[ clinical practice guidelines ]

FRANÇOIS DESMEULES, PT, PhD, OPPQ Fellow1,2 • JEAN-SÉBASTIEN ROY, PT, PhD, OPPQ Fellow3,4 • SIMON LAFRANCE, PT, PhD1,2
MAXIME CHARRON, PT, MSc, MClSc, FCAMPT, RISPT2 • MARC-OLIVIER DUBÉ, PT, PhD3,5 • FRÉDÉRIQUE DUPUIS, PT, MSc, PhD(c)3,4
JASON M. BENECIUK, DPT, PhD, MPH6 • JASON GRIMES, PT, DPT, PhD, OCS7 • H. MIKE KIM, MD8
MARTIN LAMONTAGNE, MD, Dipl. med sport (CASEM)9,10 • KAREN MCCREESH, PhD, PT, MISCP11,12 • ELLEN SHANLEY, PT, PhD, OCS13,14
TATIANA VUKOBRAT, PT, MSc2 • LORI A. MICHENER, PT, ATC, PhD, FAPTA15

Rotator Cuff Tendinopathy Diagnosis,

Nonsurgical Medical Care,
and Rehabilitation: A Clinical
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Practice Guideline

R
otator cuff (RC) disorders account for more than half of shoulder Initial diagnosis and treatment of RC
conditions and are commonly treated by physiotherapists, as well disorders often do not follow evidence-
based recommendations.9,22 Diagnoses of
as other health practitioners including physicians.92,110,184,192 The
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

shoulder disorders commonly rely on the

RC comprises the supraspinatus, infraspinatus, subscapularis, and unnecessary use of diagnostic imaging
teres minor. These muscles have different origins on the scapula and their tests such as magnetic resonance imaging
tendons converge on the greater and lesser tuberosities of the humerus (MRI),106 driving additional costs, treat-
bone. The main function of the RC is to syndrome, subacromial bursopathy, and ment delays, and potential overmedicaliza-
stabilize the shoulder joint.33This group long head of biceps tendinopathy are also tion.114,170,183 This evidence-based clinical
of disorders includes most commonly considered to fall within an RC tendi- practice guideline (CPG) provides clinical
RC tendinopathies with or without nopathy diagnosis.17,71,100,103 The term RC recommendations covering the assessment
calcifications and partial-thickness RC calcific tendinopathy is used when a cal- and prognosis of adults with shoulder pain
Journal of Orthopaedic & Sports Physical Therapy®

tears.92,100,138 Terms such as subacromial cific deposit within the RC is confirmed with suspected RC tendinopathy, the non-
pain syndrome, subacromial impingement by imaging. surgical medical care and rehabilitation
of adults with RC tendinopathy, and the
U SYNOPSIS: This evidence-based clinical practice
return to function and play for elite and
This CPG includes recommendations for managing
guideline (CPG) aims to guide clinicians with recom- RC tendinopathy with or without calcifications and
recreational athletes. This CPG includes
mendations covering the assessment, treatment, partial-thickness RC tears. J Orthop Sports Phys recommendations for managing RC tendi-
and prognosis of adults with shoulder pain with Ther 2025;55(4):235-274. Epub 30 January 2025. nopathy with or without calcifications, and
suspected rotator cuff (RC) tendinopathy, the non- doi:10.2519/jospt.2025.13182 partial-thickness RC tears. This CPG ex-
surgical medical care and rehabilitation of adults
U KEY WORDS: expert clinical practice, rotator
cludes other RC-related diagnoses such as
with RC tendinopathy, as well as the return to func-
tion and sport for elite and recreational athletes. cuff, shoulder, tendinopathy full-thickness tears. The CPG is a resource
for patients, policymakers, payers, and other

1
School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada. 2Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated
Research Center, Montreal, QC, Canada. 3School of Rehabilitation Sciences, Faculty of Medicine, Université Laval, Quebec City, QC, Canada. 4Center for Interdisciplinary Research in
Rehabilitation and Social Integration, Quebec City, QC, Canada. 5La Trobe Sport and Exercise Medicine Research Center, La Trobe University, Melbourne, Australia. 6Department
of Physical Therapy, University of Florida, Gainesville, FL. 7Department of Physical Therapy and Human Movement Science, Sacred Heart University, Fairfield, CT. 8Department
of Orthopaedic Surgery, University of Missouri, Columbia, MO. 9Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC. 10Research Center, Centre
hospitalier de l’Université de Montréal, Montreal, QC. 11School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland. 12Ageing
Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland. 13ATI Physical Therapy, Greenville, SC. 14University of South Carolina, Center for Effectiveness
Research in Orthopedics, Greenville, SC. 15Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. ORCID: Desmeules, 0000-0002-
0290-7031; Roy, 0000-0003-2853-9940; Lafrance, 0000-0001-9933-4526; Charron, 0000-0003-4557-6073; Dubé, 0000-0002-5676-2982; Dupuis, 0000-0002-0607-2908;
Beneciuk, 0000-0002-5888-3630; Grimes, 0000-0002-5888-3630; Kim, 0000-0002-5286-5335; Lamontagne, 0000-0002-0249-6762; McCreesh, 0000-0003-3702-7330;
Shanley, 0000-0001-8159-8072; Vukobrat, 0000-0002-3767-8160; Michener, 0000-0001-9469-0732. This Clinical Practice Guideline was supported by the Quebec Rehabilitation
Network (REPAR) and the Quebec Pain Research Network (QPRN) and by additional funds from the Academy of Orthopaedic Physical Therapy (AOPT) of the American Physical
Therapy Association (APTA), and from the American Physical Therapy Association (APTA). The authors certify that they have no affiliations with or financial involvement in
any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Francois Desmeules, School of
Rehabilitation, Faculty of Medicine, Université de Montréal, Orthopaedic Clinical Research Unit, Centre de recherche de l’Hôpital Maisonneuve-Rosemont (CRHMR), CIUSS de
l’Est-de-l’Île de Montréal, 5415 Blvd L’Assomption, Montreal, QC H1T 2M4, Canada. E-mail: [email protected] t Copyright ©2025 JOSPT®, Inc

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 235
 [ clinical practice guidelines ]
knowledge users, offering a comprehensive agnostic reasoning of the profes- confirm rotator cuff tendinopathy in
reference on best practice in musculoskel- sional, and a screening examination the initial management of an adult
etal (MSK) care for RC tendinopathy. of the cervical spine. with shoulder pain.
3. Clinicians must identify 10. Clinicians may recommend

SUMMARY OF F any signs or symptoms of

serious pathology (red
F or prescribe diagnostic im-
aging test(s) for adults with
RECOMMENDATIONS flags) or of systemic involvement. a rotator cuff tendinopathy if symp-

N
ote: The letter grades of rec- Signs or symptoms of serious pa- toms do not resolve or improve within
ommendations (A to F) reflect the thology include but are not limited a maximum of 12 weeks of appropri-
overall strength of the evidence sup- to suspicious deformity, fever and/ ate nonsurgical management.
porting the recommendations according or chills, signs or symptoms sug- 11. Clinicians must consider the
to guidelines described by Guyatt et al,69 as
modified by MacDermid et al.121 For more
gesting cardiovascular or visceral
impairment, and history or suspi-
F following factors when
choosing a diagnostic imag-
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information, see TABLE 4. cion of cancer. ing test: suspected pathologies, diag-
4. Clinicians should identify nostic properties, accessibility, and
Section 1: Clinical Assessment of
the Painful Shoulder and Suspected
B personal, clinical, psycho-
social, or work-related 12.
costs of the diagnostic test.
Clinicians must prioritize
Rotator Cuff Tendinopathy
1. When assessing an adult
factors that may influence the prog-
nosis of an adult with rotator cuff
F diagnostic ultrasound be-
cause of its lower cost and
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

F with shoulder pain, clini-

cians must include a subjec- 5.
tendinopathy.
Clinicians may use the fol-
its diagnostic properties being simi-
lar to magnetic resonance imaging
tive assessment, as well as a detailed
history of the injury. Early in the man-
B lowing tests to confirm or to
rule out a diagnosis of rota-
for confirming a rotator cuff
disorder.
agement, clinicians must cover the fol- tor cuff tendinopathy. To confirm the 13. Clinicians must inform the
lowing aspects of the subjective
assessment: reason for consultation,
diagnosis: Painful arc test. To rule out
the diagnosis: Hawkins-Kennedy test.
F adult with shoulder pain
of the diagnostic value and
age, gender, hand dominance, work 6. Clinicians should use an in- limitations of the various imaging
and related requirements, sports and A clinometer, goniometer, or a tests and should also discuss diag-
Journal of Orthopaedic & Sports Physical Therapy®

leisure, list of medications, comorbidi- smartphone inclinometer/ nostic imaging test results with
ties, medical history, presence of psy- goniometer application to objectively patients.
chosocial and contextual factors, measure shoulder active and passive 14. Clinicians should refer adults
history and mechanism of injury, previ-
ous investigation, previous treatments,
ROM instead of visual estimation.
Scapular ROM measures are unreli-
F with a rotator cuff tendinop-
athy who have severe and
symptoms including shoulder pain, loss able and have limited validity and, persistent pain and/or disability
of range of motion (ROM) and strength, thus, should not be used by clinicians despite a maximum of 12 weeks of
cervical pain and dysfunction, and the to objectively measure dynamic scap- appropriate nonsurgical care to a
presence of paresthesia or other neuro- ular ROM. musculoskeletal physician specialist
logical symptoms, functional limita- 7. Clinicians should use a hand- such as a primary care sports physi-

2.
tions, and patient goals.
In the physical assessment
A held dynamometer to objec-
tively measure the isometric
cian, a physiatrist, or an orthopedic
surgeon for further assessment and
F and differential diagnosis
for the adult with shoulder
muscle strength of the shoulder
complex.
treatment.

pain, clinicians must include the 8. Clinicians must use valid, Section 2: Pharmacological Treatment
observation of the shoulder com-
plex (deformity, muscle atrophy,
A reliable, and responsive
patient-reported question-
for Rotator Cuff Tendinopathy
15. Clinicians may recommend
and swelling), as well as measure-
ments of active and passive ROM
naires and/or mixed tools to objec-
tively assess pain and disability in
C acetaminophen to reduce
pain in the short term for
and muscle strength. Clinicians patients with shoulder pain including adults with rotator cuff
may include palpation of the shoul- rotator cuff tendinopathy. tendinopathy.
der structures, clinical orthopedic 9. Clinicians should not pre- 16. Clinicians may recom-
special tests selected according to
the patient’s condition and the di-
F scribe or recommend a di-
agnostic imaging test to
B mend oral nonsteroidal
anti-inflammatory drugs

236 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 (NSAIDs) to reduce pain in the reduce pain and disability in adults 28. Clinicians may use or rec-
short term for adults with rotator
cuff tendinopathy.
with rotator cuff tendinopathy.
23. Regarding hyaluronic acid injections:
C ommend acupuncture in
addition to an active re-
17. Regarding opioids: a) Clinicians may use or recom- habilitation program to reduce pain
a) Clinicians may recommend D mend hyaluronic acid injec- and disability in adults with rotator
F using opioids in the short
term for pain reduction in
tions to reduce pain and
disability in the short and medium 29.
cuff tendinopathy.
Clinicians should not use or
adults with rotator cuff tendinopathy
who have severe pain and disability
terms in adults with rotator cuff
tendinopathy.
C recommend extracorporeal
shock wave therapy to re-
and are refractory or have contraindi- b) Clinicians should not use or duce pain and disability in adults

b)
cation to other analgesic modalities.
Clinicians should not recom-
F recommend hyaluronic acid
injections as a first-line
with rotator cuff tendinopathy with-
out calcification.
C mend opioids as a first-line treatment to reduce pain and disability 30. Clinicians may use or recom-
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pharmacological treatment
to reduce pain and disability in adults
in adults with rotator cuff
tendinopathy.
C mend extracorporeal shock
wave therapy to reduce pain
with rotator cuff tendinopathy. and disability in adults with rotator
18. Prescribing clinicians must Section 3: Rehabilitation Treatments cuff calcific tendinopathy.
F regularly reassess the risks for Rotator Cuff Tendinopathy 31. Clinicians may use laser
of dependence and the 24. Clinicians should provide pa- C therapy alone or in addi-
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

need for taking opioids.

19. Regarding corticosteroid injections:
C tients with patient-centered
and individualized educa-
tion to an active rehabilita-
tion program to reduce pain and
a) Clinicians may recommend tion on their condition, pain manage- disability in adults with rotator cuff
B or administer corticosteroid
injections to reduce pain
ment options, activity modification,
and self-management. Clinicians 32.
calcific tendinopathy.
Clinicians should not use
and short-term disability in adults
with rotator cuff tendinopathy.
should consider the individual’s
level of health literacy, personal be-
C or recommend therapeutic
ultrasound alone or in ad-
b) Clinicians should not rec- liefs and goals, and relevant psycho- dition to an active rehabilitation pro-
C ommend or administer social factors. gram to reduce pain and disability
Journal of Orthopaedic & Sports Physical Therapy®

corticosteroid injections as 25. Clinicians should prescribe in adults with rotator cuff calcific
first-line treatment to reduce pain
and disability in adults with rotator
A or recommend an active
rehabilitation exercise pro- 33.
tendinopathy.
Clinicians should not use or

20.
cuff tendinopathy.
If available, clinicians should
gram, which may include motor con-
trol and/or resistance training
B recommend therapeutic ul-
trasound alone or in addition
B use or recommend using ul-
trasound guidance for sub-
exercises with various loads, as an
initial treatment to reduce pain and
to an active rehabilitation program to
reduce pain and disability in adults with
acromial corticosteroid injection to disability in adults with rotator cuff rotator cuff noncalcific tendinopathy.
reduce pain in the short term. tendinopathy. 34. Clinicians may perform or
21. Clinicians should use or rec- 26. Clinicians may perform C recommend ergonomic ad-
B ommend using calcific la-
vage to reduce pain and
B spinal and/or upper limb
manual therapy alone or in
aptations to reduce occu-
pational shoulder pain in adults.
disability in adults with calcific rota- combination with other interventions
tor cuff tendinopathy refractory to such as exercise, to help reduce pain Section 4: Return to Sport for
initial treatment. in adults with rotator cuff tendinopa- Rotator Cuff Tendinopathy
22. Regarding platelet-rich plasma (PRP) thy in the short term. Manual therapy 35. Clinicians may consider an

a)
injections:
Clinicians may use or recom-
can include soft tissue techniques
and/or joint mobilizations or
F athlete’s capacity and load
tolerance for the rotator cuff
D mend PRP injections to re-
duce pain and disability in 27.
manipulations.
Clinicians may use taping
muscles and tendons along with asso-
ciated shoulder muscles and joints to

b)
adults with rotator cuff tendinopathy.
Clinicians should not use or
D in addition to an active re-
habilitation program to 36.
develop a return-to-sport program.
Clinicians may use reli-
F recommend PRP injections
as a first-line treatment to
reduce pain in adults with rotator cuff
tendinopathy in the short term.
F able, valid, and responsive
patient-rated outcome tools

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 237
 [ clinical practice guidelines ]
for pain, disability, and readiness to and reviewed for the current guidelines synthesis on RC disorders that aimed to
return to sport, along with functional were assigned to independent reviewers. systematically review all relevant literature
performance measures to guide the The project received approval from the on assessing shoulder pain, the nonsurgi-
return-to-sport continuum and de- Ethics Committee of the Maisonneuve- cal and surgical management for RC dis-
termine timelines for return to sport. Rosemont Hospital Research Center in orders (including full-thickness tears), and
Montreal, QC, Canada (# FWA00001935 return to work with shoulder pain.155 In
and IRB00002087). This CPG was sup- 2017, based on this evidence synthesis, a
METHODS
ported by the Quebec Rehabilitation CPG was developed on diagnosing, man-
Scope of the CPG Network (REPAR) and the Quebec Pain aging (nonsurgical medical, rehabilitation,
The aim of this CPG is to (1) provide a Research Network (QPRN) and by addi- and surgical treatments), and supporting
concise summary of the evidence relat- tional funds from the Academy of Ortho- return to work of adults with RC disorders
ed to managing RC tendinopathy with paedic Physical Therapy (AOPT) of the (RC tendinopathies with or without cal-
or without calcification, and partial- American Physical Therapy Association cifications, partial- and full-thickness RC
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

thickness RC tears, and (2) develop rec- (APTA), and from the American Physical tears).44 The guide, published in French, in-
ommendations to guide clinicians. This Therapy Association (APTA). cluded additional systematic searches and
guideline is not intended to formally set a 3-round modified Delphi consultation
a standard of care. Standards of care are ICD Classification involving 51 panelists to create 74 recom-
determined by considering clinical data The primary International Classification mendations. The guide was later updated
and may change as scientific evidence of Diseases and Related Health Problems, in 2022 (later referred to as the 2022 CPG),
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

and care practices evolve. The final de- 10th version (ICD-10) codes associated and an English version was published.53,92
cision regarding a clinical procedure with RC tendinopathy are presented in The development of the current CPG
or treatment plan should be based on TABLE 1 for function and for activities and is based on these previous projects and
the clinician’s experience and expertise, participation. publications, and the methodology is
considering the patient’s clinical presen- adapted from these works to update
tation, trustworthy evidence, multiple CPG Development relevant recommendations covering the
treatment options, and the patient’s val- In 2015, the senior authors of this CPG assessment of adults with shoulder pain
ues and preferences. The recommenda- (J.S.R. and F.D.) published an evidence and suspected RC tendinopathy, the
tions provided in this CPG may not be
Journal of Orthopaedic & Sports Physical Therapy®

within the regulated scope of practice of

a practitioner depending on their title ICD Classification Codes Associated With RC
and location. Clinicians using this CPG Table 1
Tendinopathy
are responsible for practicing within the
professional standards, licensing require-
S46.0 Injury of Muscle(s) and Tendon(s) of the RC of Shoulder
ments, and regulated scope of their pro-
M75 Shoulder lesions
fession when applying recommendations.
s7202 Muscles of shoulder region
An international steering committee
s7209 Structure of shoulder region, unspecified
including expert researchers, clinicians Function
(12 physiotherapists, a physical medicine b730-b74 Muscle functions
physician, and an orthopaedic surgeon), b7300 Power of isolated muscle and muscle groups
and patient partners developed this CPG. b740 Muscle endurance functions
The steering committee included mem- b7400 Endurance of isolated muscles
bers who developed a previous CPG on b7401 Endurance of muscle groups
RC disorders for adults and workers b28014 Pain in upper limb
(F.D., J.S.R., S.L., M.C., M.L., T.V.), and Activities and Participation
a group of international researchers and d430 Lifting
clinicians (L.M., E.S., J.G., K.M., M.O.D., d4451 Pushing
H.M.K.). The CPG development team d4452 Reaching
maintained editorial independence from d4454 Throwing
the involved funding agencies, and all au- d9201 Sports
thors declared relationships and submit- d840-859 Work and employment
ted a conflict-of-interest form. Articles Abbreviation: RC, rotator cuff.
authored by members of the CPG team

238 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 nonsurgical medical care and rehabilita- strategies, eligibility criteria, and dates). • immediate: data within 1 day;
tion of adults with RC tendinopathy, and For each bibliographic search, 2 review- • short-term: data including closest
the return to function and play for elite ers independently performed each step follow-up time point to 1 month (but
and recreational athletes. of the selection process. They screened less than 2 months);
titles and abstracts to assess eligibility. • medium-term: data including closest
Evidence Eligibility Criteria Full texts of potential eligible review follow-up time point to 3 months (be-
Eligible publications for this CPG were articles were retrieved and assessed. In tween 2 and 6 months);
identified via bibliographic searches con- case of disagreement between reviewers, • long-term: data including closest
ducted in Medline, Embase, Cochrane a third reviewer was available at each follow-up time point to 12 months
Central, and CINAHL. Only new sys- stage to facilitate a consensus and a final (between 6 and 18 months); or
tematic reviews with or without meta- decision. Data extraction of included re- • very long-term: any data with follow-up
analysis published since the 2022 CPG views was performed using a predefined time points beyond 18 months after the
were included.92 A professional librarian standardized form by 1 evaluator and initiation of care.
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reviewed all search strategies. Searches revised by a second evaluator. For data Eligibility criteria for evidence included
to update the literature were conducted extraction, the follow-up periods were in the present CPG are presented in TABLE 2
between July 2022 and October 2023 operationally defined as follows for for the diagnosis and treatments. Exact
(see Appendices A and B for full search results reported: eligibility criteria per search strategies are
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Table 2 Eligibility Criteria

Clinical Assessment Evidence Content for the RC Tendinopathies Treatment Evidence

Painful Shoulder (Pharmacological and Rehabilitation Treatments) Return to Sport and Rotator Cuff Tendinopathies
Population Adults with shoulder pain or suspected RC tendi- Adults with a RC tendinopathy, including partial tear Elite or recreational athletes with a RC tendinopathy
nopathy and/or calcific tendinopathy
Interventions Clinical tests, imaging tests, measurement tools Pharmacological treatments (acetaminophen, oral Prognostic factor studies: none
(range of motion and strength) and self-reported and topical NSAIDs, opioids, corticosteroid injec- Intervention studies: any intervention as part of a
Journal of Orthopaedic & Sports Physical Therapy®

questionnaires or mixed tools tions, PRP injections, hyaluronic acid injections, rehabilitation program aimed at return to sport in
opioids, suprascapular nerve block, prolotherapy, athletes
and stem cell), rehabilitation treatments (educa-
tion, exercise, manual therapy, taping, ergonomic
interventions, TENS, therapeutic ultrasound, laser,
shockwave, acupuncture/dry needling, interferen-
tial currents, and iontophoresis)
Comparators Gold standards (imaging tests, surgery, etc) Any other intervention, no intervention or placebo Prognostic factor studies: none
Intervention studies: any intervention as part of a
rehabilitation program aimed at facilitating return
to sport in athletes
Outcomes Diagnostic accuracy (sensitivity, specificity, positive/ Measures related to pain, function, health-related Prognostic studies: proportion of athletes who
negative LR) or metrological quality (validity, reli- quality of life, or a global rating of change returned to sport (%) at a specific time, time
ability, sensitivity to change) to return to sport (days), reinjury rate (%), and
determinants associated with the above prognostic
factors or clinical outcomes (pain, disability, quality
of life, or performance)
Intervention studies: self-reported pain, disability/
function, health-related quality of life or any perfor-
mance measures
Study design Systematic review with or without meta-analysis Systematic review with or without meta-analysis Randomized controlled trials, nonrandomized
Randomized controlled trial if no review ever controlled trials, analytic observational studies, or
published or systematic review with or without descriptive observational studies published in a
meta-analysis if available peer-reviewed scientific journal
Language Published in English or French in a scientific peer-reviewed journal
Abbreviations: LR, likelihood ratio; NSAIDs, nonsteroidal anti-inflammatory drugs; PRP, platelet-rich plasma; RC, rotator cuff; TENS, transcutaneous electri-
cal nerve stimulation.

