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Rotator cuff-related shoulder pain (RCRSP)

Rotator cuff-related shoulder pain (RCRSP): the impingement model abandoned, shoulder tests, progressive exercise and the criteria for using imaging.

Posted by

Anthony BAILLON

Physiotherapist

Physiotherapy · Rotator cuff pathology · Shoulder

In brief

Rotator cuff-related shoulder pain (RCRSP), or subacromial pain syndrome, is an umbrella term covering tendinopathy, bursitis and non-traumatic partial tears of the cuff; the concept of subacromial impingement has been abandoned. It is the most frequent cause of shoulder pain. The diagnosis is above all clinical, imaging not being recommended as a first line because it correlates poorly with symptoms (96 % of ultrasound abnormalities in asymptomatic people aged 40-70). Progressive therapeutic exercise and education are the first-line treatment, the progression of load counting more than the type of exercise, and subacromial decompression brings no additional benefit. RCRSP accounts for 44 to 65 % of consultations for shoulder pain.

A clinical synthesis based on the most recent meta-analyses and international consensus statements: the 2025 JOSPT CPG (Desmeules), Dutch SAPS (Diercks 2014), Pieters JOSPT 2020, CSAW Lancet 2018, Paavola BJSM 2021 FIMPACT 5 years, Cochrane Karjalainen 2019.

Clinical diagnosis Exercise 1st line Overhead athlete Evidence-based
44-65%
of consultations for shoulder pain
Lewis 2016 Man Ther · a narrative synthesis
96%
of ultrasound abnormalities in asymptomatic people aged 40-70
Girish 2011 AJR · cohort n=51
0
benefit of subacromial decompression vs placebo at 5 years
Paavola 2021 BJSM · FIMPACT RCT n=210

Clinical synthesis

  • The terminology is changing: favour "rotator cuff-related shoulder pain" (RCRSP) or "subacromial pain syndrome" (SAPS) over the simplistic mechanical concept of "subacromial impingement" (Lewis 2016, Cuff & Littlewood 2018, Salamh & Lewis 2020).
  • It is the most frequent cause of shoulder pain (44-65 % of consultations), affecting around 1 person in 5 over a lifetime, with a peak after 50.
  • The risk factors are biopsychosocial: mechanical overload (overhead work/sport, repetitive throwing - Yamamoto 2010), diabetes, hypertension, hypercholesterolaemia (Giri 2023 Ann Phys Rehabil Med - an SR/MA of 25 studies), smoking, age.
  • The pathophysiology is a failed healing response of the tendon to overload, and not simple inflammation. The continuum model (Cook & Purdam 2009) remains the reference teaching framework.
  • Pain correlates poorly with imaging: 96 % of ultrasound abnormalities in asymptomatic people aged 40-70 (Girish 2011), 20 % of tears from the age of 60 (Yamamoto 2010). Psychosocial factors play a major role (Chester 2018, Mallows 2017).
  • The diagnosis is above all clinical. Imaging is not recommended as a first line except in the presence of red flags (2025 JOSPT CPG Desmeules).
  • No single test is enough. The 2025 JOSPT CPG recommends the Painful Arc to rule in and Hawkins-Kennedy to rule out. Salamh & Lewis 2020 argue for retiring the historical special tests.
  • Examination of the cervical spine is a compulsory step to rule out referred pain, the major differential diagnosis.
  • The modern approach stratifies into subgroups: high vs low irritability, a psychosocial-dominant profile (Chester 2018), nociceptive/nociplastic mechanisms, for precision physiotherapy.
  • The progressive therapeutic exercise and education are the first-line treatment (2025 JOSPT CPG - a strong recommendation, Pieters 2020 JOSPT umbrella SR).
  • No exercise protocol has been shown to beat another, but no trial has looked for that: Naunton 2020 (Clin Rehabil SR/MA) compares exercise with placebo, not the protocols with each other, and finds a benefit, an uncertain one, only for progressive resisted exercise. The key is progressive loading matched to tolerance.
  • The subacromial decompression surgery brings no additional benefit vs placebo or vs exercise (CSAW Lancet 2018 Beard, FIMPACT 5y Paavola 2021 BJSM, Cochrane Karjalainen 2019).
  • The corticosteroid injections give transient relief (a small effect, ≤ 8 weeks - Mohamadi 2017 CORR meta-analysis). No superiority over exercise in the medium to long term.
  • The shockwave therapy (ESWT) is useful for calcific tendinopathy (2024 SR/MA reviews). PRP is not superior to placebo.
  • The manual therapy brings a short-term benefit only when combined with exercise (Desjardins-Charbonneau 2015 SR/MA).
  • The overhead athlete (thrower, swimmer, volleyball player) shows a specific profile: GIRD, scapular dyskinesis, SLAP involvement - return to sport on criteria (strength > 90 %, symmetry of the ER/IR ratio, a throwing progression).
  • Management must be biopsychosocial : kinesiophobia, catastrophising and low self-efficacy are major predictors (Chester 2018 BJSM cohort n>1000).
  • The course is generally favourable (50-60 % improvement at 1 year), but intense initial pain and an adverse psychosocial profile predict persistence.
  • The red flags (a history of cancer, weight loss, non-mechanical night pain, fever, major trauma) call for immediate medical referral.
  • Return to sport / to work must be based on functional criteria (pain < 2/10, full range, strength ≥ 90 % of the sound side) and not on a preset timetable (2022 JOSPT CPG Return to Work, Lafrance).
  • Measure outcomes with validated PROMs: SPADI, DASH, Constant-Murley, PSFS makes shared decision-making with the patient easier (Hoffmann 2014).
  • Drug history : look for recent exposure to fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin), and to corticosteroid therapy given systemically or locally. Both raise the risk of tendinopathy and rupture, especially after the age of 60, in weight-bearing tendons and when the two are combined.

Contents

  1. What are the fundamentals to know about rotator cuff-related shoulder pain (RCRSP)?
    1. How is this condition defined, who does it affect and what are the risk factors?
    2. What happens in the tendon and how does the condition evolve naturally?
  2. How can RCRSP be assessed and diagnosed with certainty?
    1. Which questions should you ask to understand the patient and their history?
    2. Which clinical tests should you run and which other conditions must be ruled out?
    3. Should patients be classified into subgroups, and for what benefit?
  3. What are the most effective treatment strategies for RCRSP?
    1. Where do you start? What is the recommended hierarchy of interventions?
    2. Where does exercise fit in, and is there a superior approach?
    3. Manual therapies, technologies, injections: what is their real effectiveness?
    4. Beyond the physical: how do you educate the patient and address psychological factors?
  4. What is specific to the overhead athlete: thrower, swimmer, volleyball player
    1. GIRD, scapular dyskinesis and posterior internal impingement
    2. Specific criteria for return to overhead sport
  5. How do you ensure durable recovery and prevent recurrence?
    1. How do you make the patient an active participant in their recovery?
    2. When and how do you plan a safe return to sport and to work?
  6. What do concrete clinical cases teach us about RCRSP?
    1. Analysis of a "classic" case: from assessment to resolution
    2. The diagnostic challenge: when RCRSP mimics another condition
    3. Study of a complex case: calcific tendinopathy or dominant psychosocial factors
  7. How do you apply these recommendations concretely in your practice?
    1. When, and to which other health professionals, should you refer?
    2. How do you measure outcomes and overcome barriers to implementation?

What are the fundamentals to know about RCRSP?

In this chapter: the contemporary definition of Rotator Cuff-Related Shoulder Pain (Lewis 2016) and the abandonment of the "impingement" model, updated epidemiology (44-65 % of consultations for shoulder pain), metabolic risk factors ranked (Giri 2023), the Cook-Purdam tendon continuum model and the natural trajectory at 1 year.
RCRSP (Rotator Cuff-Related Shoulder Pain) is an umbrella term proposed by Jeremy Lewis in 2016 to cover what the old nosography separated artificially: rotator cuff tendinopathy, subacromial pain syndrome (SAPS), subacromial bursitis and non-traumatic partial tears.¹ The historical term "subacromial impingement", long central to management, has today been largely abandoned by the international guidelines: it presupposes a structural mechanism (bony compression) that is neither necessary nor sufficient to explain the pain, and it can instil a harmful belief in the patient ("something is catching and wearing out").²,³ RCRSP is therefore a clinical condition, defined by the symptoms and the response to movement, not by an image. 💪

How is RCRSP defined, who does it affect and what are the risk factors?

The contemporary definition, validated by the main guidelines (2025 JOSPT CPG Desmeules, 2022 JOSPT CPG Lafrance for return to work, Dutch SAPS Diercks 2014), rests on three pillars:⁴,⁵
  • Reproducible pain over the shoulder region (middle deltoid, anterolateral acromial area), triggered by active movements in elevation and rotation, without major trauma.
  • Functional limitation (dressing, reaching a shelf, sleeping on the side) with no neurological deficit and no frank instability.
  • Exclusion of the red flags and of the main differential diagnoses (cervical radiculopathy, frozen shoulder, glenohumeral instability, dominant acromioclavicular osteoarthritis).
RCRSP therefore stands against a structural nosography: the same patient can show a "supraspinatus tendinopathy" on ultrasound while being asymptomatic, and the other way round. The old distinction between "bursitis", "tendinitis" and "impingement" has no demonstrated therapeutic value: it is gradually being replaced by an approach centred on the clinical presentation and on irritability.²,³ The epidemiological burden is considerable. Shoulder pain is the 3rd most common reason for a musculoskeletal consultation in primary care after low back pain and neck pain, and RCRSP is by far the most frequent cause: across series, 44–65 % of shoulder pain in general practice is attributable to a cuff disorder.⁴ The lifetime prevalence of at least one clinically significant episode of shoulder pain is around 1 in 5 in the adult population. The prevalence of cuff tears rises linearly with age: in the pivotal Japanese cohort Yamamoto 2010 (n = 683 general population participants), the prevalence of a full-thickness tear reached around 20 % after 60, and beyond 25 % after 70, whether there was pain or not.⁶ This point is central: the ultrasound cohort Girish 2011 (AJR, n = 51 asymptomatic men) documented up to 96 % of cuff abnormalities in participants with no pain at all.⁷ The symptomatic shoulder is therefore not the "damaged" shoulder: it is the shoulder whose capacity falls short of the demand.
44-65 %Of shoulder pain in consultation = RCRSP⁴
1/5Lifetime prevalence of a shoulder episode
20 %Cuff tears after 60 (Yamamoto 2010)⁶
96 %Ultrasound abnormalities in the asymptomatic (Girish 2011)⁷

📊 Prevalence of cuff tears by age (Yamamoto 2010)

A Japanese general population cohort, n = 683, systematic bilateral ultrasound

Prevalence of cuff tears by age (Yamamoto 2010) 0 % 10 % 20 % 30 % 40 % 20-29 years ≈ 0 % 30-49 years ≈ 7 % 50-59 years ≈ 13 % 60-69 years ≈ 20 % ⚠️ A cuff tear can be asymptomatic: 96 % of ultrasound abnormalities in healthy men (Girish 2011)

Source: Yamamoto A, Takagishi K, Osawa T, et al. J Shoulder Elbow Surg. 2010;19(1):116-120. PMID 19540777. And Girish G, Lobo LG, Jacobson JA, et al. AJR. 2011;197(4):W713-9. PMID 21940544.

