Physiotherapists’ recommendations for examination and treatment of rotator cuff related shoulder pain: A consensus exercise

Abstract

BACKGROUND: Disorders associated with the rotator cuff are regarded as the most common shoulder pain presentation. The range of diagnostic terms used to explain this problem reflect uncertainty in relation to causative mechanisms, diagnosis, prognosis, and the most effective treatments. The aim of this consensus exercise was to facilitate a shared understanding as a means of reducing mixed messages, informing clinical practice and providing a foundation for future research. METHODS: Nine physiotherapists with clinical and academic expertise in shoulder pain participated in an online and face-to-face consensus exercise. RESULTS: This consensus exercise suggests specific factors in the history and physical examination that might raise the index of suspicion of Rotator Cuff Related Shoulder Pain. The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Apart from aiding exclusion of red flag pathology, imaging is not regarded as useful unless the patient does not respond as expected. Steroid injections wouldn't be considered a first-line intervention unless pain was severe and preventing engagement with exercise. CONCLUSION: This consensus exercise provides a benchmark for clinical reflection while highlighting areas of uncertainty that still exist and require further research.

Full text

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Physiotherapy Practice and Research 40 (2019) 87–94
DOI:10.3233/PPR-190129
IOS Press
87
Physiotherapists’ recommendations for
examination and treatment of rotator cuff
related shoulder pain: A consensus exercise
Chris Littlewooda,∗, Marcus Batemanb, Clare Connorc, Jo Gibsond, Ian Horsleye, Anju Jaggif,
Val Jonesg, Adam Meakinshand Martin Scotti
aArthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences
and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
bDerby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
cAneurin Bevan University Health Board, Caerleon, UK
dLiverpool Upper Limb Unit, Royal Liverpool University Hospital, Liverpool, UK
eEnglish Institute of Sport, Manchester, UK
fRoyal National Orthopaedic Hospital, Middlesex, UK
gSheffield Shoulder and Elbow Unit, Sheffield Teaching Hospital NHS Trust, Sheffield, UK
hWest Herts Shoulder Service, West Hertfordshire Hospital Trust, St Albans Herts, Spire Healthcare,
Spire Bushey Hospital, Hertfordshire, UK
iNottingham Shoulder & Elbow Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
Abstract.
BACKGROUND: Disorders associated with the rotator cuff are regarded as the most common shoulder pain presentation.
The range of diagnostic terms used to explain this problem reflect uncertainty in relation to causative mechanisms, diagnosis,
prognosis, and the most effective treatments. The aim of this consensus exercise was to facilitate a shared understanding as
a means of reducing mixed messages, informing clinical practice and providing a foundation for future research.
METHODS: Nine physiotherapists with clinical and academic expertise in shoulder pain participated in an online and
face-to-face consensus exercise.
RESULTS: This consensus exercise suggests specific factors in the history and physical examination that might raise the
index of suspicion of Rotator Cuff Related Shoulder Pain. The suggestions for non-surgical management include a minimal
number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Apart from
aiding exclusion of red flag pathology, imaging is not regarded as useful unless the patient does not respond as expected.
Steroid injections wouldn’t be considered a first-line intervention unless pain was severe and preventing engagement with
exercise.
CONCLUSION: This consensus exercise provides a benchmark for clinical reflection while highlighting areas of uncertainty
that still exist and require further research.
Keywords: Rotator cuff, diagnosis, exercise, physiotherapy
∗Corresponding author: Chris Littlewood, Research Institute
for Primary Care and Health Sciences, Keele University, Stafford-
shire, UK. Tel: +44 1782 734832; E-mail: c.littlewood@keele.
ac.uk.
1. Introduction
Many patients consult healthcare professionals
complaining of shoulder pain, with disorders associ-
ated with the rotator cuff (subacromial impingement,
subacromial pain, rotator cuff related shoulder pain
ISSN 2213-0683/19/$35.00 © 2019 – IOS Press and the authors. All rights reserved

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88 C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP
(RCRSP) and other synonyms) widely regarded as the
most common presentation [1, 2]. The wide range of
diagnostic or descriptive terms used to explain this
common clinical presentation reflect uncertainty in
relation to understanding of the pathology, diagnosis,
prognosis, and the most effective treatment options
[1, 3–5]. A range of diagnostic tests, including imag-
ing, and a range of different treatment options are
available including exercise programmes, manual
therapy, corticosteroid injections and surgery [6].