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 239
 [ clinical practice guidelines ]
available in the Appendix B. Moreover, we Tool for Quantitative Studies tool for determined elements of appraisal, in-
included the recommendations and evi- randomized controlled trials (RCTs),8,186 cluding the quality of the evidence, the
dence from the 2022 CPG to guide the for- or the Scoping Review Checklist for scop- trade-off between benefits and harms,
mulation of the current recommendations, ing reviews,38 and assigned a level of evi- the cost effectiveness, and the accept-
as it covered several aspects of this CPG. dence to each article. If the 2 evaluators ability and feasibility of the proposed
In the 2022 CPG, some recommendations did not agree on the critical appraisal or recommendations.161,196,197
for the initial assessment and referral to on the level of evidence for a particular A working group first drafted a docu-
specialized care were only based on a con- article, a third evaluator was consulted ment proposing these clinical recom-
sensus because of the absence of published to resolve disagreement. (See TABLE 3 for mendations. A list of preliminary clinical
evidence as no original studies or reviews the levels of evidence table and details recommendations approved by all mem-
were identified to inform these questions on procedures used for assigning levels bers of the working committee was devel-
specific to shoulder pain or shoulder ten- of evidence, available at www.jospt.org oped. Each preliminary recommendation
dinopathy (recommendations 1, 2, 4, and and www.handpt.org.) The evidence was included a statement of the recommen-
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

14). No literature search was made to up- organized and presented from the high- dation with explanatory details and a
date these recommendations for this CPG. est to the lowest level of evidence. An ab- summary of the supporting evidence.
For the return to play section, a literature breviated version of the grading system is The full team then reviewed these rec-
search was performed from databases in- provided in TABLE 3. ommendations, and modifications were
ception, and new recommendations were made until consensus was achieved.
created by the team. Inclusion and exclu- Developing Preliminary
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sion criteria are presented in TABLE 2. Recommendations Grades of Recommendations

We followed the National Institute for The overall certainty of the evidence was
Methodological Quality Health and Care Excellence (NICE) col- graded according to guidelines described by
Assessment of Evidence laboration’s standards.134 Recommen- Guyatt et al,69 as modified by MacDermid
Articles were rated according to criteria dations were formulated based on the et al.121 The typical A, B, C, and D grades of
adapted from the Centre for Evidence- International Classification of Function- evidence have been modified to include the
Based Medicine, Oxford, UK (http:// ing, Disability and Health (ICF) and the role of consensus expert opinion (TABLE 4).
www.cebm.net).77 In pairs, evaluators in- Population, Intervention, Comparison, In developing the recommendations, we
dependently performed a critical apprais- Outcome (PICO) frameworks. 79,196,197 considered the strengths and limitations
Journal of Orthopaedic & Sports Physical Therapy®

al using the AMSTAR II (A Measurement Each recommendation was based on a of the body of evidence and the health
Tool to Assess Systematic Reviews, ver- synthesis of the evidence addressing a benefits, potential side effects, and risks
sion 2) for systematic reviews,171,172 the clinical question within the scope of the of tests or interventions. When indicated,
Effective Public Healthcare Panacea CPG. Preliminary recommendations the certainty of evidence based on meta-
Project (EPHPP) Quality Assessment were developed considering several pre- analysis was downgraded due to risk of

Table 3 Levels of Evidence

Level Intervention Diagnosis/Diagnostic Accuracy Summary

I Systematic review of high-quality RCTs Systematic review of high-quality diagnostic studies Evidence obtained from high-quality diagnostic studies,
prospective studies, systematic reviews, or random-
ized controlled trials
II Systematic review of high-quality cohort studies or Systematic review of exploratory diagnostic studies or Evidence obtained from lesser-quality diagnostic
lower-quality RCTs consecutive cohort studies (lower-quality diagnostic studies, systematic reviews, prospective studies, or
studies) randomized controlled trialsa
III Systematic reviews of case-control studies Systematic reviews of nonconsecutive study or without Case-control studies or retrospective studies
consistently applied reference standardsb
IV Case series (NA) Case-control study (NA) Case series (NA)
V Expert opinion Expert opinion Expert opinion
Abbreviations: NA, not applicable to this clinical practice guideline; RCT, randomized controlled trial.
a
Eg, weaker diagnostic criteria and reference standards, improper randomization, no blinding, less than 80% follow-up.
b
From the work of Phillips et al.77

240 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 Table 4 Grades of Recommendations

Grades of Recommendationsa Strength of Evidence Level of Obligation (Based on Treatment Effects)

A Strong evidence A preponderance of level I and/or level II studies support the recommen- Must: benefits substantially outweigh harms

A dation
Must include at least 1 level I study
Should: benefits moderately outweigh harms
May: benefits minimally outweigh harms or benefit/harm
ratio is value dependent
Should not: harms minimally or moderately outweigh
benefits or evidence of no effect
Must not: harms largely outweigh benefits
B Moderate evidence A single high-quality randomized controlled trial or a preponderance of Should: benefits substantially outweigh harms

B
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level II studies support the recommendation May: benefits moderately or minimally outweigh harms or
benefit/harm ratio is value dependent
Should not: evidence that harms outweigh benefits or
evidence of no effect
C Weak evidence A single level II study or a preponderance of level III and IV studies, Should: benefits substantially outweigh harms

C including statements of consensus by content experts, support the

recommendation
May: benefits moderately or minimally outweigh harms or
benefit/harm ratio is value dependent
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Should not: harms minimally or moderately outweigh

benefits
D Conflicting evidence Higher-quality studies conducted on this topic disagree with respect to May: conflicting evidence, the benefit/harm ratio is value

D their conclusions
The recommendation is based on these conflicting study results
dependent.

E Theoretical / foundational A preponderance of evidence from animal or cadaver studies, from May: in the absence of evidence from clinical studies, theo-

E evidence conceptual models/principles, or from basic sciences/bench research

support this conclusion
retical and or foundational evidence supports benefit.
Should not: in the absence of evidence from clinical studies,
theoretical and or foundational evidence suggests risk
Journal of Orthopaedic & Sports Physical Therapy®

of harms.
F Expert opinion Best practice based on the clinical experience of the guideline develop- Must: strongly supported by consensus-based best practice/

F ment team supports this conclusion standard of care

Should: moderately supported by best practice/standard
of care
May: supported by expert opinion in the absence of
consensus
Should not: best practice/standard of care indicates
potential harms
Must not: potential harms are strongly supported by
consensus-based best practice/standard of care
a
Grades of recommendations based on meta-analysis could be downgraded due to risk of bias, imprecision, heterogeneity, or other factors as described by Grad-
ing of Recommendations, Assessment, Development, and Evaluation (GRADE) (https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/).

bias, imprecision, heterogeneity, or other Quebec, Canada (n = 3), County Lim- were asked to review the recommenda-
factors as prescribed by the Grading of Rec- erick, Ireland (n = 3), and California, tions and complete 2 patient feedback
ommendations, Assessment, Development, USA (n = 2), to obtain various views and questionnaires in which patients had to
and Evaluation (GRADE) system.68 opinions as these countries have different indicate their level of agreement with the
types of health care systems, and patients’ recommendations. We also developed a
Patient Involvement experiences may differ. Using a purposive semistructured interview guide and com-
The final recommendations were pre- sample, patients were recruited from pre- pleted focus groups and individual inter-
sented to patients who sought care for vious projects conducted by research team views with the participants so they could
shoulder tendinopathy in the province of members in these countries. Participants provide input on the recommendations.

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 241
 [ clinical practice guidelines ]
Participants mentioned that, based on components of the shoulder must oper- tendinopathy.102,165 Finally, psychosocial
their level of understanding, all recom- ate in a synergy to ensure an adequate factors have also strongly been advo-
mendations from the current CPG were balance between mobility and stabil- cated for as an explanation for why some
comprehensive and presented clearly and ity.190 Those components include passive individuals experience persistent symp-
that they agreed with them. Some par- (scapula, humerus, clavicle, ligaments, toms.16,90,175 Some occupations or sports
ticipants suggested minor changes to the labrum, and capsule) and active (gleno- activities may put workers or athletes at
wording of only a few recommendations. humeral and scapulothoracic muscles) higher risk of developing RC tendinopa-
These changes were incorporated in the structures relying on a dynamic inter- thy since higher demands and several risk
final revisions of the recommendation. action supported by the sensorimotor factors may be present and put the per-
system.150,151 Together those structures son at higher risk.102
Organization of the Guideline form the acromioclavicular, sternocla-
A brief section introduces pathoanatomi- vicular, and glenohumeral joints, as well SECTION 1: CLINICAL
cal features of RC tendinopathy; then, 4 as the scapulothoracic joint, a pseudo ASSESSMENT OF THE
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sections present evidence and recommen- joint.99 Most (2/3) of the movement oc- PAINFUL SHOULDER
dations for the assessment, medical, and re- curs at the glenohumeral joint while the AND SUSPECTED RC
habilitation treatments and return to sport. scapulothoracic joint allows for the re-
TENDINOPATHY
For each section, summaries of included lit- maining movement.164
erature based on systematic reviews of the RC tendinopathy is mostly associated 1.1 History and Physical Exam
literature with the corresponding evidence with pain, usually during arm elevation A pathoanatomical diagnosis model for
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

levels are followed by gaps in knowledge, and external rotation, but pain can also the shoulder remains of great value as
evidence synthesis, and rationale and by occur during sleep or rest in more irri- it guides the clinician in the evaluation
the clinical recommendation(s) including table presentations.87,129,140 In turn, this of the prognosis, establishing a patient-
the grade of recommendation. pain can lead to reduced muscle perfor- centered care plan and selecting thera-
Presented recommendations use ac- mance (strength and endurance),34,120as peutic interventions. To formulate an
tionable terms such as must, should, well as kinematic alterations of the upper adequate diagnosis, the clinical assess-
may, should not, or must not, according limb.115,116 Although there is no consensus, ment of a patient involves a detailed
to the level of obligation presented in the most consistently reported shoulder history of injury, subjective and physical
TABLE 4, but also the terms use, perform, alterations are reduced upward rotation assessments that may include standard-
Journal of Orthopaedic & Sports Physical Therapy®

prescribe, or recommend, so that it is and posterior tilt of the scapula, as well ized questionnaires, identification of any
inclusive of various regulated scopes of as an increased elevation of the shoulder red flags, screening for yellow flags, use
practice of different providers from dif- girdle. When pain persists over time, it of special clinical tests, and suggesting
ferent legislations. Practitioners have the can even lead to the development of mal- or prescribing imaging tests if relevant.
responsibility to practice according to the adaptive pain behaviors such as kinesio- Overview
professional standards of their profes- phobia, catastrophization, and reduced Based on a systematic review of
sion, licensing body, and regulated scope
of practice when using recommendations.
self-efficacy.119,125,126
Various intrinsic, extrinsic, and envi-
V CPGs48 and on recommenda-
tions from a 2021 CPG for RC
For Section 1 and for Sections 2 and ronmental factors alone or in combina- disorders44 that was based on a consen-
3 combined, 2 decision trees including tion have been suggested to explain why sus from a modified Delphi study, it is
the relevant recommendations are also RC tendinopathy occurs.108,165 Age may recommended that the evaluation of
presented. lead to morphological changes in the adults presenting with shoulder pain
tendons influencing its ability to sustain should include a thorough subjective
the loads applied.66,195,199 In addition, bony evaluation including a detailed history, a
PATHOANATOMICAL
changes and altered kinematics may in- comprehensive objective evaluation, as
FEATURES OF RC crease the compressive and shear loads well as the prompt identification of yel-
TENDINOPATHY applied on the tendons.55,63,141,142 Repeti- low and red flags early on during the ini-

T
he shoulder is the most mobile tive movements leading to fatigue may tial consultation or during the following
joint of the human body.50,133 While also predispose individuals to experience reassessment.44,48
this is convenient to allow for the RC tendinopathy.20,127 Occupational haz- Gaps in Knowledge While it is ac-
performance of daily life activities, it may ards, smoking, nutritional deficiencies, cepted that a complete history and
increase the risk of RC tendinopathy es- genetics, or variations in blood supply physical exam is crucial to ensure safe
pecially when repetitive movements are to the RC are also all factors considered and efficient patient care, there is a lack
involved.10,189 For optimal function, all to contribute to the development of RC of evidence on the diagnostic value of

242 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 these aspects when evaluating a patient 1.2 Risk Factors and Prognostic Factors (OR = 5.3) were protective factors against
with a suspected RC tendinopathy. More Risk and prognostic factors can be useful chronicity. Dominant or nondominant
evidence is needed to conclude on the to identify patients at risk of poor out- side involvement, education level, comor-
exact diagnostic accuracy of a subjective comes such as persistent and/or high lev- bidities, higher pressure point thresholds,
evaluation of a patient with a suspected els of pain and disability. Identifying these job-associated repetitive movements, per-
RC tendinopathy. factors may be helpful for the management ceived job control, job requiring the use of
Recommendations of adults with RC tendinopathy. Yellow higher shoulder forces, and psychosocial
Recommendation No. 1 flags are psychological prognostic factors factors such as emotional distress, inter-
When assessing an adult with for the development of disability following nal locus of control, and intrinsically mo-
F shoulder pain, clinicians must
include a subjective assess-
the onset of MSK pain.61,139 Personal, clini-
cal, psychosocial, or environmental factors
tivated personality were not associated
with the risk of persistent pain for adults
ment as well as a detailed history of the may affect the prognosis and therefore in- with RC tendinopathy.
injury. Early in the management, clini- fluence therapeutic choices. A systematic review21 including
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cians must cover the following aspects of Based on a systematic review of II 5 low-quality prognostic studies
the subjective assessment: reason for
consultation, age, gender, hand domi-
V CPGs48 and on recommenda-
tions from a 2021 CPG44 based
on adults with RC tendinopathy
(n = 387) receiving physiotherapy care (ex-
nance, work and related requirements, on a consensus from a modified Delphi ercises, manual therapy, electrotherapy,
sports and leisure, list of medications, study, it is recommended to identify per- and education) and other treatments such
comorbidities, medical history, presence sonal, psychosocial, or environmental as acupuncture or corticosteroid injections
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

of psychosocial and contextual factors, factors that may negatively influence the reported a lack of any valid and useful
history and mechanism of injury, previ- progression or the return-to-work pro- prognostic models to help predict out-
ous investigation, previous treatments, cess when assessing a worker with shoul- comes in adults with pain due to RC ten-
symptoms including shoulder pain, loss der pain. These include, but are not dinopathy. Authors highlighted the need
of range of motion (ROM) and strength, limited to, advanced age (50 years and for further research on prognostic models
cervical pain, and the presence of pares- over for return to work); a history of and validated tools for predicting out-
thesia or other neurological symptoms, shoulder injury; prolonged duration of comes in adults with RC tendinopathy.
functional limitations, and patient goals. symptoms; high pain intensity; delayed A systematic review on the asso-
Recommendation No. 2 medical care after the injury; delayed II ciation of psychological factors
Journal of Orthopaedic & Sports Physical Therapy®

In the physical assessment and compensation claims in relation to the and tendinopathies123 included 2
F differential diagnosis for the
adult with shoulder pain, clini-
date of the injury; a history of absentee-
ism at work; presence of psychosocial
studies on RC tendinopathy. One high-
quality cross-sectional study (n = 200) with
cians must include the observation of the factors such as psychological distress, moderate quality showed no significant as-
shoulder complex (deformity, muscle at- anxiety, catastrophizing, or kinesiopho- sociations between the presence of emo-
rophy, and swelling), as well as measure- bia; worker’s feelings of injustice; lack of tional distress and pain levels and disability
ments of active and passive ROM and social support; having 1 or more related to RC tendinopathy. A second high-
muscle/joint strength. Clinicians may dependent(s); loss of employment ties; quality longitudinal study (n = 90) with
include palpation of the shoulder struc- worker’s perception of work-related high moderate evidence suggested that initial
tures, clinical orthopedic tests selected demands, and litigation with their em- higher levels of kinesiophobia and catastro-
according to the patient’s condition and ployer or insurer. These factors are not phizing are only weakly associated with
the diagnostic reasoning of the profes- specific for RC tendinopathy as this evi- higher initial disability levels and are not
sional, and a screening examination of dence applies to general shoulder pain. predictive of future disability levels at 3
the cervical spine. A systematic review on the risk months. Authors concluded that individual-
Recommendation No. 3
Clinicians must identify any
II factors for pain chronicity179 in-
cluded 2 RCTs of patients with
ized management for tendinopathy disor-
ders is essential, and that clinicians should
F signs or symptoms of serious
pathology (red flags) or of sys-
RC tendinopathy. Authors reported mod-
erate evidence that being over 55 years old
consider using validated screening tools
(not defined) to assess psychological factors
temic involvement. Signs or symptoms of (odds ratio [OR] = 3.8), and the percep- associated with suboptimal outcomes for
serious pathology include but are not tion of high job demand (OR = 4.1) were patients suffering from tendinopathy.
limited to suspicious deformity, fever associated with higher risk of persistent A systematic review on the as-
and/or chills, signs or symptoms suggest-
ing cardiovascular or visceral impair-
pain. Undergoing rehabilitation, medical
nonsurgical or surgical care (OR = 5.4),
II sociation between psychologi-
cal factors and tendinopathy180
ment, and history or suspicion of cancer. and not taking pain medication regularly included 4 studies of moderate quality on

