Rotator Cuff Related Shoulder Pain

Original Editor - Ewa Jaraczewska based on the course by Ellie Richardson

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Shoulder pain is one of the most common presenting symptoms in musculoskeletal practice. While traditionally there has been a focus on establishing specific pathoanatomical diagnoses, these classifications or diagnoses can in themselves be nocebic. In 2016, Jeremy Lewis introduced the umbrella term "rotator cuff related shoulder pain" (RCRSP) to move away from pathological or structural diagnoses (like subacromial pain (impingement) syndrome, rotator cuff tendinopathy, tendinitis, and symptomatic partial and full thickness rotator cuff tears). This term acknowledges that symptoms may arise from many structures, including muscles, tendons, bursa, capsule, and bone, rather than an isolated tissue.

RCRSP is now considered the most common shoulder presentation in clinical practice, accounting for 50-85% of shoulder pain diagnoses. For clinicians, moving away from a "damaged structure" narrative changes patient assessment and rehabilitation, shifting the focus from treating a specific lesion to restoring overall function.

Quick Review of Rotator Cuff Anatomy

The rotator cuff is formed by four muscles: supraspinatus, infraspinatus, teres minor and subscapularis (the acronym SITS is a useful memory aid).

Table 1. Muscles of the rotator cuff

Muscle	Origin	Insertion	Action as mover
Supraspinatus	Supraspinous fossa	Superior facet, greater tuberosity	Abduction/involved in initiating flexion
Infraspinatus	Infraspinous fossa	Middle facet, greater tuberosity	External rotation
Teres minor	Axillary border of scapula	Inferior facet, greater tuberosity	External rotation
Subscapularis	Subscapular fossa	Lesser tuberosity/shaft of the humerus	Internal rotation

The rotator cuff muscles work as movers, producing torque in a given direction. They also work as stabilisers, fine-tuning the position of the humeral head within the relatively shallow glenoid fossa. Research indicates that rotator cuff muscles are recruited in a direction-specific manner to maintain shoulder stability. Specifically, the posterior muscles are more active during shoulder flexion to counteract anterior translation, while the anterior muscles are more active during extension to prevent posterior translation. This recruitment pattern remains consistent regardless of load, supporting the hypothesis that the rotator cuff provides stability by counterbalancing the forces of primary torque-producing muscles during movement. Balanced strength, capacity, and neuromuscular control across all four rotator cuff muscles is essential to healthy shoulder function.

Clinical Presentation of RCRSP

RCRSP can occur at any age, but prevalence increases with age. Onset may be insidious or traumatic. It is often accompanied by a change in load. Symptoms can also occur without any change in physical load, but due to other stressors, such as poor sleep and increased smoking. Common features include:

• pain localised to the anterior/lateral shoulder, sometimes referring down the lateral upper arm
• pain and/or weakness with specific movement, often elevation and external rotation
• functional difficulty with overhead tasks, pushing, lifting, or reaching behind the back

Neurological symptoms are not a feature of RCRSP. If present, a cervical source should be considered. In people aged under 40 years, atraumatic or microtraumatic instability should also be considered in the differential diagnosis.

Physiotherapy Assessment of RCRSP

Initial Assessment

The initial assessment is an opportunity to enhance the patient's expectation of recovery, to build their pain self-efficacy (i.e. their belief in their own capacity to manage and improve their symptoms), and to identify a specific movement or loading deficit that can be linked to a meaningful functional goal.

Subjective

A thorough history remains the foundation of assessment. Key areas to cover include:

• relevant comorbidities, including diabetes, smoking history, and previous shoulder or cervical pain
• activities that provoke symptoms, sporting or occupational demands, particularly overhead loading
• mechanism, which can be acute (e.g. fall onto an outstretched hand) or insidious/repetitive
• any change in load preceding symptom onset, including changes in sleep, stress, or other non-physical demands
• screening for cervical or thoracic referral, which can mimic or coexist with shoulder pain
• the patient's beliefs about the cause of their symptoms, and any diagnostic labels they have already been given
• their expectations of exercise and rehabilitation, their confidence in managing symptoms, and activities they want to return to

Physical Examination

The physical examination should include visual inspection, a cervical/thoracic screen, palpation, active and passive range of motion, and strength testing using manual muscle testing or hand-held dynamometry where available. It should also cover kinetic chain findings where relevant, neural sensitivity, signs of central sensitisation or cortical changes, and performance tests.

Shoulder Assessment Proforma

Consultant shoulder physiotherapist Ellie Richardson designed a shoulder assessment proforma to help structure clinical reasoning in RCRSP. This page focuses on two aspects of this proforma: the range of motion assessment and the prone capacity assessment.

Range of Motion Assessment

Key movements to assess include: flexion, horizontal flexion (adduction), abduction, scaption, external rotation in neutral, external rotation at 90/90, internal rotation in neutral and internal rotation (with hand behind the back). Record the range achieved for each movement tested and whether pain is provoked. Where pain is elicited, record whether it is modifiable and, if so, the specific technique used to achieve symptom modulation.

Prone Capacity Assessment

The prone capacity assessment compares passive glenohumeral external rotation at 90° of abduction with unassisted, active range of motion. This assessment helps to differentiate true capacity (passive) from accessible mobility (active). The assessment is then progressed through a series of stages: adding a small load (e.g. 1 kg weight), moving to an unsupported position (unloaded), and finally, adding load in an unsupported position.