Based on recent randomised controlled trials and
systematic reviews, where clinical intervention is
required, exercise is recommended as the first-line
intervention of choice with comparable outcomes but
at a lower cost and with fewer associated risks than
surgical management. [7, 8]. Despite this, there is lit-
tle research evidence to inform what constitutes an
effective exercise programme in terms of the type of
exercise, the number of sets, repetitions, acceptable
pain levels, duration and setting [9, 10]. A previ-
ous systematic review has suggested that inclusion of
some level of resistance seems to matter although the
optimal level is unclear; the optimal number of rep-
etitions is also unclear but higher repetitions might
confer superior outcomes; higher number of sets of
exercise are preferable to lower number of sets but
the optimal frequency is unknown; most programmes
should demonstrate clinically significant outcomes
by 12 weeks [9]. So, although there is some guidance
available, there still remains a number of significant
unknowns [9]. This is important because it might
mean that suboptimal exercise prescription leads to
patients moving on to more costly, invasive and risky
interventions, including corticosteroid injections and
surgery, which are of questionable effectiveness [8,
11, 12]. This concern is justified when it is recog-
nised that the practice of physiotherapists across the
UK with regards to exercise prescription is highly
variable [6, 13].
In 2012 a group of international physiothera-
pists reported their consensus on physiotherapy for
shoulder pain [14]. This guidance recommended:
active exercise prescribed in relation to the clinical
assessment and not the structural pathology; mild to
moderate pain (<4/10 on VAS) secondary to the exer-
cise was acceptable but must subside within 12 hours;
the quality of the performance of exercise was cru-
cial and exercise should be performed with optimal
scapular positioning and control without abnormal
compensatory trunk movement; exercises should be
simple and slow and unloaded to begin with, pro-
ceeding gradually to loaded and faster exercises; the
number of exercises should be limited to a maximum
of four, and dose and progressions should be indi-
vidualised [14]. Aspects of this consensus reflect the
emerging evidence, however in view of the limited
progress in understanding the most appropriate ter-
minology, approach to diagnosis, understanding of
prognosis, and optimal exercise approach and con-
tinued conflicting messages within the literature, the
purpose of this paper was to undertake an updated
consensus process. The aim was to enable a shared
understanding of this common shoulder pain pre-
sentation as a means of reducing mixed messages,
informing physiotherapy practice and providing a
basis on which future research could be developed.
2. Methods
In December 2017 the lead author, a physio-
therapist, approached nine further physiotherapists
recognised for their clinical and academic expertise
in the management of shoulder pain. Of the nine
approached, eight accepted and formed the consen-
sus group. The physiotherapist who declined did not
offer reasons for not participating.
Subsequent to this, the lead author circulated
electronically a list of questions broadly based on
approaches taken by other consensus groups [15] and
invited commentary from the group. This resulted in
a refined list of questions that would be used as the
basis for this consensus process (Table 1).
Following agreement, questions were recirculated
to the group, and comments were requested. At
the end of this stage, the lead author summarised
responses. For example, where two comments had
similar purpose and meaning they were amalgamated,
without any attempt to interpret the initial responses.
After this the group were asked to confirm that the
summarised document was a fair summary of their
inputs.
The group met face-to-face at the annual British
Elbow & Shoulder Society meeting in Glasgow in
June 2018 with a view to generating a consensus state-
ment. Each of the comments, in turn, was presented to
the group who were asked to vote whether they agreed
with the comment or not. A majority response, i.e.≥5/
9, meant that the comment was carried forward and
included in the narrative summary.
It was agreed that although a comment carried
through to the narrative summary was reflective of the
majority of the group, it does not necessarily reflect
the view of all individuals all of the time.