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 243
 [ clinical practice guidelines ]
adults with RC tendinopathy and report- • Clinical factors shoulder pain or other symptoms. Their
ed low-certainty evidence (GRADE) from ⚪ Prolonged duration of symptoms results can help establish a diagnosis and
3 cross-sectional studies supporting a ⚪ Previous history of shoulder injury assist in formulating an effective treat-
weak association between higher depres- ⚪ Delayed care after the initial injury ment plan. Combined with a full clinical
sion, anxiety, and emotional distress lev- ⚪ High shoulder pain intensity evaluation, they are fundamental in guid-
els and higher pain and disability levels. • Psychosocial factors ing health care providers toward efficient,
A systematic review,194 reported ⚪ Psychological distress evidence-based care of this population.
III on 1 low-quality cross-sectional
study on the association of psy-
⚪
⚪
Anxiety
Catastrophizing
Overview
Based on a systematic review of
chological factors with pain for adults with
RC tendinopathy. They reported that pa-
⚪
⚪
Kinesiophobia
Poor social support
V CPGs48 and on recommenda-
tions from a 2021 CPG44 that
tients with higher fear of pain demonstrat- • Work-related factors was based on a consensus from a modi-
ed a lower pain tolerance and painful ⚪ Delayed workers compensation fied Delphi study, clinicians should not
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threshold compared to patients with lower claims in relation to the date of the rely solely on clinical test results to diag-
fear of pain. A correlation was found be- injury nose RC tendinopathy.
tween pain catastrophizing and higher ⚪ Loss of employment ties Three systematic reviews with
shoulder pain intensity.
Gaps in Knowledge While it is accepted
⚪
⚪
A history of absenteeism at work
Work-related feelings of injustice
I and without meta-analysis as-
sessed the diagnostic value of
that a complete history and physical exam ⚪ For workers, having 1 or more different clinical tests for RC tendinopa-
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

including psychosocial and contextual dependent(s) at home thy.64,104,154 Roy et al reported that the
factors is necessary to ensure optimal pa- ⚪ Worker’s perception of work- Hawkins-Kennedy test is the test with the
tient-specific care, there remains limited related high demands and litigation lowest negative likelihood ratio (LR−)
evidence on their prognostic value when with their employer or insurer (Sn = 0.83; 95% confidence interval [CI]:
evaluating a patient with a suspected RC ⚪ Work physical requirements in- 0.59, 0.99; Sp = 0.69; 95% CI: 0.37, 0.77;
tendinopathy. The limited evidence is cluding more frequent or higher arm el- LR+ = 2.68; LR− = 0.25; n = 962) while
partially due to the lack of longitudinal evation, shoulder loads, hand-arm force the painful arc test is the test with the
cohort studies as several studies refer- exertion, hand-arm vibration, repetitive highest positive likelihood ratio (LR+)
enced above used a cross-sectional study movements, or awkward postures (Sn = 0.62; 95% CI: 0.31, 0.91; Sp = 0.82;
Journal of Orthopaedic & Sports Physical Therapy®

design. Additional longitudinal research However, the observed relationships 95% CI: 0.62, 1; LR+ = 3.44; LR− = 0.46;
using well-defined risk (exposure) factors are often weak and based on low-level n = 964) based on 5 studies comparing
is needed to develop or validate prognostic quality studies, and the clinical utility re- the diagnostic value of the Hawkins-
tools that efficiently identify prognostic or mains to be fully evaluated. In a recent Kennedy, painful arc, and Neer tests to
psychosocial risk factors (yellow flags) in systematic review of prognostic tools,136 diagnose RC tendinopathy.154 Gismervik
patients with RC tendinopathy.187 Despite the authors were unable to identify any et al found that the clinical performance
the lack of prognostic tools available for clinically valuable externally validated of the Hawkins-Kennedy (LR+ = 1.76;
RC tendinopathy, clinicians could consid- prognostic models for the upper limb. LR− = 0.63; 2 studies) or Neer (LR+ =
er the use of other prognostic assessment Recommendation No. 4: 1.48; LR− = 0.68; 2 studies) tests for RC
tools for general MSK disorders, such as Clinicians should identify per- tendinopathy is limited to exclude or to
the Orthopaedic Shoulder Pain and Dis-
ability Index – Youth Form (OSPRO-YF)
B sonal, clinical, psychosocial, or
work-related factors that may
confirm a diagnosis of RC tendinopathy.64
A recent systematic review by Liaghat et al
tool98 or the Start Back Screening Tool for influence the prognosis of an adult with included 1 study of high quality and re-
MSK Disorders (STarT MSK) tool.52 RC tendinopathy. ported that the combination of 3 out of 5
Evidence Synthesis and Rationale Sev- positive tests (Hawkins-Kennedy, Neer,
eral personal, clinical, psychosocial, or 1.3 Diagnostic Value of Clinical Tests painful arc, empty can (Jobe), and exter-
environmental risk factors are reported to Diagnosing RC tendinopathy involves nal rotation against resistance) have an
be associated with poor outcomes or high typically using a variety of clinical tests LR+ of 2.93 and an LR− of 0.34.104
pain levels and disability in patients with to make a valid diagnosis and excluding Gaps in Knowledge Evidence on the
RC tendinopathy. other shoulder or upper-limb disorders. diagnostic value of clinical tests for RC
These include but are not limited to the These tests, integral to the diagnostic tendinopathy is limited. Included studies
following: process, assess specific movements and suggest that the diagnostic value of these
• Personal factors responses to potentially identify struc- tests is modest at best. Methodologically
⚪ Advanced age tures that may be linked or explain sound diagnostic studies of patients with

244 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 various shoulder pain disorders evaluat- logical studies, the goniometer and the clinometer, and smartphone goniometer
ing the combination of common clinical inclinometer are recommended tools for applications are valid and reliable tools to
tests with elements of the patient’s history measuring shoulder ROM as their reli- measure shoulder ROM. Based on high
and subjective evaluation are needed to ability is generally good to excellent for quality-evidence, the measurement of
better inform clinicians on the diagnos- shoulder flexion, abduction, external ro- scapular motion using inclinometers or
tic value of a clinical evaluation for a sus- tation, and internal rotation. goniometers is not recommended due to
pected RC tendinopathy. One systematic review86 includ- limited reliability and validity.
Evidence Synthesis and Rationale The
Hawkins-Kennedy and the painful arc
I ing 6 metrological studies spe-
cific to the shoulder joint
Recommendations
Recommendation No. 6
tests have the highest diagnostic values concluded that smartphone goniometer Clinicians should use an incli-
to exclude an RC tendinopathy diagnosis.
The painful arc test is the test with the
applications are valid and reliable to
measure various shoulder ROM (flexion,
A nometer, goniometer, or a smart-
phone goniometer application
highest diagnostic value to confirm an RC abduction, internal/external rotation, and to objectively measure shoulder ROM
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tendinopathy.155 The positive and nega- horizontal adduction) and supported over visual estimation. Scapular ROM
tive LRs are considered small for both their use by clinicians. measures are unreliable and have limited
the painful arc and the Hawkins-Kenne- Based on a systematic review155 validity and, thus, should not be used by
dy tests. Clinicians should not solely rely
on clinical test results to confirm any RC
II and on a 2021 CPG,44 the mini-
mum detectable change (MDC)
clinicians to objectively measure dynamic
scapular ROM.
disorder diagnoses, but also include in- values are similar between the inclinom-
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

formation from the patient’s history and eter or the goniometer. They vary between 1.5 Psychometric Value of Outcome
subjective assessment.48 Use of combina- 8° and 23° for active ROM and between Measure Instruments: Muscle Strength
tions of tests may yield better diagnostic 3° and 21° for passive ROM for flexion, Clinicians frequently evaluate shoulder
accuracy than single tests, but evidence abduction, internal rotation, and external strength as part of the diagnostic and
is limited. rotation.155 More data on the MDC are treatment process for shoulder pain-re-
Recommendations needed to confirm these results since they lated conditions. They may utilize tools
Recommendation No. 5 mostly come from small sample sizes. like the handheld dynamometer to objec-
Clinicians may use the following Scapular ROM tively measure shoulder strength. Dyna-
B tests to confirm or to rule out Three systematic reviews46,47,144 mometers offer a quantification of muscle
Journal of Orthopaedic & Sports Physical Therapy®

the RC.
a diagnosis of tendinopathy of I assessed the validity and reli-
ability of measurement tools
strength for various shoulder muscle
groups or movements, enabling clinicians
To confirm the diagnosis: Painful for assessing scapular dynamic ROM. to make informed decisions for diagnosis
arc test They concluded that there is insufficient and for objectively monitoring strength
To rule out the diagnosis: Hawkins- evidence to recommend any instrument deficits or gains during patient care.
Kennedy test or test to measure scapular ROM as Overview
they are not reliable and may often lead Based on a 2021 CPG44 includ-
1.4 Psychometric Value of Outcome
Measure Instruments: ROM
to misinterpretation of scapular motion.
However, D'hondt et al reported that
I ing 7 metrological studies and
2 systematic reviews with me-
Clinicians have access to different tools there is high-quality evidence support- ta-analysis,30,177 there is high-quality evi-
such as the inclinometer and the goni- ing the use of inclinometer to measure dence that handheld dynamometry is
ometer to objectively measure shoulder the scapular upward rotation angle at a reliable to assess shoulder strength in
ROM either for diagnostic purposes or static position of rest.46 adults with or without shoulder pain.
to assess change over time. New tech- Gaps in Knowledge Shoulder ROM Based on moderate- to high-quality evi-
nologies have also emerged, introduc- using a goniometer or an inclinometer dence, the MDC for handheld dyna-
ing electronic tools like smartphone has a wide range of reported MDCs. mometry is probably between 15% and
applications using the principles of gy- Shoulder ROM MDCs using smart- 20%.177 Sørensen et al included 10 stud-
roscopes or photo capture to quantify phone goniometer applications were not ies using peak force (newton or kilo-
joint ROM. reported in any systematic reviews. Ac- grams), 1 study used relative peak force
Overview ceptable levels of reliability and validity (kilogram/body weight), and 1 study
Shoulder ROM are not established using any instrument used newton meters. Most studies in-
Based on a systematic review to measure scapular dynamic ROM. cluded 2 or 3 repetitions. Isokinetic test-
I with meta-analysis155 and on a
2021 CPG44 including 8 metro-
Evidence Synthesis and Rationale Based
on high-quality evidence, goniometer, in-
ing was used as the reference criteria in
these validation studies.

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 245
 [ clinical practice guidelines ]
Based on a systematic review,155 limitations. By tracking changes over A systematic review by Hao et
II the validity of manual muscle
testing is questionable as only
time, clinicians can adjust treatment
plans accordingly and optimize patient-
I al72 synthesizing level I studies
looked at the responsiveness of
20% of maximal strength is necessary centered care. self-reported questionnaires and/or mixed
to obtain a 4/5 score. Therefore, the Overview tools and reported median minimal clini-
use of manual muscle testing is not rec- Based on a 2021 CPG,44 includ- cally important difference (MCID) values
ommended, and authors recommend
using handheld dynamometry as an
I ing 16 studies on their psycho-
metric properties, there is
for various shoulder disorders including
RC tendinopathy. Another systematic re-
alternative. 155 strong evidence supporting the use of self- view from Jones et al,84 including 4 studies
Evidence Synthesis and Rationale There reported questionnaires and/or mixed specific to the WORC Index, reported a
is strong evidence supporting the use of tools to assess pain, disability, health- range of MCID values for this question-
a handheld dynamometer to measure related quality of life and other symptoms naire. MCID values reported on these 2
shoulder muscle strength, as it is valid in adults with shoulder disorders. Vali- reviews are presented in TABLE 5.
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and reliable contrary to manual muscle dated and reliable questionnaires for pa- Four systematic reviews39,72,84,188
testing.
Recommendations
tients with RC tendinopathy and other
shoulder disorders include the following:
II reported MCID values for self-
reported questionnaires as
Recommendation No. 7 1. American Shoulder and Elbow Surgeons presented in TABLE 6.
Clinicians should use a hand- Shoulder Score (ASES), Gaps in Knowledge It remains unclear
A held dynamometer to objec- 2. Constant-Murley Score (CMS), if any of the questionnaires should be
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tively measure the isometric 3. Disabilities of the Arm, Shoulder and preferred over another for clinical use to
muscle strength of the shoulder. Hand (DASH) and associated short measure pain, symptoms, and disability in
version (QuickDASH), adults with RC tendinopathy. MCID val-
1.6 Patient-Reported Questionnaires 4. Oxford Shoulder Score (OSS), ues, the minimal change considered of val-
and Mixed Outcome Tools 5. Rotator Cuff Quality of Life Index ue to the patient, have been reported in the
Numerous self-reported questionnaires (RC-QOL), literature to vary for several self-reported
have been developed to quantify pain, 6. Shoulder Pain and Disability Index questionnaires. These values are based on
symptoms, and disability for patients (SPADI), studies that included heterogeneous popu-
with shoulder pain, including RC tendi- 7. Simple Shoulder Test (STT), lations with various shoulder disorders and
Journal of Orthopaedic & Sports Physical Therapy®

nopathy. They are valuable assessment 8. Upper Extremity Functional Index not only RC tendinopathy. There are a va-
tools, offering clinicians a structured (UEFI), riety of methods to derive an MCID, which
method for assessing the impact of RC 9. Western Ontario Rotator Cuff (WORC) in part results in a range of MCID values.59
tendinopathy on patient’s subjective Index, and The use of a single MCID value could also
experiences, symptoms, and functional 10. Pennsylvania Shoulder Score (Penn). be inaccurate as baseline values influence

TABLE 5 MCID Values of Self-reported Questionnaires (Level I Evidence)

Scale Direction
(Higher Score Signs a Better or Worse
Questionnaires Score Range Condition) Construct(s) Measured MCID
Level I Evidence
DASH 0-100 Worse Pain, disability, and other symptoms Median: 10.2 (range, 4.4-25.4; 6 studies)
OSS 0-48 Better Pain, disability, and other symptoms Median: 5.3 (range, 4/48-14.7; 8 studies)
SST 0-12 Better Pain, disability, and other symptoms Median: 1.8 (range, 1.5/12-2.1; 2 studies)
CMS 0-100 Better Pain, disability other symptoms, disability, ROM, Median: 8.3 (range, 3-16.6; 10 studies)
and strength
WORC 0-2100 Worse Pain, disability, other symptoms, emotions Mean: 275.7 (range, 245.3-300; 4 studies)
Pain VAS - overall 0-10 Worse Pain Median: 1.5 (range, 1.4-1.6; 2 studies)
Abbreviations: ASES, American Shoulder and Elbow Surgeons Shoulder Score; CMS, Constant-Murley Score; DASH, Disabilities of the Arm, Shoulder and
Hand; MCID, minimal clinically important difference; OSS, Oxford Shoulder Score; PNRS, pain numeric-rating scale; ROM, range of motion; SST, Simple
Shoulder Test; VAS, Visual Analogue Scale; WORC, Western Ontario Rotator Cuff Index.

246 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 TABLE 6 MCID Values of Self-reported Questionnaires (Level II Evidence)

Scale Direction
Questionnaires Score Range (Higher Score Signs a Better or Worse Condition) Construct(s) Measured MCID
Quick DASH 0-100 Worse Pain, disability, and other symptoms Median: 13.4/100 (1 study)
PNRS 0-10 Worse Pain Median: 3.5/10 (range, 1.1-6.3; 5 studies)
ASES 0-100 Better Pain, disability, and other symptoms 6.439 Mean: 15.5 (range, 6.4-21.9)84
Penn 0-100 Better Symptoms, satisfaction, and disability 1.439
SPADI 0-100 Worse Pain, disability, and other symptoms 839
Abbreviations: ASES, American Shoulder and Elbow Surgeons Shoulder Score; DASH, Disabilities of the Arm, Shoulder and Hand; MCID, minimal clinically
important difference; PNRS, pain numeric-rating scale; Penn, Pennsylvania Shoulder Score; SPADI, Shoulder Pain and Disability Index.
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the magnitude of the MCID.19,97 Because disability with shoulder pain including Based on a systematic review
baseline scores impact the magnitude of
MCID, a single MCID value is likely not
RC tendinopathy. III with a network meta-analysis,
the diagnostic value of MRA (Sn =
to be accurate to assess treatment out- 1.7 Diagnostic Value of 0.81; 95% CI: 0.74, 0.86; Sn = 0.90; 95%
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

comes across all patients.19,97 The smallest Diagnostic Imaging Tests CI: 0.86, 0.93; 28 studies) is superior than
worthwhile effect is defined as the small- Clinicians should primarily rely on a com- MRI (Sn = 0.67; 95% CI: 0.60, 0.73; Sp =
est beneficial effect of an intervention that prehensive clinical examination (patient’s 0.86; 95% CI: 0.81, 0.89; 41 studies) or di-
justifies its costs and harms. This estimate history, subjective assessment, and physical agnostic ultrasound (Sn = 0.62; 95% CI:
using the benefit-harm trade-off method exam) to diagnose an adult with a suspect- 0.53, 0.71; Sp = 0.85; 95% CI: 0.80, 0.89;
has been suggested as an indicator to ed RC tendinopathy. However, diagnostic 39 studies) for partial-thickness RC tear.112
compare 2 different interventions.57,58 The imaging tests, including radiography, di- A 2021 CPG44 stated that clini-
estimated smallest worthwhile effects for
various interventions for RC disorders are
agnostic ultrasound, MRI, and MRI with
intra-articular contrast (MRA) may be re-
V cians should inform adults
with shoulder pain of the diag-
Journal of Orthopaedic & Sports Physical Therapy®

unknown, which is an area that should be quired to exclude other shoulder disorders nostic value, possible pitfalls, and limi-
examined in future research. in particular clinical presentations. tations of the various prescribed imaging
Evidence Synthesis and Rationale There Overview tests, and should also discuss diagnostic
is strong evidence supporting the use of Based on 2 systematic reviews imaging test results with patients.
self-reported questionnaires and/or mixed
tools to assess and monitor pain and dis-
II with meta-analyses, MRA and
MRI have similar diagnostic
Gaps in Knowledge Even if initial im-
aging for a suspected RC tendinopa-
ability in adults with shoulder pain during values for partial-thickness RC tear. thy should not be performed, more
the course of care. There are numerous Huang et al78 reported LR for MRA (LR+ research on potentially relevant imag-
valid, reliable, and responsive self-reported = 43.1; 95% CI: 14.5, 128.2; LR− = 0.23; ing findings related to RC tendinopa-
questionnaires. Clinicians should refer 95% CI: 0.16, 0.34; 8 studies) and MRI thy in patients with persistent pain and
to established MCIDs of these question- (LR+ = 10.17; 95% CI: 3.00, 34.49; LR− disability could help identify imaging
naires when objectively measuring change = 0.31; 95% CI: 0.18, 0.54; 6 studies). Liu findings or measures that may have a
in a patient’s shoulder condition to deter- et al111 reported sensitivity and specificity clinically useful prognostic value. It is
mine if change is meaningful. However, values for MRA (Sn = 0.45; 95% CI: 0.07, important to note that in patients with
MCIDs are likely valid only for a specific 0.89; Sp = 0.76; 95% CI: 0.05, 1.00) and persistent pain, disability, and other fac-
range of baseline scores. Use of MCIDs MRI (Sn = 0.70; 95% CI: 0.50, 0.85; Sp = tors, such as psychosocial factors, may
obtained from baseline score measure- 0.95; 95% CI: 0.90, 0.98). play a determining role in the persistence
ments, when available, are preferred. Three systematic reviews112,155,182 of and the level of symptoms experienced
Recommendations
Recommendation No. 8
II concluded that because of its
lower cost and comparable di-
by the patient.
Evidence Synthesis and Rationale Di-
Clinicians must use valid, reli- agnostic accuracy, diagnostic ultrasound agnostic imaging tests should be used in
A able, and responsive patient-
reported questionnaires and/or
should be prioritized over the use of
MRA or MRI for partial-thickness RC
the presence of a trauma, if there is a clin-
ical suspicion of a significant structural
mixed tools to objectively assess pain and tear. lesion such as a full-thickness RC tear,

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 247
 [ clinical practice guidelines ]
Shoulder Pain

Subjective and physical

assessment #1-2 and 5-8,
Grade A to F

Appropriate Presence of
management and red flags?
referral as needed

Consider identified psychosocial factors

for the selection of therapeutic
interventions and return to daily, work,
and sports activities
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Formulate a Diagnostic
Hypothesis
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Hypothesis of Rotator Cuff

Other diagnostic hypotheses
Tendinopathy

Initiate treatment:
Refer to Decision tree 2

FIGURE 1. Shoulder pain assessment and initial management decision tree. The symbol # represents the associated recommendation number. Grade letters indicate that the
Journal of Orthopaedic & Sports Physical Therapy®

guidelines are based on (A) strong evidence, (B) moderate evidence, (C) weak evidence, (D) conflicting evidence, (E) theoretical/foundational evidence, or (F) expert opinion.

or after failure of adequate nonsurgical Recommendation No. 12 cialized nonsurgical care. This could be a
management. Clinicians should prioritize di- sports medicine physician, a physiatrist,
Recommendations
Recommendation No. 9
F agnostic ultrasound because of
its lower cost and its diagnostic
or an orthopedic surgeon. This decision
should be discussed with the patient.
Clinicians should not prescribe properties being similar to MRI to con- Overview
F or recommend diagnostic imag- firm an RC disorder. Based on recommendations
ing tests to confirm an RC ten-
dinopathy in the initial management of an
Recommendation No. 13
Clinicians should inform the
V from a 2022 CPG,92 which was
based on a consensus from a
adult with shoulder pain.
Recommendation No. 10
F adult with shoulder pain of the
diagnostic value and limita-
modified Delphi study, following the fail-
ure of initial nonsurgical care, a consulta-
Clinicians may recommend or tions of the various imaging tests, and tion with a MSK specialist such as a
F prescribe diagnostic imaging
test(s) for adults with an RC ten-
should also discuss diagnostic imaging
test results with the patient.
sports physician, a physiatrist, or an or-
thopedic surgeon is recommended.
dinopathy if symptoms do not resolve or Gaps in Knowledge There is limited
improve within a maximum of 12 weeks of 1.8 Indications for Referral to evidence on the indications for MSK phy-
appropriate nonsurgical management. a MSK Medical Specialist sician specialists’ referral as the available
Recommendation No. 11 When a patient presents with persistent evidence is based on expert consensus.
Clinicians must consider the fol- pain related to RC tendinopathy and Evidence Synthesis and Rationale
F lowing factors when choosing a
diagnostic imaging test: suspect-
shows limited improvement following
initial nonsurgical interventions, health
Adults with an RC tendinopathy who
experience significant and/or persistent
ed pathologies, diagnostic properties, ac- care providers may decide to refer the pa- pain and/or disability after adequate non-
cessibility, and costs of the diagnostic test. tient to a MSK medical specialist for spe- surgical management could benefit from

248 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

FIGURE 2. Management of rotator cuff tendinopathy decision tree. The symbol # represents the associated recommendation number. Grade letters indicate that the guidelines
are based on (A) strong evidence, (B) moderate evidence, (C) weak evidence, (D) conflicting evidence, (E) theoretical/foundational evidence, or (F) expert opinion.
Abbreviation: NSAIDs, nonsteroidal anti-inflammatory drugs.

a consultation with a medical specialist with meta-analysis85 that high-certainty 12 weeks of adequate nonsurgical care to
such as a sports physician, a physiatrist, evidence shows that subacromial decom- a MSK physician specialist such as a
or an orthopedic surgeon for further as- pression with an acromioplasty surgery sports physician, a physiatrist, or an or-
sessment and treatment. The scope of does not provide clinically important thopedic surgeon for further assessment
the current CPG only covers nonsurgical benefits when compared to a placebo sur- and treatment.
interventions, but it is important to note gery in terms of pain and disability reduc-
that our group had previously published tions in adults with RC tendinopathy who SECTION 2:
a recommendation in the 2022 CPG that failed initial nonsurgical management PHARMACOLOGICAL
subacromial decompression surgery is and are referred to a medical specialist
TREATMENTS
not recommended to treat RC tendinopa- such as an orthopedic surgeon.

