinetic dynamometer; participant stabilized; pain-free ROM (0–90° abduction; neutral–45° rotation); 3 sets × 10 reps at 60°/s and 120°/s; 60–90 s rest 3 sessions/week, 30–40 min/session, 8 weeks Intensity and velocity progressively increased; eccentric loading in later stages; pain, strength, and ROM periodically re-evaluated Open in a new tab Control group Participants in the control group received conventional physiotherapy, consisting of scapular stabilization, range-of-motion (ROM), and resistance band strengthening exercises. Scapular stabilization exercises targeted muscles such as the serratus anterior and trapezius, including scapular retraction/protraction, wall slides, and prone Y, T, and W lifts. ROM exercises aimed to maintain shoulder mobility and included pendulum movements, active-assisted flexion and abduction with a stick or pulley, and external rotation with the elbow at the side. Strengthening exercises with resistance bands focused on external and internal rotation, scapular retraction, and abduction. Each 30-minute session was conducted five times per week for eight weeks under the supervision of a licensed physiotherapist, ensuring correct technique, gradual progression, and pain-free execution [ 25 ]. Both groups received standardized education on shoulder care, including advice on activity modification and home exercises to prevent symptom exacerbation. The home-exercise program included gentle active range-of-motion drills, posterior capsule stretches, and scapular-stabilization exercises. Participants were instructed to perform these exercises five days per week, for approximately 20 min per day. Compliance was monitored through weekly logs, and participants were reminded to avoid any activity that provoked significant pain. Outcomes Pain intensity was designated as the primary outcome measure of the study. The primary endpoint for analysis was defined as the six months’ follow-up assessment conducted after completion of the 8-week intervention program. All outcome assessments were conducted at predefined time points: baseline (week 0, prior to randomization), mid-intervention assessment (week 4), post-intervention assessment (week 8), and long-term follow-up evaluation conducted six months after the start of the intervention. Primary outcome Pain intensity was the primary outcome, assessed using a Numeric Pain Rating Scale (NPRS), a reliable (ICC = 0.95–0.99) and validated tool for measuring subjective pain. Participants marked their current shoulder pain on an 11-point scale ranging from “0 = no pain” to “10 = worst imaginable pain,” following standardized, non-prompted instructions. The assessor then measured the mark using a calibrated transparent ruler, with higher scores indicating greater pain intensity [ 26 ]. Secondary outcome Pain pressure threshold: Pain pressure threshold (PPT) over the deltoid muscle was measured using a calibrated handheld digital algometer (Somedic, Hörby, Sweden) with a 1-cm² rubber-tipped probe. With participants seated and the arm relaxed, pressure was applied perpendicularly at the midpoint of the lateral deltoid at a rate of 1 kg/s. Participants indicated the point at which pressure first became painful, and three readings were taken with 30–60 s between trials; the mean value was used for analysis. All measurements were performed by the same assessor using standardized instructions. Pressure algometry demonstrates high intra-rater reliability (ICC 0.85–0.97), good inter-rater reliability (ICC 0.75–0.90), and strong validity for assessing mechanical pain sensitivity [ 27 ]. Range of motion Shoulder range of motion, specifically abduction and external rotation, was evaluated using a standard universal goniometer (National 360 Goniometer, National Tools Ltd., New Delhi) and has (ICC 0.94–0.99). For abduction, the goniometer’s fulcrum was placed over the anterior aspect of the acromion, with the stationary arm aligned parallel to the sternum and the moving arm following the midline of the humerus. For external rotation, the fulcrum was positioned over the olecranon process with the arm in 90° abduction, and the stationary and moving arms aligned with the ulna. This method is widely recognized for its reliability and validity in clinical assessment of shoulder mobility [ 28 ]. Shoulder function Shoulder function was assessed using the Shoulder Pain and Disability