Rotator Cuff-Related Shoulder Pain: The Modern Approach to a Common Condition

All information in this blog is supported by peer-reviewed research, including a major 2025 clinical practice guideline. Reference numbers appear throughout, with the full list at the bottom of the page.

A Shift in How Shoulder Pain Is Understood

If you've previously been told you have "shoulder impingement," it's worth knowing that this terminology, and the thinking behind it, has genuinely moved on. The classic impingement model, proposed in the 1970s, suggested pain was caused by the rotator cuff tendons being physically pinched beneath the acromion bone during arm movement. ¹ This idea led to widespread use of subacromial decompression surgery, aiming to shave away bone thought to be causing the pinching.

The trouble is, the evidence simply hasn't supported this model. Multiple high-quality trials have now found that subacromial decompression surgery offers no better results than placebo surgery, and a review of 15 studies on the space beneath the acromion found no meaningful difference between people with and without shoulder pain. ² This led to a genuine shift in clinical language and understanding, away from "impingement" and toward a broader, more accurate term: rotator cuff-related shoulder pain, or RCRSP.

What Is Rotator Cuff-Related Shoulder Pain?

RCRSP is an umbrella term encompassing a spectrum of shoulder conditions, including subacromial pain syndrome, subacromial impingement syndrome, rotator cuff tendinopathy, bursitis, and symptomatic partial and full-thickness rotator cuff tears. ³ It was deliberately proposed to move away from older, scientifically uncertain diagnostic labels and to better reflect what's actually understood about shoulder pain. RCRSP is considered the leading cause of shoulder pain, affecting between 44% and 65% of all people presenting with shoulder complaints. ⁴

Symptoms are typically described as pain in the anterolateral (front-outer) part of the shoulder, with difficulty during shoulder elevation and rotation. ⁵ The condition relates to the structures around the subacromial space, the proximal humerus, the rotator cuff tendons themselves, and the surrounding bursa, the fluid-filled sac that cushions the tendons.

Why "Impingement" Doesn't Tell the Whole Story

This matters practically, not just academically. Current research has demonstrated that mechanical factors including a reduction in the subacromial space, scapular dyskinesia (altered shoulder blade movement), and different acromial shapes are unlikely to be directly contributing to RCRSP. ⁶ Whilst acromial spurs have historically been suggested as a major external cause, available evidence does not support this hypothesis. ⁷

What this means is that the pain you're experiencing is very unlikely to be simply down to "your bones pinching the tendon." Modern understanding instead points toward tendinopathy, bursitis, and load-related tendon failure as more accurate explanations. ¹ In plain terms, the tendon is reacting to how it has been loaded over time, not being physically squashed by your skeleton.

This shift is also important from a treatment perspective. Research has found that diagnostic labels genuinely influence how people think about treatment, with terms like "subacromial impingement syndrome" leading people to perceive a higher need for imaging, and a "rotator cuff tear" label leading to a higher perceived need for surgery, compared with simpler terms like bursitis. ⁸ Getting the language right genuinely helps you make better-informed decisions about your care.

Risk Factors

• Age and natural tendon changes over time

• Repetitive movement, whether through sport or job-related tasks ⁹

• Poor shoulder mechanics, including how the shoulder blade and surrounding muscles coordinate movement ⁹

• Occupational demand, particularly high physical job demands and overhead reaching, seen in occupations such as construction, farming, and healthcare ¹⁰

• Psychosocial factors, including high stress, fear avoidance, anxiety, and low confidence in movement, all genuinely shown to influence both the presence and recovery of RCRSP ⁹ ¹¹

• Work-related stress factors, including poor social support, perceived injustice, and job-related stress ¹¹

• Cervical and thoracic spine involvement, covered in more detail below

It's worth noting just how broad this list is. The cause of RCRSP is genuinely multifactorial, including age, loading history, biomechanical factors, psychosocial factors, lifestyle, and general health. ⁵ This is exactly why a thorough, whole-person assessment matters more than chasing a single structural cause.