P
thy (level A recommendation – Strength Recommendations hysiotherapists are essential
of Recommendation Taxonomy [SORT] Recommendation No. 14 health care providers. While they
scale) as it does not provide any clinically Clinicians should refer adults primarily focus on education, ex-
important benefits when compared to
a placebo surgery.92 This recommenda-
F with an RC tendinopathy who
have severe and persistent pain
ercises, and other physical modalities,
they can recommend or refer for medical
tion is based on a systematic review and/or disability despite a maximum of interventions or prescriptions within

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 249
 [ clinical practice guidelines ]
to reduce mild to moderate MSK pain in-
cluding RC tendinopathy.
Recommendation
Recommendation No. 15
Clinicians may recommend ac-
C etaminophen to reduce pain in
the short term for adults with
RC tendinopathy.

2.2 Oral Nonsteroidal Anti-

inflammatory Drugs
Nonsteroidal anti-inflammatory drugs
(NSAIDs) encompass 2 classes of medi-
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cations, namely, selective cyclooxygen-

ase (COX-2) inhibitors and nonselective
inhibitors.17 NSAIDs are prescribed for
their analgesic and anti-inflammatory
FIGURE 3. Developing a return-to-sport plan for elite and recreational athletes with rotator cuff tendinopathy. effects143 and are commonly used to treat
MSK disorders including tendinopathies.
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Overview
their regulated scope of practice. Physio- in the treatment of shoulder pain. Pain Oral NSAIDs
therapists play a crucial role in health care management is often necessary to ensure Based on a 2021 CPG,44 there is
systems worldwide, though the extent of
their scope of practice varies internation-
optimal outcomes and prevent persistent
pain and disability for various MSK dis-
II low- to moderate-quality evi-
dence that oral NSAIDs may
ally and is continuously expanding to orders and in adults with RC tendinopa- significantly reduce pain in the short
meet evolving health care needs. When thy. Acetaminophen has been widely term in adults with RC tendinopathy.
necessary, they collaborate with other recommended in several CPGs as an ini- A systematic review28 reported
health care providers to ensure patients tial pharmacological treatment to reduce II that, based on low-certainty
Journal of Orthopaedic & Sports Physical Therapy®

receive comprehensive care. Therefore, MSK-related pain and is recommended evidence (GRADE), oral
this section includes medical intervention to treat shoulder pain in general.114,149 NSAIDs significantly reduce night pain
recommendations to be used by physio- Overview in the short term (MD, −0.80/10; 95%
therapists and other health care providers. Based on a systematic review of CI: −1.37, −0.23; 1 RCT; n = 365) when
These recommendations may not always
be within their scope of practice, and it is
V CPGs48 and on recommenda-
tions from a 2021 CPG for RC
compared to placebo in adults with RC
tendinopathy. The evidence suggests that
important for clinicians to respect their disorders44 that was based on a consensus this effect for night pain may or may not
regulated scope of practice. from a modified Delphi study, acetamino- be clinically important.
Note: An international steering com- phen is recommended as a first-line phar- A systematic review178 reported
mittee including expert researchers, cli-
nicians (12 physiotherapists, a physical
macological treatment to relieve mild to
moderate MSK pain.
II that, based on low- to very low–
certainty evidence (GRADE),
medicine physician, and an orthopaedic Gaps in Knowledge There is limited oral NSAIDs significantly reduce pain
surgeon) and patient partners partici- available evidence on the efficacy of ac- (SMD, −0.29; 95% CI: −0.53, −0.05; 1
pated in the development of this CPG etaminophen for pain management of RCT; n = 306) when compared to placebo
and section. Previous versions of this RC tendinopathy. However, several stud- in adults with RC tendinopathy at an un-
CPG were also reviewed by various cli- ies report benefits of acetaminophen for specified follow-up time. Based on very
nicians including MSK physicians and the management of acute MSK pain as uncertain evidence, these effects for oral
surgeons. reported in a systematic review and net- NSAIDs may be trivial to moderate for
work meta-analysis of randomized tri- pain.
2.1 Acetaminophen als on acute MSK pain excluding spinal A pairwise comparison from a
Shoulder pain is a common reason for
consultation in the general population.118
pain.25
Evidence Synthesis and Rationale Ex-
II network meta-analysis11 report-
ed that NSAIDs significantly re-
Therefore, it is justified to consider pain pert consensus suggests that acetamino- duce pain in the short term (SMD, −0.56;
relief as one of the goals to be achieved phen can be used as a first-line treatment 95% CI: −1.01, −0.1) when compared to

250 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 placebo or no intervention in adults with prescribing of opioids for the treatment Gaps in Knowledge There is no evi-
RC tendinopathy. The evidence suggests of pain in patients with RC disorders re- dence on the efficacy of opioids compared
that these effects for NSAIDs may be trivial mains high across multiple settings and to oral NSAIDs or other interventions
to large. specialties in several health care systems, for RC tendinopathy. However, indirect
Oral vs Topical NSAIDs more often to control postoperative pain evidence supports small to moderate
Based on a 2021 CPG,44 topical but often to treat more severe nonsurgi- effects for pain reduction, but evidence
II NSAIDs could lead to a similar
disability reduction when com-
cal shoulder pain.65 The current opioid
crisis is a significant public health issue;
does not appropriately consider poten-
tial side effects and other risks related
pared to oral NSAIDs while being associ- in response to it, it is important to as- to dependency. Moreover, debilitating
ated with fewer adverse events. However, sess the risks of opioid dependence and pain because of an RC tendinopathy is
this is not specific for RC tendinopathy as to ensure that each opioid prescription is uncommon.
this evidence applies to general MSK pain. justified.45,89 Evidence Synthesis and Rationale There
COX-2 vs Nonselective NSAIDs Overview is no specific evidence that opioids may
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Based on a 2021 CPG,44 both Based on 2021 CPG,44 includ- reduce pain in the short term in indi-
II types of NSAIDs lead to similar
pain reduction. There also does
II ing 1 systematic review on the
efficacy of oral opioids for
viduals with severe and/or persistent
RC tendinopathy. In individuals with
not seem to be significant differences in chronic MSK pain, oral opioids signifi- chronic MSK pain, opioid use results
terms of gastro-intestinal adverse events cantly reduce pain (MD, −0.69/10; 95% only in a small reduction in pain when
between both types when taken over a CI: −0.82, −0.56; 42 RCTs; n = 16 617) compared to a placebo and is compa-
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

short period of time. and disability on the 36-Item Short rable to oral NSAIDs. 26 Opioids are
Gaps in Knowledge There is currently Form Physical Component Score (MD, associated with more adverse events,
very limited evidence on the efficacy of −2.04/100; 95% CI: −2.68, −1.41; 51 such as vomiting, nausea, constipa-
oral NSAIDs to reduce disability. In ad- RCTs; n = 15 754) when compared to a tion, dizziness, drowsiness, pruritus, or
dition, there are no long-term follow-up placebo but do not significantly reduce dry mouth, and have an increased risk
studies on the benefits and the associated pain (MD, −0.60/10; 95% CI: −1.54, of dependency, overdose, or death.26
long-term risks on the MSK system of a 0.34; 9 RCTs; n = 1431) and disability When considering opioids as an ad-
prolonged oral NSAIDs use. There is also on the 36-Item Short Form Physical junct to treatment, clinicians should
no evidence specific to RC tendinopathy Component Score (MD, 0.9/100; 95% establish that their use is necessary
Journal of Orthopaedic & Sports Physical Therapy®

on the efficacy of topical NSAIDs. The CI: −0.89, 2.69; 7 RCTs; n = 1311) when and ensure that the opioid depen-
fact that the RC tendons underlie the compared to oral NSAIDs in adults with dency risk profile has been evaluated
deltoid muscle could also lead to a lesser chronic MSK pain. Opioid use is also beforehand. 45,89
effect given possible poorer penetration significantly associated with an increased Recommendations
from such a topical product. risk of adverse events, such as vomiting, Recommendations #17
Evidence Synthesis and Rationale When nausea, constipation, dizziness, drowsi- Regarding opioids:
compared to a placebo, oral NSAIDs may ness, pruritus, dry mouth, and in- a) Clinicians may use or rec-
lead to a significant pain reduction. How-
ever, they can cause adverse effects, nota-
creased risks of dependency, overdose,
or death.
F ommend using opioids in
the short term for pain re-
bly on the gastrointestinal4,17,74,155 and the Based on a systematic review of duction in adults with RC tendinopa-
cardiovascular systems,4,17,74,153 and animal
studies show they might affect tendon
V CPGs48 and on recommenda-
tions from a 2021 CPG for RC
thy who have severe pain and
disability and are refractory or have
health as well.51 Potential benefits and disorders44 that was based on a consen- contraindications to other analgesic
harms should be discussed with patients. sus from a modified Delphi study, opi- modalities.
Recommendations oids are not recommended as a first-line b) Clinicians should not use or
Recommendation No. 16
Clinicians may recommend oral
pharmacological treatment to reduce
pain and disability in adults with RC
C recommend opioids as a
first-line pharmacological
B NSAIDs to reduce pain in the
short term for adults with RC
tendinopathy. If used, opioids should be
prescribed in the short term for adults
treatment to reduce pain and disabil-
ity in adults with RC tendinopathy.
tendinopathy. with persistent and severe pain that are Recommendations #18
refractory to other analgesic modalities. Prescribing clinicians must reg-
2.3 Opioids for Shoulder Pain
Opioid prescriptions and use continue
The risks of dependence and the relevance
of the prescription of opioids should be
F ularly reassess the risks of de-
pendence and the relevance of
to be a topic of intense scrutiny, and the reassessed regularly. taking opioids.

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 251
 [ clinical practice guidelines ]
2.4 Corticosteroid Injections significantly reduce pain when compared term effects for corticosteroid injec-
Corticosteroid injection is a commonly to a placebo in adults with RC tendinopa- tions may or may not be clinically
used modality to relieve pain caused by thy in the short term (SMD, −0.51; 95% important for pain and trivial to large
various MSK injuries, including RC ten- CI: −1.01, −0.01; 7 RCTs; n = 398) but for disability.
dinopathy.155 Injections are usually per- these differences do not remain in the me- A pairwise comparison from a
formed in the subacromial space either
with or without ultrasound guidance.
dium (SMD, −0.20; 95% CI: −0.83, 0.43;
5 RCTs; n = 308) and long term (SMD,
II network meta-analysis11 re-
ported that subacromial corti-
Overview 0.20; 95% CI: −0.07, 0.48; 3 RCTs; n = costeroid injections significantly reduce
A 2021 CPG44 reported that, 222). They also reported that corticoste- pain when compared to oral NSAIDs
I based on high-quality evidence,
corticosteroid injections lead to
roid injections significantly reduce disabil-
ity when compared to a placebo in adults
(SMD, −1.13; 95% CI: −1.63, −0.62) in
adults with RC tendinopathy in the short
small but significant pain and disability with RC tendinopathy in the short term term. The evidence suggests that these
reductions in the short-term only (effect (SMD, −0.33; 95% CI: −0.67, 0.00; 7 effects for subacromial corticosteroid in-
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up to 8 weeks) when compared to a place- RCTs; n = 398), but these differences do jections may be moderate to large for
bo. However, they also reported that, based not remain in the medium term (SMD, pain. They also reported that exercises
on low- to high-quality evidence, cortico- −0.21; 95% CI: −0.84, 0.43; 5 RCTs; n = significantly reduced pain when com-
steroid injections do not significantly 308) and the long term (SMD, 0.26; 95% pared to subacromial corticosteroid in-
reduce pain and disability when compared CI: −0.01, 0.53; 3 RCTs; n = 222). Based jections (SMD, −0.25; 95% CI: −0.48,
to other interventions (sodium bicarbon- on 2 high-quality RCTs, 4 moderate-qual- −0.03) in adults with RC tendinopathy
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ate injection, manual therapy, platelet-rich ity RCTs, and 1 low-quality RCT, these ef- in the medium term. The evidence sug-
plasma (PRP) injections, topical analge- fects for corticosteroids may be trivial to gests that these effects for exercises com-
sics, or kinesiotaping). large for pain and trivial to moderate for pared to subacromial corticosteroid
A 2021 CPG44 reported that disability in the short term. injections may be trivial to small for pain.
V based on expert opinion, it is A systematic review with meta- Ultrasound Guided vs Landmark Guided
recommended that if pain and II analysis178 reported that, based A CPG44 reported that ultra-
disability have not improved after 2 injec-
tions, a third one is not indicated.
on low- to very low–certainty
evidence (GRADE), corticosteroid injec-
II sound-guided corticosteroid in-
jections significantly reduce
A systematic review36 reported tions significantly reduce pain (SMD, pain and disability when compared to
Journal of Orthopaedic & Sports Physical Therapy®

I that, based on high-quality evi-

dence from 8 trials, corticoste-
−0.65; 95% CI: −1.04, −0.26; 6 RCTs; n =
372) and disability (SMD, −0.56; 95% CI:
landmark-guided injections in the short
term (6 weeks), although these differences
roid injections significantly reduce −1.06, −0.05; 5 RCTs; n = 362) when com- are probably not clinically meaningful.
pain and disability when compared to pared to a control (sham or placebo con- A Cochrane review201 reported
anaesthetic-only injections in adults with
RC tendinopathy in the short term. Au-
trol) in adults with RC tendinopathy at an
unspecified follow-up time. Based on very
I that, based on moderate-
certainty evidence (GRADE),
thors also reported that based on moder- uncertain evidence, these effects for corti- ultrasound-guided corticosteroid injec-
ate-quality evidence from 7 trials, costeroid injections may be small to large tions significantly reduce pain (MD,
corticosteroid injections do not signifi- for pain and trivial to large for disability. −0.58/10; 95% CI: −1.05, −0.11; 12
cantly reduce pain and disability when A systematic review with meta- RCTs; n = 777) but not disability (MD,
compared to anaesthetic-only injections
in adults with RC tendinopathy in the
II analysis191 reported that cortico-
steroid injections significantly
−5.06/10; 95% CI: −13.35, 3.23; 11
RCTs; n = 687) when compared to land-
medium term. Authors also reported that reduce pain (MD, −1.59; 95% CI: −2.89, mark or intramuscular corticosteroid in-
corticosteroid injections do not signifi- −0.30; 3 RCTs; n = 180) and disability jections in adults with RC tendinopathy
cantly reduce pain and disability when (SMD, −0.80; 95% CI: −1.42, −0.18; 5 in the short term. Based on low-certainty
compared to anaesthetic-only injec- RCTs; n = 260) when compared to PRP evidence (GRADE), there are no signifi-
tions in adults with RC tendinopathy in injections in adults with RC tendinopathy cant differences between the 2 interven-
the long term at 6 months (based on in the short term. These differences for tions regarding quality of life and number
high-quality evidence from 2 trials) and pain (MD, 0.17; 95% CI: −0.63, 0.97; 3 of adverse events. It is likely that these
≥1 year (based on high-quality evidence RCTs; n = 150) and disability (SMD, 0.35; effects for ultrasound-guided corticoste-
from 1 low risk of bias trial). 95% CI: −0.35, 1.04; 5 RCTs; n = 217) roid may not be clinically important for
A pairwise comparison from a did not remain significant in the medium pain. The nonsignificant CIs are large,
II network meta-analysis107 report-
ed that corticosteroid injections
term. Based on 3 moderate-quality RCTs
and 2 low-quality RCTs, these short-
and the true effects remain unclear for
disability reductions.

