Rotator Cuff Tendinopathy

Upper Limb

Overview

Rotator cuff tendinopathy is a degenerative condition affecting one or more of the four rotator cuff tendons (supraspinatus, infraspinatus, teres minor, subscapularis), characterized by pain, weakness, and functional limitation of the shoulder. It represents a continuum from reactive tendinopathy through to tendon degeneration and partial or full-thickness tears. The condition is common in both overhead athletes and sedentary individuals with poor posture or scapular dysfunction.

Pathophysiology

Rotator cuff tendinopathy develops through repetitive microtrauma, overload, or cumulative stress that exceeds the tissue's capacity to adapt and repair. The pathological cascade involves initial inflammation and reactive changes, progressing to tendon fiber disorganization, calcification, and eventual degeneration with potential partial or complete rupture. Altered neuromuscular control and motor patterns perpetuate the condition through abnormal load distribution.

Typical Presentation

Site

Anterolateral shoulder, often with referral to lateral arm. Pain typically localized to subacromial space; may involve infraspinatus region (posterior shoulder). Symptoms may be unilateral or bilateral.

Quality

Dull, aching pain with superimposed sharp pain on provocative movements. Patients often report clicking, catching, or grinding sensations. Night pain with lying on affected side is characteristic.

Intensity

Mild to moderate in early stages (3-5/10), progressing to moderate-severe (6-8/10) with functional limitation. Pain intensity varies with activity level and loading patterns.

Aggravating

Overhead reaching activities, throwing, swimming, pushing movements, lying on affected shoulder, repetitive gripping, prolonged static postures with forward shoulder position, activities requiring sustained abduction or external rotation

Relieving

Rest from provocative activities, anti-inflammatory modalities (ice, NSAIDs), pendulum exercises, scapular support, postural correction, specific rotator cuff strengthening exercises

Associated

Weakness in abduction and external rotation, reduced shoulder range of motion (especially internal rotation), scapular winging or dyskinesis, neck stiffness, thoracic spine restriction, postural changes (forward head posture, rounded shoulders), sleep disturbance, morning stiffness

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Neer Impingement Test

Procedure

Patient seated or standing. Stabilise the scapula with one hand and, with the arm internally rotated (thumb down), passively raise it forwards to full flexion.

Positive Finding

Reproduction of the familiar anterior or lateral shoulder pain near the end of range.

Sensitivity / Specificity

72%/60%

Reference: Hegedus EJ et al., Br J Sports Med 2012; PMID 22773322

Interpretation

Supports a subacromial pain source, which includes rotator cuff tendinopathy. It is positive in many shoulder problems, so do not use it alone. Neer sign pooled figures (72%/60%) are from Hegedus (2012) meta-analysis; original description Neer 1972.

Sources

No accuracy study

Hawkins-Kennedy Impingement Test

Procedure

Patient seated or standing. Raise the arm to 90° of forward flexion with the elbow bent to 90°, support the elbow, then turn the forearm down to internally rotate the shoulder.

Positive Finding

Reproduction of the familiar anterolateral shoulder pain.

Interpretation

Supports a subacromial pain source but does not identify the structure. Combine it with the loading tests (resisted abduction and external rotation) and the history. Pooled sensitivity/specificity for the Hawkins–Kennedy test vary widely across studies (Hegedus 2012); no single confirmed pair is shown. Original description: Hawkins & Kennedy 1980 (Am J Sports Med, not JBJS).

Sources

No accuracy study

Empty Can Test (Jobe's Test)

Procedure

Patient standing. Arms elevated to 90° in the scapular plane, elbows straight, thumbs pointing down. Apply a downward force at the forearms while the patient resists; compare sides.

Positive Finding

Reproduction of the familiar shoulder pain, or weakness compared with the other side.

Interpretation

Pain on loading fits rotator cuff tendinopathy. Clear weakness, especially after an injury, should raise concern for a tear and may need imaging. Itoi (1999, Am J Sports Med — not JSES) compared the empty-can and full-can tests by diagnostic accuracy (~70–75%), not a sensitivity/specificity pair.

Sources

No accuracy study

External Rotation Lag Sign

Procedure

Patient seated with the elbow bent to 90°. Take the arm into about 20° of elevation in the scapular plane and near-full external rotation, supporting the elbow. Ask the patient to hold that position as you let go of the wrist.

Positive Finding

The forearm drifts back towards the body (a lag) because the patient cannot hold the rotated position.