Index (SPADI), a validated self-reported questionnaire with 13 items measuring pain and difficulty in daily activities. Participants rated each item on a 0–10 scale, and subscale and total scores were expressed as percentages, with higher scores indicating greater pain or disability. SPADI demonstrates high internal consistency (Cronbach’s alpha 0.81–0.92), excellent test–retest reliability (ICC 0.89–0.92), and good validity for evaluating shoulder function [ 29 ]. Radiographic assessments included measurements of the coracohumeral interval, supraspinatus tendon thickness, and the thickness of the sub-acromial bursa. These parameters were evaluated using magnetic resonance imaging (MRI) (Koninklijke Philips N.V., Netherlands) and high-resolution ultrasound (US) (Philips Healthcare, Netherlands). MRI was performed with a 1.5 T scanner using standard axial, coronal, and sagittal sequences to evaluate coracohumeral interval space and supraspinatus tendon thickness. Ultrasound was conducted with a 7–15 MHz linear transducer, allowing dynamic assessment of thickness of sub-acromial bursa. These are considered validated and reliable tools for detecting rotator cuff and subacromial pathologies, with good intra- and inter-rater reliability (ICC 0.85–0.95) [ 30 ]. Statistical methods Descriptive statistics were used to summarize baseline characteristics. Approximately 70% of the variables (e.g., NPRS pain scores, shoulder ROM, PPT values) were normally distributed, while the remaining 30% were non-normally distributed. A 4 × 2 mixed-model ANOVA was used to evaluate the effects of time and group on outcome measures. The reported p-values for the interaction term reflect changes over time between groups. All continuous outcome data were assessed for normality using the Shapiro–Wilk test, with normally distributed data, paired t-tests were used for within-group comparisons and independent t-tests for between-group comparisons, while repeated-measures ANOVA was employed to evaluate changes over time across groups. Post-hoc pairwise comparisons with Bonferroni correction were applied to control for type I error. Non-normally distributed data were analyzed using appropriate non-parametric tests (Mann–Whitney U and Wilcoxon signed-rank tests). The study followed the intention-to-treat principle method, in which all participant’s data are included in the analysis. A p-value of < 0.05 was considered statistically significant. Effect sizes were calculated to quantify the magnitude of treatment effects. For between-group comparisons, Cohen’s d was calculated as the difference between group means divided by the pooled standard deviation. Effect sizes were interpreted according to Cohen’s guidelines: 0.2 = small, 0.5 = medium, and 0.8 = large. All the statistical analyses were performed using IBM SPSS Statistics (Version 30.0.0, IBM Corp., Armonk, NY, USA). Results At the beginning of the study, one member of the research team screened 118 participants based on the selection criteria for inclusion in the study. Out of these, thirteen participants had a history of joint and soft tissue injuries, twelve had referred pain from cervical spine, eight had joint instabilities and six recently undergone joint surgeries. In addition, fifteen participants refused to participate in the study due to some personal reasons. Finally, sixty ( N = 60) participants were recruited through random allocation method and assigned to intervention and control groups. At the end of the eight-week intervention period, two participants in the intervention group and two participants in the control group did not complete follow-up measurements due to personal reasons or time constraints. Similarly, at the 6-month measurement, one participant in intervention group and two participants in control group did not provide measurements due to personal reasons and time constraint. Demographic characteristics such as age, height, weight, and duration of pain did not show any statistically significant differences between the groups ( p > 0.05). Also, in both groups, the right side (intervention group − 67% & control group – 63%) is involved more than the left side (intervention group − 33% & control group – 37%) and the previous episodes of pain in the intervention group is 17% and in the control group is 20%. Participants had 4.2 ± 0.8 years (intervention group) and 4.1 ± 