The risk factors for RCRSP are at once mechanical, metabolic and psychosocial. The meta-analysis Giri 2023 (Ann Phys Rehabil Med, 25 studies retained: 12 on diabetes, 5 on hypertension, 8 on dyslipidaemia) finds a modest but significant association between metabolic comorbidity and cuff disease:⁸
  • Age > 50 : progressive deterioration of the tendon matrix, falling cellularity and healing capacity. The prevalence of tears rises sharply after 60 (Yamamoto 2010).⁶
  • Repeated mechanical overload : manual work with the arm elevated (painter, plumber, electrician), overhead sports (throwing, swimming, volleyball, javelin), see chapter 4, devoted to the overhead athlete.
  • Diabetes : the meta-analysis Giri 2023 finds a moderate association with cuff disease (OR 1.49; 95 % CI 1.43 to 1.55), possibly through non-enzymatic glycation of collagen and chronic microangiopathy.⁸
  • Hypertension and dyslipidaemia : associations of the same order (OR 1.40 for hypertension, OR 1.48 for dyslipidaemia), the authors judging the risk of bias highest for hypertension.⁸
  • Smoking : reduced tendon oxygenation, documented delay in healing after surgery.
  • Psychosocial factors : kinesiophobia, catastrophising and low self-efficacy, independent predictors of the prognosis at 6-12 months (Chester 2018, a multicentre cohort of 1030 patients).⁹,¹⁰
Conversely,imaging is not a good predictor: the presence of a partial or even full-thickness asymptomatic tear in more than half of participants over 60 makes it a sign of tissue senescence, not a symptomatic aetiology.⁶,⁷

⚖️ Metabolic risk factors for cuff disease

A qualitative synthesis: meta-analysis Giri 2023 (Ann Phys Rehabil Med)

Metabolic risk factors for the cuff No association (ref) Weak Moderate Strong Very strong Age > 50 Very strong Diabetes Moderate (OR 1.49) Arm-elevated / overhead work Strong Hypertension / dyslipidaemia Moderate Smoking Moderate Kinesiophobia / catastrophising Prognostic predictor (Chester 2018)

Sources: Giri A, O'Hanlon D, Jain NB. Ann Phys Rehabil Med. 2023 (PMC9974529) for the metabolic factors, Yamamoto 2010 for age, Chester 2018 (PMID 27445360) for the psychosocial factors. A qualitative visualisation (narrative synthesis), not weighted by a pooled OR.

« RCRSP is not a local disease of the tendon. It is the painful expression of a mismatch between the capacity of the shoulder and the demand placed on it, modulated by metabolism, age, and the meaning the patient gives to their pain. »

What happens in the cuff and how does it evolve naturally?

The conceptual framework most used to understand tendon pathology of the cuff remains the Cook & Purdam 2009 continuum, taken up and refined by the successive international consensus statements on tendinopathy. The Nature Reviews Disease Primers 2021 review (Millar et al.) places rotator cuff tendinopathy in a three-phase model that is non-inflammatory in the classic sense of the term:¹¹,¹²
  1. Reactive : a proliferative and non-inflammatory response to an acute overload (painting a ceiling, an unusual day's work, a sudden increase in sporting load). The tendon thickens transiently through an increase in water and proteoglycan content in order to resist the stress. A reversible state with a reduction in load and analgesic isometrics.
  2. Dysrepair : if the overload persists, the matrix disorganises, cellularity rises, angiogenic factors appear. A partially reversible state: progressive loading stimulates remodelling.
  3. Degenerative : areas of cell necrosis, severe matrix disorganisation, dense neovascularisation. Often localised and surrounded by still-healthy tissue. The structural changes are barely reversible; the therapeutic objective is to optimise the function of the remaining healthy tissue, not to "heal" the degenerate area.¹¹

🔄 The cuff continuum: 3 tendon states

The Cook-Purdam framework transposed to cuff pathology (Millar 2021 Nat Rev Dis Primers)

Cuff tendon continuum 1. Reactive Acute overhead overload Transient thickening No disorganisation REVERSIBLE ↓ Overhead load + Analgesic isometrics + Pain education 2. Dysrepair Persistent overload Matrix disorganisation Increased cellularity PARTIALLY REVERSIBLE Progressive loading Cuff + scapular strengthening Endurance and motor control 3. Degenerative Cell necrosis A possible partial tear Healthy tissue at the periphery BARELY REVERSIBLE Optimise the remaining healthy tissue Recruit the scapula + latissimus dorsi No rush to imaging Unsuitable mechanical load ↓ Tendon capacity ↑ progression Load reduction + progressive work ↑ Tendon capacity ↓ regression

Source: Cook JL, Purdam CR. Br J Sports Med. 2009;43(6):409-416. PMID 18812414. Framework integrated by Millar NL et al. Nat Rev Dis Primers. 2021;7(1):1. doi:10.1038/s41572-020-00234-1.

The model is conceptual and pedagogical. The three states can coexist within the same cuff tendon and it is impossible to tell them apart formally on imaging alone. Its clinical value lies in the guidance it gives for load modulation : a "reactive" cuff (after a day of painting) responds to an immediate reduction in overhead load and to isometrics, whereas a "degenerative" cuff (a 60-year-old, a partial tear on ultrasound, pain for 18 months) requires prolonged strengthening and scapular integration work.¹¹ The natural course of RCRSP is variable but frequently becomes chronic without structured intervention. The systematic review Kuijpers 2004 (Pain), covering the prognostic cohorts of shoulder disorders, finds that around 50–60 % of patients report a clinically significant improvement at one year, but that 40 to 50 % keep residual pain or disability.¹³ The independent adverse prognostic factors identified are: symptom duration > 3 months at the first consultation, high initial pain intensity, kinesiophobia and catastrophising.⁹,¹⁰ Conversely, neither age nor imaging predicts the prognosis once these psychosocial factors are taken into account: a key argument for a biopsychosocial model and not a purely structural one.

Key points

  • The RCRSP (Lewis 2016) is an umbrella term covering tendinopathy, bursitis and non-traumatic partial tears of the cuff. The historical term "subacromial impingement" has been abandoned by the international guidelines.¹,²,³
  • Prevalence : 44-65 % of shoulder pain in consultation, a lifetime prevalence of 1 in 5, up to 20 % of tears after 60 (Yamamoto 2010), 96 % of ultrasound abnormalities in the asymptomatic (Girish 2011).⁶,⁷
  • Risk factors : age, overhead load, diabetes and metabolic comorbidity (Giri 2023), smoking. The psychosocial (kinesiophobia, catastrophising, Chester 2018) ones are independent predictors of the prognosis.⁸,⁹,¹⁰
  • The Cook-Purdam continuum (reactive → dysrepair → degenerative) remains the reference teaching framework for guiding load modulation.¹¹,¹²
  • Natural course : 50-60 % spontaneous improvement at 1 year, but 40-50 % with residual pain or disability without structured intervention (Kuijpers 2004).¹³imaging is not a prognostic predictor once the psychosocial factors are taken into account.
Bibliography
  1. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. PMID 26882892.
  2. Cuff A, Littlewood C. Subacromial impingement syndrome — What does this mean to and for the patient? A qualitative study. Musculoskelet Sci Pract. 2018;33:24-28. PMID 29065348.
  3. Lewis J. The end of an era? J Orthop Sports Phys Ther. 2018;48(3):127-129. doi:10.2519/jospt.2018.0102.
  4. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  5. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322. PMID 24847788.
  6. Yamamoto A, Takagishi K, Osawa T, et al. Prévalence and risk factors of a rotator cuff tear in the général population. J Shoulder Elbow Surg. 2010;19(1):116-120. PMID 19540777.
  7. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011;197(4):W713-9. PMID 21940544.
  8. Giri A, O'Hanlon D, Jain NB. Risk factors for rotator cuff disease: A systematic review and meta-analysis of diabetes, hypertension, and hyperlipidemia. Ann Phys Rehabil Med. 2023;66(1):101631. PMC9974529.
  9. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269-275. PMID 27445360.
  10. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743-748. PMID 27852585.
  11. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416. PMID 18812414.
  12. Millar NL, Silbernagel KG, Thorborg K, et al. Tendinopathy. Nat Rev Dis Primers. 2021;7(1):1. doi:10.1038/s41572-020-00234-1.
  13. Kuijpers T, van der Windt DAWM, van der Heijden GJMG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109(3):420-431. PMID 15157703.

How can RCRSP be assessed and diagnosed with certainty?

In this chapter: a clinically guided approach (history + functional tests), the tests recommended by the 2025 JOSPT CPG (Painful Arc / Hawkins-Kennedy), the critique of the historical tests put "out to pasture" (Salamh & Lewis 2020), the secondary place of imaging, the differential diagnoses (cervical radiculopathy, frozen shoulder, instability, AC joint), stratification by irritability and psychosocial profile.
The diagnosis of RCRSP is essentially clinical. The two main recent international guidelines (2025 JOSPT CPG Desmeules and Dutch SAPS Diercks 2014) are aligned: imaging is not recommended as a first-line investigation, and the correlation between structural abnormalities and symptoms is weak (a reminder from chapter 1: up to 96 % of ultrasound abnormalities in healthy men, Girish 2011).¹,²,³ The clinician must therefore treat the patient, not the image. 🩺

Which questions should you ask to understand the patient and their history?

