Managing the Patient
with Shoulder Pain

Managing the Patient
with Shoulder Pain

Shoulder pain is a common complaint seen by physicians and physical therapists. Rotator cuff disease (tendinopathies, partial or full-thickness rotator cuff tears, subacromial impingement) is the most common pathology affecting the shoulder. Varying degrees of rotator cuff tearing is demonstrated in 50-85% of patients with shoulder pain seen by health care providers.

Incidence increases with age, especially over age 60 (31%) and 80 (65%). So, how should we be managing these patients? Looking to the literature, some important factors should be considered.

  • 80% of patients with rotator cuff tears are successfully managed with physical therapy (Dunn et al., 2016).
  • The strongest predictor of failure of physical therapy intervention leading to subsequent surgical intervention is the patient’s expectations regarding physical therapy (Dunn et al., 2016).
  • Patients had significant improvement in patient-related outcome scores at 6 and 12 weeks with physical therapy (Kuhn et al., 2013).
  • 75% of patients with atraumatic full-thickness rotator cuff tears at 5 years were managing well without surgery (Kuhn et al., 2013).
  • Of patients with shoulder pain associated with rotator cuff related disease or tears, 78% had successful management with an active 12-week progressive rehabilitation program, whereas 11% went on to have surgical intervention (Chepeha et al., 2020).
  • After 13 years, 72% (n=103) of patients treated non-operatively reported continued pain relief and reported no problems with ADL (Kijima et al., 2012).
  • Patients undergoing surgical and non-surgical management of rotator cuff tears demonstrate functional improvement (Moosmayer et al., 2010).
  • Functional assessment scores are similar at 1 year after surgery and after rehabilitation alone (Kukkonen et al., 2015).
  • The 5 year rate of treatment failure was the same for patients undergoing surgery and patients managed conservatively with PT (Moosmayer et al., 2010).

Non-operative management is successful in 75-85% of patients with shoulder pain associated with rotator cuff disease or tears.

Evolution of Managing Patients
with Rotator Cuff Pathology

Research is increasingly identifying physical therapy as THE strategy to successfully manage the large majority of patients with rotator cuff pathology (including tears). Physical therapy is no longer considered the default or “trial” before surgery but considered the complete treatment. This is not saying that all patients will be successful with non-operative management. However, patient expectations play an important role in determining rehabilitation outcomes. As health care providers we have a large role to play in influencing our patient’s expectations and treatment success.

Managing the patient with shoulder pain should always include referral to a physical therapist. Treatment should primarily be active and exercise-based. Patients should be given a home-based exercise program that they should do at a minimum of 4 days/week with periodic follow-up to assess changes and progress their program with their therapist. Pain management should include education regarding rest positions and activity modification. Exercise should focus on posture, core stabilization and strength, and scapular and rotator cuff strengthening. An active exercise program should be adhered to for a minimum of 3 months before evaluation of benefit can be determined. Patients should be educated that exercise is important for long-term management of their symptoms. Discontinuation of their home exercise program can result in recurrence of symptoms and/or a decline in function. If pain returns they should be advised to consult their physical therapist for re-evaluation.

The following link is the rehabilitation protocol the EBJC Shoulder Assessment Clinic recommends when treating patients with rotator cuff-related pain syndrome.

Additional Resources

The documents below include information on the management of rotator cuff disease. Feel free to view or download them by pressing the buttons below.