0.9 years (control group) of prior competitive basketball experience. The demographic characteristics of the study participants in both groups were presented as mean and standard deviation and are shown in Table 2 . Table 2. Demographic and clinical characters of intervention and control groups Variable Intervention group ( n = 30) Mean ± SD Control group ( n = 30) Mean ± SD p -value Age (y) 19.28 ± 1.2 19.56 ± 1.3 0.389 Gender Male (Number/Percentage) 22 (73%) 23 (77%) - Female (Number/Percentage) 8 (27%) 7 (23%) - Height (meter) 1.71 ± 0.17 1.70 ± 0.18 0.825 Weight (kg) 78.3 ± 7.2 77.8 ± 6.9 0.784 Side involved (%) Right side (Number/Percentage) 20 (67%) 19 (63%) - Left side (Number/Percentage) 10 (33%) 11 (37%) - Dominance side (%) Dominance = Right 27 (90%) 28 (93%) - Dominance = Left 3 (10%) 2 (7%) - Duration of prior training (y) 4.2 ± 0.8 4.1 ± 0.9 Previous episodes of pain N (%) 5/30 (17%) 6/30 (20%) - Duration of pain (months) 6.2 ± 1.4 6.4 ± 1.3 0.568 Pain intensity (NPRS) - cm 7.4 ± 1.2 7.3 ± 1.3 0.758 Open in a new tab SD Standard deviation, y year, kg kilogram, cm centimetre The data for all outcome measures were presented as mean and standard deviation with a 95% confidence interval (CI), including upper and lower limits. The 4 × 2 mixed model for repeated measures (MMRM) of the primary variable (pain intensity measured by Numerical pain rating scale) showed a statistically significant difference ( p = 0.001) between intervention and control group at baseline, 4 weeks, 8 weeks, and at 6 months’ follow-up. The baseline measurement of pain intensity did not show a significant difference − 0.1 (95%CI=-0.7466 to 0.5466; p = 0.758). However, at 4 weeks, intervention group showed an improvement of 2.3 (95% CI 1.78 to 2.81) compared to control group. Similar effects were observed after 8 weeks of intervention 2.8 (95% CI 2.45 to 3.14). At the 6-month follow-up, a greater effect of 2.6 (95% CI 2.34 to 2.85) was observed ( p = 0.001) in intervention group compared to control group, as shown in Tables 3 , 4 and 5 . The repeated measures analysis of variance (rANOVA) for the primary outcome, pain intensity within intervention and control group, showed a significant difference ( p = 0.001). The effect size of pain intensity (d = 6.66) indicated a larger effect in the intervention group compared to control group. The graphical data representation of primary outcome variable between the is shown in Fig. 2 . Table 3. Pre and post primary and secondary outcome measures of intervention and control groups Variable Duration Intervention group ( n = 30) Mean ± SD Control group ( n = 30) Mean ± SD Group × Time Pain intensity – NPRS (0–10 cm) Base line 7.4 ± 1.2 7.3 ± 1.3 p = 0.001* 4 weeks 3.4 ± 0.9 5.7 ± 1.1 8 weeks 1.6 ± 0.5 4.4 ± 0.8 6 months 0.9 ± 0.08 3.5 ± 0.7 Pain pressure threshold – Deltoid (kPa) Base line 302.4 ± 30.6 304.5 ± 31.5 p = 0.001* 4 weeks 314.0 ± 31.4 308.4 ± 31.7 8 weeks 329.6 ± 31.8 314.2 ± 31.7 6 months 348.2 ± 32.2 321.0 ± 31.8 Shoulder abduction (degree) Base line 43.8 ± 4.1 45.5 ± 4.3 p = 0.001* 4 weeks 56.2 ± 4.8 53.2 ± 4.6 8 weeks 64.5 ± 5.2 59.2 ± 4.9 6 months 79.8 ± 5.9 62.6 ± 5.1 Shoulder – External rotation (degree) Base line 27.2 ± 2.1 27.4 ± 2.0 p = 0.001* 4 weeks 30.2 ± 2.4 29.5 ± 2.2 8 weeks 32.9 ± 2.7 30.3 ± 2.3 6 months 38.1 ± 3.6 32.2 ± 2.5 Shoulder disability (SPADI) Base line 46.2 ± 4.5 46.4 ± 4.6 p = 0.001* 4 weeks 32.8 ± 3.8 42.9 ± 4.4 8 weeks 24.1 ± 2.8 35.4 ± 3.4 6 months 18.3 ± 1.4 28.8 ± 2.8 MRI Coracohumeral interval space – cm Base line 5.8 ± 0.6 5.7 ± 0.6 p = 0.001* 4 weeks 6.7 ± 0.6 5.9 ± 0.6 8 weeks 7.4 ± 0.6 6.2 ± 0.6 6 months 8.8 ± 0.7 6.5 ± 0.6 Ultrasound Supraspinatus tendon thickness (mm) Base line 6.9 ± 0.7 6.8 ± 0.7 p = 0.001* 4 weeks 6.5 ± 0.6 6.7 ± 0.6 8 weeks 6.2 ± 0.5 6.5 ± 0.6 6 months 5.7 ± 0.4 6.2 ± 0.5 Ultrasound Thickness of sub-acromial bursa (mm) Base line 10.9 ± 0.9 10.8 ± 0.8 p = 0.001* 4 weeks 10.5 ± 0.9 10.6 ± 0.8 8 weeks 10.2 ± 0.8 10.4 ± 0.6 6 months 9.8 ± 0.8 10.2 ± 0.5 Open in a new tab *Significant, SD Standard deviation, NPRS Numerical pain rating scale, cm centimeter, kPa Kilo pascal, SPADI Shoulder Pain and Disability Index, MRI Magnetic resonance imaging, mm millimeter Table 4. Mean and (SD) difference within groups for primary and secondary outcome variables Variables Difference within groups Week 4 minus Baseline Week 8 minus Baseline Month 