252 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 A systematic review with meta- trivial to large for pain and trivial to moder- second-line treatment, has gained popu-
II analysis42 reported that, based
on moderate-certainty evidence
ate for disability.
Gaps in Knowledge There is limited evi-
larity in the last decades and is a mini-
mally invasive intervention consisting
(GRADE), ultrasound-guided injections dence on the medium and long-term ef- in the introduction of a needle into the
significantly reduce pain (MD, −0.58; fects of repeated corticosteroid injections calcific deposit. A saline and/or an anaes-
95% CI: −1.05, −0.10; 10 RCTs; n = 795) on the MSK system. thetic solution is then injected into the
when compared to landmark-guided in- Evidence Synthesis and Rationale Cor- calcification with several short injections,
jections in adults with RC tendinopathy ticosteroid injections may significantly each followed by release of pressure on
in the short term. These effects for ultra- reduce pain and disability in the short the plunger to allow the solution and cal-
sound-guided injections may or may not term (up to 8 weeks) when compared cific material to evacuate back into the sy-
be clinically important for pain. They also to a placebo or oral NSAIDs, but the ringe. Guided lavage is often followed by
reported that based on very low–certainty evidence when compared to other inter- a subacromial corticosteroid injection.23
evidence (GRADE), ultrasound-guided ventions in the medium term support Overview
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injections significantly reduce disability the use of other less invasive interven- A systematic review with meta-
(SMD, −0.84; 95% CI: −1.41, −0.27; 11
RCTs; n = 851) when compared to
tions such as exercise, manual therapy,
or kinesiotaping. Corticosteroid injec-
II analysis93 reported that ultra-
sound-guided lavage significantly
landmark-guided injections in adults tions could be associated with additional reduces pain in the short to medium term
with RC tendinopathy in the short term. but rare side effects (ie, tendon rupture (MD, −1.98; 95% CI: −2.52, −1.45; 2 RCTs;
Based on very uncertain evidence, these and infections). Patients have to be in- n = 226), in the long term (MD, −1.84 /10;
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

effects for ultrasound-guided injections formed by the clinicians (referring and/ 95% CI: −2.63, −1.04; 2 RCTs; n = 220)
may be small to large for disability. or provider) regarding the potential risks and disability on the Constant-Murley
A systematic review with me- and benefits of corticosteroid injections, Score (MD, 11.7/100; 95% CI: 0.01, 23.29;
II ta-analysis54 reported that, ul-
trasound-guided injections
when an injection is considered. Overall,
ultrasound-guided corticosteroid injec-
1 RCT; n = 25) in the short term when
compared with shockwave therapy in
significantly reduce pain (SMD, −0.48; tions appear to offer greater reduction in adults with calcific RC tendinopathy. These
95% CI: −0.79, −0.17; 15 RCTs; n = 850) pain and disability and may be preferred, authors also report that the addition of
and disability (SMD, −0.35; 95% CI: if available. ultrasound-guided lavage to a corticoste-
−0.65, −0.05; 9 RCTs; n = 482) when Recommendations roid injection significantly reduces disabil-
Journal of Orthopaedic & Sports Physical Therapy®

compared to landmark-guided injections Recommendations #19 ity on the Constant-Murley Score (MD,
in adults with shoulder disorders includ- Regarding corticosteroids injections: 17.9/100; 95% CI: 2.0, 33.7; 1 RCT; n = 48)
ing RC tendinopathy in the short term. a) Clinicians may recommend or when compared to a corticosteroid injec-
Based on 10 moderate-quality RCTs and
5 low-quality RCTs, these effects for ultra-
B perform corticosteroid injec-
tions to reduce pain and
tion alone in the long term in adults with
chronic calcific RC tendinopathy.
sound-guided injections may be trivial to short-term disability in adults A systematic review with meta-
moderate for pain and trivial to moderate
for disability. There were no significant b)
with RC tendinopathy.
Clinicians should not recom-
II analysis202 reported that ultra-
sound-guided lavage/needling
differences between the compared groups
in terms of side effects (Risk Ratio, 0.45;
C mend or perform corticoste-
roid injections as a first-line
with or without extracorporeal shockwave
therapy or corticosteroid injection signifi-
95% CI: 0.15, 1.34; 8 RCTs; n = 412). treatment to reduce pain and disabil- cantly reduce pain (MD, −1.96/10; 95% CI:
A systematic review with meta- ity in adults with RC tendinopathy. −2.20, −1.72; 4 RCTs; n = 378) and dis-
II analysis178 reported that, based
on low- to very low–certainty evi-
Recommendation No. 20
If available, clinicians should
ability on the Constant-Murley Score (MD,
10.49/100; 95% CI: 6.99, 13.98; 5 RCTs; n
dence (GRADE), ultrasound-guided corti-
costeroid injections significantly reduce
B use or recommend using ultra-
sound guidance for subacro-
= 281) when compared to extracorporeal
shockwave therapy or corticosteroid injec-
pain (SMD, −0.51; 95% CI: −0.89, −0.13; 5 mial corticosteroid injection to reduce tion alone in individuals with RC calcific
RCTs; n = 298) and disability (SMD, −0.43; pain in the short term. tendinopathy in the long term. They also
95% CI: −0.71, −0.15; 4 RCTs; n = 298) reported that, based on evidence from 1
when compared to landmark-guided corti- 2.5 Calcific Lavage moderate-quality RCT, there were no sig-
costeroid injections in adults with RC ten- RC calcific tendinopathy is characterized nificant differences between ultrasound-
dinopathy at an unspecified follow-up time. by the deposition of hydroxyapatite crys- guided lavage and ultrasound-guided
Based on very uncertain evidence, these ef- tals in one of the RC tendons.23,60 Calcific needling to reduce pain at the medium
fects for corticosteroids injections may be lavage, using ultrasound guidance as a term. Based on 5 moderate-quality RCTs,

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 253
 [ clinical practice guidelines ]
these effects for ultrasound-guided lavage/ Overview tal of 3 RCTs that are also included in a
needling are clinically important for pain Effect of PRP Injection Compared to a more recent meta-analysis mentioned
and may or may not be clinically important Placebo, Saline Alone, or in Conjunction With above13 and reported similar results.
for disability. Other Modalities A pairwise comparison from a
Gaps in Knowledge There is some evi- Based on a 2021 CPG,44 there is II network meta-analysis107 com-
dence on the efficacy of calcific lavage for
individuals with calcific RC tendinopa-
II very low–quality evidence that
PRP injections may significant-
pared PRP injections with a pla-
cebo (saline or excipient) in adults with
thy. However, the evidence is related ly reduce pain and disability when com- RC tendinopathy and included 2 RCTs.
specifically to persistent painful cases. pared to placebo in adults with RC These RCTs included were also included
The efficacy of calcific lavage for acute tendinopathy in whom other nonsurgical in more recent meta-analyses of Barman
cases and as an initial treatment is not treatment has failed. et al13 and in a 2021 CPG by Desmeules
demonstrated. A systematic review with meta- et al46 presented above.
Evidence Synthesis and Rationale For I analysis13 reported that PRP PRP vs Exercise
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

individuals with calcific RC tendinopathy, injections do not significantly A systematic review13 reported
calcific lavage/needling with or without
corticosteroid injection may significantly
reduce pain when compared to a placebo
(saline or other injections) in the medium
II that PRP injections do not sig-
nificantly reduce pain in the
reduce pain and disability compared to term (MD, −0.28/10; 95% CI: −0.61, medium term (MD, −0.20/10; 95% CI:
extracorporeal shockwave therapy or cor- 0.05; 3 RCTs; n = 192). They also report- −1.09, 0.69; 1 RCT; n = 44) and long
ticosteroid injection alone. Clinicians can ed that PRP injections significantly re- term (MD, 0.80/10; 95% CI: −0.09,
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

consider this treatment option if the cal- duce pain in the long term at 6 to 7 1.69; 1 RCT; n = 44) and disability in the
cific RC tendinopathy has been refractory months (MD, −1.64/10; 95% CI: −2.87, long term (SMD, −0.22; 95% CI: −0.83,
to other modalities, such as oral NSAIDS −0.40; 5 RCTS; n = 281), but not at a 0.39; 1 RCT; n = 42) when compared to
and a corticosteroid injection. Patients long- to very long–term follow-up at ≥1 exercise therapy in adults with shoulder
have to be informed by the clinicians (re- year (MD, −1.92/10; 95% CI: −5.13, 1.29; disorders including RC tendinopathy.
ferring and/or provider) regarding the po- 3 RCTs; n = 212) in adults with shoulder Based on 1 low-quality RCT, PRP is not
tential risks and benefits of calcific lavage/ disorders including RC tendinopathy. more effective than exercise to reduce
needling with or without corticosteroid These authors also report that PRP injec- pain and disability. The CIs are below
injection. tions do not significantly reduce disabil- any clinically important differences for
Journal of Orthopaedic & Sports Physical Therapy®

Recommendations ity when compared to placebo (saline or pain and below a moderate effect size for
Recommendation No. 21 other injections) in the medium term disability.
Clinicians should recommend (SMD, −0.79; 95% CI: −2.53, 0.95; 3 A systematic review81 reported a
B or use using calcific lavage to
reduce pain and disability in
RCTs; n = 192), in the long term at 6 to 7
months (SMD, −1.36; 95% CI: −2.92,
II narrative synthesis of 2 RCTs
that compared PRP injections to
adults with calcific RC tendinopathy re- 0.21; 5 RCTs; n = 281), and in the long- to exercise therapy for the treatment of RC
fractory to initial treatment. very long–term at ≥1 year (SMD, −2.52; tendinopathy. Based on 1 low-quality RCT
95% CI: −5.76, 0.72; 3 RCTs; n = 212). (Nejati et al,137 n = 22 treated with PRP, n
2.6 PRP Injections Based on 4 high-quality RCTs and 1 low- = 20 treated with exercise therapy), there
PRP is an autologous concentration of quality RCT, the effect of PRP injections was a significant difference for pain in fa-
platelets, growth factors, and cellular may or may not be clinically important vor of exercise therapy when compared to
signaling factors that are derived from for pain reduction in the long term. PRP in the short to medium term and no
whole blood through the centrifugation A systematic review with meta- significant difference between groups for
process.117,152 Injecting PRP is said to fos-
ter the natural tissue repair response to
II analysis70 included 8 RCTs,
seven of which were already
pain in the medium term. Exercise therapy
significantly reduces disability on the
injury through the action of blood plate- included in another reviewed systematic WORC but not on the DASH when com-
lets, which undergo degranulation and review,13 and reported similar results and pared to PRP in the medium term. Based
release bioactive proteins or growth fac- conclusions. on another low-quality RCT (Ilhanli et al,83
tors that encourage the healing process Two systematic reviews81,152 car- n = 30 treated with 3 PRP injections, n =
once they are activated by mediators at
the site of injury.76 Using PRP injections
II ried out narrative syntheses
that compared PRP injections
32 treated with exercise therapy) exercise
therapy significantly reduces pain (at rest
as a modality for the treatment of MSK to placebo (saline injections) in adults and with activity) when compared with
injuries has been gaining in popularity in with shoulder disorders including RC PRP injections in the long term, while PRP
recent years.44 tendinopathy. These authors found a to- injections significantly reduce disability

254 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 on the DASH when compared to exercise duce pain and disability when compared b) Clinicians should not use or
therapy in the long term.
A systematic review with meta-
to dry needling in the medium term.
Gaps in Knowledge There is conflict-
F recommend PRP injections
as a first-line treatment to
II analysis117 reported that, based
on 1 high-quality RCT (n = 70)
ing evidence on the effectiveness of PRP
injections compared to other treatments
reduce pain and disability in adults
with RC tendinopathy.
and 1 moderate-quality RCT (n = 62), for RC disorders, and high-quality stud-
PRP injections do not significantly re- ies are missing. Available evidence mostly 2.7 Hyaluronic Acid Injections
duce pain compared to physiotherapy in included mixed populations, comprising Hyaluronic acid is naturally produced in
the long term (no additional information various RC disorders (ie, RC tears), and the extracellular matrix of soft tissue and
on intervention) for adults with RC dis- evidence related to the treatment effica- synovial fluid and is gaining interest as
orders, including RC tendinopathy. cy for RC tendinopathy alone is missing. a potential option for the management
PRP vs Corticosteroids Two systematic reviews13,152 mention that of soft tissue injuries.88 Secreted by the
A systematic review with meta- some trials163 reported adverse effects tendon sheath, hyaluronic acid reduces
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II analysis13 reported that PRP

injections significantly reduce
such as pain for more than 48 hours and
cases of frozen shoulder. These authors
sliding friction and optimizes tendon
nutrition.1 Intra-articular hyaluronic acid
pain in adults with RC tendinopathy note that these adverse effects occurred injections are intended as an alternative
(MD, −0.81/10; 95% CI: −1.51, −0.10; 2 in both the PRP group and the placebo treatment modality to corticosteroid in-
RCTs; n = 110) when compared to cor- saline group but appear higher in the jections, and increasing evidence is show-
ticosteroid injections in the long term, PRP group. While some evidence report- ing the use of hyaluronic acid to treat
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

but do not significantly decrease pain in ed that PRP injections are relatively safe osteoarthritis of the knee or shoulder.31
the medium term (MD, 0.41/10; 95% and carry a low risk of complications,13,152 Overview
CI: –0.20, 1.01; 5 RCTs; n = 95). Based more studies are needed to investigate Hyaluronic Acid Injections Compared to
on 1 high-quality RCT and 1 moderate- potential adverse events related to the use Placebo
quality RCT, the effect of PRP injections of PRP injections for RC tendinopathy. In A 2021 CPG44 reported that,
may or may not be clinically important
for pain reduction in the medium and
addition, the complexity and variability
in preparation techniques has been re-
II based on very low evidence, hy-
aluronic acid injections do not
long terms. ported to be an issue in a recent review,7 significantly reduce pain and disability in
Two systematic reviews81,152 re- there is still uncertainty regarding the adults with RC tendinopathy.
Journal of Orthopaedic & Sports Physical Therapy®

II ported a narrative synthesis of risks and benefits of their use and the A systematic review with meta-
3 RCTs that compared PRP in-
jections to corticosteroid injections for
cost-effectiveness of such interventions
as they may be costly for patients.
II analysis88 reported that hyalur­
onic acid injections significantly
the treatment of shoulder pain, including Evidence Synthesis and Rationale Ef- reduce pain in the short term (MD,
RC tendinopathy. Based on 1 low-quality ficacy of PRP injections when compared −1.16/10; 95% CI: −1.44, −0.88; 10 RCTs;
RCT (Damjanov et al,40 n = 32, n = 16 to a placebo, exercise therapy, or cortico- n = 593), the medium term (MD,
treated with PRP), PRP injections signifi- steroid injections is unclear, and evidence −1.44/10; 95% CI: −1.73, −1.15; 8 RCTs;
cantly reduce pain and disability com- is conflicting and tends to show that PRP n = 536) and the long term (MD, −1.78/10;
pared to corticosteroid injections in the injections are not superior to other treat- 95% CI: −2.20, −1.36; 3 RCTs; n = 209)
medium term, but based on 2 other low- ments to decrease pain and disability. and disability on the Constant-Murley
quality RCTs (Shams et al,166 n = 40, n = Patients refractory to other modalities Score in the short term (MD, 5.86/100;
20 treated with PRP; Ibrahim et al,82 n = presenting with chronic pain and disabil- 95% CI: 4.38, 7.33; 3 RCTs; n = 244) and
30, n = 14 treated with PRP), PRP injec- ity have to be informed by the clinicians the medium term (MD, 9.4/100; 95% CI:
tions do not significantly reduce pain and (referring and/or provider) regarding 8.83, 9.97; 4 RCTs; n = 290) when com-
disability in the short and long terms. the costs, potential risks, and benefits pared to other interventions, including
PRP vs Dry Needling of PRP injections, when an injection is placebo, corticosteroid injections, or PRP
A systematic review81 reported considered. injections, for adults with shoulder pain,
II a narrative synthesis of 1 RCT
that compared PRP injections
Recommendations
Recommendation No. 22
including RC tendinopathy. Based on 1
high-quality RCT, 4 moderate-quality
with dry needling for the treatment of RC Regarding PRP injections: RCTs and 6 low-quality RCTs, these effects
tendinopathy. Based on 1 low-quality a) Clinicians may use or rec- for hyaluronic injections may or may not
RCT (Rha et al,148 n = 16 treated with
PRP, n = 14 treated with dry needling),
D ommend PRP injections to
reduce pain and disability
be clinically important when compared to
these several heterogenous comparators
PRP injections do not significantly re- in adults with RC tendinopathy. for pain and disability.

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 255
 [ clinical practice guidelines ]
A pairwise comparison from a should not be a first line of treatment and with RC tendinopathy. Based on 1 high-
II network meta-analysis107 report-
ed that, based on 3 high-quality
may be considered for refractory cases.
Recommendations
quality RCT and 3 moderate-quality
RCTs, the effects of hypertonic dextrose
RCTs, hyaluronic acid injections do not sig- Recommendation No. 23 injection are not more effective than
nificantly reduce pain when compared to Regarding hyaluronic acid injections: comparators, the nonsignificant CIs are
placebo in the short (3-6 weeks) (SMD, a) Clinicians may use or recom- large, and the true effect remains un-
−0.49; 95% CI: −1.65, 0.66; 3 RCTs; n =
197), medium (12 weeks) (SMD, −0.18;
D mend hyaluronic acid injec-
tions to reduce pain and
clear for short- to medium-term pain
reduction.
95% CI: −1.75, 1.39; 2 RCTs; n = 157), and disability in the short and medium Two systematic reviews29,152 that
long terms (≥24 weeks) (SMD, 0.23; 95%
CI: −0.18, 0.64; 1 RCT; n = 106) in adults b)
terms in adults with RC tendinopathy.
Clinicians should not use or
II included 5 RCTs already in-
cluded in the meta-analysis by
with RC tendinopathy. They also reported
that hyaluronic acid injections do not sig-
F recommend hyaluronic acid
injections as a first-line
Aris-Vazquez et al7 presented a narrative
synthesis of the results. Based on 1 good-
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nificantly reduce disability when compared treatment to reduce pain and disability in quality RCT and 1 low-quality RCT (n =
to placebo in the short (3-6 weeks) (SMD, adults with RC tendinopathy. 67), prolotherapy does not significantly
0.01; 95% CI: −0.33, 0.35; 2 RCTs; n = reduce pain and disability when com-
157), medium (12 weeks) (SMD, −0.64; 2.8 Prolotherapy pared to placebo (saline injection,) and
95% CI: −2.14, 0.87; 3 RCTs; n = 197), and Prolotherapy is an intra-articular and/or corticosteroid injection in adults with
long terms (≥24 weeks) (SMD, 0.29; 95% extra-articular injection on ligament and RC tendinopathy. Based on 1 good-qual-
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

CI: −0.13, 0.70; 1 RCT; n = 106) in adults tendon insertions. In clinical practice, ity RCT (n = 120), prolotherapy signifi-
with RC tendinopathy. The nonsignificant the most frequently injected agent is a cantly reduces pain and disability
CIs are large, and the true effects remain hypertonic dextrose solution, with con- (P<.05) when compared to a 12-week
unclear for pain and disability. centration levels varying most commonly physiotherapy intervention in the long
Gaps in Knowledge There are still very from 12.5% to 25%.7 Prolotherapy aims term at 12 months. Based on a low-qual-
few good-quality RCTs that evaluate the to repair connective tissue and reduce ity RCT,15 prolotherapy significantly re-
efficacy of hyaluronic acid injections for pain, but its mechanism is not complete- duces pain when compared to placebo
the treatment of RC disorders. These in- ly understood. The supposed principle (saline injection) in the long term at
jections may be effective to reduce pain of action is the injection of a prolifer- 9 months.
Journal of Orthopaedic & Sports Physical Therapy®

and disability when compared to other in- ant. Dextrose, for example, will initiate A pairwise comparison from a
jections, but most of the existing literature
is not specific to patients with RC tendi-
inflammatory reaction locally, which
will then attract inflammatory cells and
II network meta-analysis107 re-
ported that prolotherapy sig-
nopathy, which limits the applicability of eventually lead to the proliferation of nificantly reduces pain (SMD, −2.63;
the results to this population. Based on 1 connective tissues.152 There is literature 95% CI: −3.38, −1.88; 1 RCT; n = 54)
systematic review with meta-analysis,107 on the use of prolotherapy for treating when compared to placebo (saline injec-
no adverse events were related to the use various pathologies in the upper and tion) in the long term in adults with RC
of hyaluronic acid injections (based on lower limbs such as knee osteoarthritis, tendinopathy (24 weeks). The effect on
3 good-quality RCTs). However, there is Achilles tendinopathy, plantar fasciitis, pain reduction may be large.
still a need for more high-quality studies Osgood-Schlatter disease, hand osteoar- Gaps in Knowledge The exact effect of
evaluating the effectiveness and safety thritis, and lateral epicondylitis showing prolotherapy remains unclear as some
of hyaluronic acid injections in the long positive results as a treatment option.7 evidence shows reduction in pain in the
term in patients with RC tendinopathy. Overview long term, but not in the short or medi-
Evidence Synthesis and Rationale Hy- A systematic review with meta- um terms. The reasons for this delayed
aluronic acid injections may signifi-
cantly reduce pain and disability when
II analysis7 reported that prolo-
therapy (hypertonic dextrose
reduction are unclear. Types of prepara-
tion and dosage evaluated across studies
compared to other interventions such injections) does not significantly reduce are also very heterogeneous.
as corticosteroid and PRP injections in pain in the short (SMD, −0.05; 95% CI: Evidence Synthesis and Rationale Pro-
the short and medium terms. However, −0.71, 0.62; 4 RCTs; n = 307) and me- lotherapy may significantly reduce pain
evidence is conflicting when comparing dium terms (SMD, −0.01; 95% CI: and disability in the long term when
hyaluronic acid injections to placebo and −0.45, 0.43; 4 RCTs; n = 349) when compared to other interventions, such
the true effects remain unclear in RC compared to placebo injections (saline), as placebo and exercise therapy. How-
tendinopathy. With the current state of other injections (corticosteroid, anesthet- ever, its effects in the short and me-
the evidence, hyaluronic acid injection ics, PRP) or exercise programs in adults dium terms remain unclear as evidence