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C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP 89
Table 1
List of questions on which the consensus exercise was based
Question
1 What key information is required from the history to raise the index of suspicion of this
classification or diagnosis over other shoulder pain presentations?
2 Do you consider age, gender and occupation as relevant factors within your diagnostic reasoning
with regard to ‘rotator cuff syndrome’?
3 What key information is required from the physical examination to confirm this classification or
diagnosis?
4 What is the role of imaging in confirming this classification or diagnosis?
5 What is the preferred terminology for this shoulder pain classification?
6 In summary, what is ‘rotator cuff syndrome’?
7 How do you explain ‘rotator cuff syndrome’ to your patients?
8 What is/ are the preferred methods of treatment?
9 Do you consider the role of lifestyle, e.g. sedentary behaviour, and metabolic factors, e.g. obesity
when assessing and treating patients with this pain presentation?
10 If exercise is prescribed, what are the preferred parameters guiding this prescription?
– Type of exercise and the factors that inform this
– Number of sets and repetitions and the factors that inform this
– Frequency of exercise and the factors that inform this
– Number of exercises and the factors that inform this
– Intensity/ effort of exercise and the factors that inform this
– Painful versus painless and the factors that inform this
– Duration of exercise
11 Which factors or characteristics do you see as important indicators of prognosis?
12 What is the expected prognosis of ‘rotator cuff syndrome’?
3. Results
The results are summarised in Table 2 with a full
narrative description.
3.1. What key information is required from the
history to raise the index of suspicion of this
classification or diagnosis over other
shoulder pain presentations?
The majority opinion of the group was that pain
should be broadly over the deltoid and upper arm
region to raise the suspicion of this sub-group of
shoulder pain. If there is complaint of subluxation
or dislocation as the primary problem, then the index
of suspicion would be reduced. For this sub-group
of shoulder pain, pain is activity related (better or
worse), typically worse reaching overhead or behind
the back, with minimal pain at rest except when lying
on the affected shoulder. Pain in the neck, repro-
duction of shoulder pain on movement of the neck,
and distal neurovascular symptoms would reduce the
index of suspicion.
3.2. Do you consider age, gender and
occupation as relevant factors within your
diagnostic reasoning with regard to ‘rotator
cuff syndrome’? If so, why and how?
The majority opinion of the group was that changes
in occupation or participation demands rather than
occupation alone were relevant in raising the index
of suspicion of RCRSP. Majority opinion on other
factors was not reached.
3.3. What key information is required from the
physical examination to confirm this
classification or diagnosis?
The majority opinion of the group was that there
should be no significant loss (>50%) of passive
range of movement in any direction, particularly

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90 C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP
Table 2
Summary of recommendations
History Examination Treatment Prognosis
Factors increasing index of
suspicion of RCRSP:
Factors increasing index of
suspicion of RCRSP:
Progressive loading of upper
limb and kinetic chain with
a minimal number of
exercises (≤3),
incorporating graded
exposure to painful
movements or graded
activity guided by
acceptable symptom
response
Prognosis is likely to be
favourable but this will take
a minimum of 12 weeks,
but further improvement
may be expected up to 24
weeks
Pain over the deltoid/ upper arm
Familiar pain is reproduced with
resisted testing of the shoulder,
usually abduction and lateral
rotation
Activity related
Minimal pain at rest except when
lying on affected side
Imaging not recommended as a
first line investigation unless
red flag pathology suspected,
for example tumour or fracture Individualised exercise
should be prescribed in
relation to specific
functional difficulty, broken
down in to component parts
Referral for investigation or
orthopaedic opinion would
be considered for patients
whose symptoms remain
unacceptable despite an
appropriate period of
engagement with an
exercise based management
approach or if the patient
remains anxious or
unconvinced about the
treatment approach.
Associated with changes in load
from a specific activity or
repetitive use. Consider
changes in occupation or
participation demands.