6 minus Baseline Intervention Mean ± SD Control Mean ± SD Intervention Mean ± SD Control Mean ± SD Intervention Mean ± SD Control Mean ± SD Pain intensity -4.0 (0.5) -1.6 (0.6) -5.8 (0.5) -2.9 (0.7) -6.5 (0.5) -3.8 (0.6) p = 0.001 p = 0.001 p = 0.001 p = 0.001 p = 0.001 p = 0.001 Pain pressure threshold 11.6 (21.2) 3.9 (21.3) 27.2 (21.2) 9.7 (21.3) 45.8 (21.2) 16.5 (21.3) p = 0.485** p = 0.964** p = 0.006 p = 0.636** p = 0.001 p = 0.187** Shoulder abduction 12.4 (3.4) 7.7 (3.1) 20.7 (32.4) 13.7 (3.1) 36.0 (3.4) 17.1 (3.1) p = 0.001 p = 0.001 p = 0.001 p = 0.001 p = 0.001 p = 0.001 Shoulder External rotation 3.0 (1.8) 2.1 (1.6) 5.7 (1.8) 2.9 (1.6) 10.9 (1.8) 4.8 (1.6) p = 0.001 p = 0.002 p = 0.001 p = 0.001 p = 0.001 p = 0.001 Shoulder function -13.4 (2.2) -3.5 (2.6) -22.1 (2.2) -11.0 (2.6) -27.9 (2.2) -17.6 (2.6) p = 0.001 p = 0.003 p = 0.001 p = 0.001 p = 0.001 p = 0.001 Coracohumeral interval space 0.9 (0.4) 0.2 (0.4) 1.6 (0.4) 0.5 (0.4) 3.0 (0.4) 0.8 (0.4) p = 0.001 p = 0.605** p = 0.001 p = 0.013 p = 0.001 p = 0.001 Supraspinatus tendon thickness -0.4 (0.3) -0.1 (0.4) -0.7 (0.3) -0.3 (0.4) -1.2 (0.3) -0.6 (0.4) p = 0.033 p = 0.900** p = 0.001 p = 0.169** p = 0.001 p = 0.001 Thickness of sub-acromial bursa -0.4 (0.5) -0.2 (0.5) -0.7 (0.5) -0.4 (0.5) -1.1 (0.5) -0.6 (0.5) p = 0.269** p = 0.673** p = 0.009 p = 0.115** p = 0.001 p = 0.005 Open in a new tab ** Non-Significant, SD Standard deviation Table 5. Mean (95% CI upper - lower) difference between groups for primary and secondary outcome variables Variables Difference between groups 4 weeks 8 weeks 6 months Intervention - Control Intervention – Control Intervention – Control Pain intensity 2.3 (1.78 to 2.81) p = 0.001 2.8 (2.45 to 3.14) p = 0.001 2.6 (2.34 to 2.85) p = 0.001 Pain pressure threshold -5.6 (-21.9 to 10.7) p = 0.500** -15.4 (-31.8 to 1.00) p = 0.066** -27.2 (-43.73 to -10.66) p = 0.001 Shoulder abduction -3.0 (-5.4 to -0.57) p = 0.001 -5.3 (-7.91 to -2.68) p = 0.001 -17.2 (-20.05 to -14.34) p = 0.001 Shoulder External rotation -0.7 (-1.88 to 0.48) p = 0.245** -2.6 (-3.89 to -1.30) p = 0.001 -5.9 (-7.5 to -4.29) p = 0.001 Shoulder function 10.1 (7.97 to 12.22) p = 0.001 11.3 (9.69 to 12.9) p = 0.001 10.5 (9.35 to 11.64) p = 0.001 Coracohumeral interval space -0.8 (-1.11 to -0.48) p = 0.001 -1.2 (-1.51 to -0.88) p = 0.001 -2.3 (-2.63 to -1.96) p = 0.001 Supraspinatus tendon thickness 0.2 (-0.11 to 0.51) p = 0.200** 0.3 (0.01 to 0.58) p = 0.001 0.5 (0.26 to 0.73) p = 0.001 Thickness of sub-acromial bursa 0.1 (-0.34 to 0.54) p = 0.656** 0.2 (-0.16 to 0.56) p = 0.276** 0.4 (0.05 to 0.74) p = 0.001 Open in a new tab ** Non-Significant Fig. 2. Open in a new tab Figure showing the mean and standard deviation of primary and secondary outcomes in intervention and control groups The 4 × 2 mixed model for repeated measures (MMRM) of the secondary variables (pain pressure threshold, shoulder abduction & external rotation, shoulder function, coracohumeral interval space, supraspinatus tendon thickness and sub-acromial bursa thickness) showed a statistically significant difference ( p = 0.001) between the intervention and control groups at baseline, 4 weeks, 8 weeks, and at 6 months. The baseline measures of all the secondary outcome measures such as pain pressure threshold 2.1 (95%CI=-13.9496 to 18.1496, p = 0.7943), shoulder abduction 1.7 (95%CI=-0.4713 to 3.8713, p = 0.1225) & external rotation 0.2 (95%CI=-0.8598 to 1.2598, p = 0.7070), shoulder function 0.2 (95%CI=-2.1518 to 2.5518, p = 0.8654), coracohumeral interval space − 0.1 (95%CI=-0.4101 to 0.2101, p = 0.5212), supraspinatus tendon thickness − 0.1 (95%CI=-0.4618 to 0.2618, p = 0.5822) and sub-acromial bursa thickness − 0.1 (95%CI=-0.5401 to 0.3401, p = 0.6509) did not show any statistical difference. At 4 weeks’ measurement, improvements were observed in intervention group compared to control group in shoulder abduction − 3.0 (95% CI -5.4 to -0.57), shoulder function 10.1 (95% CI 7.97 to 12.22), and coracohumeral interval space − 0.8 (95% CI -1.11 to -0.48), ( p = 0.001), but not in pain pressure threshold − 5.6 (95% CI -21.9 to 10.7), shoulder external rotation − 0.7 (95% CI -1.88 to 0.48), supraspinatus tendon thickness 0.2 (95% CI -0.11 to 0.51) and sub-acromial bursa thickness 0.1 (95% CI -0.34 to 0.54) which is shown in Tables 3 , 4 and 5 . At the 8 weeks post intervention measurement, all the