Rotator cuff-related shoulder pain is one of the most common musculoskeletal complaints
presenting in primary care and physiotherapy clinics. Yet, overmedicalization, inconsistent
assessment strategies, and reliance on imaging remain widespread. The 2025 Clinical
Practice Guideline by Desmeules et al., published in the Journal of Orthopaedic & Sports
Physical Therapy, delivers a comprehensive and evidence-based overview for the diagnosis,
non-surgical management, and rehabilitation of adults with rotator cuff tendinopathy (RCT).
This article summarizes the key updates and takeaways from the 2025 guideline, helping
clinicians apply them with confidence and clarity in everyday practice.
The 2025 Clinical Practice Guideline delivers a comprehensive and evidence-based overview for the diagnosis, non-surgical management, and rehabilitation of adults with rotator cuff tendinopathy.
Why This Guideline Matters
Developed by an international team of experts across physiotherapy, orthopaedics, and
physical medicine, the clinical practice guideline is grounded in systematic reviews, patient
involvement, and rigorous methodological standards. Backed by the Quebec Rehabilitation
Network (REPAR), Quebec Pain Research Network (QPRN), and the Academy of
Orthopaedic Physical Therapy (AOPT) of the American Physical Therapy Association
(APTA), it consolidates the best available evidence for clinicians worldwide. With eight
patient representatives from three countries involved in the revision process, this guideline
also reflects the lived experience and preferences of those receiving care.
Evidence Grades Explained
Each recommendation in the clinical practice guideline is assigned a grade reflecting the
strength and certainty of the supporting evidence:
- Grade A – Strong evidence: Supported by multiple high-quality randomized controlled trials (RCTs) or systematic reviews.
- Grade B – Moderate evidence: Supported by at least one high-quality RCT or several lower- quality RCTs or cohort studies.
- Grade C – Weak evidence: Based on single studies of lower quality or expert consensus where research is limited.
- Grade D – Conflicting evidence: Studies disagree in their findings.
- Grade E – Theoretical/foundational: Based on cadaveric, biomechanical, or animal research.
- Grade F – Expert opinion: Based on best practices and clinical consensus in the absence of empirical evidence.
อาการปวดไหล่ที่เกี่ยวข้องกับเอ็นหมุนไหล่
Gain the confidence and expertise to effectively manage rotator cuff-related shoulder pain in your patients with Filip Struyf. You’ll be equipped with the tools and knowledge to enhance shoulder function, reduce pain, and improve quality of life for your patients.
Key Clinical Recommendations
1. Assessment & Diagnosis
- Comprehensive Subjective History (Grade F): Clinicians must include a thorough patient
history considering age, gender, hand dominance, job demands, sport activities, medication
use, comorbidities, psychosocial influences, mechanism of injury, previous treatments,
current symptoms (pain, range of motion [ROM] limitation, weakness), and patient goals. - Physical Assessment (Grade F): Should include inspection for deformity, muscle atrophy,
and swelling; measurement of active/passive ROM and strength; and optional palpation and
special tests based on clinical reasoning. Cervical spine should be screened to rule out
referred pain. - Red Flags (Grade F): Clinicians must screen for serious pathologies such as infection,
cancer, cardiovascular conditions, or systemic involvement.
Prognostic Factors (Grade B): Identification of personal, clinical, and work-related factors
affecting prognosis is recommended to guide individualized care plans. - Special Tests (Grade B): Painful arc test can help confirm diagnosis, while the Hawkins-
Kennedy test can assist in ruling it out. - Objective Measures (Grades A): ROM should be measured using a goniometer,
inclinometer, or validated smartphone application. Scapular ROM is unreliable and not
recommended. Strength testing should be performed using a handheld dynamometer. - Patient-Reported Outcome Measures (Grade A): Use validated, reliable, and responsive
tools such as the Shoulder Pain and Disability Index (SPADI) or the Disabilities of the Arm,
Shoulder and Hand (DASH) questionnaire to track pain and disability. - Imaging (Grades F): Should not be used initially. Diagnostic ultrasound is preferred if
imaging is needed after 12 weeks of failed conservative care. Magnetic Resonance Imaging
(MRI) is not routinely recommended. Discuss pros/cons of imaging openly with patients. - Referral (Grade F): Patients with persistent and severe symptoms after 12 weeks of care
should be referred to a musculoskeletal specialist (e.g., sports physician, physiatrist, or
orthopedic surgeon).