The history opens the whole line of reasoning. 📝 It must characterise the pain, identify the actionable risk factors and, above all, stratify irritability and the psychosocial profile, which will dictate the pace of loading.⁴
  • Precise site : ask the patient to point. Pain over the shoulder region, middle deltoid, anterolateral acromial area → consistent with RCRSP. Cervicoscapular pain, radiation into the upper limb with paraesthesiae → suspicion of cervical radiculopathy. Focal acromioclavicular pain → isolated AC involvement.
  • Mode of onset : insidious over several weeks to months (typical of RCRSP) vs acute after clear trauma (a fall on the shoulder, traction on the arm) → suspicion of a traumatic tear or a glenohumeral lesion.
  • Time course :
    • Waking at night when rolling onto the shoulder → typical of RCRSP, frequent and disabling.
    • Pain on starting to move, improving after warming up → consistent with RCRSP.
    • Constant pain, at night without movement, deterioration in general condition → reconsider (a tumour, an infection, a systemic rheumatological process).
  • Triggering movements : elevation above the head, rotations (putting on a belt, doing up a bra behind the back), hand behind the back, carrying a load with the arm elevated. These "patterns" point to RCRSP rather than to frozen shoulder (where the loss of passive mobility dominates).
  • Recent changes in load : an intensification of manual work, overhead sport (thrower, swimmer, volleyball player, see chapter 4), moving house, painting, DIY, carrying a child.
  • Medical history : age > 50, diabetes, hypertension, dyslipidaemia, smoking (Giri 2023).⁵
  • Psychosocial profile : fear of movement, catastrophising, beliefs about pain ("my cuff is torn, so I am going to make it worse"), level of self-efficacy, major predictors of the prognosis (Chester 2018, Mallows 2017).⁶,⁷
  • Baseline PROMs : SPADI (Shoulder Pain and Disability Index, 13 items, 0-100, MCID ≈ 8-10 points), DASH or QuickDASH, PSFS for the patient's target activities. They make it possible to quantify severity and to follow progress.

🚩 Red flags to screen for from the history onwards

  • Clear trauma + complete functional impairment + the epaulette sign → suspicion of glenohumeral dislocation. An orthopaedic emergency.
  • Trauma + marked weakness + complete loss of active elevation in a young person → suspicion of an acute massive tear of the cuff → prompt surgical work-up (Desmeules CPG 2025).¹
  • Fever + hot swelling + exquisite tenderness → septic arthritis, an emergency.
  • A progressive palpable mass, night sweats, unexplained weight loss, deterioration in general condition → oncological work-up (bone metastases, primary tumour, rare but to be considered).
  • Paraesthesiae, motor deficit, absent reflexes in a root territory → cervical radiculopathy, thoracic outlet syndrome, plexopathy → neurological examination + cervical MRI.
  • Atypical referred pain (the left shoulder in a cardiac patient, the right shoulder in a biliary or pulmonary one) → rule out projected visceral pain.

Which clinical tests should you run and which other conditions must be ruled out?

The physical examination combines inspection, palpation, active/passive movement and specific tests. ⚠️ The most important finding of the recent literature is the failure of the historical tests to discriminate between injured structures: the umbrella review Hegedus 2012 (BJSM, a synthesis of SRs/MAs), the Cochrane review Hanchard 2013 and the meta-analysis Alqunaee 2012 all converge: no specific test has sufficient sensitivity and specificity taken in isolation.⁸,⁹,¹⁰ Salamh & Lewis (2020, JOSPT) symbolically called for the special tests to be "put out to pasture" (out to pasture).¹¹ Recommendations of the 2025 JOSPT CPG (Desmeules): only two clinical tests are retained with a level of evidence sufficient for decision-making:¹
  • Painful Arc Sign (a painful arc between 60° and 120° of active abduction in the scapular plane) → a reasonable rule-in for RCRSP (the highest specificity among the usual tests).
  • Hawkins-Kennedy test (90° flexion + passive internal rotation) → a reasonable rule-out (the highest sensitivity); a negative test lowers the probability of RCRSP.
The other historical tests (Neer, Jobe / empty can, Yocum, drop arm, full can) are not recommended as discriminating tests: their added diagnostic value is low, and using them keeps alive the obsolete structural model of "impingement".¹¹ Functional examination : assessment of active movement (elevation, abduction, medial-axillary and inferior rotations) and passive movement, preserved full passive mobility is an essential criterion for ruling out a frozen shoulder. Isometric strength tests (abduction at 0°, external rotation at 0°) to assess strength and reproduce the pain. Controlled active examination of the scapula (dyskinesis) in the overhead athlete (see chapter 4).
Clinical testWhat it assessesPerformance (Hegedus 2012 / Alqunaee 2012)2025 JOSPT CPG recommendation
Painful Arc SignReproduction of pain at 60-120° of active abductionSp ~ 80 %, Se ~ 53 %Recommended (rule-in)
Hawkins-Kennedy90° flexion + passive internal rotationSe ~ 80 %, Sp ~ 56 %Recommended (rule-out)
Neer testMaximal passive flexionSe ~ 79 %, Sp ~ 53 %Limited diagnostic value
Jobe / empty canSupraspinatus testSpecial tests are not discriminatingNot recommended for discrimination
Drop arm testSuspicion of a major tearGood specificity, low sensitivityAn adjunct if a tear is strongly suspected
Overall passive mobilityTelling RCRSP from a frozen shoulderPreserved passive mobility = the diagnostic pivotEssential
SPADI / DASH / PSFS (PROMs)Overall severity, follow-upDocumented validity and responsivenessRecommended for follow-up
Imaging (ultrasound / MRI)Anatomical work-up as a second-line investigationWeak symptom / image correlation (Girish 2011)Not as a first line
The place of imaging : neither the Dutch SAPS Diercks 2014 nor the 2025 JOSPT CPG Desmeules recommends first-line imaging in non-traumatic RCRSP.¹,² It is justified in 4 situations:
  1. Suspicion of an acute traumatic tear in a younger person with marked functional impairment.
  2. Failure of at least 6-12 weeks of structured conservative treatment with reassessment of the diagnosis.
  3. Suspicion of an alternative diagnosis (a tumour, a systemic rheumatological disorder, an acutely painful calcification).
  4. Preoperative work-up if surgery is being considered.
🎯 The major differential diagnoses of RCRSP:
  • Cervical radiculopathy (C5-C6) : the most frequent "mimic". Cervicoscapular pain radiating into the arm, sometimes paraesthesiae in the C5 territory (lateral aspect of the arm) or C6 (thumb, index finger). Spurling test, Lhermitte sign, examination of the reflexes (biceps, brachioradialis).
  • Frozen shoulder (adhesive capsulitis) : loss of passive mobility (lateral rotation at 0° of abduction and passive elevation in particular) is the central criterion. Often associated with diabetes. It runs in 3 phases over 12-24 months.
  • Glenohumeral instability : suspect it in a young person with a history of dislocation/subluxation. Apprehension tests, relocation test.
  • Isolated acromioclavicular osteoarthritis : focal pain over the AC joint, pain on cross-body adduction, tenderness on direct palpation.
  • Acute calcific tendinopathy : abrupt pain, sometimes extremely intense, without trauma. An anteroposterior radiograph in external rotation = an immediate diagnosis (dense calcium).
  • Rheumatoid arthritis / spondyloarthritis : multi-joint involvement, prolonged morning stiffness, inflammatory markers.
  • Projected visceral pathology : cardiac (left shoulder), biliary or diaphragmatic (right shoulder), apical pulmonary (Pancoast sign).

Should patients be classified, and along which axes?

Yes. The 2025 JOSPT CPG does not offer a stratification grid; the one that follows is an editorial synthesis, along two axes, intended to guide the pace and the content of management:
  1. Irritability :
    • High irritability : pain ≥ 7/10, frequent night waking, pain at rest, pain already on small movements. → First approach: education + analgesic modalities + sub-painful isometrics + low-load exercises. Short-term objective: modulate the irritability before progressing the load.
    • Moderate irritability : pain 4-6/10, functional, triggered by moderate effort. → Progress to cuff strengthening and scapular stabilisation.
    • Low irritability : pain ≤ 3/10, functional, triggered by high load only. → Progress to functional loading, eccentric exercises, return to the target activities.
  2. Psychosocial profile :
    • A dominant psychosocial profile (high kinesiophobia, catastrophising, low self-efficacy, painful comorbidity, depression): pain education, a cognitive behavioural approach, possibly shared care with a psychologist alongside the motor programme (Chester 2018, Mallows 2017).⁶,⁷
    • A dominant motor profile (a strength deficit, poor scapular control, intolerance of load with no yellow flags): a progressive strengthening programme centred on the cuff and the scapula.
« You do not treat an ultrasound scan. You treat a patient who is in pain, who can no longer sleep on their side, who can no longer lift their child. Imaging answers a precise question (an acute tear? a tumour?), not the general diagnostic question. »

Key points

  • The diagnosis of RCRSP is essentially clinical. Imaging is not recommended as a first line (Desmeules 2025 JOSPT CPG, Dutch SAPS 2014).¹,²
  • The 2025 JOSPT CPG retains only two useful tests : Painful Arc Sign (rule-in) and Hawkins-Kennedy (rule-out). The other historical tests (Neer, Jobe, drop arm taken in isolation) are not discriminating (Hegedus 2012, Hanchard 2013, Alqunaee 2012, Salamh & Lewis 2020).⁸,⁹,¹⁰,¹¹
  • PROMs recommended: SPADI, DASH/QuickDASH, PSFS, at baseline and at every reassessment.
  • Major differential diagnoses : cervical radiculopathy, frozen shoulder, glenohumeral instability, isolated AC osteoarthritis, acute calcific tendinopathy, projected visceral pathology.
  • Red flags to screen for: clear trauma + impairment (dislocation, massive tear), fever + swelling (septic arthritis), a mass + deterioration + night sweats (oncological), neurological signs (radiculopathy, plexopathy).
  • Stratify along 2 axes (an editorial synthesis, absent from the 2025 JOSPT CPG): irritability (high / moderate / low) and psychosocial profile. The content and the pace of the programme follow from them.
Bibliography
  1. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  2. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322. PMID 24847788.
  3. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011;197(4):W713-9. PMID 21940544.
  4. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. PMID 26882892.
  5. Giri A, O'Hanlon D, Jain NB. Risk factors for rotator cuff disease: A systematic review and meta-analysis of diabetes, hypertension, and hyperlipidemia. Ann Phys Rehabil Med. 2023;66(1):101631. PMC9974529.
  6. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269-275. PMID 27445360.
  7. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743-748. PMID 27852585.
  8. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Br J Sports Med. 2012;46(14):964-978. PMID 22773322.
  9. Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y. Physical tests for shoulder impingements and local lésions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev. 2013;(4):CD007427. PMID 23633343.
  10. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93(2):229-36. PMID 22289231.
  11. Salamh P, Lewis J. It Is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture. J Orthop Sports Phys Ther. 2020;50(5):222-225. PMID 32272031.
  12. Lewis J. The end of an era? J Orthop Sports Phys Ther. 2018;48(3):127-129. doi:10.2519/jospt.2018.0102.

