Saanich Physiotherapy Blog

Rotator cuff pain recommendations

Major Recommendations for rotator cuff pain

Source: Hopman K, Krahe L, Lukersmith S, McColl AR, Vine K. Clinical practice guidelines for the management of rotator cuff syndrome in the workplace. Port Macquarie (Australia): University of New South Wales; 2013. 80 p

Levels of evidence (I-IV) and grades of recommendation (A-D, Consensus, Mandatory) are defined at the end of the “Major Recommendations” field.

Initial Presentation

Clinical History

Recommendation 1. Diagnosis of rotator cuff syndrome requires a thorough history-taking which should include the following factors and consideration of their implications (refer to Table 2 in the original guideline document for indicators identified in the clinical history to assist assessment and differential diagnosis):

  • Age
  • Occupation and sports participation
  • Medical history
  • Mechanism of injury
  • Pain symptoms
  • Weakness and/or loss of range of motion (body function impairments)
  • Activity limitations
  • Social situation

(Grade: Consensus)

Physical Examination

Recommendation 2. Assessment of rotator cuff syndrome requires physical examination which should include: direct observation of the shoulder and scapula; assessment of active and passive range of motion; resisted (isometric) strength testing; and evaluation of the cervical and thoracic spine (as indicated). It may also include administration of other clinical tests but these are dependent upon the experience and preference of the clinician. (Grade: Consensus)

Identification of Red Flags

Recommendation 3. The clinician must exclude ‘red flags’ in the diagnosis of rotator cuff syndrome. ‘Red flags’ are signs and symptoms which suggest serious pathology (see Figure 1 in the original guideline document).

The following ‘red flags’ may present as shoulder pain and/or loss of function:

  • Unexplained deformity or swelling or erythema of the skin
  • Significant weakness not due to pain
  • Past history of malignancy
  • Suspected malignancy (e.g., weight loss or loss of appetite)
  • Fevers/chills/malaise
  • Significant unexplained sensory/motor deficits
  • Pulmonary or vascular compromise

(Grade: Consensus)

Identification of Yellow Flags

Recommendation 4. The clinician should take note of ‘yellow flags’ discussed or identified during history-taking. Yellow flags are contextual factors such as personal, psychosocial, or environmental factors that could impact on recovery and/or return to work (RTW) following injury (see Appendix 1 of the original guideline document). (Grade: Consensus)

Limitations of Imaging in Early Presentations

Recommendation 5. X-rays and imaging are not indicated in the first four to six weeks for an injured worker presenting with suspected rotator cuff syndrome in the absence of ‘red flags’ (see Figure 1 in the original guideline document). (Grade: C)

Recommendation 6. Clinicians will educate injured workers with suspected rotator cuff syndrome on the limitations of imaging and the risks of ionising radiation exposure. (Grade: Consensus)

Development of a Management Plan

Treatment Principles

Maintain Activity and Participation in Life Areas

Recommendation 7. In established rotator cuff syndrome, maintaining activity within the limits of pain and function should be recommended. Its reported benefits include: earlier RTW; decreased pain, swelling, and stiffness; and greater preserved joint range of motion. (Grade: Consensus)

Shared Decision-making

Recommendation 8. Clinicians should use a shared decision-making process with the injured worker to develop a management plan. (Grade: Consensus)

Outcome Measurement

Recommendation 9. Clinicians should use and document appropriate outcome measures at baseline and at other stages during the recovery process to measure change in the injured worker’s impairments, activity limitations, and/or participation restrictions. (Grade: Mandatory)

Cultural and Language Issues

Recommendation 10. Health care providers should consider any additional issues, potential disadvantages, or need for additional resources (such as an interpreter) for the injured worker and their family if the injured worker identifies as Aboriginal and/or Torres Strait Islander, or is from a culturally and linguistically diverse or non-English speaking background. (Grade: Consensus)


Pain Management



Recommendation 11. Injured workers should be prescribed paracetamol as the initial choice for mild to moderate pain. (Grade: C)

Oral and Topical Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Recommendation 12. Injured workers with acute shoulder pain may be prescribed NSAIDs (either oral or topical) for pain relief. NSAIDs may be prescribed alone or in conjunction with paracetamol. (Grade: B)


Cold Therapy

Recommendation 13. To reduce pain and swelling following acute rotator cuff syndrome, injured workers may intermittently apply cold within the first 48 hours. (Grade: Consensus)


Recommendation 14. From 48 hours post-injury, injured workers may intermittently apply either heat or cold for short periods for pain relief. (Grade: Consensus)