secondary outcome measures showed significant differences except pain pressure threshold − 15.4 (95% CI -31.8 to 1.00) and sub-acromial bursa thickness 0.2 (95% CI -0.16 to 0.56). At the 6-month follow-up, greater improvements were seen in intervention group compared to control group; pain pressure threshold − 27.2 (95% CI -43.73 to -10.66), shoulder abduction − 17.2 (95% CI -20.05 to -14.34). shoulder external rotation − 5.9 (95% CI -7.5 to -4.29), shoulder function 10.5 (95% CI 9.35 to 11.64), coracohumeral interval space − 2.3 (95% CI -2.63 to -1.96), supraspinatus tendon thickness 0.5 (95% CI 0.26 to 0.73) and sub-acromial bursa thickness 0.4 (95% CI 0.05 to 0.74), which are shown in Tables 3 , 4 and 5 . The effect size of pain pressure threshold (d = 0.85), shoulder abduction (d = 3.40) & external rotation (d = 1.93), shoulder function (d = 5.00), coracohumeral interval space (d = 3.53), supraspinatus tendon thickness (d = 1.11) and sub-acromial bursa thickness (d = 0.61) indicated a larger effect in intervention group compared to control group. The graphical data representation of secondary outcome variables between the groups is shown in Fig. 2 . Discussion The findings of this study suggest that MFR combined with IT is more effective than conventional physiotherapy for university basketball players suffering from SIS. The intervention led to superior improvements in pain reduction, range of motion (ROM), shoulder function, and coracohumeral interval space and thickness of Supraspinatus tendon & sub-acromial bursa outcomes compared to conventional therapy alone. These results highlight the importance of integrating both MFR and IT as a comprehensive rehabilitation approach for athletes with SIS. In our study, pain intensity, assessed using the Numerical pain rating scale (NPRS), and pain threshold assessed through pressure algometer showed a significantly greater reduction in the intervention group compared with the control group. The improvement in pain intensity and pain threshold is much greater than the minimal clinically important difference (MCID = 2.6 & 27.2) scores and minimal detectable change (MDC = 0.58 & 26.8) scores, indicating a highly clinically meaningful improvement for the patients [ 31 ]. These results are consistent with the findings of Ajimsha et al., who demonstrated that myofascial release techniques effectively reduce muscle tension and improve tissue mobility, leading to immediate pain relief [ 12 ]. Similarly, van den Tillaar et al. reported that IT enhances muscular endurance and decreases mechanical strain on the shoulder joint, thereby promoting sustained pain reduction over an 8-week intervention period and during subsequent follow-ups [ 32 ]. Together, these studies support the conclusion that the combined application of myofascial release and IT in our study likely played a significant role in the observed improvements in pain outcomes, highlighting the effectiveness of this multimodal approach for managing SIS. Conversely, conventional physiotherapy, which focused primarily on scapular stabilization and resistance band exercises, showed only moderate improvements in pain levels. The combination of manual therapy and targeted strength training appears to have provided a more comprehensive solution for pain management. Similarly, assessments of shoulder range of motion (ROM), specifically in abduction and external rotation, demonstrated significantly greater improvements in the intervention group compared with the control group. The improvement in shoulder abduction and external rotation is much greater than the (MCID = 17.2 & 5.9) scores and (MDC = 1.14 & 0.58) scores, indicating a highly clinically meaningful improvement for patients [ 33 ]. This is consistent with findings from Barnes et al., who reported that MFR directly targets restricted soft tissue structures, enhancing muscle extensibility and facilitating improved joint mechanics [ 33 ]. Additionally, the results align with those of Ellenbecker et al., who observed that structured interventions can effectively improve shoulder mobility. The controlled and progressive nature of isokinetic exercises likely further contributed to the observed gains in ROM by systematically strengthening the dynamic stabilizers of the shoulder joint, thereby promoting both stability and functional movement [ 34 ]. In contrast, conventional