256 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 showed no significant difference for for patients with RC tendinopathy lasting ASES in the medium and long term when
pain and disability reduction when more than 3 months. compared to corticosteroid injection (n =
compared to other interventions, in- Recommendations There is insufficient 8). Stem cell injections do not significantly
cluding placebo. Only minor and rare evidence to formulate a recommendation. reduce pain compared to corticosteroid
adverse events have been reported in injection in the medium and long terms.
3 RCTs. 2.10 Stem Cell Injections Gaps in Knowledge There is very limited
Recommendations There are no In the past decade, research has been evidence available on the efficacy of stem
recommendations due to conflicting emerging to assess the potential of stem cell injection to reduce pain and disability
evidence. cell injection therapy for MSK disorders. in adults with RC tendinopathy in the short
Studies injecting adult stem cells isolated and medium terms. There is also limited
2.9 Suprascapular Nerve Block from adipose tissue into animal models evidence on the risks versus benefits of this
Suprascapular nerve blocks can be with pathologic RC tissues state they intervention.
landmark or ultrasound guided.156 Aim- have had effects such as decreasing the Evidence Synthesis and Rationale Stem
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ing for pain relief, the suprascapular amount of inflammatory cells, improv- cell injections have been proposed for the
nerve block technique consists in in- ing tendon regeneration by reducing treatment of RC tendinopathy based on
jecting a long-lasting anesthetic, such scar tissue, improving the arrangement of the principle that increasing the number
as mepivacaine or bupivacaine 2%, at 1 collagen fibers, allowing increased load- of stem cells in the local cell population
of 2 possible sites of passage of the su- to-failure, and increasing levels of tensile would increase the regenerative potential
prascapular nerve, either the coracoid strength of the treated animal tendons.80 of the tendon. To date, there are still very
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

notch or the spinoglenoid notch.130 As The literature about the use of stem cell few studies that evaluate its effectiveness
the suprascapular nerve plays an im- for RC tendinopathy reports using adi- to reduce pain and disability in patients
portant role with the shoulder girdle pose-derived stem cells, which are a type with RC tendinopathy to recommend its
sensory innervation,167 there are studies of mesenchymal stem cell (MSC) that use. The 2 RCTs found for RC tendinopa-
proposing this modality for many pain- are said to be easier to harvest.174 MSCs thy both used adipose-derived regenera-
ful chronic shoulder pathologies such are sometimes also used and described tive cells.
as rheumatoid arthritis, osteoarthritis, as adult stem cells that were originating Recommendations Insufficient evidence
and shoulder pain after a stroke of due from the bone marrow.174 to formulate a recommendation.
to motor neuron disease. 168 Overview
Journal of Orthopaedic & Sports Physical Therapy®

Overview A moderate-quality RCT32 in- 2.11 Botulinum Toxin Injections

A low-quality RCT14 included II cluded 24 patients with chronic Botulinum toxin is used to inhibit overac-
II 96 patients with RC tendinopa-
thy lasting more than 3 months
RC tendinopathy with partial
tears (>3 months), and reported that
tive or spastic muscles and may be used
to alleviate pain with overactive muscle
and reported that a single suprascapular MSCs injections (allogenic adipose tis- spasms or contractions. There has been
nerve block injection (solution of prilo- sue-derived adult MSC with fibrin glue) research on botulinum toxin showing
caine and triamcinolone acetate, n = 51) do not significantly reduce pain during it reduces pain in peripheral joints, in
significantly reduces pain and disability activity and disability on the American the low back, and for the buttocks (piri-
on the Constant-Murley Shoulder score, Shoulder and Elbow Score (ASES) in the formis syndrome) with alleged minimal
in the short and medium terms when short, medium, and long to very long side effects.96 Botulinum toxin is being
compared to placebo (saline injection, terms when compared to placebo (saline). investigated for its potential to give an al-
n = 45). For the primary pain outcome, the ternative to corticosteroids as a pain con-
Gaps in Knowledge There is very limited change between baseline and 3 months trol modality as it may have longer-lasting
available evidence on the effectiveness of was MD: −1.37/10 ± 2.85 in the stem cell clinical benefits.96
suprascapular nerve block to reduce pain injections group and −3.0/10 ± 2.56 in Overview
and disability in adults with RC tendi- the placebo group (P = .35). A high-quality RCT96 included
nopathy in the short and medium terms. A low-quality pilot RCT80 in- II 61 adults (n = 31 botulinum
There is no evidence on the risks versus
benefits of suprascapular nerve block in
II cluded 20 patients with RC
tendinopathy who had not re-
toxin injection and n = 30 cor-
ticosteroid injection) with subacromial
the long term. sponded to physical therapy treatments bursitis and subacromial impingement
Evidence Synthesis and Rationale There for at least 6 weeks and reported that stem syndrome who had not responded to
is very limited evidence that a suprascap- cell injections (unmodified autologous physiotherapy or analgesic treatments,
ular nerve block could reduce pain and adipose-derived regenerative cells) (n = and reported that botulinum toxin injec-
disability in the short and medium terms 12) significantly reduce disability on the tions significantly reduce pain on the

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 257
 [ clinical practice guidelines ]
numeric rating scale and disability, as and diagnosis information, behavioral ap- be patient-centered, individualized, and
measured with the DASH, when com- proaches, and pain biology. The authors consider the individual’s level of health
pared to corticosteroid injections in the suggested that clinicians may need to con- literacy, goals, concerns, beliefs, and so-
medium term. sider integrating education about pain cial support.
Gaps in Knowledge There is very limited mechanisms and psychological factors Recommendation
available evidence on the efficacy of botuli- into their management of patients with Recommendation No. 24
num toxin injection for pain management RC tendinopathy, tailoring these to pa- Clinicians should provide pa-
of RC tendinopathy. There is no evidence
on the risks vs benefits of botulinum toxin
tient-specific health literacy, goals, beliefs,
and support systems.
C tients with patient-centered
and individualized education
injections in the long term. A scoping review,18 including 93 on their condition, pain management op-
Evidence Synthesis and Rationale There
is very limited evidence that botulinum
V randomized and quasi-random-
ized controlled trials about ther-
tions, activity modification, and self-
management. Clinicians should consider
toxin injections could reduce pain and apeutic shoulder exercise intervention, the individual’s level of health literacy,
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disability in the medium term for pa- documented the behavior change tech- personal beliefs and goals, and relevant
tients with RC tendinopathy who had not niques and education used in the manage- psychosocial factors.
responded to physiotherapy or analgesic ment of RC related shoulder pain and
treatments. compared them to the recommendations in 3.2 Exercise
Recommendations Insufficient evidence 3 CPGs. The authors reported that 53% of Overview Exercise is a core component
to formulate a recommendation. trials they analyzed included some form of of nonoperative management of RC ten-
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

education, the most common one being ex- dinopathy.178 The components of exercise
SECTION 3: REHABILITATION ercise education. They also noted that edu- therapy reported in clinical trials include
TREATMENTS FOR RC cation was underutilized in these trials exercises for the neck and thoracic mus-
TENDINOPATHY when comparing to the recommendations cles, scapula-focused exercises, motor
of CPGs regarding elements such as activity control exercises, concentric or eccen-
3.1 Education modifications. The authors reported that tric strengthening, and variable levels of
A patient-centered approach in reha- over two thirds of included trials had some high- or low-intensity resistance train-
bilitation appears to lead to better out- type of behavior change technique included ing, as well as whole-body exercises and
comes.200 Patients’ education about their with exercise interventions for RC tendi- aerobic conditioning.24,109 These exercise
Journal of Orthopaedic & Sports Physical Therapy®

pathology, pain education, and strategies nopathy, but they mostly consisted of exer- programs are proposed to decrease pain
to cope with their condition is an inher- cise supervision. The authors recommend and disability, increase muscle strength
ent part of this approach. A better under- that future trials consider using behavior and endurance, improve neuromuscu-
standing of the experienced symptoms change techniques aimed at improving lar control, and increase ROM and load
may reinforce patients’ involvement in exercise adherence and outcomes. tolerance.101
their rehabilitation for patient with MSK Gaps in Knowledge There is a need for Efficacy of Exercise Programs Compared to
disorders including RC tendinopathy. future research looking at the content of No Intervention
Overview advice and education for the management Based on a 2021 CPG,44 includ-
Based on a 2021 CPG,44 there is of RC tendinopathy, as well as their mode I ing 2 systematic reviews and 5
II limited evidence to conclude
that a multimodal interven-
of delivery.128 In addition, there are few, if
any, studies comparing the effect of educa-
RCTs, it is recommended to
prescribe an active rehabilitation pro-
tion, which may include, but is not lim- tion to other interventions or the effect gram as an initial treatment modality to
ited to, pain education, self-efficacy of different modes of education. Future re- reduce pain and disability in adults with
advice, psychosocial and workplace inter- search should explore the mediation effect RC tendinopathy.
ventions, and/or exercises, leads to addi- that education may have on other interven- Based on an umbrella review,145
tional benefits compared to usual care for
adults with RC tendinopathy.
tions, such as exercise therapy.18
Evidence Synthesis and Rationale The
I there is moderate to high levels
of evidence from 7 systematic
A scoping review,128 including 82 inclusion of education is recommended reviews supporting the use of exercise
V studies of various designs, re-
ported that physiotherapy ad-
in the management of RC tendinopathy.
It should include advice pertaining to
therapy to reduce symptoms and improve
disability in patients with RC tendinopa-
vice for RC tendinopathy covered 7 key exercise supervision, goal setting, activ- thy in the short to long term.
themes: exercise intensity and pain re- ity modification, and information about A systematic review113 reported
sponse, activity modification, posture,
pain self-management, pathoanatomical
the condition and pain management op-
tions. The information provided should
I that, based on very low–certainty
evidence (GRADE), home-based

258 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 exercise significantly reduces pain (MD, when compared to no exercise in the 95% CI: −0.66, 0.03; 3 RCTs; n = 478) or
−1.47/10; 95% CI: −2.33, −0.61; 1 RCT; short term in adults with RC tendinopa- disability (SMD, −0.12; 95% CI: −0.71,
n = 67) and disability (SMD, −0.81; 95% thy. The evidence suggests that the effects 0.47; 1 RCT; n = 44) in the short to me-
CI: −1.31, −0.31; 1 RCT; n = 67) in the for supervised exercise may or may not be dium term when compared to home-
short term, when compared to no treat- clinically important for pain at rest and based exercise in adults with RC
ment in adults with RC tendinopathy. during movement and may be trivial to tendinopathy. The evidence suggests that
Based on very uncertain evidence, these moderate for disability. supervised exercise is not more effective
effects for home-based exercise may or A systematic review with meta- than unsupervised (home-based) exercise
may not be clinically important for pain
and may be small to large for disability.
II analysis178 reported that, based
on low- to very low–certainty
to reduce pain. The CIs are below any
clinically important differences for pain.
A systematic review with meta- evidence (GRADE), exercise significantly For disability reductions, the nonsignifi-
I analysis135 including 4 studies
reported that, based on low-
reduces pain (SMD, −0.94; 95% CI:
−1.69, −0.19; 5 RCTs; n = 189) and dis-
cant CIs are large, and the true effects
remain unclear.
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

quality evidence (GRADE), progressive ability (SMD, −0.57; 95% CI: −0.85, A systematic review with meta-
and resisted exercises significantly reduce
pain (MD, −1.07/10; 95% CI: −1.57, −0.56;
−0.29; 4 RCTs; n = 202) when compared
to no treatment in adults with RC tendi-
I analysis67 reported that super-
vised physiotherapy does not
3 RCTs; n = 197) and disability on the Con- nopathy at an unspecified follow-up time. significantly reduce pain (MD, 0.21/10;
stant-Murley Score (MD, −14.96/100; Based on very uncertain evidence, the ef- 95% CI: −1.36, 1.78; 4 RCTs; n = 216)
95% CI: −21.37, −8.55; 4 RCTs; n = 271) fects for exercise may be trivial to large for and disability (SMD, −0.14; 95% CI:
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

when compared to basic advice, placebo pain and moderate to large for disability. −1.04, 0.76; 4 RCTs; n = 216) when com-
detuned laser or no treatment in adults A pairwise comparison from a pared to home-based exercises in adults
with RC tendinopathy in the short to me-
dium term. The evidence suggests that
II network meta-analysis11 report-
ed that exercise significantly re-
with RC tendinopathy at an unspecified
follow-up time. Based on 2 moderate-
these effects for progressive and resisted duces pain when compared to no quality RCTs and 2 low-quality RCTs, the
exercise may or may not be clinically im- intervention (SMD, −0.42; 95% CI: −0.68, nonsignificant CIs are large, and the true
portant for pain and disability. −0.15) or corticosteroid injections (SMD, effects remain unclear for reductions in
Based on low-quality evidence (GRA­ −0.25; 95% CI: −0.48, −0.03) in adults pain and disability.
DE), nonprogressive resisted exercises with RC tendinopathy in the medium A systematic review with a nar-
Journal of Orthopaedic & Sports Physical Therapy®

and nonresisted exercises do not signifi-

cantly reduce pain (MD, −0.33/10; 95%
term. They reported that exercise signifi-
cantly reduces disability when compared
I rative synthesis73 reported that,
based on 1 high-quality trial,
CI: −0.81, 0.15; 3 RCTs; n = 198) and dis- to no intervention in the short to medium supervised exercise combined with
ability (MD, −3.62/100; 95% CI: −9.43, term (SMD, −0.69; 95% CI: −0.99, −0.39) home-based exercise does not in the
2.18; 3 RCTs; n = 198) when compared to and in the medium term (SMD, −0.32; short or long term, significantly reduce
various comparators of a shoulder brace, 95% CI: −0.58, −0.06). They also reported pain or disability (1 RCT, n = 46) when
ultrasound, or sham ultrasound in adults that shoulder taping significantly reduces compared to home exercise only in adults
with RC tendinopathy in the short to me- disability (SMD, −0.48; 95% CI: −0.82, with RC tendinopathy. Both groups pre-
dium term. Moreover, the nonsignificant −0.15) when compared to exercise in the sented significant reductions in pain and
CIs are large. Based on these 3 studies, long term. However, the number of RCTs disability. Neither the magnitude of the
nonprogressive resistance exercise and per meta-analyses and the quality of these effect nor the CIs were reported.
nonresisted exercise do not appear to RCTs are not reported. Based on unknown A systematic review105 included a
provide benefits in pain and disability
over a passive intervention or a sham.
certainty of the evidence, these effects for
exercise ranged from trivial to large when
II single RCT, which was already
included in 2 other reviewed
A systematic review with meta- compared to the various comparators systematic reviews, 67,113 and reported
II analysis, 105 reported that,
based on low-certainty evi-
mentioned above.
Efficacy of Supervised Exercise Programs
similar results and conclusions.
Efficacy of Different Types of Exercises
dence (GRADE), supervised exercise Compared to Unsupervised Exercise Programs
significantly reduces pain at rest (MD, Programs A systematic review with
−1.68/10; 95% CI: −3.06, −0.31; 4 RCTs; A systematic review with meta- I meta-analysis performed by
n = 286), during movement (MD,
−1.84/10; 95% CI: −2.76, −0.91; 5 RCTs;
I analysis113 reported that, based
on low-certainty evidence
Lafrance et al91 reported that,
based on low-to moderate-certainty evi-
n = 353), and disability (SMD, −0.30; (GRADE), clinic-based exercise does not dence (GRADE), motor control exercise
95% CI: −0.52, −0.07; 5 RCTs; n = 396) significantly reduce pain (MD, −0.31/10; programs do not significantly reduce

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 259
 [ clinical practice guidelines ]
pain in the short term (SMD, −0.19; A systematic review with meta- of scapula-focused exercise programs to
95% CI: −0.41, 0.03; 7 RCTs; n = 323,
moderate) but do significantly reduce
I analysis 95 reported that,
based on low-quality evidence
small in favor of standard exercise
programs.
pain in the medium (SMD, −0.38; 95% (GRADE), eccentric exercises do not sig- A systematic review with meta-
CI: −0.71, −0.05; 5 RCTs; n = 286, low)
and in the long term (SMD, −0.57; 95%
nificantly reduce pain when compared to
other types of exercises (resistance and
II analysis performed by Lafrance
et al91 reported, based on low
CI: −0.98, −0.16; 2 RCTs; n = 96, low), mobility exercises) in the short term (MD, evidence (GRADE), that in adults with RC
as well as disability in the short (SMD, −13.5; 95% CI: − 28.5, 1.4; 6 RCTs; n = tendinopathy eccentric exercise programs
−0.29; 95% CI: −0.51, −0.07; 7 RCTs; 281) and in the long term (MD, −4.9; 95% do not significantly reduce pain in the
n = 323, moderate), medium (SMD, CI: − 15.4, 5.6; 3 RCTs; n = 167) but it did short term (SMD, −0.32; 95% CI: −0.75,
−0.33; 95% CI: −0.57, −0.09; 5 RCTs; in the medium term (MD, −11.9; 95% CI: 0.12; 2 RCTs; n = 82), but significantly
n = 286, moderate), and long term − 18.2, − 5.5; 3 RCTs; n = 194). The evi- reduce pain in the medium term (SMD,
(SMD, −0.48; 95% CI: −0.88, −0.07; 2 dence suggests that these effects for eccen- −0.62; 95% CI: −1.11, −0.13; 2 RCTs; n =
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

RCTs; n = 96, low) when compared to tric exercises may or may not be clinically 70). Based on very low–certainty evidence
standard exercise programs (more ge- important for pain in the medium term, (GRADE) eccentric exercise programs do
neric shoulder resistance or strengthen- but in the short and long term, the nonsig- not significantly reduce disability in the
ing exercise programs without emphasis nificant CIs are large and the true effects short (SMD, 0.1; 95% CI: −0.65, 0.86; 4
on muscle control, scapular muscles/ remain unclear for pain reductions. RCTs; n = 177) or medium terms (SMD,
stability, or eccentric exercises) in adults In addition, based on very low–quality −0.16; 95% CI: −0.81, 0.49; 4 RCTs; n =
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

with RC tendinopathy. The evidence evidence (GRADE), eccentric exercises 165) when compared to standard exercise
suggests that these effects for motor do not significantly reduce disability programs. Based on uncertain evidence,
control exercise programs may be trivial in the short and medium terms (SMD, these effects may be large in favor of ec-
to large for pain and disability. It re- −0.10; 95% CI: − 0.79, 0.58; 6 RCTs; n = centric exercise programs to small in favor
mains unclear if these effects could be 281) and in the long term (SMD, 0.28; of standard exercise programs.
due to the types of exercise (motor con- 95% CI: − 0.67, 1.24; 3 RCTs; n = 167) A systematic review with meta-
trol exercises compared to standard ex-
ercises) or to other program characteristics
when compared to other type of exercises
(resistance and mobility exercises). The
II analysis173 reported that an exer-
cise program involving specific
such as the frequency, intensity, specificity, nonsignificant CIs are large, and the true exercises (ie, exercise targeting the activa-
Journal of Orthopaedic & Sports Physical Therapy®

or level of tailoring. effects on disability reduction remain tion and coordination of scapulothoracic
A systematic review with meta- unclear. musculature and/or the dynamic humeral
I analysis94 including 1 study of A systematic review with meta- head stabilizers that encompass the shoul-
moderate quality and 4 studies
of low quality reported that motor control
II analysis performed by Lafrance
et al91 reported that, based on
der joint) does not significantly reduce
pain (SMD, −0.19; 95% CI: −0.61, 0.22; 4
exercises programs (ie, exercises target- very low to low evidence (GRADE), scap- RCTs; n = 132) and disability (SMD, 0.30;
ing the activation of specific musculature, ula-focused programs do not significantly 95% CI: −0.16, 0.76; 5 RCTs; n = 193)
neuromuscular control exercises, dynam- reduce pain (SMD, −0.1; 95% CI: −0.54, when compared to general resistance ex-
ic muscular stabilization exercises, pro- 0.35; 4 RCTs; n = 150, very low) or dis- ercises in adults with RC tendinopathy in
prioceptive exercises, specific movements, ability (SMD, −0.42; 95% CI: −0.99, the short term. Based on 4 moderate-qual-
or movement control exercises) signifi- 0.16; 4 RCTs; n = 150, very low) in the ity RCTs and 1 low-quality RCTs, the non-
cantly reduce pain (MD, −0.79/10; 95% short term, while they significantly re- significant CIs are large, and the true
CI: −1.47, −0.12; 2 RCTs on RC tendi- duce pain (SMD, −0.45; 95% CI: −0.74, effects remain unclear for pain and dis-
nopathy and 2 RCTs on instability; n = −0.26; 3 RCTs; n = 187, low) and disabil- ability reductions.
157) and disability (SMD, −0.42; 95% CI: ity (SMD, −0.51; 95% CI: −1.01, −0.02; A systematic review35 concluded
−0.69, −0.15; 3 RCTs on RC tendinopa-
thy and 2 RCTs on shoulder instability, n
3 RCTs; n = 187, very low) in the medium
term when compared to standard exer-
II that, based on limited evidence
(2 RCTs, n = 63), isometric ex-
= 217) when compared to strengthening cise programs (more generic shoulder ercises are not superior to cryotherapy to
exercise programs in the short to medium resistance or strengthening exercise pro- reduce pain and disability in adults with
term. Certainty of the evidence was eval- grams without emphasis on muscle con- an acute RC tendinopathy (≤12 weeks) in
uated only for their primary analysis in- trol, scapular muscles/stability, or the short term.
cluding various disorders for upper and eccentric exercises) in adults with RC A systematic review with meta-
lower extremity and was considered
moderate (GRADE).
tendinopathy. Based on uncertain evi-
dence, these effects may be large in favor
II analysis178 reported that, based
on low- to very low–certainty