Return to Work Program

Recommendations 15. There must be early contact between the injured worker, workplace, and health care provider. (Grade: C)

Recommendation 16. A specific and realistic goal for the RTW of the injured worker, with appropriate time frames, should be established early with outcomes measured and progress monitored. (Grade: Consensus)

Recommendation 17. The RTW program must involve consultation and engagement with a team which includes: the injured worker, relevant health care providers, and the workplace. (Grade: B)

Recommendation 18. The RTW program should include a workplace assessment and job analysis matching worker capabilities and possible workplace accommodations. (Grade: B)

Recommendation 19. The RTW program, where possible, should be workplace-based. Improved outcomes occur if rehabilitation processes take place within the workplace. (Grade: C)

Recommendation 20. When planning a RTW program, a graded RTW should be considered and adjusted following review of objectively measured outcomes. (Grade: Consensus)

Prescribed Exercise

Recommendation 21. Injured workers should be initially treated with exercise prescribed and reviewed by a suitably qualified health care provider. There is no evidence of adverse impacts for prescribed exercise programs for patients with rotator cuff syndrome. (Grade: B)

Manual Therapy

Recommendation 22. Manual therapy may be combined with prescribed exercise by a suitably qualified health care provider*, for additional benefit for patients with rotator cuff syndrome. (Grade: B)

*Under the New South Wales workers compensation system, health care providers who are eligible to be paid for this treatment are physiotherapists, chiropractors, and osteopaths. These treatment providers are trained in the prescription and modification of exercises consistent with pathology.


Recommendation 23. Clinicians may consider acupuncture in conjunction with exercise; both modalities should be provided by suitably qualified health care providers. (Grade: C)

Electro-physical Agents

Therapeutic Ultrasound

Recommendation 24. The evidence suggests that therapeutic ultrasound does not enhance outcomes compared to exercise alone. The health care provider should refrain from using ultrasound for either pain reduction and/or increased function for injured workers with subacromial impingement syndrome. (Grade: C)


Recommendation 25. Injured workers with suspected rotator cuff syndrome should be reviewed by their clinician within two weeks of initial consultation, with the proviso that the injured worker can contact their clinician earlier if they have had no response to their prescribed treatment, or if they have experienced treatment side effects. (Grade: Consensus)

Patient Experiencing Significant Persisting Pain and/or Activity Restriction

Preferred Imaging for Rotator Cuff Syndrome

Recommendation 26: Injured workers with suspected rotator cuff syndrome who have experienced significant activity restriction and pain four to six weeks following initiation of an active, non-surgical treatment program and have had no response to the treatment program should be referred for magnetic resonance imaging (MRI) and plain film X-ray. (Grade: B)

Recommendation 27: In the absence of access to MRI or for those with contradictions for MRI, refer injured workers with suspected rotator cuff syndrome for ultrasound and plain film X-ray. Ultrasound performed by a skilled clinician provides equivalent diagnostic accuracy to MRI for rotator cuff tears (partial- or full-thickness). (Grade: B)

Subacromial Injections of Corticosteroids

Recommendation 28. For pain reduction in injured workers with persistent pain or who fail to progress following initiation of an active, non-surgical treatment program, the clinician may consider subacromial corticosteroid injections combined with a local anaesthetic. (Grade: A)

Recommendation 29. Injured workers should be educated regarding the possible risks and benefits of corticosteroid injections. (Grade: Consensus)

Recommendation 30. Subacromial corticosteroid injections should only be administered by suitably trained and experienced clinicians. (Grade: Consensus)

Recommendation 31. If pain and/or function have not improved following two corticosteroid injections, additional injections should not be used. (Grade: Consensus)

Referral for Specialist Opinion

Recommendation 32. Clinicians should refer for specialist opinion if an injured worker experiences significant activity limitation and participation restrictions and/or persistent pain following engagement in an active, non-surgical treatment program for three months. (Grade: Consensus)

Rotator Cuff Tears

Rotator Cuff Surgery

Recommendation 33. On review, clinicians should refer injured workers for surgical opinion if there is a symptomatic, established small or medium full-thickness rotator cuff tear. (Grade: B)

Recommendation 34. Clinicians should refer injured workers for surgical opinion if there is a symptomatic, full-thickness rotator cuff tear greater than 3 centimetres. (Grade: Consensus)

Recovery and Outcomes Following Rotator Cuff Surgery

Recommendation 35. The clinician should be aware of factors that may influence prognosis post-rotator cuff surgery (refer to Table 8 in the original guideline document for factors that may influence recovery following rotator cuff surgery). (Grade: Consensus)

Leave a Reply

Your email address will not be published. Required fields are marked *