physiotherapy, while beneficial, may lack the same degree of targeted tissue mobilization and progressive overload, which could explain the comparatively slower improvements in ROM observed in the control group. Shoulder function, as measured by the SPADI score, showed significantly greater improvements in the intervention group compared with the control group. The improvement in shoulder function is much greater than the (MCID = 10.5) and (MDC = 3.53) scores, indicating a highly clinically meaningful improvement for patients [ 35 ]. This finding is supported by Hains et al., who reported that MFR effectively addresses myofascial restrictions and trigger points that contribute to shoulder dysfunction, thereby enhancing joint mobility and flexibility [ 36 ]. In addition, IT offers controlled and progressive resistance, which strengthens the shoulder musculature systematically while minimizing excessive joint stress, as demonstrated by Ellenbecker et al. [ 34 ]. Together, these interventions likely acted synergistically to improve both the structural and functional aspects of the shoulder, leading to the superior gains in overall shoulder function observed in the intervention group. This facilitated more efficient neuromuscular adaptations, which enhanced overall shoulder performance. In contrast, conventional physiotherapy, while effective, lacked the specificity and progressive resistance provided by IT, leading to comparatively lower functional gains. MRI and US reports demonstrated a greater improvement in coracohumeral interval space and thickness of Supraspinatus tendon & sub-acromial bursa in the intervention group compared with the control group. Although these changes (MCID = 2.3, 0.5 & 0.4) and (MDC = 0.37, 0,37 & 0.56) were statistically significant, the absolute magnitude of change was relatively small and should be interpreted with caution. Such differences may fall within the inherent measurement variability of musculoskeletal ultrasound and are unlikely to be independently perceived by patients as clinically meaningful. Therefore, these structural changes should not be considered primary drivers of clinical improvement. Instead, they may reflect underlying biological responses to the intervention, such as reduced local inflammation or improved tissue organization. This interpretation aligns with current evidence suggesting that structural changes in musculoskeletal tissues do not always correlate directly with symptom improvement. Accordingly, the findings of reduced tendon and bursal thickness in this study should be viewed as complementary to, rather than determinative of, the overall clinical benefit. This is consistent with the findings of Tate et al., who reported that combining MFR with IT can optimize scapular positioning and decrease compressive forces within the subacromial space [ 37 ]. Likewise, Seitz et al. noted that these interventions enhance neuromuscular control and flexibility, thereby creating a more favorable biomechanical environment for the shoulder joint [ 38 ]. Overall, these results suggest that the multimodal approach not only reduces pain and improves shoulder function but also induces structural adaptations that may support long-term joint health and reduce the risk of impingement. Conventional physiotherapy also led to some improvements but was less effective in modifying subacromial space dynamics. Reduced pain, increased ROM, and enhanced functional activity collectively contributed to better shoulder function, allowing participants to engage in their daily and athletic activities with greater ease. The reduction in disability and functional limitations observed in the intervention group in the present study underscores the added value of integrating MFR and IT into rehabilitation protocols for SIS [ 39 ]. The benefits of the intervention were sustained beyond the 8-week intervention period, as evidenced by the follow-up assessments at 6 and 12 months. Participants in the intervention group maintained their functional improvements and continued to report lower pain levels compared to the control group. This suggests that the combination of MFR and IT not only provides short-term relief but also promotes long-term recovery and injury prevention. Similar findings have been reported in previous studies. For instance, a randomized controlled trial conducted by Barnes JF et