What are the most effective treatment strategies for RCRSP?

In this chapter: the evidence-based therapeutic hierarchy (2025 JOSPT CPG Desmeules, Dutch SAPS Diercks 2014), what Naunton 2020 and Pieters 2020 really say about exercise protocols, the limited place of manual therapy (Desjardins-Charbonneau 2015), the demonstrated failure of subacromial decompression surgery (CSAW Beard 2018, FIMPACT Paavola 2021, Cochrane Karjalainen 2019), the small and transient effect of corticosteroids (Mohamadi 2017), psychosocial factors (Chester 2018).
The management of RCRSP has undergone a conceptual revolution over the past decade. The historical idea that a "subacromial impingement" would justify surgical decompression has been refuted by three pivotal RCTs: CSAW Beard 2018 (Lancet, n = 313), FIMPACT Paavola 2018/2021 (BMJ/BJSM, sham-controlled, 5-year follow-up), and Cochrane Karjalainen 2019.¹,²,³ In parallel, the recent systematic reviews have established the primacy of active interventions without, however, separating the protocols from one another: Naunton 2020 (CR) sets exercise against placebo and Pieters 2020 (JOSPT update) concludes that the type, dose and duration remain to be established.⁴,⁵ The practical consequence is clear: no "magic bullet" exists, and the quality of the education and load modulation counts at least as much as the exact technique of the exercises.

Where do you start? What is the recommended hierarchy of interventions?

The 2025 JOSPT CPG Desmeules and the Dutch SAPS 2014 are aligned: two unavoidable pillars before any other intervention.⁶,⁷
  1. Patient education and reassurance : deconstruct the "impingement" model (Cuff & Littlewood 2018), explain the not purely structural nature of the pain, set realistic expectations (recovery = 3-6 months for most, sometimes longer where there are psychosocial factors), normalise the presence of ordinary imaging abnormalities with age (Girish 2011, Yamamoto 2010).⁸
  2. A progressive exercise programme centred on the cuff and on scapular stabilisation: the cornerstone of treatment, strongly recommended as a first line (Pieters 2020), even though the placebo-controlled trials remain few and of low certainty (Naunton 2020).⁴,⁵
The adjunct therapies (manual therapy, ESWT for calcifications, taping) are justified only as a complement to a well-conducted exercise programme. The subacromial corticosteroid injections give small and transient relief (the meta-analysis Mohamadi 2017: an effect at 8 weeks that dies away by 6 months), with an opportunity cost if they delay getting the shoulder moving.⁹ The subacromial decompression surgery is not superior to placebo in non-traumatic RCRSP: one of the most striking results in the orthopaedic literature of the past decade.¹,²,³

🔺 Therapeutic pyramid for RCRSP

From the most invasive (top) to the most universal (base): a hierarchy of intent

Therapeutic pyramid RCRSP ⬆ + invasive ⬇ + universal Subacromial decompression Not superior to placebo CSAW Beard 2018 · FIMPACT Paavola 2021 · Cochrane 2019 Subacromial corticosteroid injections Small, transient Mohamadi 2017 MA: an effect at 8 weeks, gone by 6 months Manual therapy + ESWT (calcific) An adjunct Desjardins-Charbonneau 2015: a short-term effect Progressive exercise (cuff + scapula) The central pillar Naunton 2020 · Pieters 2020: the progression of load Education + reassurance + load adaptation 100 % The foundation: deconstructing the "impingement" model

Sources: Beard DJ et al. CSAW Lancet 2018 (PMID 29169668); Paavola M et al. FIMPACT 5 years BJSM 2021 (PMID 33020137); Karjalainen Cochrane 2019 (PMID 30707445); Mohamadi 2017 (PMID 27469590); Naunton 2020 SR/MA; Pieters 2020 JOSPT update.

Where does exercise fit in, and is there a superior approach?

🏋️ Exercise is the best-documented active treatment in RCRSP, with a high level of evidence (Desmeules 2025 JOSPT CPG).⁶ The debate of the past decades has been about the best protocol : eccentric vs concentric, progressive vs non-progressive, high vs low load. The meta-analysis Naunton 2020 (Clin Rehabil, 7 trials, 468 participants) does not settle that debate, because it does not compare the protocols with each other: it sets progressive resisted exercise, and then non-progressive non-resisted exercise, separately against placebo or no treatment. The first achieves an uncertain clinical benefit on pain and function (15 points out of 100, 95 % CI 9 to 21, between 6 weeks and 6 months), the second no significant benefit (4 points, 95 % CI -2 to 9), with low certainty in both cases.⁴ The review Pieters 2020 (JOSPT update) strongly recommends exercise as a first line but concludes that the type, dose and duration of exercise remain to be established.⁵ Several practical principles emerge:
  1. Cuff strengthening : abduction, external rotation (ER) and internal rotation (IR) in closed as well as open chain. Progression from sub-painful to a significant load.Sub-painful isometrics are useful in a phase of high irritability to modulate the pain without provoking a flare-up.
  2. Scapular stabilisation and motor control : activation of serratus anterior, of the scapular fixators (middle and lower trapezius, rhomboids), correction of dyskinesis, particularly in the overhead athlete (see chapter 4).
  3. Functional reintegration : exercises that integrate the shoulder into the whole kinetic chain, movements specific to the work or the sport, a gradual return to the target load.
  4. Dosage : 2 to 3 sessions a week for at least 8 to 12 weeks, movements within a tolerable zone (acceptable pain, modulated by irritability).Adherence is more decisive than the exact technique: a patient who keeps up a simple programme for 12 weeks will do better than a patient who abandons a complex one at 4 weeks.

⚖️ Effect of the active interventions in RCRSP

A qualitative synthesis: the effect against placebo or no treatment (Naunton 2020, Pieters 2020)

Effect of the active interventions in RCRSP Effect = 0 (control) Weak Moderate Large Progressive cuff strengthening Uncertain (15 pts/100) Non-progressive exercise Not significant (4 pts) Scapular stabilisation Moderate Manual therapy (adjunct) Small, short-term Wait-and-see / placebo Reference

Sources: Naunton J et al. Clin Rehabil. 2020 (doi:10.1177/0269215520934147); Pieters L et al. JOSPT 2020 (doi:10.2519/jospt.2020.8498); Desjardins-Charbonneau A et al. JOSPT 2015 for manual therapy (doi:10.2519/jospt.2015.5455). A qualitative visualisation.

Adjunct therapies and surgery: what should be expected of them?

💡 The adjunct modalities must all be considered as a complement to exercise, never as a substitute. Manual therapy (glenohumeral and thoracic mobilisation, manipulation of the cervicothoracic region): the meta-analysis Desjardins-Charbonneau 2015 (JOSPT): an adjunct short-term effect on pain when combined with exercise. No superiority in the long term. It can make it easier to get a highly irritable patient moving.¹⁰ Subacromial corticosteroid injections : the meta-analysis Mohamadi 2017 (Clin Orthop Relat Res) quantified their effect precisely: a small relief, perceptible in the short term (4-8 weeks), which dies away by 6 months.⁹ A potential indication: a patient with high irritability in whom an analgesic window would allow active work to start. The risk: if the injection is presented as a "treatment", it can on the contrary delay active management and keep alive the purely biomedical model. NSAIDs and analgesics : reasonable relief in the short term, without changing the long-term prognosis. The 2025 JOSPT CPG mentions NSAIDs as an occasional option for managing a flare.⁶ ESWT (shockwave therapy) : the best-documented indication is in calcific tendinopathy of the cuff. For RCRSP without calcification, the additive effect on exercise is more debated. To be reserved for refractory chronic cases. Subacromial decompression surgery : this is the pivotal point of the decade. Three RCTs converge:
  • CSAW Beard 2018 (Lancet, n = 313, 32 UK hospitals, 3 arms: arthroscopic decompression vs diagnostic arthroscopy vs active monitoring): no clinically significant superiority of decompression over diagnostic arthroscopy, and a clinically marginal difference vs monitoring.¹
  • FIMPACT Paavola 2018/2021 (BMJ then BJSM 5 years): sham-controlled, decompression vs diagnostic arthroscopy vs supervised exercise. At 5 years, none of the three interventions is superior to the others.²
  • Cochrane Karjalainen 2019 (CD005619): a systematic review pooling the RCTs: it confirms the absence of a clinically important benefit of subacromial decompression vs control interventions.³
The Cochrane review Karjalainen 2019 on tendon repair surgery (non-massive tears, CD013502) does not conclude in favour of a benefit either: at one year, repair probably does not improve pain or function compared with exercises, with or without a corticosteroid injection, and the authors remain uncertain about its clinical value.¹¹ Surgical indications must stay reserved for acute traumatic tears in the young or for documented failures of structured conservative treatment.
ModalityMain indicationLevel of evidenceExpected effect
Education + load modulationAll patientsHigh↗ adherence, ↘ recurrence, ↘ fear of movement
Progressive exercise (cuff + scapula)All patients, 8-12+ weeksHighThe central pillar, Naunton 2020 and Pieters 2020
Education + reassurance + load adaptationAll patientsHighThe foundation. Deconstructing the "impingement" model (Lewis 2018)
Manual therapy (adjunct)Short term, high irritabilityModerateA small, short-term effect (Desjardins-Charbonneau 2015)
NSAIDsAn acute painful episodeModerate in the short termNo effect on the long-term prognosis
Subacromial corticosteroid injectionA patient with high irritabilityA small, transient effectDies away by 6 months (Mohamadi 2017)
ESWTCalcific tendinopathy above allModerate if there are calcificationsMore debated without calcification
Subacromial decompression (surgery)—Not superior to placeboCSAW 2018, FIMPACT 2021, Cochrane 2019¹,²,³
Surgical tendon repairAn acute traumatic tear in a young personSelected casesNo clear superiority vs exercise (Cochrane Karjalainen 2019)¹¹
Ultrasound / laser / TENS aloneA symptomatic adjunctLowInsufficient evidence

Beyond the physical: how do you act on the psychosocial factors?