260 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 evidence (GRADE), specific exercises sig- −11.31/100; 95% CI: −17.20, −5.41; 5 for higher load and volume exercises may
nificantly reduce pain (SMD, −0.65; 95% RCTs; n = 182) when compared to usual or may not be clinically important for
CI: −0.99, −0.32; 2 RCTs; n = 145) and care in adults with RC tendinopathy imme- pain and may be trivial to small for
disability (SMD, −0.68; 95% CI: −1.26, diately postintervention. Based on 4 mod- disability.
−0.10; 2 RCTs; n = 145) when compared erate-quality RCTs and 2 low-quality RCTs, Based on very low–certainty evidence
to nonspecific exercises in adults with RC these effects for scapular-focused interven- (GRADE), the efficacy of higher versus
tendinopathy at an unspecified follow-up tions may or may not be clinically impor- lower doses (load only) of exercises does
time. Based on very uncertain evidence, tant for pain and may be moderate to large not significantly differ in the short term
these effects for specific exercises may be for disability. However, scapular-focused (MD, −5.00; 95% CI: −15.85, 5.85; 1
moderate to large for pain and trivial to interventions do not significantly reduce RCT; n = 61) in terms of function. The
large for disability. pain with activities (MD, −0.87/10; 95% nonsignificant CIs are large, and the true
A systematic review49 including 6 CI: −1.80, 0.07; 2 RCTs; n = 57) and dis- effects of higher versus lower load doses
II studies of low quality reported ability (MD, −3.12/100; 95% CI: −12.49, of resistance exercise remain unclear.
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

that there were no statistically 6.25; 2 RCTs; n = 57) when compared to Based on very low–certainty evidence
significant differences between the different usual care in adults with RC tendinopathy (GRADE), higher dose (volume only)
exercise approaches (concentric vs eccentric in the short term. The nonsignificant CIs as compared to lower dose of exercises
exercises [2 RCTs, n = 154], exercises with are large, and the true effects remain un- significantly reduces disability on the
vs without co-activation of RC [1 RCT, n = clear for pain and disability reductions. Shoulder Rating Questionnaire (MD,
42], exercises with vs without pain [1 RCT, Dosage −12.9/100; 95% CI: −18.1, −7.6; 1 RCT;
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

n = 22], eccentric vs strengthening and/or A systematic review with meta- n = 56) of exercises in adults with RC
stretching exercises [3 RCTs, n = 135] to
reduce pain and disability in adults with RC
I analysis91 reported that, based
on very low evidence (GRADE),
tendinopathy in the medium term. The
evidence suggests that these effects for
tendinopathy at various follow-up times in high-load exercise programs do not sig- higher-volume exercises may be trivial to
the short to long term. nificantly reduce pain in the short (SMD, moderate for disability.
A systematic review with narra- −0.15; 95% CI: −0.93, 0.62; n = 221; 2 Gaps in Knowledge While resistance
II tive synthesis132 looked at the
effect of various types of inter-
RCTs) and medium terms (SMD, −0.19;
95% CI: −0.49, 0.11; n = 453; 4 RCTs),
exercise is supported in systematic re-
views to improve pain and disability for
ventions such as scapular muscle nor disability in the short (SMD, −0.21; RC tendinopathy, there are questions
Journal of Orthopaedic & Sports Physical Therapy®

strengthening, scapular stabilization ex- 95% CI: −0.72, 0.29; n = 301; 3 RCTs) or remaining as to the optimal parameters.
ercise, and stretching in adults with scap- medium terms (SMD, −0.49; 95% CI: Stronger evidence is needed about su-
ular dyskinesis that may include RC −1.02, 0.05; n = 453; 4 RCTs) when com- pervised versus unsupervised exercise
tendinopathy at an unspecified follow-up pared to low-load exercise programs in programs, and more research is needed
time. All RCTs of interest included in this adults with RC tendinopathy. Based on about optimal dosage parameters. Re-
systematic review are included in the sys- very uncertain evidence and no signifi- garding the efficacy of different types of
tematic review by Lafrance et al.94 cant effects, high load cannot be recom- exercises programs, current evidence is
A systematic review with a nar- mended over low-load resistance exercise quite divided even though a fair number
II rative synthesis147 concluded
that scapular stabilization exer-
programs. These effects may be large in
favor of high-load exercise programs to
of systematic reviews were published on
the subject. It remains unclear if specific
cises are effective without specifying spe- moderate in favor of standard exercise exercise programs are more effective than
cific outcomes. The authors’ conclusion programs. general exercise programs. The FITT
was based on 7 RCTs (2 high-quality and A systematic review122 reported principle has been proposed to indicate
5 medium-quality, n = 228) using a vari-
ety of comparators with follow-ups in the
I that, based on low-certainty
evidence (GRADE), higher
that the components of frequency, inten-
sity, type and time are needed to replicate
short to medium term. dose (load and volume) exercises signifi- exercises.3 More research is needed about
A systematic review with meta- cantly reduce pain with activity (MD, which parameters for frequency, intensi-
II analysis157 reported that scapu-
lar-focused interventions, which
−1.6/10; 95% CI: −2.7, −0.5; 1 RCT; n =
102) and disability on the Constant-Mur-
ty, type, and time show the best results
for the efficacy of exercise programs to
include scapular mobilization and muscle ley Score (MD, −20/100; 95% CI: −28.5, treat pain and disability related to RC
retraining, as well as taping and stretching, −11.6; 1 RCT; n = 102) when compared tendinopathies.
significantly reduce pain with activities to lower dose of exercises in adults with Evidence Synthesis and Rationale Evi-
(MD, −0.88/10; 95% CI: −1.19, −0.58; 6 RC tendinopathy in the medium term. dence generally shows that using an exer-
RCTs; n = 250) and disability (MD, The evidence suggests that these effects cise program is more effective to reduce

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 261
 [ clinical practice guidelines ]
pain and disability in adults with RC ten- Based on an umbrella review,145 exercise significantly reduces pain (SMD,
dinopathies than no treatment or other
intervention. Current evidence seems
I there is low to high levels of evi-
dence from 6 systematic re-
−1.07; 95% CI: −1.85, −0.28; 5 RCTs; n =
230) but not disability (SMD, −0.10; 95%
to indicate that supervised exercise pro- views supporting the use of manual ther- CI: −0.33, 0.14; 4 RCTs; n = 315) when
grams are not superior to home-based apy in combination with exercises to compared to exercises alone in adults
unsupervised exercise programs for pain reduce pain and disability, especially in with RC tendinopathy at an unspecified
and disability reductions. Motor control the short term. follow-up time. Based on these high-
exercise programs could be better than A systematic review,73 concluded quality RCTs, the effect of adding manual
standard exercise programs for pain and
disability reductions. It remains unclear
I that mobilization with move-
ment significantly reduces pain
therapy to exercise may be small to large
for pain. However, the addition of manual
if specific exercise programs are more when compared to sham mobilization in therapy to exercise is not effective to re-
effective than general exercise programs adults with RC tendinopathy in the duce disability as the CIs are below a
and if higher-load exercise programs short term. Neither the magnitude of the moderate effect size for disability.
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

show better efficacy than lower-load ex- effect nor the CIs were reported in this A systematic review131 reported
ercise programs.
Recommendations
review. The authors’ conclusion was
based on 1 high-quality RCT (n = 42).
II that, based on 3 moderate-
quality RCTs, there is no differ-
Recommendation No. 25 The authors also reported that there is ence between thoracic manipulation and
Clinicians should prescribe or strong evidence that a single thoracic a sham thoracic manipulation to decrease
A recommend an active rehabili- manipulation is no better than a sham immediate pain and disability in adults
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tation exercise program, which thoracic manipulation to reduce pain with RC tendinopathy. The authors con-
may include motor control and/or resis- and disability in adults with RC tendi- cluded that there is limited evidence on
tance training exercises of various load, nopathy as reported in 3 high-quality the efficacy of thoracic spine thrust ma-
as an initial treatment modality to reduce RCTs (n = 147). Neither the magnitude nipulation to reduce pain or disability in
pain and disability in adults with RC of the effect nor the CIs were reported. adults with RC tendinopathy.
tendinopathy. A systematic review with meta- A pairwise comparison from a

3.3 Manual Therapy

I analysis159 reported that, based
on very low–certainty evidence
II network meta-analysis11 re-
ported that manual therapy
Physiotherapists often use manual thera- (GRADE), mobilization with movement significantly reduces pain (SMD, −1.61;
Journal of Orthopaedic & Sports Physical Therapy®

py interventions to address impairments alone or the addition of mobilization with 95% CI: −2.33, −0.9) and disability
potentially associated with RC tendinop- movement to physiotherapy care (exercise (SMD, −1.03; 95% CI: −1.71, −0.35) in
athy. Manual therapy interventions have and/or physical modalities) significantly the short term when compared to shoul-
been defined as skilled hand movements reduces pain (SMD, −1.07; 95% CI: −1.87, der taping. Manual therapy combined
performed by a therapist on a patient. −0.26; 7 studies; n = 228) but does not with exercises also significantly reduces
Manual therapy can include soft tissue significantly reduce disability (SMD, disability (SMD, −0.52; 95% CI: −1.03,
techniques, massage, muscle release −0.88; 95% CI: −2.18, 0.43; 5 studies; −0.02) in the short to medium term
techniques, passive stretching, and joint n = 155) when compared to sham mobili- when compared to no intervention.
mobilizations or manipulation of the zation with movement or physiotherapy However, the number of RCTs per meta-
spine.43 For RC tendinopathy, manual care (exercises or physical modalities) at analyses and the quality of these RCTs
therapy can be applied to the glenohu- an unspecified follow-up time. Based on are not reported. Based on unknown cer-
meral joint, the shoulder girdle, or the very uncertain evidence, these effects for tainty of the evidence, these effects for
thoracic and cervical spine. mobilization with movement alone or manual therapy ranged from trivial to
Overview combined with electrotherapeutic mo- large when compared to taping or no
Based on a 2021 CPG,44 includ- dalities are small to large for pain. For dis- intervention.
II ing 1 systematic review with ability, the nonsignificant CIs are large, A systematic review with meta-
meta-analysis and 6 RCTs,
there is low- to moderate-quality evi-
and the true effects remain unclear. Eli-
gible trials in this review included adults
II analysis178 reported that, based
on low- to very low–certainty
dence that manual therapy performed with shoulder pain and dysfunction re- evidence (GRADE), that manual thera-
alone or in combination with other treat- lated to movement, not limited to those py significantly reduces pain when
ments such as exercise, may significantly with an RC tendinopathy diagnosis. compared to placebo immediately after
reduce pain and disability among adults A systematic review with meta- the intervention (SMD, −0.62; 95% CI:
with an RC tendinopathy, but only in the
short term.
I analysis169 reported that the ad-
dition of manual therapy to
−0.97, −0.28; 3 RCTs; n = 134) in
adults with RC tendinopathy. It is also

262 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 noted that manual therapy significantly disability reductions in adults with RC with various RC disorders such as RC ten-
reduces pain (SMD, −0.35; 95% CI: tendinopathy. dinopathy in the short term. Based on very
−0.69, −0.01; 4 RCTs; n = 137) but not Recommendations uncertain evidence, the effect of kinesio-
disability (SMD, 0.17; 95% CI: −0.41, Recommendation No. 26 taping may or may not be clinically impor-
0.75; 2 RCTs; n = 47) at an unspecified Clinicians may perform spinal tant to reduce pain with movement but is
follow-up time in adults with RC tendi-
nopathy. Based on very uncertain evi-
B and/or upper limb manual ther-
apy alone or in combination
not effective to reduce overall pain as the
CI is below any clinically important differ-
dence, these effects for manual therapy with other modalities, such as exercise, to ences. Regarding disability, the nonsig-
may be trivial to large for pain, but the help reduce pain in adults with RC tendi- nificant CIs are large, and the true
true effects remain unclear for disabil- nopathy in the short term. Manual therapy effects remain unclear.
ity reductions as the nonsignificant CIs can include soft tissue techniques and/or A Cochrane review on kinesio-
is large.
Also based on low- to very low–qual-
joint mobilizations or manipulations. II taping for adults with RC disor-
ders such as RC tendinopathy62
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ity evidence, these authors reported that 3.4 Taping reported that, based on very low–certainty
manual therapy combined with exercise For RC tendinopathy, when applied to evidence (GRADE), kinesiotaping, in the
significantly reduces pain (SMD, −0.32, the scapulothoracic and glenohumeral short term, does not significantly reduce
95% CI: −0.62, −0.01; 9 RCTs; n = 363) joints and their surrounding muscles, pain with movement (MD, −0.06/10; 95%
and disability (SMD, −0.41; 95% CI: taping is believed to improve posture CI: −0.80, 0.68; 6 RCTs; n = 225) or over-
−0.71, −0.11; 7 RCTs; n = 301) when and shoulder kinematics as well as to de- all pain (MD, −0.44/10; 95% CI: −1.33,
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

compared to exercise alone in adults with crease pain. There are 2 broad categories 0.46; 5 RCTs; n = 266) but significantly
RC tendinopathy at an unspecified but of taping: nonelastic taping and elastic reduces disability (SMD, −0.66; 95% CI:
probably short follow-up time. Based on kinesiology taping. −1.22, −0.1; 12 RCTs; n = 499) when com-
very uncertain evidence, these effects for Overview pared to other treatments such as conven-
manual therapy may be trivial to moder- Based on a 2021 CPG,44 includ- tional taping, exercise, medications,
ate for pain and disability.
Gaps in Knowledge While manual ther-
II ing 2 low-quality RCTs, the cur-
rent evidence is insufficient to
corticosteroid injections, or other inter-
ventions. The efficacy of kinesiotaping to
apy may be integrated as an adjunct inter- formulate recommendations on the use reduce pain and disability compared to
vention to reduce pain in adults with RC of proprioceptive taping. other interventions is very unclear as the
Journal of Orthopaedic & Sports Physical Therapy®

tendinopathy, there are questions remain- A systematic review158 reported certainty of evidence is very low and be-
ing as to what the optimal parameters are.
The optimal type of spinal or upper limb
I weak and conflicting results on
the effectiveness in the short
cause the comparison includes heteroge-
nous interventions.
manual therapy (manipulation, mobiliza- term of the addition of rigid or elastic tap- A systematic review with meta-
tion, mobilization with movement, mas-
sage) and the parameters (duration and
ing to physiotherapy care including exer-
cise, manual therapy, and/or other
II analysis 5 compared several
interventions, including kine-
frequency) are unknown. Furthermore, it physical modalities for adults with RC siotaping in a single meta-analysis.
is difficult to conclude whether some man- tendinopathy (3 RCTs and 1 controlled Comparisons were made for (1) kinesio-
ual therapy treatments to the soft tissue trial, n = 135). The authors concluded that taping compared to sham taping, (2) ex-
and/or joint are better than others, since taping might be a therapeutic option in ercise and kinesiotaping compared to
they are frequently combined in trials. In the early phase of rehabilitation of adults exercise with corticosteroid injections,
addition, more research is needed to high- with RC tendinopathy but that high- (3) exercise and kinesiotaping compared
light the individuals who are most likely quality RCTs are needed to draw firm to exercise and manual therapy with
to benefit from the addition of manual conclusions on the efficacy of taping. thermotherapy and/or electrotherapy.
therapy to a rehabilitation treatment plan A Cochrane review62 reported However, based on the authors’ methods
including education and exercise.
Evidence Synthesis and Rationale Spinal
II that, based on very low–certainty
evidence (GRADE), kinesio-
that compared simultaneously multiple
interventions, it is not possible to isolate
and upper limb manual therapy, manip- taping significantly reduces pain with the effect of kinesiotaping alone nor the
ulation, mobilization, mobilization with movement (MD, −1.48; 95% CI: −2.25, effect of the addition of kinesiotaping to
movement, and massage can be used as −0.71; 4 RCTs; n = 153), but not overall other interventions. No conclusion on
an addition to exercise for the treatment pain (MD, 0.07/10; 95% CI: −0.77, 0.9; 3 the efficacy of kinesiotaping can be drawn
of RC tendinopathy. Alone or combined RCTs; n = 106) or disability (SMD, −0.49; from this review.
with other modalities, manual therapy 95% CI: −1.28, 0.30; 6 RCTs; n = 214) Gaps in Knowledge Description of in-
can provide mostly short-term pain and when compared to sham taping in adults terventions, sample sizes, and statistical

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 263
 [ clinical practice guidelines ]
analyses in current trials are not optimal, ability in adults with RC noncalcific −0.7; 95% CI: −1.22, −0.18) in the short
leading to uncertainty on the effectiveness tendinopathy but may reduce pain and/ term. In the medium term, laser therapy
of rigid taping or kinesiotaping on pain and or disability in adults with RC calcific significantly reduces pain when com-
disability in people with RC tendinopathy. tendinopathy. pared to control intervention (SMD,
Future research should investigate the • Acupuncture may reduce pain −0.84; 95% CI: −1.37, −0.31). Regarding
effect of taping with rigorous methodol- and/or disability, especially when com- disability, laser therapy significantly re-
ogy, including adequately powered studies bined with exercises, in adults with RC duces disability when compared to taping
and registered published protocols. Trials tendinopathy. (SMD, −1.21; 95% CI: −1.87, −0.55) or to
should also improve a description of the • Extracorporeal shockwave therapy a control intervention in the short term
taping interventions, such as description does not reduce pain and/or disability in (SMD, −1.54; 95% CI: −2.12, −0.96) and
of the intervention provider(s), targeted adults with RC noncalcific tendinopathy, in the medium term (SMD, −1.73; 95%
muscle(s), and modalities of applications but it may reduce pain, disability, and CI: −2.32, −1.13).
(ie, indications when to apply and dura- the size of the calcification in RC calcific • Acupuncture significantly reduces
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tion) to better assess the potential benefits tendinopathy. High-energy extracorpo- pain when compared to taping (SMD,
of such interventions. Trials should focus real shockwave therapy appears to be −0.58; 95% CI: −0.78, −0.39) in the
on standardizing outcomes, measuring po- superior to low-energy extracorporeal short term and when compared to TENS
tential adverse events, relevant data collec- shockwave therapy to reduce pain and/ (SMD, −0.74; 95% CI: −0.93, −0.54) or to
tion timepoints, and follow-up period. or disability. a control intervention (SMD, −0.81; 95%
Evidence Synthesis and Rationale There • The use of laser in combination with CI: −1.12, −0.51) in the medium term.
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

is a lack of high-level quality evidence to other modalities does not reduce pain Regarding disability, acupuncture signifi-
conclude on the efficacy of taping. There and/or disability. cantly reduces disability when compared
is uncertain evidence regarding the effect • There is insufficient evidence to sup- to TENS (SMD, −0.52; 95% CI: −0.72,
of taping alone or in combination to re- port the use of TENS, pulsed electromag- −0.33) or to a control intervention (SMD,
duce pain and disability in adults with RC netic fields, interferential currents, or −1.75; 95% CI: −3.26, −0.23) in the short
tendinopathy when compared to a sham iontophoresis for RC tendinopathy. term.
or other conservative interventions. Based on an umbrella review,145 • Extracorporeal shockwave therapy
Recommendation
Recommendation No. 27
I authors report that there is low
to high levels of evidence from
significantly reduces pain when compared
to control (SMD, −0.32; 95% CI: −0.55,
Journal of Orthopaedic & Sports Physical Therapy®

Clinicians may use taping in ad- 6 systematic reviews strongly recom- −0.09) in the medium term. Regarding
D dition to an active rehabilita-
tion program to reduce pain in
mending not to use laser therapy for
adults with RC tendinopathy as a single
disability, extracorporeal shockwave ther-
apy significantly reduces disability when
adults with RC tendinopathy in the short treatment. However, authors report that compared to control (SMD, −0.48; 95%
term. laser therapy could reduce pain and dis- CI: −0.94, −0.01) in the short term.
ability if added to an exercise or multi- It is important to note that in this sys-
3.5 Physical Modalities modal program. In addition, these tematic review, the number of RCTs in-
Various physical modalities are com- authors write that there is low to moder- cluded and participants per analysis are
monly used in the rehabilitation of ate levels of evidence from 5 systematic unknown. Therefore, it is difficult to draw
adults with RC tendinopathy. These reviews not to use therapeutic ultrasound clear conclusions on the true clinical ef-
may include therapeutic ultrasound, for adults with RC tendinopathy. These ficacy of these interventions and uncer-
acupuncture, extracorporeal shock- authors also state that there is low to tainty remains.
wave therapy, laser, or transcutaneous moderate levels of evidence from 3 sys- A systematic review56 reported
electrical nerve stimulation (TENS).
Depending on the type of tendinopathy,
tematic reviews not to use extracorporeal
shockwave therapy for adults with RC
II conflicting evidence for reduc-
tions in pain and disability
calcific or noncalcific, some interven- tendinopathy. when comparing extracorporeal shock-
tions may be preferred. Most common- The systematic review by wave therapy to other conservative inter-
ly, the use of these physical modalities
is part of a multimodal program to treat
II Babatunde et al11 conducted the
following pairwise comparisons:
ventions in adults with RC calcific and
noncalcific tendinopathy in the medium
adults with RC tendinopathy. • Laser therapy significantly reduces term to a very long term. Based on 4
Overview pain when compared to ultrasound ther- high-quality RCTs, 4 moderate-quality
Based on a 2021 CPG:44 apy (SMD, −1.2; 95% CI: −1.61, −0.78), RCTs, and 1 moderate-quality pilot study,
II • Therapeutic ultrasound does
not reduce pain and/or dis-
taping (SMD, −1.66; 95% CI: −2.35,
−0.97), or a control intervention (SMD,
the true effects remain unclear for pain
and disability reductions.