al. investigated that structured shoulder rehabilitation in overhead athletes, demonstrated sustained improvements in shoulder function and pain reduction following targeted strengthening and neuromuscular training programs [ 33 ]. Likewise, a systematic review evaluating rehabilitation strategies for SIS, highlighted that multimodal physiotherapy interventions combining soft tissue techniques and strengthening exercises are associated with improved functional outcomes [ 34 ]. These findings are consistent with our results, which demonstrated significant improvements in pain, range of motion, and shoulder function among participants who received the combined MFR and IT intervention. The superior outcomes observed in the intervention group can be attributed to the synergistic effects of MFR and IT in young athletes. MFR directly addresses myofascial restrictions, trigger points, and soft tissue adhesions, improving local circulation and reducing pain sensitivity [ 33 ]. IT, on the other hand, provides controlled resistance that enhances neuromuscular control, strength, and endurance, leading to better overall shoulder stability and function [ 34 ]. Conventional physiotherapy, while effective, does not incorporate the same level of targeted soft tissue mobilization and progressive resistance, which may explain its comparatively lower efficacy. Unlike prior research that examined manual therapy or IT in isolation, our study uniquely investigates the combined effect of MFR plus IT in a young athletic (collegiate basketball) population with SIS. Previous studies have shown that adding manual therapy to exercise—such as joint mobilization, trigger-point inactivation, or soft-tissue release—can lead to greater improvements in pain, function, and range of motion compared with exercise alone [ 40 ]. Similarly, IT has demonstrated some benefit for shoulder impingement or related dysfunctions, but existing reviews concluded that evidence is limited and heterogeneous: many programs combined IT with other modalities, making it difficult to isolate its true effect [ 14 ]. In this context, our findings are significant: the combined protocol produced statistically and clinically meaningful reductions in pain, improvements in functional scores, and favorable radiological changes. Because to our knowledge no prior randomized trial has examined the simultaneous use of MFR and IT in a young, active, athletic cohort, our study adds novel insight and suggests that this multimodal approach may be more effective than either component alone; this has important implications for rehabilitation protocols targeting SIS in athletes.” Clinical implications These findings have important implications for clinical practice. The integration of MFR and IT should be considered a first-line rehabilitation approach for athletes with SIS, particularly those involved in high-performance sports like basketball. The results support the need for a multimodal treatment strategy that addresses both soft tissue dysfunction and neuromuscular deficits to achieve optimal patient outcomes. Moreover, the long-term benefits observed in this study suggest that incorporating these techniques into routine physiotherapy protocols could reduce the recurrence of SIS and improve overall shoulder health. Because the observed increase in subacromial space width, along with improvements in neuromuscular control, shoulder strength, and soft-tissue flexibility, provides a strong rationale for interpreting that the intervention may help reduce the recurrence of shoulder injuries. Limitations and future directions While this study provides strong evidence, some limitations should be acknowledged. First, the sample size was relatively small, and larger trials are needed to confirm these findings. Second, the participants and therapists were not fully blinded, and some outcomes relied on self-report, which may introduce bias. Third, the limb dominance was not considered when identifying the affected shoulder. As dominance can influence neuromuscular demands and movement patterns in overhead athletes, this omission may have impacted the interpretation of shoulder function and injury characteristics. Fourth, the diagnosis of SIS was based on a cluster of orthopedic special tests with variable validity and reliability, which may have introduced diagnostic misclassification and consequently affected