Factors reducing index of
suspicion of RCRSP:
Factors reducing index of
suspicion of RCRSP:
The exercise programme
should be a minimum of 12
weeks’ duration
Complaint of subluxation or
dislocation
Significant loss (>50%) of
shoulder passive range of
movement in any direction,
particularly external rotation
A corticosteroid injection
would not be considered as
a first-line intervention
unless the pain was severe
or not improving with
exercise
Pain in the neck
Distal neurovascular symptoms Reproduction of shoulder pain on
movement of the neck Consider relevance of sleep,
nutrition, alcohol, physical
activity, and smoking
Presence of neurological signs
external rotation. Typically, familiar pain should
be reproduced with loading/ resisted testing, usu-
ally abduction and lateral rotation. In keeping with
findings from the history to raise the index of this sub-
group of shoulder pain, movement of the neck should
not produce or abolish the shoulder pain and there
should be no neurological signs, including upper limb
mechano-sensitivity tests.
3.4. What is the role of imaging in confirming
this classification or diagnosis?
The majority opinion of the group was that imag-
ing is useful to rule out red flag pathology if the
index of suspicion is raised during the history and
physical examination, e.g. tumour or fracture or if
suspected dislocation. In the absence of stiffness
and with a consistent history, as described above,
the group consensus was that imaging would not be
indicated initially due to the poor correlation between
pain and structural pathology. Imaging findings do
not influence non-surgical management options and
could potentially be a barrier to patient engagement,
but imaging may have a role if patients do not follow
the expected trajectory of improvement.
3.5. What is the preferred terminology for this
shoulder pain classification?
The majority opinion of the group was that RCRSP
or weak and painful shoulder were the preferred
descriptors but this depends on context, including
who we are communicating with and what the patient
has been told before. The majority opinion of the
group was that healthcare professionals, including
GPs, orthopaedic surgeons, radiologists, physiother-
apist, should now avoid using the term ‘impingement‘
but it is clear that discourse is still needed regarding
the most useful term(s).

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C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP 91
3.6. In summary, what is ‘rotator cuff syndrome’?
The majority opinion of the group conceptualised
RCRSP as symptoms of pain and signs of weakness
related to the rotator cuff when loaded, and movement
related shoulder pain without significant stiffness.
3.7. How do you explain ‘rotator cuff syndrome’
to your patients?
The majority opinion of the group was that this
could be explained as ’an issue with the muscles
and tendons of the shoulder, they’re lacking strength,
capacity, tolerance and fitness that’s why they com-
plain when you lift your arm.’
3.8. What is/are the preferred methods of
treatment?
The majority opinion of the group was that loading
through exercise, including progressions and regres-
sions, within acceptable symptom response, was the
preferred approach to treatment. Progressive loading
of upper limb and kinetic chain was advocated by
the majority incorporating graded exposure to painful
movements or graded activity. Cognitive behavioural
principles may need to be adopted if there is evidence
of avoidance behaviour.
A steroid injection would not be considered as a
first-line intervention by the majority unless the pain
was severe or not improving with exercise over an
acceptable period of time (e.g. 6 to 12 weeks). Beyond
a programme of physiotherapist-led exercise, fur-
ther referral for investigation or orthopaedic opinion
would be considered for patients whose symptoms
remain unacceptable despite an appropriate period
of engagement with an exercise based management
approach or if the patient remains anxious or uncon-
vinced about the treatment approach.
3.9. Do you consider the role of lifestyle, e.g.
sedentary behaviour, and metabolic factors,
e.g. obesity when assessing and treating
patients with this pain presentation?
The majority opinion of the group was that assess-
ment of sleep, nutrition, alcohol, physical activity,
and smoking should be conducted with promotion of
change where relevant to the patient. However, how to
recognise, implement and support behaviour change
remains unclear but the majority opinion of the group
was that brief interventions should be incorporated to
make every contact count with regard to lifestyle and
musculoskeletal health.
3.10. If exercise is prescribed, what are the preferred
parameters guiding this prescription?
3.11. Type of exercise and the factors that inform
this
The majority opinion of the group was to use iso-
metric, isotonic or eccentric exercise according to
what is most acceptable to the patient while still pro-
viding sufficient stimulus to challenge what is weak
and work to fatigue. The majority opinion was to
prescribe exercise to challenge specific functional
difficulty but break down into component parts within
limits of acceptable symptom response and to stage
loading according to patient’s ability and symptom
irritability. Majority opinion on more specific param-
eters was not reached.
