Reviewed by Muhammad Ali Raja, Advanced Physiotherapy Practitioner (HCPC registered, MCSP), Birmingham Physiocare Ltd.
Introduction
Rotator cuff-related shoulder pain, also termed subacromial pain syndrome or subacromial impingement syndrome, is the most common cause of shoulder pain, affecting an estimated 67% of adults at some point. This article reviews current evidence for its diagnosis and management, referencing the 2025 clinical practice guideline published in the Journal of Orthopaedic & Sports Physical Therapy and associated systematic reviews.
What Is Rotator Cuff Tendinopathy?
The terminology in this area has evolved. “Subacromial impingement syndrome” was the original term, describing shoulder pain attributed to mechanical stress on the rotator cuff tendon from the acromion during arm elevation. More recent literature favours “subacromial pain syndrome” or “rotator cuff-related shoulder pain” as broader, more accurate umbrella terms, reflecting that multiple structures, the subacromial bursa, rotator cuff muscles and tendons, and surrounding tissue, may contribute, and that the condition is not a single diagnosis but a descriptive term covering several related presentations, including rotator cuff tendinopathy, subacromial bursitis, and partial-thickness rotator cuff tears.
Signs And Symptoms
Typical presentation includes unilateral shoulder pain localised around the acromion, pain during arm elevation (particularly through a “painful arc”), and difficulty with overhead activities. Contributing factors identified in the literature include altered shoulder movement patterns, rotator cuff and scapular muscle dysfunction, sustained overhead work, and posture.
Evidence-Based Treatment Options
Exercise therapy is the primary recommended intervention. Multiple systematic reviews converge on this finding. A 2020 update of systematic reviews concluded there is a growing body of evidence supporting exercise therapy for subacromial shoulder pain, with a strong recommendation for including manual therapy in the initial treatment phase. Structured physiotherapy has been shown in trials to be potentially as effective as surgery for this condition, with significant improvements demonstrated through scapular retraining, rotator cuff strengthening, and flexibility exercises.
No single exercise protocol is clearly superior. This is an important, honest finding to communicate: despite extensive research, no consensus exists regarding the single optimal exercise intervention. A 2024 systematic review with meta-analyses (22 RCTs, n=1,281) using the GRADE framework found motor control exercise programmes were probably slightly superior to nonspecific exercise programmes, but noted it remains unclear whether this benefit stems from the specific exercise type or from other programme characteristics such as progression and individualised tailoring. A separate systematic review found moderate evidence supporting therapeutic exercise alone, with more limited evidence for combined manual and exercise therapy specifically.
Exercise dose (higher vs. lower load/volume) evidence is uncertain. A systematic review of RCTs comparing higher versus lower dose exercise found only low to very low certainty evidence, with conflicting results, higher load and volume exercise may improve function in some analyses but not consistently across pain and activity outcome measures.
Corticosteroid injection provides short-term benefit only. The 2025 JOSPT clinical practice guideline reports that, based on high-quality evidence, corticosteroid injections produce small but statistically significant pain and disability reductions in the short term (up to 8 weeks) compared with placebo. However, based on low-to-high-quality evidence, corticosteroid injections do not significantly outperform other interventions such as manual therapy or platelet-rich plasma injections. The guideline also notes expert-opinion-based guidance that if pain and disability have not improved after two injections, a third is not indicated.
Surgery does not outperform placebo surgery for decompression. This is one of the more striking findings in this evidence base: high-quality evidence cited in the 2025 clinical practice guideline indicates subacromial decompression with acromioplasty does not provide clinically important benefits compared with placebo surgery for pain and disability. This has significant implications for how surgical referral decisions should be framed.
Platelet-rich plasma (PRP) has not been shown to provide additional benefit at short-term follow-up according to systematic review evidence, and the American Academy of Orthopaedic Surgeons has specifically not recommended routine PRP use in non-operative management of partial-thickness rotator cuff tears, citing limited quality evidence.
