Non-Surgical Management of Rotator Cuff Tendinopathy: What the Latest Guidelines Recommend
Desmeules F, Roy JS, Bédard J, et al. Rotator cuff tendinopathy: diagnosis, nonsurgical medical care, and rehabilitation: a clinical practice guideline. J Orthop Sports Phys Ther. 2025;55(2):CPG1–CPG33. doi:10.2519/jospt.2025.12650
Background
Shoulder pain is the third most common musculoskeletal complaint seen in primary care, and one of the leading causes is rotator cuff tendinopathy. This condition, often involving pain, weakness, and difficulty with overhead activities, affects adults of all ages but becomes more common with age or repetitive strain.
Rotator cuff tendinopathy is often confused with other shoulder issues, and patients are frequently referred for imaging or even surgery prematurely. Fortunately, most people improve with structured, conservative care.
That’s where this Clinical Practice Guideline (CPG) comes in. Developed by a multidisciplinary panel including physical therapists, physicians, and researchers, it reviews and ranks the best evidence-based approaches for diagnosing and managing rotator cuff tendinopathy without surgery. This guideline was released by the Journal of Orthopedic Sports Physical Therapy in 2025.
What Question Is the Study Trying to Answer?
This guideline seeks to answer a broad but important question:
What are the most effective and evidence-based ways to diagnose, treat, and manage rotator cuff tendinopathy using non-surgical methods?
The panel evaluated literature from 2000 to 2023 to determine:
Which clinical tests are most reliable for diagnosis
How well treatments like exercise, injections, or manual therapy work
What factors influence a patient’s recovery
Which approaches lead to the best outcomes without needing surgery
Who Was in the Study and What Were the Groups?
This is not a traditional single study with patient groups; it’s a Clinical Practice Guideline (CPG) that synthesizes over 400 studies, including randomized controlled trials, systematic reviews, and observational studies.
Populations included in these studies ranged widely:
Age: Mostly adults 30–70 years old
Condition duration: Acute (<3 months) and chronic (>3 months)
Injury types: Tendinopathy with or without imaging-confirmed tears (small or partial)
Participants across studies had pain with shoulder movement, difficulty sleeping on the affected side, and weakness with lifting or overhead tasks. Notably, these guidelines focus on non-surgical care, so the studies excluded full-thickness rotator cuff tears requiring repair.
What Did the Study Find?
Here are the most patient-relevant findings, organized by topic:
🔍 Diagnosis
No single test is perfect. Instead, a combination of signs, like painful arc, weakness with external rotation, and a positive Hawkins-Kennedy test, should be used.
Imaging is often unnecessary early on unless there are red flags or the patient fails a trial of conservative care.
💪 Exercise Therapy
Strong evidence supports progressive loading of the rotator cuff and scapular muscles.
Eccentric and concentric strengthening, stretching, and posture correction are all effective.
Supervised physical therapy leads to better outcomes than home exercise alone.
Adherence matters: patients who complete their exercise program consistently show greater pain reduction and function gains.
💉 Injections
Corticosteroid injections may offer short-term relief (2–6 weeks) but do not improve long-term outcomes.
Multiple injections are discouraged due to potential tissue weakening and diminished returns.
Injections should only be considered when pain severely limits participation in exercise.
👐 Manual Therapy
May offer additional benefit when combined with exercise, especially in the short term.
Includes joint mobilizations, soft tissue techniques, and neuromuscular facilitation.
On its own, manual therapy is not sufficient.
⚠️ Passive Modalities
Ice, ultrasound, and other passive treatments show low evidence of benefit and should not be used as stand-alone care.
They may serve a role in pain management early in rehab but should not replace active treatment.
🧠 Psychosocial Factors
Patients with fear-avoidance beliefs, low self-efficacy, or depressive symptoms may have poorer outcomes.
Addressing these factors through education and graded exposure improves treatment response.
📈 Prognostic Factors
Better outcomes are associated with:
Strong baseline function
Fewer comorbidities
Higher self-efficacy and motivation
Early initiation of physical therapy
Poorer outcomes are linked to:
Chronic symptoms (>6 months)
Multiple prior injections
Inconsistent follow-up or home exercise adherence
What Are the Potential Limitations of the Study?
As a guideline, this document is based on existing research, not a new trial. While the panel used rigorous criteria, some recommendations rely on lower-quality evidence or expert opinion where trials were lacking.
The guideline does not prescribe exact sets, reps, or exercises, leaving room for clinical interpretation.
Patient heterogeneity (differences in age, tear severity, chronicity) means that recommendations may not apply equally to everyone.
Emerging treatments (e.g., platelet-rich plasma, dry needling) were excluded or underrepresented, so they are not addressed in depth.
What Does This Mean for You as a Patient?
If you’ve been diagnosed with rotator cuff tendinopathy, or have ongoing shoulder pain with activity, this guideline offers a hopeful message:
Most people get better without surgery if they receive the right care and stick with it.
Here’s what you should keep in mind:
Start with physical therapy. It’s the best-supported treatment and should be your first step, not a last resort.
Movement matters. Targeted strengthening of your rotator cuff, shoulder blade, and postural muscles is key to recovery.
Don’t rely solely on injections. They may dull the pain temporarily but don’t fix the root issue.
Stay consistent. Even the best program won’t help if it’s only followed for a few days or done inconsistently.
Ask about tailored care. A therapist should adjust your program based on your pain, goals, and lifestyle, not just give you a handout.
Expect gradual progress. Most people improve over 8–12 weeks, with further gains over 6 months.
Final Thoughts
Shoulder pain can feel like it hijacks your daily life, whether you’re reaching, sleeping, or trying to get dressed. But this guideline confirms what many therapists see daily: you don’t always need surgery to get better.
With expert guidance, a customized exercise plan, and consistency on your part, your shoulder can get stronger, more resilient, and pain-free over time.
If you’re struggling with rotator cuff pain, consider asking your provider about starting a structured rehab program based on these evidence-based principles. You’re not alone, and the path forward doesn’t have to involve a scalpel.
Reference
Desmeules F, Roy JS, Bédard J, et al. Rotator cuff tendinopathy: diagnosis, nonsurgical medical care, and rehabilitation: a clinical practice guideline. J Orthop Sports Phys Ther. 2025;55(2):CPG1–CPG33. doi:10.2519/jospt.2025.12650