🧠 Psychosocial factors are a major determinant of the prognosis in RCRSP, and are frequently under-treated. The multicentre cohort Chester 2018 (n = 1030, BJSM) established that kinesiophobia, catastrophising and low self-efficacy are independent predictors of the outcome of physiotherapy at 6 and 12 months.¹² The review Mallows 2017 confirms these results for tendinopathy in general.¹³ Patient education must be active and proactive on four points:
  • Reframe the pain : the presence of an imaging abnormality is not "proof" that the pain will be permanent or that the tissue is going to "break". 96 % of asymptomatic men have ultrasound abnormalities (Girish 2011)¹⁴: a key message to deliver very early.
  • Deconstruct the myths : "my cuff is catching and wearing out", "it needs an operation", "if I move I will make it worse", "rest heals the cuff", so many structural beliefs that keep kinesiophobia alive (Cuff & Littlewood 2018, a qualitative study).⁸
  • Set realistic expectations : recovery = 3 to 6 months for most, sometimes longer where there are psychosocial factors, non-linear, with fluctuations to be expected.
  • Self-efficacy : give the patient concrete tools (a written programme, PROM follow-up, simple criteria for adjusting the load) so that they become an actor in their recovery.
For patients with a dominant psychosocial profile (chapter 2), a cognitive behavioural approach or referral to a psychologist specialising in chronic pain may be needed alongside the motor management.¹²,¹³

Critique and controversy

The "exercise protocol war" (pure eccentric vs progressive vs concentric-eccentric) has in fact never been settled for RCRSP: neither Naunton 2020 nor Pieters 2020 compares the protocols with each other, and Pieters concludes that the type, dose and duration of exercise remain to be documented.⁴,⁵ The commercial pressure around specific techniques (a "single protocol") owes more to marketing than to evidence. More problematic: despite three pivotal RCTs (CSAW, FIMPACT, Cochrane) showing the absence of superiority of subacromial decompression, the procedure is still widely performed in many health systems.¹,²,³ This "knowing-doing gap" is a major challenge of the coming decade, with far from negligible economic and iatrogenic-exposure consequences. The clinician must pass these data on to the patient to inform a shared decision (chapter 7). Finally, the "symptomatic patient vs abnormal imaging" dichotomy is still poorly accepted by some: a typical clinical presentation of RCRSP with a partial tear on ultrasound is not an indication for surgery in the short term: a fact that still sometimes contradicts common discourse.

Key points

  • ✅ First line : education + reassurance + a progressive exercise programme (cuff + scapula) over at least 8-12 weeks. A high level of evidence (2025 JOSPT CPG Desmeules).⁶
  • ✅ No exercise protocol has been shown to beat another in RCRSP, for want of trials comparing them (Naunton 2020, Pieters 2020): what is documented is the benefit of progression and of resisted loading.⁴,⁵
  • ✅ Manual therapy : a short-term adjunct only (Desjardins-Charbonneau 2015).¹⁰
  • ⚠️ Corticosteroid injections : a small and transient effect (Mohamadi 2017). To be used sparingly, never as a standalone "treatment".⁹
  • ❌ Subacromial decompression is not superior to placebo in non-traumatic RCRSP (CSAW Beard 2018 Lancet, FIMPACT Paavola 2021 BJSM 5 years, Cochrane Karjalainen 2019).¹,²,³
  • ✅ Systematically address psychosocial factors : Chester 2018 (n = 1030), kinesiophobia and catastrophising are independent predictors of the prognosis.¹²
Bibliography
  1. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial décompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-338. PMID 29169668.
  2. Paavola M, Malmivaara A, Taimela S, et al. Subacromial décompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. Br J Sports Med. 2021;55(2):99-107. PMID 33020137.
  3. Karjalainen TV, Jain NB, Page CM, et al. Subacromial décompression surgery for rotator cuff disease. Cochrane Database Syst Rev. 2019;1(1):CD005619. PMID 30707445.
  4. Naunton J, Street G, Littlewood C, Haines T, Malliaras P. Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2020;34(9):1198-1216. doi:10.1177/0269215520934147.
  5. Pieters L, Lewis J, Kuppens K, et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. J Orthop Sports Phys Ther. 2020;50(3):131-141. doi:10.2519/jospt.2020.8498.
  6. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  7. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322. PMID 24847788.
  8. Cuff A, Littlewood C. Subacromial impingement syndrome — What does this mean to and for the patient? A qualitative study. Musculoskelet Sci Pract. 2018;33:24-28. PMID 29065348.
  9. Mohamadi A, Chan JJ, Claessen FM, et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017;475(1):232-243. PMID 27469590.
  10. Desjardins-Charbonneau A, Roy JS, Dionne CE, et al. The Efficacy of Manual Therapy for Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis. J Orthop Sports Phys Ther. 2015;45(5):330-350. doi:10.2519/jospt.2015.5455.
  11. Karjalainen TV, Jain NB, Heikkinen J, et al. Surgery for rotator cuff tears. Cochrane Database Syst Rev. 2019;12(12):CD013502. PMID 31813166.
  12. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269-275. PMID 27445360.
  13. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743-748. PMID 27852585.
  14. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011;197(4):W713-9. PMID 21940544.
  15. Lewis J. The end of an era? J Orthop Sports Phys Ther. 2018;48(3):127-129. doi:10.2519/jospt.2018.0102.

What is specific to the overhead athlete (thrower, swimmer, volleyball player)?

In this chapter: the specific profile of the overhead athlete (baseball, javelin, swimming, volleyball, handball, tennis), GIRD and the adaptations of the dominant shoulder (Wilk 2002, Wilk 2013), the differential diagnoses (SLAP, posteroinferior instability, posterosuperior internal impingement), a scapular prevention programme (Cools 2015), the criteria for return to sport.
The overhead athlete (baseball pitcher, javelin thrower, competitive swimmer, volleyball, tennis or handball player), represents a specific population within RCRSP. The repeated biomechanical demands of the throwing or serving movement produce physiological adaptations of the dominant shoulder (called the thrower's shoulder) that are at once protective and risk-bearing, and that make a generic approach insufficient.¹,² 🤾

GIRD, scapular dyskinesis and the "thrower's shoulder" profile

The review by Wilk et al. 2002 (Am J Sports Med) and then 2013 (Int J Sports Phys Ther) describes precisely the chronic adaptations of the thrower's dominant shoulder:¹,²
  • An increase in external rotation at 90° of abduction (up to +15 to +20° vs the non-dominant side), allowing the cocking phase of the throw.
  • A decrease in internal rotation at 90° of abduction: the well-known GIRD (Glenohumeral Internal Rotation Deficit). A GIRD is defined clinically as a difference > 20° between the dominant and the non-dominant side. Part of it is adaptive (humeral retroversion acquired during skeletal maturation), another part pathological (a stiff posterior capsule, accentuation of the posterosuperior internal impingement).
  • Total ROM (TROM) : the sum of ER + IR must be comparable on the dominant and the non-dominant side (the rule of a < 5° difference). A loss of TROM is a warning sign: independently of the GIRD.
  • Scapular dyskinesis : an altered scapulohumeral rhythm, reduced activation of serratus anterior, dominance of upper trapezius. The scapular dyskinesis test allows a reproducible visual assessment.³
  • Strength deficits of the external rotators : a lowered ER/IR ratio (ER force/IR force), the classic target is > 0.66, or even > 0.75 for high-level throwing sports.

🎯 The typical GIRD of the thrower

Dominant vs non-dominant side, rotation at 90° of abduction

GIRD in the thrower Non-dominant side Dominant side (throwing) ER 100° IR 65° TROM = 165° ER 120° (+20° adaptive) IR 40° (-25° GIRD) TROM = 160° →

⚠️ Interpretation: GIRD > 20° = a warning sign. The loss of Total ROM (TROM > 5° between the two sides) is a more powerful risk factor than an isolated GIRD. Sources: Wilk KE et al. Am J Sports Med. 2002 (PMID 11799012); Manske R, Wilk KE et al. Int J Sports Phys Ther. 2013 (PMID 24175137).

> 20°GIRD = a warning sign (Wilk 2002)¹
> 0.66Target ER/IR ratio for the thrower²
< 5°Acceptable TROM difference between sides
> 90 %Minimum strength symmetry for RTS

Differential diagnoses specific to the overhead athlete

Shoulder pain in the overhead athlete is not limited to RCRSP. Several entities must be actively looked for:
  • SLAP lesion (Superior Labrum Anterior to Posterior): detachment of the superior labrum. In the thrower, a sensation of an internal "pop", pain in late cocking, a loss of throwing velocity. The O'Brien, Speed and Yergason tests have limited diagnostic value (chapter 2, Salamh & Lewis 2020). MR arthrography remains the reference examination if surgery is being considered.⁴
  • Posteroinferior (subclinical multidirectional) instability : capsular laxity with chronic microsubluxation. Sulcus, posteroinferior apprehension and drawer tests. Often responsible in the competitive swimmer.
  • Posterosuperior internal impingement (described by Walch): pathological contact of the supraspinatus tendon and the posterosuperior labrum in maximal abduction-external rotation (the cocking phase). It can be associated with a SLAP lesion and with a GIRD.
  • Isolated tendinopathy of the long head of biceps : reproducible by palpating the bicipital groove, the Speed and Yergason tests.
  • Anterosuperior subscapularis impingement : anterior pain, weakness in internal rotation against resistance, the belly-press sign.

Prevention in the overhead athlete: what do we know?

The review by Cools et al. 2015 (Braz J Phys Ther) brings together the main determinants of prevention:³
  1. Specific strengthening of the scapular fixators : serratus anterior, middle and lower trapezius, rhomboids. Typical exercises: Y-T-W, push-up plus, dynamic hug, robbery (low rows).
  2. Strengthening of the external rotators : restore an ER/IR ratio > 0.66, isometric and concentric-eccentric exercises with a band or a pulley.
  3. Posterior capsular stretching : sleeper stretch, cross-body stretch, the structural effect is debated but they are widely used to correct a pathological GIRD.
  4. Monitoring of the throwing load : pitch count in the baseball pitcher (rules published by USA Baseball/MLB Pitch Smart by age), serve volume in tennis, weekly distance in the swimmer.
  5. Periodisation : development, competition and recovery phases, avoiding abrupt jumps in volume / intensity.
The effectiveness of prevention programmes in cluster RCTs is moderate but the biomechanical and clinical argument remains strong enough to recommend them widely, particularly in the young thrower with a growing skeleton.³
« The thrower's shoulder is not a shoulder like any other. An external rotation of 120° is not laxity: it is an adaptation. But an internal rotation of 40° is a yellow flag, and a sign that the kinetic chain is folding back onto the shoulder. »

Specific criteria for return to overhead sport

🏈 The return to overhead sport after an episode of RCRSP must never be based on elapsed time alone. The function-based criteria derive from the Wilk 2013 and Cools 2015 recommendations:²,³
  1. No pain at rest and during everyday movements.
  2. Isometric strength symmetry > 90 % vs the sound side (ER at 0° and 90° of abduction, IR, abduction).
  3. ER/IR ratio > 0.66 (preferably > 0.75 for the high-level thrower).
  4. Symmetrical TROM (a < 5° difference between the sides at 90° of abduction).
  5. Progressive tolerance of the target load : a progressive throwing/serving programme (interval throwing programme, return-to-serve programme), low volumes and controlled intensity to begin with, a gradual increase respecting a rule of acceptable pain and manageable fatigue.
  6. Restoration of the whole kinetic chain : a poor trunk-to-upper-limb transfer overloads the shoulder. The return to sport goes through assessment and work on the lower limbs, the core and energy transfer.