The Neck and Mid-Back Connection

This ties in directly with what we've covered in our neck pain and stiffness blog. Recent research has specifically investigated whether the cervical and thoracic spine play a role in RCRSP, given how interconnected these regions are functionally. A 2024 comparative study examined cervical and thoracic spine mobility in people with RCRSP against asymptomatic controls, recognising that diagnostic uncertainty around this condition relates in part to the potential involvement of the neck and upper back as a contributing source. ¹² This reinforces a theme we return to often, shoulder pain rarely exists in complete isolation from the rest of the spine and movement system above and around it.

When Should You Be Concerned? Red Flags to Watch For

Clinicians should identify any signs or symptoms of serious pathology, including a suspicious deformity, fever and chills, signs suggesting cardiovascular or visceral impairment, and any history or suspicion of cancer. ¹³ Please seek prompt medical assessment if you experience:

• Sudden, significant weakness or inability to move the shoulder

• A visible deformity following injury

• Fever, chills, or feeling generally unwell alongside shoulder pain

• Symptoms suggesting a cardiac or visceral problem, such as chest pain or pressure

• Unexplained weight loss alongside persistent shoulder pain

• Significant pain following major trauma

How Is It Diagnosed?

No single test provides a definitive answer on its own. The painful arc test helps confirm rotator cuff involvement, whilst the Hawkins-Kennedy test can help rule it out, but combining multiple findings, history, symptom pattern, and clusters of clinical tests, alongside clinical judgement, is what leads to an accurate diagnosis. ¹¹ Diagnostic imaging for RCRSP is generally considered unnecessary, as it cannot reliably identify a specific cause and does not typically inform management decisions. ¹⁴ This is consistent with the broader evidence base across musculoskeletal conditions covered throughout our blogs, where structural findings on a scan often don't correlate well with someone's actual symptoms.

How We Can Help

First-line treatment of RCRSP should be nonoperative, including exercise prescription, with or without other modalities such as manual therapy. ⁵

Osteopathic manual techniques and manual therapy: used to complement exercise, address restriction in the shoulder, and given the evidence on cervical and thoracic involvement, we routinely assess and treat the neck and mid-back alongside the shoulder itself, not in isolation.

Deep tissue and sports massage: targeted soft tissue work to address compensatory tension that builds up around the shoulder girdle, neck, and upper back as the body adapts to pain and altered movement.

Medical acupuncture: used as part of a broader treatment plan to support pain management alongside exercise.

Addressing psychosocial factors: given how clearly research links stress, fear of movement, and low confidence to both the presence and recovery from RCRSP, we take time to understand and address these factors as part of your treatment, not just the physical structures involved. ⁹ ¹¹

Exercise and Rehabilitation

Exercise sits at the core of recovery, and the evidence base here is substantial.

Despite ample evidence supporting the effectiveness of exercise therapy for RCRSP, no single consensus exists on the single best exercise approach. ¹⁵ What does have good supporting evidence:

• Motor control and scapular-focused exercise, retraining how the shoulder blade and surrounding muscles coordinate movement, has shown meaningful improvement in pain and disability, particularly over the medium term.

• Progressive, individually tailored loading matters more than any single exercise type, with structured, supervised programmes generally outperforming generic, unstructured advice.

• Addressing the whole picture, not just isolated shoulder exercises, but also thoracic mobility work (covered in our neck pain and stiffness blog) and broader movement confidence, given the evidence linking psychosocial and biomechanical factors together.

Your practitioner will build a programme specific to your presentation, your job or sporting demands, and the factors most relevant to your individual recovery.

What to Expect at Your First Appointment

We will take a thorough history, including your occupation, activity levels, and any stress or movement-related anxiety that may be contributing, alongside a hands-on shoulder assessment using a cluster of clinical tests rather than relying on any single test in isolation. We will also assess your neck and thoracic spine, given the genuine evidence linking these regions to shoulder pain. We will explain clearly what we find, using language that reflects current understanding rather than outdated terms like "impingement," and build a progressive, evidence-based treatment plan with you.