Interpretation

A lag means the posterior cuff (infraspinatus and supraspinatus) cannot hold the position, which points to a full-thickness tear rather than tendinopathy. A positive sign warrants imaging and referral. A 2013 JAMA review (Hermans et al.) found a positive external rotation lag sign one of the most accurate findings for a full-thickness rotator cuff tear (likelihood ratio 7.2), which is why a positive sign points to a tear rather than tendinopathy. The lag signs were first described by Hertel (1996).

Sources

No accuracy study

Lift-off Test (Gerber's Test)

Procedure

Patient standing. Place the back of the hand on the lower back, then ask the patient to lift the hand away from the back. If they can, add gentle resistance.

Positive Finding

Unable to lift the hand off the back, or clear weakness compared with the other side.

Interpretation

Tests subscapularis. Inability to lift off suggests a subscapularis tear. If the patient cannot reach behind the back, use the belly-press test instead. Original description Gerber & Krushell 1991 (JBJS Br — the previously cited "Gerber 1992" year was incorrect); no clean diagnostic-accuracy pair.

Sources

No accuracy study

Painful Arc Test

Procedure

Ask the patient to raise the arm slowly out to the side as far as possible and lower it again. Note where pain appears and disappears.

Positive Finding

Pain in the middle of the range (roughly 60–120° of elevation) that eases above and below it.

Interpretation

Fits a subacromial pain source such as rotator cuff tendinopathy or bursitis; it does not separate the two. A 2013 JAMA review of the examination for rotator cuff disease (Hermans et al.; 28 studies, all in patients seen by specialists) found the painful arc the most useful pain-provocation test: a positive arc made rotator cuff disease more likely (likelihood ratio 3.7) and a normal arc made it less likely (0.36). The review reports likelihood ratios rather than one sensitivity and specificity pair, so no figure is shown.

Sources

⚠ Red Flags

  • •Signs of complete rotator cuff rupture with acute trauma and inability to initiate abduction (drop-arm test positive)
  • •Acute severe pain with significant trauma suggesting acute tear rather than tendinopathy
  • •Progressive neurological deficit, particularly radiculopathy pattern suggesting cervical spine involvement
  • •Signs of infection: fever, systemic illness, localized heat and swelling
  • •Symptoms suggesting acromioclavicular osteoarthritis with osteophyte-induced subacromial impingement and recurrent symptoms unresponsive to conservative care
  • •History of malignancy with shoulder pain suggesting metastatic disease
  • •Acute shoulder dislocation or subluxation with ongoing instability
  • •Chest pain, dyspnea, or systemic symptoms suggesting referred cardiac or pulmonary pathology

⚡ Yellow Flags

  • •Anxiety or fear-avoidance behaviors leading to excessive protective guarding and reduced activity participation
  • •Catastrophizing about shoulder pain or excessive worry about permanent damage or disability
  • •Poor self-efficacy and belief that recovery is not possible with conservative management
  • •Secondary gain factors, including pending litigation or workers compensation claims affecting motivation to recover
  • •Psychosocial distress, depression, or sleep disturbance exacerbating pain perception and limiting rehabilitation engagement
  • •Occupational or sporting demands exceeding realistic capacity during recovery period, creating ongoing overload
  • •Poor compliance with rehabilitation exercises and reluctance to modify provocative activities
  • •Belief that pain indicates tissue damage requiring complete rest rather than understanding tendinopathy continuum

Osteopathic Techniques

Exercise is the first-line treatment, and most add-ons may not beat exercise alone. Manual therapy can be added for a small, mostly short-term drop in pain; the evidence is low quality.

Region

Upper and mid thoracic spine

Technique

Articulation, thoracic
Grade B
Moderate evidence: supported by at least one good study
Reviews found thoracic mobilisation reduced pain and disability in shoulder impingement. Thrust manipulation (HVLA) did not show the same effect.

Rationale

Gentle, rhythmic mobilisation of a stiff upper back. Reviews found it reduced shoulder pain and disability in impingement.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of restricted thoracic segments within their passive range, with no thrust. The patient is seated, side-lying or prone. For neck problems the upper thoracic segments (T1–T6) are the usual focus.

Evidence in Rotator Cuff Tendinopathy

A 2026 meta-analysis of 12 studies found thoracic Maitland mobilisation improved pain and disability in subacromial impingement more than control, while thrust (HVLA) techniques showed no significant effect. A 2025 meta-analysis of 10 trials found thoracic manual therapy reduced pain and disability, including versus placebo. An earlier 2018 review found a single session was no better than placebo straight after treatment.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)
Grade C
Limited evidence: indirect or low-quality support only
Manual therapy eased pain a little more than placebo or exercise alone, with low-quality evidence. The best placebo-controlled trial found no clinically important difference.