⭐ Key points

  • The thrower's shoulder is an adapted shoulder: increased ER, decreased IR (GIRD), with a warning threshold of > 20° for the GIRD and > 5° for the loss of TROM (Wilk 2002, Wilk 2013).¹,²
  • Critical differential diagnoses: SLAP, posteroinferior instability, posterosuperior internal impingement, biceps tendinopathy, anterosuperior impingement.⁴
  • A prevention programme (Cools 2015): scapular fixators + external rotators + posterior stretching + load monitoring. Widely recommended in the young thrower.³
  • Return to sport = functional criteria: strength > 90 %, ER/IR ratio > 0.66, symmetrical TROM, a progressive throwing programme. No "magic timetable".
  • The imaging keeps its role in confirming or ruling out a clinically suspected SLAP, but must not replace a thorough clinical examination.
Bibliography
  1. Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30(1):136-151. PMID 11799012.
  2. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. The recognition and treatment of superior labral (slap) lesions in the overhead athlete. Int J Sports Phys Ther. 2013;8(5):579-600. PMID 24175139.
  3. Cools AM, Johansson FR, Borms D, Maenhout A. Prévention of shoulder injuries in overhead athletes: a science-based approach. Braz J Phys Ther. 2015;19(5):331-339. PMID 26537804.
  4. Salamh P, Lewis J. It Is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture. J Orthop Sports Phys Ther. 2020;50(5):222-225. PMID 32272031.
  5. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  6. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. PMID 26882892.

How do you ensure durable recovery and prevent recurrence?

In this chapter: structured self-management and patient empowerment, progressive load management, the role of psychosocial factors (Chester 2018, Mallows 2017), functional criteria for return to sport, the 2022 Lafrance CPG on return to work (JOSPT), a realistic trajectory to share with the patient.
The durable recovery and the prevention of recurrence are the central challenge in managing RCRSP. The review Kuijpers 2004 recalled that 40 to 50 % of patients keep residual pain or disability at one year without structured intervention.¹ Beyond the resolution of the acute episode, the patient must be prepared for active long-term management of their load, their beliefs and their self-efficacy.

How do you make the patient an actor in their recovery?

🎯 Structured self-management is one of the key principles defended by the 2025 JOSPT CPG Desmeules.² It rests on four concrete pillars:
  • Education about pain and about the not purely structural nature of RCRSP: imaging abnormalities are ordinary with age (96 % in asymptomatic men, Girish 2011; up to 20 % of tears after 60, Yamamoto 2010).³,⁴ This information alone reduces fear of movement in many patients (Cuff & Littlewood 2018, a qualitative study).⁵
  • A written home exercise programme : 2 to 3 sessions a week, cuff and scapular stabilisation exercises, movements within a tolerable zone. Simplicity and repeatability come before complexity.
  • Progressive load management : a return to everyday and work activities, the principle of graded exposure to the avoided movements. Applying the principles of the 2022 Lafrance CPG (Return to Work).⁶
  • PROM follow-up : SPADI, DASH or PSFS every 4-6 weeks to objectify progress and disconnect the clinical decision from emotionally "bad days".
The psychosocial factors must be actively taken into account. Chester 2018 (n = 1030, BJSM) established that kinesiophobia, catastrophising and self-efficacy explain a significant part of the variance in outcomes at 6 months.⁷ For patients with a dominant psychosocial profile, a cognitive behavioural approach (included in the physiotherapy work where there is competence, or in shared care with a psychologist) improves outcomes.⁷,⁸

When and how do you plan a safe return to sport and to work?

🏋️ The return to activities (work, everyday life, sport) must be based on functional criteria and not on a preset timetable. The 2022 Lafrance CPG (JOSPT) offers specific recommendations for return to work in cuff disorders: a gradual return, adaptation of the workstation where possible, joint management with the employer and the occupational physician, support for occupational self-efficacy.⁶ General criteria to aim for before a full return to activity (a synthesis of the Desmeules 2025 CPG, Wilk 2002 for overhead):
  1. Pain ≤ 2/10 at rest and during everyday activities (dressing, reaching a high shelf, sleeping on the side).
  2. Active range preserved or symmetrical (elevation in particular, rotations at 90° of abduction).
  3. Isometric strength symmetry > 90 % vs the sound side (abduction, ER, IR).
  4. Progressive tolerance of the target load : sustain the critical work or sporting movement for the usual duration without clear reproduction of the pain.
  5. A clinically significant improvement in the PROM (SPADI: a reduction of ≥ 8-10 points; DASH: a reduction of around ≥ 10 points).
  6. For the overhead athlete: additional specific criteria (ER/IR ratio > 0.66, symmetrical TROM, a throwing progression: chapter 4).

🚦 Flow chart: a function-based return to activity

A sequenced, criterion-based decision (vs calendar-based)

Flow chart return to activity RCRSP Step 1: Self-management Education + home exercises Step 2: Progressive loading Graded exposure to the avoided movements Step 3: Return to work Adaptation of the workstation (Lafrance 2022) Step 4: Check the functional criteria Pain ≤ 2/10 · Strength > 90 % · PROM improved ≥ MCID · Target movement tolerated If the criteria are met Return to the target activities If the criteria are partly met Keep up the programme, reassess in 4-6 weeks If a plateau at ≥ 12 weeks Reassess the diagnosis, red flags, referral

Adapted from the 2025 JOSPT CPG Desmeules recommendations (RCRSP)² and the 2022 JOSPT CPG Lafrance (Return to Work).⁶

« The return to activity is not granted by a calendar: it is earned with functional criteria. A SPADI of 15/100 and symmetrical abduction strength speak louder than "3 months without pain". The patient is not a calendar, they are an actor. »
A realistic trajectory to share with the patient : a clinically perceptible improvement is expected at 4-6 weeks of active management, with continuous but non-linear progress (fluctuations are expected) and a peak of improvement at around 3-6 months. For most, a return to everyday activities at 3 months, a return to competitive sport at 4-9 months. 40-50 % of patients remain symptomatic at 1 year without structured intervention (Kuijpers 2004)¹, hence the importance of keeping up the programme and of monitoring the load in the long term.

Critique and controversy

The thresholds for return to activity (strength > 90 %, pain ≤ 2/10) are logical and derive from good practice, but their predictive value for non-recurrence at 1-2 years remains only moderately documented for RCRSP, less solidly than for the ACL, for example. Most studies measure the rate of return, not the rate of recurrence. In everyday practice, applying these criteria strictly takes time, tools (a dynamometer, PROMs) and training. The risk is that these criteria remain theoretical, and that the clinician allows the return on looser criteria (no pain at rest alone, which is very insufficient). Finally, the tension between self-management and support is subtle: too much autonomy without follow-up can lead to dropping out; too much support keeps dependence alive. The right balance depends on the patient's psychosocial profile (chapter 2).

Key points

  • Structured self-management is a key principle of the 2025 JOSPT CPG Desmeules: education + a written programme + progressive load management + PROM follow-up.²
  • The psychosocial factors (kinesiophobia, catastrophising, self-efficacy) are independent determinants of the prognosis (Chester 2018, n = 1030).⁷
  • The return to activity must be based on functional criteria : pain ≤ 2/10, strength > 90 %, PROM improvement ≥ MCID, progressive tolerance of the target load.
  • The 2022 Lafrance CPG (JOSPT) offers specific recommendations for return to work in cuff disorders.⁶
  • A realistic trajectory: improvement perceived at 4-6 weeks, a peak at 3-6 months, a return to everyday activities at ≈ 3 months, a return to competitive sport at 4-9 months. 40-50 % of patients remain symptomatic at 1 year without structured intervention (Kuijpers 2004).¹
Bibliography
  1. Kuijpers T, van der Windt DAWM, van der Heijden GJMG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109(3):420-431. PMID 15157703.
  2. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  3. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011;197(4):W713-9. PMID 21940544.
  4. Yamamoto A, Takagishi K, Osawa T, et al. Prévalence and risk factors of a rotator cuff tear in the général population. J Shoulder Elbow Surg. 2010;19(1):116-120. PMID 19540777.
  5. Cuff A, Littlewood C. Subacromial impingement syndrome — What does this mean to and for the patient? A qualitative study. Musculoskelet Sci Pract. 2018;33:24-28. PMID 29065348.
  6. Lafrance S, Charron M, Roy JS, et al. Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2022;52(10):647-664. PMID 35881707.
  7. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269-275. PMID 27445360.
  8. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743-748. PMID 27852585.
  9. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. PMID 26882892.

What do concrete clinical profiles teach us about RCRSP?

In this chapter: 4 typical RCRSP profiles built from the reference literature. ⚠️ An important note : these are abstract typical profiles derived from the subgroups validated by the literature (2025 JOSPT CPG, Chester 2018, Mallows 2017), not real patients or anonymised cases. The aim is to illustrate a line of reasoning, not to present individual cases.
RCRSP is not a uniform entity. The recent literature, in particular the Chester 2018 cohort on prognostic factors, makes it possible to adapt management to the patient rather than to the diagnosis alone.¹,² Rather than presenting individual clinical cases (which carry only a low level of evidence, see the GRADE pyramid below), we describe here four typical profiles met in practice, anchored in the literature, to inform clinical decisions. 🧐

Profile 1: RCRSP with a classic presentation

The most frequent profile in practice is the adult patient (typically 45-65) with insidious pain over the shoulder region, triggered by movements in elevation and worse at night when rolling onto the shoulder, without initial trauma. Irritability is moderate : pain 4-6/10 on effort, functional at rest, sleep sometimes disturbed. Passive mobility is preserved, the clinical examination reproduces the pain (Painful Arc and Hawkins-Kennedy often positive, 2025 JOSPT CPG).¹

Recommended management (aligned with Naunton 2020, Pieters 2020, Desmeules 2025):³,⁴,¹

  • Education about the not purely structural nature of the pain, deconstructing the "impingement" model.
  • A progressive exercise programme (cuff + scapula), 2-3 sessions a week, movements within a tolerable zone.
  • PROM follow-up (SPADI or DASH) at 4-6 weeks to objectify progress.
  • Adaptation of the occupational load if there is overhead exposure (2022 Lafrance CPG).⁵

Expected prognosis : a clinically perceptible improvement at 4-6 weeks, a return to everyday activities at 3 months for most. This profile corresponds to the target indication of standard evidence-based treatment, and to the epidemiological base of the SRs/MAs cited.