Throughout the assessment, the clinician watches for compensatory strategies that indicate insufficient capacity or control, such as an elbow drop or the wrist flicking up. This information is used to determine if there is a strength deficit, a motor control deficit, or a combination of both.

Special Tests

The clinical value of special tests for RCRSP has been increasingly questioned. In a recent Delphi study, no special tests achieved the level of consensus to "become a relevant clinical descriptor for RCRSP diagnosis." Despite this, they remain regularly used in clinical practice. When used, they can be considered as part of the broader clinical picture rather than a stand-alone diagnostic tool, and they may be of more value in detecting full-thickness rotator cuff tears than in identifying a source of symptoms. Commonly used shoulder special tests include: Hawkins-Kennedy, Neer's test, Painful Arc, and Empty Can Test.

Imaging

A large proportion of people with structural rotator cuff changes on imaging remain asymptomatic, and asymptomatic individuals can become symptomatic without any clear new injury. Structural findings alone are therefore poor predictors of pain or function, and imaging is essentially only recommended where it will change management.

Requejo-Salinas et al. recommend imaging for RCRSP when there are red flags, a history of trauma, and a lack of response after three months of conservative treatment:

• X-ray: does not visualise the rotator cuff muscles or tendons directly, but is useful to identify avulsion fractures, calcific deposits, arthritic change, or bony deformity.
• MRI and ultrasound: both are valid for diagnosing massive rotator cuff tears and have comparable sensitivity and specificity. Their sensitivity decreases as lesion size decreases.

Physiotherapy Management: Exercise Therapy

Exercise therapy remains the first-line treatment for RCRSP and is the mainstay of major clinical practice guidelines. However, its supporting evidence is at best of moderate quality, no single exercise protocol has shown superiority over another, and the causal mechanisms driving improvement remain poorly understood.

Because it is unclear what makes exercise effective, the factors that help or hinder a patient's engagement with exercise are highly relevant. Qualitative research suggests that diagnostic labels, a patient's beliefs about the cause of their shoulder pain, and their expectations of exercise can all act as barriers or enablers to rehabilitation. Chester et al. have also noted that psychological factors are consistently associated with physiotherapy outcomes in shoulder pain, whereas clinical examination findings directed towards a specific structural diagnosis are not.

Leveraging the Impact of Non-clinical Factors on Outcomes

In a qualitative study of people with RCRSP, Powell et al. explored how and why exercise therapy influenced outcomes. Participants consistently identified three causal mechanisms of success: shoulder strength; changes to psychoemotional status; and the widespread health effects of exercise. But these mechanisms were only activated when the following conditions were present:

1. Strong therapeutic alliance: trust, collaboration, reassurance, and empathy developed between clinician and patient.
2. Tailored exercise prescription: creating programmes that feel personal and specific, rather than generic sheets pulled from a database.
3. Timely clinical progress: allowing patients to see and feel change within a reasonable timeframe, and clinicians providing enough clinical contact to monitor and adjust the plan.

A systematic review and meta-analysis by Jafarian Tangrood et al. supports the value of making early contact count. It pooled data from studies in which patients with subacromial pain received either no intervention or usual care (education, advice, physiotherapy, exercise therapy, etc.). Improvement at three months was unlikely in the no-intervention group but likely in those receiving usual care. Of the improvement occurring over 12 months in the usual care group, 40% took place in the first six weeks. These findings suggest a substantial early window to maximise improvement with exercise therapy.

Exercise Selection and Progression

In RCRSP, no exercise protocol has been found to be superior to others. Exercise selection and progression should, therefore, be tailored to each person depending on their presentation, provocation patterns and goals. Given the limitations in the evidence base, it is also reasonable to draw on a range of loading strategies, including open chain, closed chain, reactive and isometric, shifting emphasis according to the phase of rehabilitation and the patient's response.

Early-phase work tends to focus on foundational strength and motor control, and exercises should target the specific deficit identified in assessment. At this stage, it is often useful to incorporate short-lever, supported positions to minimise load while maximising control (e.g. supported internal rotation through range, prone scapular retraction).

Once foundational strength and control are established, the load can be progressed and exercises often start to resemble the provocative task itself (e.g. task specific pushing for people with pain on opening heavy doors or longer-lever internal rotation with a band, pulled into extension for people who have difficulty reaching behind their back).

Later phase exercises focus on restoring capacity in long-lever, functionally demanding positions that closely resemble real-world provocative activities (e.g. through-range isometrics in previously provocative positions).

Progression through these phases is better driven by criteria than by time, so it is worth defining what readiness looks like at each stage (e.g. side-to-side strength parity or symptom-free range).

Additional Considerations in RCRSP Management

• Activity modification is not always necessary. When provocative activities are well tolerated and do not worsen symptoms, there may be no need to avoid them
• The clinical context may be as important as the exercise itself. It is therefore worth planning how clinical contact is used and spaced across an episode of care.
• Exercise therapy is not necessary for everyone with RCRSP. The approach described here applies to presentations where a movement or loading deficit has been identified and linked to a meaningful goal.

Resources

• Ezzatvar Y, Dueñas L, Balasch-Bernat M, Lluch-Girbés E, Rossettini G. Which Portion of Physiotherapy Treatments' Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials. J Orthop Sports Phys Ther. 2024 Jun;54(6):391-399.
• Powell JK, Costa N, Schram B, Hing W, Lewis J. "Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain. Phys Ther. 2023 Dec 6;103(12):pzad088.