3.12. Number of sets and repetitions and the
factors that inform this
The majority opinion of the group was that this
should be individualised based on acceptable symp-
tom response and functional requirement, e.g. speed
vs sustained. Majority opinion on more specific
parameters was not reached.
3.13. Frequency of exercise and the factors that
inform this
The majority opinion of the group was that if
patients are exercised to the point of muscle fatigue,
exercise on alternate days. If heavy load or plyomet-
ric exercises are included, this should be limited to
exercise over two to three sessions per week. Majority
opinion on more specific parameters was not reached.
3.14. Number of exercises and the factors that
inform this
The majority opinion of the group was that a
minimal number of different exercises, rarely more
than three, should be prescribed. Exercises should be
adapted to address the specific functional difficulties
that the patient reports and be developed in the con-
text of their physical capabilities, functional deficits
and available time to devote to exercise.

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92 C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP
3.15. Intensity/effort of exercise and the factors
that inform this
The majority opinion of the group was that this
should be adapted according to patient specific
acceptable symptom response.
3.16. Painful versus painless and the factors that
inform this
The majority opinion of the group was that exercise
could provoke pain providing that it settles suffi-
ciently to enable the patient to perform the next set of
exercises shortly afterwards within a session. How-
ever, pain provocation was not seen as an essential
feature of the exercise as long as the patient is being
challenged by the exercise.
3.17. Duration of exercise
The majority opinion of the group was that an
exercise programme should be adhered to over a min-
imum of 12 weeks, but sometimes a longer period, up
to 24 weeks, will be required.
3.18. Which factors or characteristics do you see
as important indicators of prognosis?
The majority opinion of the group was that a num-
ber of factors might be relevant including patients’
attitudes regarding pain and exercise, fear avoidance,
litigation, lifestyle factors, e.g. smoking, sedentary
behaviour, diet, alcohol, educational levels, multiple
pain sites, level of baseline pain and disability, pre-
vious experience and response to treatment, patient
expectations regarding recovery and physiotherapy,
co-morbidities, levels of self-efficacy, psychological
distress, and social circumstances, e.g. employment,
social engagement and hobbies.
3.19. What is the expected prognosis of ‘rotator
cuff syndrome’?
The majority opinion of the group was that
patients, and other clinical colleagues, should be
advised that the prognosis is likely to be favourable
but this will take a minimum of 12 weeks, but further
improvement may be expected up to 24 weeks.
4. Discussion
This consensus exercise has resulted in suggestions
regarding patient history and physical examination
findings that might raise the index of suspicion of
RCRSP as well as suggestions regarding prognosis
and suggested terminology to describe this common
presentation to patients and clinical colleagues. Fur-
ther suggestions related to non-surgical management
are reported as well as factors that might influence
the response to this. In summary, the suggestions for
non-surgical management include a minimal number
of exercises prescribed to challenge the functional
deficit of the patient over a minimum 12-week period.
Unless there is concern about red flag pathology
then imaging was not regarded as useful unless the
patient did not respond as expected. Similarly, steroid
injections would not be considered as a first-line
intervention unless pain was severe and preventing
engagement with exercise.
The caution regarding use of imaging expressed
through this consensus approach is unsurprising
given the now well recognised lack of association
between such findings, structural diagnosis and the
pain that patients complain of (4, 16). Similar cau-
tion with regards to use of steroid injection is also
not surprising given contemporary research evidence
highlighting concerns about this treatment approach
for patients with RCRSP (17, 18).
The dearth of evidence to inform the specific pre-
scription parameters of an exercise programme for
RCRSP has been recognised (9). The findings from
this consensus exercise are broadly in agreement
with the scant research evidence-based guidance and
there is overlap with the previous consensus exercise
undertaken by physiotherapists in 2012 (14) in terms
of history, physical examination, use of imaging and
exercise as the mainstay of treatment.