the accuracy and generalizability of the findings. Fifth, possibility of potential measurement bias due to the use of a manual goniometer and lack of assessor blinding, which may have affected the accuracy of the findings. Sixth, the use of the total SPADI score may confound pain and functional outcomes, as the disability component can be influenced by pain intensity, limiting precise interpretation of shoulder function. Seventh, while US provided objective measures of subacromial space width, additional imaging techniques such as MRI could have provided more detailed insights into soft tissue changes. Eighth, adherence to home exercise programs was not objectively monitored, which may have influenced long-term outcomes. Ninth, the six-month follow-up measurement limit the long-term conclusions regarding the recurrence of the symptoms. Finally, the results may not be applicable to populations beyond university basketball players. Future studies should explore the cost-effectiveness of this intervention and its applicability to other populations beyond university basketball players. Conclusion In conclusion, the combined intervention of myofascial release therapy and isokinetic training resulted in significant improvements in pain intensity, pressure pain threshold, range of motion, and functional outcomes in individuals with Subacromial impingement syndrome. Although reductions in tendon and subacromial bursal thickness were observed, these structural changes should be interpreted with caution, as they may not directly correlate with patient-perceived improvements in pain and function. The overall clinical benefits observed in this study are more likely attributable to neuromuscular, biomechanical, and analgesic effects of the intervention rather than structural alterations alone. These findings support the use of combined therapeutic approaches to achieve meaningful functional recovery. Supplementary Information Supplementary Material 1. (55.2KB, docx) Acknowledgements This study is supported via funding from Prince Sattam bin Abdulaziz University project number (PSAU/2024/R/1445). Abbreviations ANOVA Analysis of variance CI Confidence interval CONSORT Consolidated Standards of Reporting Trials CTRI Clinical Trials Registry of India DEC Departmental Ethical Committee IT Isokinetic Training MFR Myofascial Release Therapy MMRM Mixed model for repeated measures MRI Magnetic resonance imaging NSAID Non-steroidal anti-inflammatory drugs NPRS Numerical pain rating scale ROM Range of motion SIS Subacromial impingement syndrome SPADI Shoulder pain and disability index Authors’ contributions Gopal Nambi (GN), Mshari Alghadier (MA), Mohammed Moustafa Alddosouki Hegazy (MM) Julie Saji George (JG), Osama R. Aldhafian (OA), Alaa Jameel A. Albarakati (AA), Shahul Hameed Pakkir Mohamed (SM), Hani Fahad Albalawi (HA), Mohamed Taher Mahmoud Eldesoky (ME), Enas Elsayed Mohamed Abutaleb (EA), Samah Saad Zahran (SZ)Conceptualization: GN, MA, MM, JG, OA, AA, SM, HA, ME, EA, SZ Data curation: GN, MA, MM, JG, OA, SZ Formal analysis: JG, OA, AA, SM, HA Funding acquisition: GN, MA, MM, JG, OA, AA, SM, SZ Investigation: GN, MA, JG, OA, SM, HA, ME, EA Methodology: GN, MA, JG, OA, AA, SM, HA, ME, EA Project administration: GN, MA, MM, SM, HA, ME, EA, SZ Resources: SM, HA, ME, EA, SZ Software: SM, HA, ME, EA, SZ Validation: GN, MA, MM, JG, OA, AA Visualization: GN, MA, JG, OA, SM, HA, SZ Writing – original draft: GN, MA, MM, JG, OA, AA, SM, HA, ME, EA, Writing – review & editing: GN, MA, MM, JG, OA, AA, SM, HA, ME, EA, SZ. Funding No funding. Data availability The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate The trial received acceptance from the department of ethical committee (DEC), Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia with an approval number of RHPT/020/023. The DEC approved the subject consent form, treatment protocols and the outcome parameters measured in the trial. The trial was executed in accordance with the ethical guidelines laid down in the 1964 Declaration of Helsinki and was registered in the clinical trial registry with registration number CTRI/2020/06/025602 on 04/06/2020. A written informed consent was obtained from all the selected subjects for the trial. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Tsai L-C, Chen C-H, Chou W-Y, et al. 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