Frequently Asked Questions

Is this the same as "impingement"? Largely, yes, RCRSP has become the preferred, more accurate term, reflecting updated evidence that the old impingement model doesn't fully explain the condition. ¹ ³

Do I need a scan? Usually not. Imaging is generally not necessary for diagnosis and rarely changes the treatment plan. ¹⁴

Will I need surgery? Most people don't. Evidence does not support surgical decompression as superior to structured exercise and conservative treatment. ²

Why are you asking about my stress levels for a shoulder problem? Because the evidence is genuinely clear that psychosocial factors, including stress, fear of movement, and confidence, meaningfully influence both symptoms and recovery in RCRSP, alongside the physical factors. ⁹ ¹¹

Recognise this pattern of shoulder pain? Get in touch using the contact form and we will carry out a thorough, modern assessment to find out exactly what's going on.

BOOK YOUR APPOINTMENT HERE

References

1. Rotator Cuff-Related Shoulder Pain (RCRSP): From Impingement to Modern Biomechanical Understanding. Available at: https://exerciseprescriptor.com/painful-conditions/rotator-cuff-related-shoulder-pain/

2. Beard DJ, et al. Arthroscopic subacromial decompression is no more effective than placebo surgery. Referenced in: Rotator Cuff-Related Shoulder Pain (RCRSP). Available at: https://exerciseprescriptor.com/painful-conditions/rotator-cuff-related-shoulder-pain/

3. Shoulder mobility and strength impairments in patients with rotator cuff related shoulder pain: a systematic review and meta-analysis. PMC. 2024. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11214432/

4. Pain localization and associations with strength and range of motion deficits in rotator cuff-related shoulder pain vs asymptomatic. ScienceDirect. 2025. Available at: https://www.sciencedirect.com/science/article/abs/pii/S246878122500102X

5. Lafrance S, et al. The Efficacy of Exercise Therapy for Rotator Cuff-Related Shoulder Pain According to the FITT Principle. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(8):499-512. Available at: https://www.jospt.org/doi/10.2519/jospt.2024.12453

6. The major pain source of rotator cuff-related shoulder pain: A narrative review on current evidence. PubMed. Available at: https://pubmed.ncbi.nlm.nih.gov/37316968/

7. Rotator Cuff Related Shoulder Pain: An Update of Potential Pathoaetiological Factors. Available at: https://www.researchgate.net/publication/362228984

8. Rotator cuff-related shoulder pain (RCRSP): semistructured patient interviews to explore the barriers and enablers to rehabilitation exercises. PMC. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11481144/

9. Rotator Cuff Tendinopathy: 2025 Clinical Practice Guideline Insights. Available at: https://glennwellmanndpt.com/2025/10/27/rotator-cuff-tendinopathy-2025-clinical-practice-guideline-insights/

10. Biomechanical risk factors for rotator cuff syndrome in high-risk occupations: A prospective study protocol. PubMed. 2025. Available at: https://pubmed.ncbi.nlm.nih.gov/40540472/

11. Optimize shoulder rotator cuff recovery with these new 2025 clinical guidelines. KRU Physical Therapy and Performance Lab. Available at: https://www.kruperformance.com/blog/rotator-cuff-tendinopathy-what-new-2025-guidelines-mean-for-clinicians-and-patients

12. Cervical and Thoracic Spine Mobility in Rotator Cuff Related Shoulder Pain: A Comparative Analysis with Asymptomatic Controls. PMC. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11348207/

13. Desmeules F, Roy J-S, Lafrance S, et al. Rotator Cuff Tendinopathy: Diagnosis, Nonsurgical Medical Care, and Rehabilitation, A Clinical Practice Guideline. Journal of Orthopaedic & Sports Physical Therapy. 2025;55(4):235-274. Available at: https://www.jospt.org/doi/10.2519/jospt.2025.13182

14. Rotator cuff-related shoulder pain (RCRSP): semistructured patient interviews to explore the barriers and enablers to rehabilitation exercises. PMC. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11481144/

15. Effects of seven types of exercise in the treatment of rotator cuff-related shoulder pain (RCRSP): a systematic review and Bayesian network meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. Available at: https://link.springer.com/article/10.1186/s13018-025-06514-4