There is some divergence between the consensus
reports with regards to the specifics of exercise pre-
scription though with, arguably, a more progressive
approach suggested via this current consensus exer-
cise. There is also divergence with regardsto expected
response time and prognosis, with this current con-
sensus exercise suggesting a minimum of 12-weeks
required, often longer, depending on patient factors
including baseline levels of pain and disability, expec-
tations of physiotherapy, social circumstances etc.
Also within this current consensus exercise there was
recognition of the potential for lifestyle factors to
influence the onset and persistence of RCRSP. Iden-
tification of such lifestyle factors, including smoking

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C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP 93
and physical activity, were seen as important although
the optimal way to address these factors within a
physiotherapy setting was less clear.
One clear finding from this current consensus exer-
cise is the lack of agreement on the specific exercise
prescription parameters including type and dose of
exercise. Given the lack of research evidence this is
perhaps unsurprising but given the widespread recog-
nition now that exercise should be the mainstay of
treatment for RCRSP this is a clear gap that needs
to be addressed through well-designed, adequately
powered, randomised controlled trials. However, it
should be recognised that RCRSP affects a diverse
and heterogenous population and therefore it is ques-
tionable whether a homogeneous type or dosage of
exercise will be found. Evaluations that are required
include comparison of different types of exercise, e.g.
standardised versus individualised, painful versus
non-painful, while controlling for other parameters
that might influence outcome such as dose of exer-
cise (sets and repetitions). Furthermore, evaluation
of the comparative effectiveness of different doses
should ensure that other factors including the type
of exercise, are adequately controlled to enable a
valid comparison. Once a guiding framework, rather
than a prescriptive recipe, for the optimal prescrip-
tion parameters has been established then it would be
appropriate to evaluate this against other approaches,
including ‘wait-and-see’, to establish whether any
effects of exercise, and other approaches, are due to
reasons other than natural history and placebo.
Further evaluation could focus on approaches to
optimise exercise adherence, approaches to identify
and address relevant psychosocial factors, evaluation
of the impact of lifestyle factors and whether impor-
tant diagnostic and prognostic factors upon which to
stratify care for RCRSP can be identified.
4.1. Implications
This report is by no means definitive in its recom-
mendations but provides an opportunity for clinicians
and researchers to reflect on their own current practice
and consider the differences between the approaches
described in this paper and their own approach. This
process offers the potential to consider such ques-
tions as; ‘why do we do what we do?’ and ‘why do
we believe what we believe?’ Hence, the paper pro-
vides a benchmark for reflection and a stimulus to
challenge practice while at the same time highlight-
ing the many areas of uncertainty that still exist in
this area and require further research.
4.2. Limitations
This is a report of a consensus developed through
consultation with physiotherapists who have clini-
cal and academic expertise in shoulder pain. Such
processes are necessarily reflective of the individu-
als involved and are not necessarily generalisable.
Furthermore, consensus was based on achieving a
majority through a voting system based on agree-
ment or not. When aiming to synthesise complex
processes into a digestible report, such compromises
are necessary.
5. Conclusion
The findings from this consensus exercise suggest
clear features in the history and physical examination
that raise the index of suspicion of RCRSP. Further-
more, suggestions have been made about preferred
terminology and factors that might impact on progno-
sis. In the absence of suspicion of red flag pathology,
caution regarding the use of imaging was suggested
because the findings do not inform initial treatment
choices and could be nocebic. Exercise is recognised
as the mainstay of treatment for RCRSP with agree-
ment that a minimal number of exercises should be
prescribed to challenge the functional deficit of the
patient over a minimum of 12-week period. How-
ever, there was little agreement beyond this. This is
reflective of the dearth of research evidence available
to inform optimal exercise prescription for RCRSP.
Given the widespread recognition now that exercise
should be the mainstay of treatment for RCRSP this
is a clear gap that needs to be addressed through
well-designed, adequately powered, randomised con-
trolled trials.
Conflict of interest
CL, MB, IH, AJ, JG, AM have taught and lec-
tured nationally and internationally on the shoulder
and received payment for this.
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