Profile 2: The cervical "mimic"

The most frequent diagnostic trap is C5-C6 cervical radiculopathy presenting as a "false" RCRSP. The patient describes pain over the shoulder region, but a more careful history reveals associated cervicoscapular pain, with paraesthesiae in the C5 territory (lateral aspect of the arm) or C6 (thumb, index finger), sometimes a subtle motor deficit. Shoulder movements can reproduce the pain atypically (pain on taking up a cervical position more than on pure shoulder movement). ⚠️ Salamh & Lewis 2020 (JOSPT) stress the importance of a systematic cervical examination before making the diagnosis of RCRSP.⁶

Diagnostic keys :

  • Spurling test, cervical distraction.
  • Examination of the reflexes (biceps, brachioradialis), of dermatomal sensation, of segmental motor strength.
  • Cervical imaging (MRI) if the suspicion is confirmed: neurosurgical or rheumatological referral according to context.

Not recognising this profile means treating a cuff that is not the source of the problem. The pain persists and the patient loses confidence in physiotherapy.

Profile 3: Acute calcific tendinopathy

The calcific tendinopathy of the cuff is a particular subtype. The typical presentation: shoulder pain of abrupt onset, sometimes with no trigger, of extreme intensity (pain "10/10", the shoulder impossible to move, an antalgic posture). The diagnosis is radiographic: an anteroposterior film in external and internal rotation shows a dense calcification in the area of the cuff tendons.

Specific management :

  • Acute phase: NSAIDs, analgesics, sometimes a local corticosteroid injection to manage the crisis (Mohamadi 2017, a small/transient effect but useful in these hyperalgesic presentations).⁷
  • Second phase: an exercise programme similar to standard RCRSP.
  • ESWT (shockwave therapy): this is l'the best-documented indication for ESWT in cuff pathology: several recent SRs/MAs show a superior effect on calcific resorption and on pain (moderate to strong evidence).
  • Possibly ultrasound-guided needling or percutaneous lavage for refractory residual calcifications.

Profile 4: A dominant psychosocial profile

The most complex profile is that of a patient whose RCRSP sits within a dominant psychosocial context : high kinesiophobia, catastrophising, low self-efficacy, sometimes painful comorbidity (chronic low back pain, fibromyalgia), depression, anxiety. The multicentre cohort Chester 2018 (n = 1030 shoulder patients, 6-month follow-up) established that these variables explain a large part of the variance in outcomes: independently of the initial severity and of imaging.²

The exercise programme alone is insufficient for this profile. Management requires:

  • An in-depth pain education (the concepts of pain "modulated" by the nervous system, hypersensitivity vs tissue damage).
  • An approach informed by cognitive behavioural therapy, as far as the physiotherapist's skills allow, or in shared care with a psychologist specialising in chronic pain.
  • A graded exposure to the avoided movements, with explicit work on kinesiophobia (graded exposure).
  • Realistic management of expectations: the trajectory is slower, fluctuations are expected, the prognosis depends more on how the psychosocial factors evolve than on structural parameters.⁸

🧩 The 4 typical RCRSP profiles

A simplified stratification derived from the 2025 JOSPT CPG Desmeules¹

4 typical RCRSP profiles Stratify the patient to guide the content and the pace Profile 1: Classic RCRSP Adult 45-65, insidious onset Mobility preserved, moderate irritability → Education + progressive exercises Naunton 2020 · Pieters 2020 · Desmeules 2025 Profile 2: Cervical mimic Cervicoscapular pain Paraesthesiae, a possible motor deficit → Systematic cervical examination Salamh & Lewis 2020 JOSPT Profile 3: Calcific tendinopathy Abrupt, hyperalgesic pain Radiograph: a dense calcification → Acute-phase analgesia + ESWT Recent SRs/MAs on ESWT for calcifications Profile 4: Dominant psychosocial Kinesiophobia + catastrophising Painful comorbidity → A biopsychosocial approach + CBT Chester 2018 · Mallows 2017

An illustrative diagram: an editorial synthesis based on the 2025 JOSPT CPG¹ and on the data of Chester 2018² and Mallows 2017⁸. These profiles are not exclusive: the same patient can combine several traits (for example profile 1 + psychosocial traits).

« RCRSP is not only a cuff problem. It is an intersection between mechanical load, metabolism and mind. The clinician must navigate between the three: an exercise programme changes nothing if fear of movement prevents it being carried out, or if the differential diagnosis (cervical radiculopathy, acute calcification) has not been made. »

Critique and controversy: where do case reports sit in the hierarchy of evidence?

🧠 The individual clinical cases are fundamental for generating hypotheses and flagging rare presentations, but their level of evidence is the lowest of the whole scientific hierarchy. A single case illustrates a possibility, not a generality. It cannot control for placebo, regression to the mean or spontaneous evolution. Publication bias is massive (failures are rarely published). That is why we have preferred here to work with typical profiles anchored in the aggregated literature, rather than presenting fictional or anecdotal individual cases.

📐 Hierarchy of scientific evidence: where does each type of study belong?

Strength of evidence decreasing from the top (meta-analyses) towards the bottom (isolated cases)

LEVEL
1a
Meta-analyses & systematic reviews of RCTs
E.g. : Naunton 2020 SR/MA · Pieters 2020 SR · Mohamadi 2017 MA on corticosteroids · Cochrane Karjalainen 2019 · Desjardins-Charbonneau 2015 MA
LEVEL
1b
Randomised controlled trials (RCTs)
E.g. : CSAW Beard 2018 (Lancet) · FIMPACT Paavola 2018/2021 (BMJ/BJSM) · Cochrane Karjalainen 2019
LEVEL
2
Prospective cohort studies
E.g. : Chester 2018 (n = 1030, BJSM) psychosocial factors · Kuijpers 2004 shoulder prognostic cohorts
LEVEL
3
Case-control & cross-sectional studies
E.g. : Yamamoto 2010 prevalence of tears · Girish 2011 ultrasound abnormalities in the asymptomatic · Giri 2023 metabolic factors
LEVEL
4
Case series
E.g. : small surgical series · non-randomised pre/post ESWT series · clinical rehabilitation series
LEVEL
5
Case reports (n=1) & expert opinion
E.g. : individual cases published in peer-reviewed journals · expert opinion on experimental protocols

A simplified GRADE / Oxford CEBM hierarchy. The length of the coloured bar on the right illustrates the relative strength of evidence. Practical implication: where a seductive case report and a meta-analysis diverge, the decision must follow the meta-analysis. Case reports remain valuable for generate hypotheses, flagging rare presentations, or illustrating a line of clinical reasoning.

A persistent controversy in RCRSP is the place of imaging. Faced with the inflation of ultrasound and MRI requests in consultation, the international guidelines recall the weak correlation between structural abnormalities and symptoms (up to 96 % of abnormalities in asymptomatic men, Girish 2011; asymptomatic tears frequent after 60, Yamamoto 2010).⁹,¹⁰ The 2025 JOSPT CPG Desmeules repeats: treat the patient, not the image.¹ Another controversy concerns the "knowing-doing gap" of subacromial decompression. Despite three pivotal RCTs (CSAW, FIMPACT, Cochrane), the intervention is still widely performed in many health systems. The clinician must be able to pass these data on to the patient for a shared decision (chapter 7). Finally, the heterogeneity of RCRSP patients makes generalisation perilous. A standardised exercise programme that is effective in the motivated adult of profile 1 can be unsuitable for profile 4 (dominant psychosocial). Stratification by irritability and psychosocial profile proposed in chapter 2, which is an editorial synthesis and not a recommendation, is a major avenue for individualising management.

⭐ Key points

  • Four typical RCRSP profiles met in practice: (1) a classic presentation, (2) a C5-C6 cervical mimic, (3) acute calcific tendinopathy, (4) a dominant psychosocial profile.
  • Profile 1 (the most frequent) responds well to education + progressive exercises (Naunton 2020, Pieters 2020, Desmeules 2025).³,⁴,¹
  • Profile 2 (the cervical mimic) must be ruled out by a systematic cervical examination before making the diagnosis of RCRSP (Salamh & Lewis 2020 JOSPT).⁶
  • Profile 3 (acute calcific) benefits from acute-phase analgesia (possibly a corticosteroid injection, Mohamadi 2017) and from ESWT (recent SR/MA evidence).⁷
  • Profile 4 (dominant psychosocial) requires a biopsychosocial approach and CBT: an independent predictor of the prognosis (Chester 2018 n = 1030).²,⁸
  • ⚠️ Level of evidence : an individual case report = level 5 (the weakest). When they diverge, follow the meta-analyses (level 1a), not the isolated case. The typical profiles illustrate, they do not demonstrate anything.
Bibliography
  1. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  2. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269-275. PMID 27445360.
  3. Naunton J, Street G, Littlewood C, Haines T, Malliaras P. Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2020;34(9):1198-1216. doi:10.1177/0269215520934147.
  4. Pieters L, Lewis J, Kuppens K, et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. J Orthop Sports Phys Ther. 2020;50(3):131-141. doi:10.2519/jospt.2020.8498.
  5. Lafrance S, Charron M, Roy JS, et al. Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2022;52(10):647-664. PMID 35881707.
  6. Salamh P, Lewis J. It Is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture. J Orthop Sports Phys Ther. 2020;50(5):222-225. PMID 32272031.
  7. Mohamadi A, Chan JJ, Claessen FM, et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017;475(1):232-243. PMID 27469590.
  8. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743-748. PMID 27852585.
  9. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011;197(4):W713-9. PMID 21940544.
  10. Yamamoto A, Takagishi K, Osawa T, et al. Prévalence and risk factors of a rotator cuff tear in the général population. J Shoulder Elbow Surg. 2010;19(1):116-120. PMID 19540777.
  11. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. PMID 26882892.
  12. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial décompression for subacromial shoulder pain (CSAW). Lancet. 2018;391(10118):329-338. PMID 29169668.

How do you apply these recommendations concretely in your practice?

In this chapter: red flags specific to the shoulder (dislocation, acute massive tear, infection, oncological, radiculopathy, projected pain), criteria for interprofessional referral, RCRSP PROMs (SPADI, DASH, Constant-Murley, PSFS), shared decision-making (Hoffmann 2014), barriers to evidence-based implementation.
Applying the recommendations in everyday practice remains the weak link in the evidence-based chain. Knowing what should be done (2025 JOSPT CPG, Dutch SAPS, Naunton 2020, Pieters 2020) is not knowing how to apply it with each patient, with their time constraints, their preferences and their comorbidity. 🧑‍⚕️

When, and to which other health professionals, should you refer?