Rationale

Graded mobilisation of the shoulder through its range. Adds a small, short-term pain benefit to exercise.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in Rotator Cuff Tendinopathy

A 2015 meta-analysis of 21 trials found manual therapy cut pain by about 1 point out of 10 versus placebo or when added to exercise; its effect on function was unclear. A 2017 meta-analysis found it beat placebo and, added to exercise, helped only at the shortest follow-up (very low quality). A 2016 Cochrane review found the one high-quality trial of manual therapy plus exercise versus placebo showed no clinically important difference. These trials tested shoulder mobilisation in general, not the Spencer sequence.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular muscles
Grade C
Limited evidence: indirect or low-quality support only
Massage helped pain, function and range in the short term versus no treatment (low-quality evidence). Added to exercise, it gave no extra benefit in a trial.

Rationale

Eases tension in the rotator cuff and shoulder blade muscles. Short-term help; it adds little to exercise.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in Rotator Cuff Tendinopathy

A 2014 meta-analysis found low-quality evidence that soft tissue massage improved pain, function and range of motion in non-specific shoulder pain in the short term, versus no treatment. A 2015 trial of 80 patients found adding massage to exercise gave no extra benefit; at 12 weeks exercise alone did slightly better for pain. A 2025 review found trigger point manual therapy matched other passive treatments for pain in rotator cuff related shoulder pain, with slightly better function.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracic
Grade C
Limited evidence: indirect or low-quality support only
Thoracic MET beat placebo for pain and disability in shoulder impingement, up to 1 year. This is one trial of 75 patients.

Rationale

Low-force, patient-powered upper-back technique. Beat placebo for pain and disability in one impingement trial.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Rotator Cuff Tendinopathy

A 2022 placebo-controlled trial of 75 patients aged 40 or over with shoulder impingement, run in an osteopathic practice, found 4 weekly sessions of MET to the thoracic spine improved pain and disability more than placebo at discharge, 6 and 12 months. MET plus soft tissue massage improved disability but not pain.

Rehabilitation Exercises

Pendulum Exercises

Range of MotionBeginner

Sleeper Stretch (Internal Rotation)

Range of MotionBeginner

Cross-Body Shoulder Stretch

StretchingBeginner

Thoracic Spine Extension Mobilization

StretchingBeginner

Isometric External Rotation (Neutral Position)

StrengtheningBeginner

Side-Lying External Rotation with Light Weight

StrengtheningIntermediate

Prone Horizontal Abduction (Prone Y)

StrengtheningIntermediate

Prone Shoulder I-Y-T Series

StrengtheningIntermediate

Scapular Push-Up Plus (Wall or Quadruped)

PosturalIntermediate

Quadruped Shoulder Stability Hold

PosturalBeginner

Half-Kneeling Pallof Press

BalanceIntermediate

Prone Shoulder External Rotation at 90/90

StrengtheningAdvanced

Referral Criteria

  • •Suspicion of complete rotator cuff tear based on positive drop-arm test, weakness out of proportion to pain, or imaging findings of full-thickness tear requiring surgical consultation
  • •Failure to improve with conservative management after 6-8 weeks of consistent treatment and exercise compliance, suggesting need for imaging (MRI/ultrasound) and specialist orthopedic assessment
  • •Acute traumatic injury with severe pain and significant functional loss requiring emergency assessment for acute tear
  • •Neurological deficit or radicular symptoms suggesting cervical spine involvement or nerve compression requiring specialist evaluation
  • •Suspected acromioclavicular osteoarthritis with osteophyte causing recurrent subacromial impingement unresponsive to conservative care
  • •Signs of adhesive capsulitis developing (progressive stiffness exceeding pain limitation) requiring specialist intervention
  • •Systemic symptoms, fever, or signs of infection suggesting septic arthritis requiring urgent medical investigation
  • •Persistent night pain significantly disrupting sleep and function unresponsive to conservative measures, suggesting need for orthopedic assessment
  • •Patient demonstrating significant psychosocial barriers to recovery (high anxiety, catastrophizing, depression) requiring mental health professional involvement
  • •Occupational or sporting demands requiring specialized rehabilitation planning with sports medicine physician or athletic trainer
  • •Suspected underlying pathology (malignancy, cardiac referral, systemic disease) based on red flag symptoms requiring appropriate specialist referral