264 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 A systematic review with meta- A systematic review with a nar- sound-guided lavage or needling is supe-
II analysis178 reported that, based
on low- to very low–certainty
II rative synthesis73 reported that,
based on 1 acceptable-quality
rior than medium/high-energy
extracorporeal shockwave therapy in
evidence (GRADE), long-duration ultra- trial, low-frequency TENS significantly reducing pain and calcification size in the
sound (8 minutes) significantly reduces reduces pain just after the therapeutic long term (2 RCTs).
pain (SMD, −1.32; 95% CI: −1.76, −0.89; treatment (1 RCT, n = 20) when com- A pairwise comparison from a
1 RCT; n = 100) and disability (SMD,
−0.42; 95% CI: −0.82, −0.02; 1 RCT; n
pared to sham TENS in adults with RC
tendinopathy. Neither the magnitude of
II network meta-analysis198 re-
ported that high-energy extra-
= 100) when compared to short-duration the effect nor the CIs were reported. corporeal shockwave therapy significantly
ultrasound (4 minutes) in adults with RC In addition, these authors report that reduces pain (MD, −2.43/10; 95% CI:
tendinopathy at an unspecified follow-up low-level laser therapy combined with −3.48, −1.38; 4 RCTs) and disability on
time. Based on very uncertain evidence, exercise significantly reduces pain when the Constant-Murley Score (MD,
these effects for long-duration ultrasound compared to sham laser therapy with ex- 17.43/100; 95% CI: 10.43, 24.42; 5 RCTs)
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may be large for pain and trivial to large ercise (1 RCT, n = 20) in adults with RC when compared to low-energy extracor-
for disability. tendinopathy at an unspecified follow-up poreal shockwave therapy at an unspeci-
Also based on low- to very low–certainty time. It is also mentioned that low-level fied follow-up time in adults with chronic
evidence (GRADE), these authors reported laser therapy combined with ultrasound, calcific RC tendinopathy.
that extracorporeal shockwave therapy sig- TENS, thermotherapy, and exercise sig- A systematic review with meta-
nificantly reduces pain (SMD, −0.39; 95% nificantly reduces pain when compared II analysis28 reported that, based on
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

CI: −0.78, −0.01; 3 RCT; n = 117) but not to the same intervention with sham laser very low–quality evidence
disability (SMD, −0,27; 95% CI: −0.90, therapy (1 RCT, n = 50) in adults with RC (GRADE), laser therapy does not signifi-
0.35; 3 RCTs; n = 117) when compared tendinopathy in the short term. Neither cantly reduce night pain (MD, −1.2/10;
to a sham intervention in adults with RC the magnitude of the effect nor the CIs 95% CI: −4.09, 1.69; 1 RCT; n = 35) when
tendinopathy at an unspecified follow-up were reported. compared to a placebo in adults with RC
time. Based on very uncertain evidence, Two acceptable quality reviews includ- tendinopathy in the medium term. The
these effects for extracorporeal shock- ed report that extracorporeal shockwave nonsignificant CIs are large, and the true
wave therapy may be trivial to moderate therapy is not effective for the treatment effects remain unclear for pain reductions.
for pain. For disability, the nonsignifi- of noncalcific RC tendinopathy. Neither Also based on very low–quality evidence
Journal of Orthopaedic & Sports Physical Therapy®

cant CIs are large, and the true effects the magnitude of the effect nor the CIs (GRADE), extracorporeal shock wave ther-
remain unclear. were reported. apy does not significantly reduce pain (MD,
Also based on low- to very low–certainty For RC calcific tendinitis, these au- 0.17/10; 95% CI: −0.31, −0.03; 2 RCTs; n =
evidence (GRADE), these authors reported thors found 5 acceptable-quality reviews 158) in the short to medium term and dis-
that laser therapy significantly reduces and 1 high-quality review and note that ability on the SPADI (MD, 5.0/100; 95%
pain (SMD, −0.88; 95% CI: −1.48, these systematic reviews indicate that ex- CI: −7.4, 17.4; 1 RCT; n = 74) in the medium
−0.27; 3 RCTs; n = 128) but not disability tracorporeal shockwave therapy is effec- term when compared to a placebo in adults
(SMD, −0.67; 95% CI: −1.60, 0.25; 2 tive and safe to treat calcific tendinopathy with RC tendinopathy in the medium term.
RCTs; n = 125) when compared to sham after failed nonsurgical treatment, even Based on very uncertain evidence, extracor-
laser therapy in adults with RC tendi- though some adverse events were report- poreal shock wave therapy is not more ef-
nopathy at an unspecified follow-up time. ed (all were resolved after a few days). fective than placebo in reducing pain and
Also, these authors note that laser thera- Neither the magnitude of the effect nor disability. The CIs are below any clinically
py plus exercise significantly reduces pain the CIs were reported. important differences for pain and below a
(SMD, −0.65, 95% CI: −0.99, −0.31; 6 A systematic review with narra- trivial effect size for disability.
RCTs; n = 313) but not disability (SMD, II tive synthesis176 reported that, for A systematic review with meta-
0.12, 95% CI: −0.24, 0.49; 4 RCTs; n =
190) when compared to sham laser ther-
adults with calcific RC tendinop-
athy, high-energy extracorporeal shock-
II analysis181 reported that, based
on moderate-quality evidence
apy plus exercise in adults with RC tendi- wave therapy is superior than low-energy (GRADE), extracorporeal shockwave ther-
nopathy at an unspecified follow-up time. extracorporeal shockwave therapy in re- apy significantly reduces pain (MD
Based on very uncertain evidence, these ducing pain and disability in the medium −0.78/10; 95% CI: −1.4, −0.17; 9 RCTs
effects for laser therapy may be moderate term (3 RCTs), high-energy extracorpo- and 1 quasi-randomized trial; n = 608)
to large for pain. For disability, the real shockwave therapy is superior than a and disability (MD, −7.9/100; 95% CI:
nonsignificant CIs are large, and the true sham intervention to reduce disability in −14, −1.6; 9 RCTs or QRCT; n = 612)
effects remain unclear. the medium term (2 RCTs), and ultra- when compared to a sham intervention in

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 265
 [ clinical practice guidelines ]
adults with a calcific or noncalcific RC ten- RC noncalcific tendinopathy. Acupunc- with various types of exposures such as
dinopathy in the medium term (sensitivity ture and laser may be useful to reduce awkward postures and repetitive mo-
analyses suggest that there is no significant pain and/or disability in adults with RC tion. These interventions usually consist
difference between adults with or without tendinopathy. Therapeutic ultrasound of the integration of compensatory tools
a calcification). Based on low-quality evi- and extracorporeal shockwave therapy, and new equipment or workspace ad-
dence (GRADE), it is unclear if shockwave especially high-energy extracorporeal aptations. The following section reports
therapy increased or reduced the risk of shockwave therapy, may be useful to re- evidence on ergonomics for adults experi-
adverse event when compared to a sham duce pain and/or disability in adults with encing shoulder pain, and it may include
intervention. It is likely that these effects RC calcific tendinopathy. adults with RC tendinopathy.
for extracorporeal shockwave therapy may Recommendations Overview
or may not be clinically important for pain Recommendation No. 28 Based on the CPG by
and may be trivial for disability. Clinicians may use or recom- II Desmeules­ et al,44 the use of er-
A systematic review with narra- C mend acupuncture in addition gonomic adaptations may be
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

II tive synthesis185 notes that ex-

tracorporeal shockwave therapy
to an active rehabilitation pro-
gram to reduce pain and disability in
useful to reduce pain and disability in
adults with shoulder pain. These results
reduced pain (2 RCTs, n = 137) and the adults with RC tendinopathy. are based on 2 RCTs including partici-
calcification size (3 RCTs, n = 450) in pa- Recommendation No. 29 pants with shoulder pain (n = 433).
tients with calcific RC tendinopathy in Clinicians should not use or rec- A Cochrane systematic review
the medium to long term. The RCTs men- C ommend extracorporeal shock II with meta-analysis75 reported
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tioned above all used a variety of different wave therapy to reduce pain and that, based on low-certainty
comparators for the control group. These disability in adults with RC tendinopathy evidence (GRADE), the use of an arm
authors also noted that it is unclear if ex- without calcification. support with an alternative mouse sig-
tracorporeal shockwave therapy reduces Recommendation No. 30 nificantly reduces pain and discomfort in
pain or disability in patients with noncal- Clinicians may use or recom- the neck and shoulder (SMD, −0.41;
cific RC tendinopathy (8 RCTs, n = 430)
in the short to very long term. The RCTs
C mend extracorporeal shock
wave therapy to reduce pain
95% CI: −0.69, −0.12; 2 RCTs; n = 96)
when compared to the use of a conven-
mentioned above all used a variety of dif- and disability in adults with RC calcific tional mouse in office workers in the long
ferent comparators for the control group tendinopathy. term. However, based on low-certainty
Journal of Orthopaedic & Sports Physical Therapy®

or no control group and one of these Recommendation No. 31 evidence (GRADE), the use of an alter-
RCTs combined extracorporeal shock- Clinicians may use laser therapy native mouse alone does not significantly
wave therapy with physical therapy for
the experimental group.
C alone or in addition to an active
rehabilitation program to re-
decrease neck and shoulder discomfort
(SMD, 0.04; 95% CI: −0.26, 0.33; 2
A systematic review with net- duce pain and disability in adults with RC RCTs; n = 96) when compared to the use
III work meta-analysis 11 assessed
the efficacy of several physical
calcific tendinopathy.
Recommendation No. 32
of a conventional mouse in office workers
in the long term. The evidence suggests
modalities for adults with RC tendi- Clinicians should not use or rec- that these effects for the use of an arm
nopathy. The authors concluded that
laser therapy, acupuncture, and TENS
C ommend therapeutic ultra-
sound alone or in addition to an
support with an alternative mouse may
be trivial to moderate. The use of an al-
are interventions with a high probabil- active rehabilitation program to reduce ternative mouse alone is not more effec-
ity of being effective, but with very low pain and disability in adults with RC cal- tive than the use of a conventional mouse
certainty for most interventions. cific tendinopathy. for decreasing neck and shoulder dis-
Gaps in Knowledge At the moment, Recommendation No. 33 comfort. The CI is below any moderate
there is insufficient evidence and a lack Clinicians should not use or rec- effect size.
of reviews and high-quality original stud- B ommend therapeutic ultra- A Cochrane systematic review
ies to reach conclusions for the use of
dry needling, TENS, pulsed electromag-
sound alone or in addition to an
active rehabilitation program to reduce
II with meta-analysis75 reported
that, based on low-certainty
netic fields, interferential currents, and pain and disability in adults with RC evidence (GRADE), the use of a sit-
iontophoresis. noncalcific tendinopathy. stand workstation does not significantly
Evidence Synthesis and Rationale Ther- reduce pain and discomfort in the neck
apeutic ultrasound and extracorporeal 3.6 Ergonomic Interventions and shoulder (MD, −0.30/10; 95% CI:
shockwave therapy are not useful to re- Ergonomic interventions aim to prevent −1.69, 1.09; 1 RCT; n = 25) when com-
duce pain and/or disability in adults with MSK injuries and disorders associated pared to usual working conditions in

266 | april 2025 | volume 55 | number 4 | journal of orthopaedic & sports physical therapy
 office workers in the short to medium good quality are needed specific to that formance tests, or established criteria that
term (8 weeks). The nonsignificant CI population. should be used to guide the return to sport.
is large, and the true effects remain Recommendation As suggested in the Bern consensus,162 evi-
unclear. Recommendation No. 34 dence is needed to define the factors and
A Cochrane systematic review Clinicians may perform or rec- determinants that are associated with suc-
II with meta-analysis75 reported
that, based on very low–
C ommend ergonomic adapta-
tions to reduce occupational
cessful return to sport in those with RC
tendinopathy. There is a lack of evidence as
certainty evidence (GRADE), the use of shoulder pain in adults. to the specific shoulder-related factors as
supplementary breaks significantly reduc- well as the kinetic chain factors that have
es shoulder or upper arm discomfort (MD, SECTION 4 – RETURN the ability to guide the return to sport in an
−0.33; 95% CI: −0.46, −0.19; 2 RCTs; n TO SPORT FOR RC athlete with RC tendinopathy.
= 186) when compared to usual breaks in TENDINOPATHY Evidence Synthesis and Rationale It
office workers in the short term. Based on is accepted that a comprehensive as-
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A
very uncertain evidence, these effects for n important component for re- sessment of the athlete should include
the use of supplementary breaks may or turn to sport is the assessment of patient-reported outcome measures to
may not be clinically important for shoul- pain, disability, and the athlete’s assess the athlete’s pain, functional limi-
der or upper arm discomfort. perception as to the readiness to return tations, disability, and psychosocial and
Gaps in Knowledge Evidence is weak to sport.6,37,162 When developing a return- contextual factors that can impact their
and sometimes contradictory on the ef- to-sport program, the athlete’s capacity perceived readiness to return to sport.2
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

fectiveness of ergonomic interventions and load tolerance for the RC muscles and To guide clinicians, a group of researchers
to reduce pain and disability in people tendons along with associated shoulder and experts through a Delphi study (not
with RC tendinopathy, and more studies muscles and joints are considered.162,193 presented in the overview) recommends
of high quality are needed. Most of the This includes measures of muscle perfor- for various shoulder disorders, a mea-
evidence identified conducted analyses mance, ROM, coordination, and control. sure of shoulder function specific to the
in workers with neck and shoulder symp- The trunk, pelvis, and lower extremities RC such as the WORC (Western Ontario
toms, which limits the ability to conclude can also be evaluated as it is an important Rotator Cuff Index) or shoulder-specific
on the specific effect of ergonomic inter- component in the kinetic chain in gener- such as the Pennsylvania Shoulder Score
ventions for pain and disability in people ating force for upper extremity sports.193 (Penn), and a measure of pain such as the
Journal of Orthopaedic & Sports Physical Therapy®

experiencing shoulder RC tendinopathy. Psychological readiness to return to numeric pain rating scale.12 This Delphi
There are also very few studies that have sport, as well as the presence of psycho- consensus also recommends that mea-
compared ergonomic interventions to a social and contextual factors are also to sures of physical performance be used,
control intervention, which again limits be considered.146,162 such as the Closed Kinetic Chain Upper
interpretation of the results. To date, the Overview Extremity Stability Test (CKCUEST) that
ergonomic interventions identified in Based on 3 reviews,27,124,160 RC have established reliability and validity,
the literature mainly focus on computer
workplace stations and include the use
II tendinopathy is the first or sec-
ond most common injury occur-
and indicates that physical assessment of
the shoulder and entire kinetic chain (ie,
of arm support and ergonomic mouse in ring in baseball and water polo. However, trunk, pelvis, and lower extremities) are
computer users. There is a lack of stud- these 3 reviews27,124,160 provided very limited indicated to determine return-to-sport
ies investigating the potential benefits or evidence as to the factors to consider when readiness for shoulder MSK disorders.12,41
ergonomic interventions in other work working with an athlete to guide their re- The Bern consensus, a resource support-
environments or contexts for people with turn-to-sport activity. One review27 found ing the return-to-sport continuum of
RC tendinopathy. that in major league baseball players, the all level athletes with shoulder injuries,
Evidence Synthesis and Rationale The reinjury rate for RC tendinopathy was 1.6% highlights 6 domains to consider: pain;
use of ergonomic adaptations, including to 2.6% but did not describe determinants active shoulder ROM; strength, power,
the adjustment of workplace station, associated with reinjury proportions. and endurance; the entire kinetic chain;
ergonomic education, the use of ergo- Gaps in Knowledge None of the 3 re- psychology; and return to sport–specific
nomic mouse and arm support in com- views provided timelines for return to activities.162
puter workplace stations, and the use of sport or factors (clinical, psychosocial, Recommendations
frequent short breaks, could be useful to or contextual) that may impact return to Recommendation No. 35
reduce pain and disability in people ex- sport. Moreover, there is no evidence as Clinicians may evaluate an ath-
periencing RC tendinopathy. Evidence is,
however, uncertain, and more studies of
to the optimal set of patient-reported out-
come tools, physical measures, and per-
F lete’s capacity and load tolerance
for the RC muscles and tendons

journal of orthopaedic & sports physical therapy | volume 55 | number 4 | april 2025 | 267
 [ clinical practice guidelines ]
along with associated shoulder muscles authors contributed the elaboration of in patients with subacromial impingement syn-
and joints to develop a return-to-sport clinical recommendations and decision drome: a systematic review with meta-analysis.
program. trees; all the authors were involved in Scand J Med Sci Sports. 2022;32:273-​289.
https://doi.org/10.1111/sms.14084
Recommendation No. 36 the drafting of the manuscript; F.D. 6. Ardern CL, Glasgow P, Schneiders A, et al.
Clinicians may use reliable, was responsible for obtaining project 2016 Consensus statement on return to
F valid, and responsive patient-
rated outcome tools for pain,
funding and takes responsibility for the
integrity of the work as a whole; all au-
sport from the First World Congress in Sports
Physical Therapy, Bern. Br J Sports Med.
2016;50:853-​864. https://doi.org/10.1136/
disability, psychosocial factors, or readi- thors have read and agreed to the pub- bjsports-2016-096278
ness to return to sport, along with func- lished version of the manuscript. 7. Arias-Vázquez P, Tovilla-Zárate C, González-Graniel K,
tional performance measures to guide the DATA SHARING: Data are available from et al. Efficacy of hypertonic dextrose infiltrations for
pain control in rotator cuff tendinopathy: system-
return-to-sport continuum and deter- the corresponding author (F.D.) upon
mine timelines for return to sport. t
atic review and meta-analysis. Acta Reumatologica
reasonable request. Interested indi- Portuguesa. 2021;46:156-​170. https://doi.
viduals may contact him by email: org/10.48780/arprheumatology.2021.46.2.156
Downloaded from www.jospt.org at on September 10, 2025. For personal use only. No other uses without permission.

KEY POINTS [email protected]. 8. Armijo-Olivo S, Stiles CR, Hagen NA, Biondo PD,
Cummings GG. Assessment of study quality
• Clinicians must incorporate a de- PATIENT AND PUBLIC INVOLVEMENT: Eight for systematic reviews: a comparison of the
tailed history, physical examination, patient partners who sought care for Cochrane Collaboration Risk of Bias Tool and
and identification of psychosocial shoulder pain in Quebec, Canada (n = the Effective Public Health Practice Project
Quality Assessment Tool: methodological re-
factors when assessing patients with 3); Limerick, Ireland (n = 3); and
search. J Eval Clin Pract. 2012;18:12-​18. https://
shoulder pain and suspected rotator California, USA (n = 2), participated in
Copyright © 2025 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

doi.org/10.1111/j.1365-2753.2010.01516.xS
cuff tendinopathy. Tools like incli- the recommendations revision of this 9. Artus M, van der Windt DA, Afolabi EK, et al.
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practitioners (GPs): a national survey. BMJ
patient-reported outcome measures
Open. 2017;7:e015711. https://doi.org/10.1136/
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agnosis and monitoring. acknowledge the contribution of the health care 10. Asker M, Brooke HL, Waldén M, et al. Risk fac-
• Nonsurgical interventions such as librarian, Marie Désilets, for her assistance tors for, and prevention of, shoulder injuries
in overhead sports: a systematic review with
structured exercise programs (in- in optimizing our search strategies and of
best-evidence synthesis. Br J Sports Med.
cluding motor control and resistance Kassandra Dewyse for her support and valu- 2018;52:1312-​1319. https://doi.org/10.1136/
training) and manual therapy are rec- able contributions to this research project. We bjsports-2017-098254
Journal of Orthopaedic & Sports Physical Therapy®

ommended as initial treatment mo- would also like to acknowledge the collabora- 11. Babatunde OO, Ensor J, Littlewood C, et al.
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