The first non-negotiable step in triage is screening for red flags. The clinician must have a low threshold for referral: sensitivity takes precedence over specificity when serious conditions are at stake.

🚩 Red flags specific to the shoulder

  • Glenohumeral dislocation : clear trauma + the epaulette sign + complete functional impairment + intense pain. An orthopaedic emergency.
  • An acute traumatic massive tear in a relatively young person: trauma + marked weakness + complete loss of active elevation + pain. A prompt surgical work-up (2025 JOSPT CPG).¹
  • Infection (septic arthritis) : fever + hot swelling + exquisite tenderness + erythema. An emergency.
  • A tumour (rare but to be considered): a progressive palpable mass, night pain without movement, night sweats, unexplained weight loss, deterioration in general condition. An oncological work-up.
  • Cervical radiculopathy / plexopathy : radicular pain in a territory, paraesthesiae, a motor or sensory deficit, an absent reflex → neurological examination + cervical MRI.
  • Projected visceral pain : cardiac (the left shoulder above all), biliary or diaphragmatic (the right shoulder), apical pulmonary (Pancoast). Adapt the general examination if the presentation is atypical.
  • Systemic rheumatological disease : rheumatoid arthritis, spondyloarthritis, polymyalgia rheumatica (an older patient, shoulder + pelvic girdle pain, raised ESR/CRP).

⚠️ Any red flag → prompt medical referral (general practitioner, emergency department, sports physician, orthopaedic surgeon) before, or alongside, physiotherapy management.

Beyond the emergencies, the yellow flags (psychosocial factors of failure) justify a broader approach. The Chester 2018 cohort (n = 1030, BJSM) identified high kinesiophobia, catastrophising and low self-efficacy as independent predictors of the prognosis.² In these cases, consider collaboration with a psychologist specialising in chronic pain, and build a cognitive behavioural approach into the rehabilitation programme. The interprofessional collaboration is required for complex profiles:
  • General practitioner / sports physician : an overall work-up, management of metabolic comorbidity (diabetes, hypertension, dyslipidaemia, Giri 2023), blood tests if a rheumatological disorder is suspected.
  • Rheumatologist : suspicion of a systemic inflammatory disorder, multi-joint involvement.
  • Orthopaedic shoulder surgeon : an acute traumatic massive tear, documented failure of 6-12 weeks of structured conservative treatment, a surgical request from the patient after being informed of the evidence-based data.
  • Psychologist specialising in chronic pain : a dominant psychosocial profile (chapter 6, profile 4), high kinesiophobia, psychiatric comorbidity.
  • Occupational physician / ergonomist : adaptation of the workstation where there is overhead exposure (2022 Lafrance CPG).³
  • Strength and conditioning coach for the overhead athlete: reviewing the throwing load, periodisation, the progression of the return to sport (chapter 4).

How do you measure outcomes and overcome barriers to implementation?

📊 Measuring outcomes is the sine qua non of quality practice. Several validated PROMs exist for RCRSP, each with its strengths and its limits:⁴

📋 PROMs for RCRSP: a functional comparison

Choosing according to the clinical context (community physiotherapy, research, follow-up)

Comparison of RCRSP PROMs SPADI Shoulder Pain & Disability Index 13 items (5 pain + 8 function) Score 0-100 MCID ~ 8-10 pts ✓ Short ✓ Shoulder-specific ✓ Responsive to change DASH / QuickDASH Disabilities of Arm, Shoulder and Hand 30 items (DASH) 11 items (QuickDASH) Score 0-100 MCID ~ 10 pts (DASH) ✓ Whole upper limb ✓ Everyday activities + QuickDASH if time is short Constant-Murley A mixed score (subjective + objective) 100 points 35 subj. + 65 obj. Strength + ROM + daily living + Pain ✓ The orthopaedic reference ✓ Follow-up after surgery ⚠ Longer, needs equipment PSFS Patient-Specific Functional Scale 3-5 activities chosen by the patient Score 0-10 / activity MCID ~ 2 pts ✓ Patient-centred ✓ Very quick ✓ Individualised follow-up

⚠️ A practical tip: in community physiotherapy, SPADI + PSFS are amply enough to follow RCRSP. The Constant-Murley is reserved for specialist settings (shoulder surgery, research). DASH/QuickDASH = the standard for whole upper limb disorders.

Building these PROMs into everyday practice runs into documented barriers: a lack of time (the most frequent), the absence of a suitable software tool, a lack of training in interpretation, and the perception that it is "administrative" rather than clinically useful. Implementation strategies to overcome these barriers:
  • Digital tools : a tablet or smartphone app that the patient fills in in the waiting room, automatic scoring, graphical display of progress.
  • Continuing education : practical workshops on using PROMs and on shared decision-making.
  • Clinical champions : opinion leaders in the practice or the clinic who spread the use of EBP.
  • Building it into the routine : SPADI / PSFS at every follow-up consultation (every 4-6 weeks), not only at the start and the end of care.
  • Shared decision-making (shared decision-making, Hoffmann 2014 JAMA)⁵: present the patient with the options and their level of evidence (evidence-based progressive exercise, surgical decompression not superior to placebo, a corticosteroid injection with a small and transient effect), and discuss them in the light of their preferences and their timetable. It significantly increases adherence and satisfaction. ✅

Critique and controversies: beyond the guidelines

The red flag paradox still holds: no sign taken in isolation has a high positive predictive value. It is the convergence of evidence plus probabilistic clinical reasoning that guides referral, not a checklist. The risk is twofold: over-diagnosing (sending every painful tendon for MRI) or under-diagnosing (missing a reduced dislocation or an acute traumatic tear by putting the pain down to a simple RCRSP). The "knowing-doing" gap is particularly striking in RCRSP: the SR/MA Naunton 2020 and the SR Pieters 2020 have placed progressive exercise in the first line for 5 years, the rejection of subacromial decompression as superior to placebo has been confirmed by 3 pivotal RCTs since 2018-2021, and yet practice resists.⁶,⁷,⁸,⁹ Moving to genuine EBP requires more than the diffusion of information: it requires an overhaul of the economic incentives and of continuing education. Finally, the standardisation versus personalisation tension is central. PROMs and CPGs are essential for comparability and safety, but the clinician must be able to navigate between standardised tools and individualisation (the patient's real needs). Stratification by irritability and psychosocial profile proposed in chapter 2, which is an editorial synthesis and not a recommendation, is one way of reconciling these two demands.

⭐ Key points

  • Referral is crucial for safety : red flags (dislocation, an acute massive tear, infection, oncological, radiculopathy, projected pain) → prompt medical referral.
  • Psychosocial yellow flags (kinesiophobia, catastrophising, Chester 2018 n = 1030)² → collaboration with a psychologist, a biopsychosocial approach.
  • Measure outcomes with validated PROMs: SPADI (short, shoulder-specific, MCID 8-10 pts), DASH/QuickDASH (whole upper limb), Constant-Murley (orthopaedic), PSFS (patient-centred).⁴
  • The shared decision-making (Hoffmann 2014 JAMA)⁵, informing the patient of the evidence-based data (exercise = the first line; decompression surgery not superior to placebo; corticosteroids a small transient effect), increases adherence and satisfaction.
  • For refractory cases after 3-6 months: reconsider the diagnosis (targeted imaging, cervical examination), discuss with a sports physician or a surgeon according to context.
  • The "knowing-doing gap" is the major challenge of the coming decade: bringing into everyday practice the evidence accumulated since 2017-2025 (CSAW Beard 2018, FIMPACT Paavola 2021, 2025 JOSPT CPG Desmeules).⁶,⁷,¹
Bibliography
  1. Desmeules F, Roy JS, Lafrance S, et al. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. doi:10.2519/jospt.2025.13182.
  2. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269-275. PMID 27445360.
  3. Lafrance S, Charron M, Roy JS, et al. Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2022;52(10):647-664. PMID 35881707.
  4. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322. PMID 24847788.
  5. Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared décision making. JAMA. 2014;312(13):1295-1296. PMID 25268434.
  6. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial décompression for subacromial shoulder pain (CSAW). Lancet. 2018;391(10118):329-338. PMID 29169668.
  7. Paavola M, Malmivaara A, Taimela S, et al. Subacromial décompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up. Br J Sports Med. 2021;55(2):99-107. PMID 33020137.
  8. Naunton J, Street G, Littlewood C, Haines T, Malliaras P. Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2020;34(9):1198-1216. doi:10.1177/0269215520934147.
  9. Pieters L, Lewis J, Kuppens K, et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. J Orthop Sports Phys Ther. 2020;50(3):131-141. doi:10.2519/jospt.2020.8498.
  10. Giri A, O'Hanlon D, Jain NB. Risk factors for rotator cuff disease: A systematic review and meta-analysis of diabetes, hypertension, and hyperlipidemia. Ann Phys Rehabil Med. 2023;66(1):101631. PMC9974529.
  11. Karjalainen TV, Jain NB, Page CM, et al. Subacromial décompression surgery for rotator cuff disease. Cochrane Database Syst Rev. 2019;1(1):CD005619. PMID 30707445.
  12. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther. 2016;23:57-68. PMID 26882892.

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Physio Learning: Evidence-based clinical syntheses

This article has undergone rigorous bibliographic checking: every reference cited is linked to a verified PubMed PMID or CrossRef DOI. The figures and the claims are sourced. The clinical cases cited come from the published literature.

Last revisedMay 2026 MethodologyA synthesis of meta-analyses + international consensus statements Level of evidenceMixed (from level 1a meta-analyses to level 5 case reports, ranked within the article) Conflicts of interestNone declared A question, or an error to report?WhatsApp button at the bottom right of the screen 💬

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Anthony Baillon, physiotherapist and co-founder of Physio Learning
✍️ Author

Anthony Baillon

Physiotherapist · co-founder of Physio Learning

Marked for life by his first four-hour lecture without a single image, he took a master’s in instructional design so that it would never happen to anyone again. He hunts down publication bias and unreadable slides with the same intransigence.

PhysiotherapistInstructional designerCare design
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Robin Vervaeke, head of scientific content at Physio Learning✓ Checked

Robin Vervaeke

Scientific lead

Physiotherapist specialising in neuro-musculoskeletal practice and holder of a master’s in public health. He checks the methodological rigour of every article: primary sources, levels of evidence, no exceptions.

NeuromusculoskeletalMaster's in public health
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