Extracorporeal shockwave therapy has been described as safe and effective for upper limb soft tissue conditions, including rotator cuff tendinopathy, in one systematic review of 26 studies, though the review noted variability in study quality across the included literature.
How Physiotherapy Can Help
Given the consistent evidence base supporting exercise over passive or surgical alternatives for most presentations, physiotherapy-led rehabilitation, combining rotator cuff strengthening, scapular stabilisation exercises, and, in the initial phase, manual therapy, represents the most strongly evidence-supported starting point for rotator cuff-related shoulder pain. A systematic review specifically examining scapular-focused rehabilitation found added scapular stabilisation exercises produced a significant difference in shoulder pain and function outcomes for subacromial impingement specifically.
What Does Current Research Show?
The overall picture from current systematic reviews and the 2025 clinical practice guideline is that exercise therapy is well-supported, generally as effective as more invasive options, and carries none of the risks associated with injection or surgery. Corticosteroid injection has a legitimate but time-limited role, primarily for short-term symptom control rather than lasting resolution. Surgical decompression, once a common intervention, is now supported by high-quality placebo-controlled evidence showing no clinically important benefit over sham surgery, a finding with substantial implications for shared decision-making in this condition. Where research remains genuinely unsettled is in identifying which specific exercise protocol, dose, and progression produces the best outcomes for a given patient.
When To Contact Birmingham Physiocare
If you have shoulder pain affecting overhead movement or daily function, a physiotherapy assessment can establish whether your presentation is consistent with rotator cuff-related shoulder pain and set out a structured, evidence-based exercise programme, which current research supports as a well-founded first-line approach for most presentations.
Final Thoughts
Rotator cuff-related shoulder pain is common, and the evidence base strongly favours structured exercise therapy as the primary treatment, with manual therapy as a useful early adjunct. Corticosteroid injection has a legitimate but time-limited role. Surgical decompression, despite historical popularity, is not supported by placebo-controlled evidence for typical presentations. The main area of ongoing uncertainty is not whether exercise helps, but precisely which exercise approach and dose is optimal for a given individual.
This article is for educational purposes only and does not replace individual medical assessment. If symptoms persist or worsen, seek professional healthcare advice.
Sources
- Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235-274. https://www.jospt.org/doi/10.2519/jospt.2025.13182
- 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. https://pubmed.ncbi.nlm.nih.gov/31726927/
- The Efficacy of Exercise Therapy for Rotator Cuff–Related Shoulder Pain According to the FITT Principle: A Systematic Review With Meta-analyses. J Orthop Sports Phys Ther. 2024;54(8):499-512. https://www.jospt.org/doi/10.2519/jospt.2024.12453
- Effects of seven types of exercise in the treatment of rotator cuff-related shoulder pain (RCRSP): a systematic review and Bayesian network meta-analysis. J Orthop Surg Res, 2025. https://link.springer.com/article/10.1186/s13018-025-06514-4
- The Efficacy of Higher Versus Lower Dose Exercise in Rotator Cuff Tendinopathy: A Systematic Review of RCTs. https://www.sciencedirect.com/science/article/abs/pii/S0003999320304263
- Effect of scapular stabilization exercises on subacromial pain (impingement) syndrome: a systematic review and meta-analysis. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC10940535/
- Exercise-Based Muscle Development Programmes and Their Effectiveness in the Functional Recovery of Rotator Cuff Tendinopathy: A Systematic Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002167/
- Conservative treatment of partial-thickness rotator cuff tears and tendinopathy with platelet-rich plasma: a systematic review and meta-analysis. https://www.medrxiv.org/content/10.1101/2020.12.19.20248575.full.pdf
- Testa G, Vescio A, Perez S, et al. Extracorporeal Shockwave Therapy Treatment in Upper Limb Diseases: A Systematic Review. J Clin Med. 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7074316/