2. Pharmacological Treatment
- Acetaminophen (Grade C): May be recommended for short-term pain relief. Non-Steroidal
- Anti-Inflammatory Drugs (NSAIDs) (Grade B): Effective for short-term pain management.
- Opioids (Grades F/C): Should not be used as first-line treatment. May be considered short-term in severe cases where other options are ineffective or contraindicated. Requires regular risk reassessment.
- Corticosteroid Injections (Grades B/C): May be used for short-term pain relief but not as a
- first-line intervention. Ultrasound guidance is recommended if injections are given.
- Calcific Lavage (Grade B): Recommended for calcific tendinopathy that is unresponsive to
- initial treatments.
- Platelet-Rich Plasma (PRP) & Hyaluronic Acid (Grades D/F): May be considered
3. Rehabilitation Principles
- Education (Grade C): Clinicians should educate patients on their condition, activity
modification, pain neuroscience, prognosis, and self-management strategies. Tailor
communication to the level of literacy and psychosocial context. - Exercise Therapy (Grade A): Core intervention. Should include progressive resistance
training and motor control exercises. Individualize based on pain tolerance and patient goals. - Manual Therapy (Grade B): May reduce pain short-term when used with exercise.
Techniques include soft tissue work and joint mobilizations/manipulations. - Taping (Grade D): Can be used adjunctively to reduce pain short-term.
- Acupuncture (Grade C): May offer additional short-term benefits when combined with active
rehab. - Shockwave Therapy (Grade C): Useful in calcific tendinopathy. Not recommended in non-
calcific RCT. - Laser Therapy (Grade C): May reduce pain in calcific tendinopathy.
- Therapeutic Ultrasound (Grades C/B): Not recommended for either calcific or non-calcific
RCT due to lack of benefit. - Ergonomic Modifications (Grade C): May help reduce occupational stress on the shoulder.
4. Return to Sport
- Load Tolerance (Grade F): Return-to-sport plans should be based on athlete’s ability to
tolerate shoulder and rotator cuff loading. - Outcome Measures (Grade F): Use validated tools to assess pain, disability, readiness to
return, and functional performance. Examples include sport-specific performance tests and
return-to-sport checklists.
สรุป
The 2025 Clinical Practice Guideline for rotator cuff tendinopathy delivers a clear and
comprehensive framework for conservative shoulder care. It prioritizes individualized
assessment based on patient history and clinical examination, discourages early imaging,
and supports objective measurement tools for range of motion and strength.
Pharmacological interventions are secondary to active rehabilitation, with exercise therapy
positioned as the cornerstone of recovery. Adjunct therapies like manual therapy, taping, and
acupuncture may be considered selectively. The guideline also highlights the importance of
patient-centered education and gradual, load-based return-to-sport programming. Overall, it
encourages clinicians to rely less on diagnostic imaging and passive modalities, and more on
active, evidence-informed strategies that empower patients.
Changes from the 2022 guideline:
- Integration of systematic reviews up to October 2023.
- New recommendations specifically addressing return to sport.
- Clearer grading of evidence using GRADE-adapted methodology.
- Enhanced patient-centered language and prioritization of shared decision-making.
The Rotator Cuff Management Decision Tree
The authors provided an additional decision tree that guides clinicians in their patients
process of rehabilitation from rotator cuff tendinopathy.
Limitations & Conclusion
While this guideline is extensive, some areas, such as return to sport timelines and PRP
effectiveness, still lack high-quality RCTs. Further research is needed to individualize
treatment and identify prognostic subgroups.
The 2025 Rotator Cuff Tendinopathy CPG offers an evidence-based, patient-centered
approach that can reduce overtreatment and improve clinical outcomes. By aligning practice
with these recommendations, clinicians can more confidently assess, educate, and
rehabilitate adults with RCT.
อ้างอิง
Desmeules, F., Roy, J-S., Lafrance, S., et al. (2025). Rotator Cuff Tendinopathy Diagnosis,
Non-Surgical Medical Care and Rehabilitation: A Clinical Practice Guideline. Journal of
Orthopaedic & Sports Physical Therapy. https://doi.org/10.2519/jospt.2025.13182
