Rotator Cuff Tendinopathy: What NEW 2025 Guidelines Mean for Clinicians and Patients
More than half of shoulder pain cases can be attributed to pathology of the rotator cuff. Yet, despite how common it is, care for rotator cuff tendinopathy has often been inconsistent: overuse of imaging, short-term symptom fixes, and underuse of exercise-based rehabilitation.
That’s what makes the 2025 Clinical Practice Guideline (CPG) so important. It consolidates the latest international evidence to clarify how clinicians should assess, diagnose, and manage rotator cuff tendinopathy — with a strong emphasis on conservative, active, and patient-centered care.
1. Diagnosis: Start with People, Not Pictures
The new guideline makes one thing clear: you don’t need an MRI right away.
Initial diagnosis should be rooted in a thorough subjective assessment and clinical reasoning — not imaging.
Clinicians are encouraged to:
Take a full history (onset, aggravating factors, lifestyle, sport/work demands)
Assess range of motion and strength objectively using goniometers or smartphone apps
Screen for red and yellow flags early
Focus on patient goals, beliefs, and context
Why this matters:
Unnecessary imaging can delay care, increase costs, and lead to overmedicalization. Most shoulder pain can be accurately identified through structured examination.
Imaging is only recommended after 12 weeks of appropriate nonsurgical care if symptoms fail to improve — and ultrasound is preferred over MRI for its cost-effectiveness and comparable accuracy.
2. Prognosis: Beyond the Shoulder
Prognosis improves when we treat the person, not just the pathology.
The guideline highlights several factors that influence recovery:
Personal: age, duration of symptoms, prior injury history
Psychosocial: distress, fear of movement, anxiety, catastrophizing, low self-efficacy
Work-related: high physical demand, poor social support, perceived injustice, job stress
Clinicians are encouraged to use screening tools like STarT MSK or OSPRO-YF to identify these influences and tailor care.
3. Clinical Testing: Keep It Simple and Smart
Special tests are still useful — but limited.
The painful arc test helps confirm rotator cuff involvement, while the Hawkins-Kennedy test can help rule it out. But neither provides definitive answers on their own.
Combine multiple findings — history, symptom pattern, test clusters, and clinical judgment — to reach an accurate diagnosis.
4. Medication and Injections: Short-Term Help, Not Long-Term Solutions
Shift away from symptom suppression toward long-term recovery.
Pharmacology recommendations for treatment of rotator cuff tendinopathy
These tools can help manage pain temporarily, but they do not rebuild tissue capacity or function.
5. Rehabilitation: Exercise Is the Gold Standard
Clinicians should prescribe or recommend an active rehabilitation exercise program as initial treatment.
What that looks like in practice:
Motor control exercises to restore shoulder coordination
Resistance training to progressively build load tolerance
Functional strengthening based on the patient’s sport or work tasks
Gradual load progression respecting pain thresholds
Manual therapy may complement exercise for short-term pain relief but should not replace active rehab.
Adjunct therapies like taping or acupuncture can be considered, but therapeutic ultrasound and passive modalities are discouraged due to lack of evidence.
For calcific tendinopathy, options such as shockwave therapy, laser, or lavage may be used if conservative treatment fails.
6. Education: The Underrated Pillar of Recovery
When patients understand their condition, they engage better — and outcomes improve.
Education is central to care. The guideline emphasizes individualized, patient-centered explanations covering:
What rotator cuff tendinopathy is a load tolerance issue, not a tear that needs “fixing”
Why pain doesn’t always equal damage
How progressive movement builds resilience
What to expect over the course of rehab
When patients understand their condition, they engage better — and outcomes improve.
7. Return to Sport: Progress by Capacity, Not Calendar
Athletes return when the shoulder can handle the demands of their sport — not when a certain number of weeks have passed.
The new CPG challenges the idea of “six weeks off” or “three months until return.” Instead, it emphasizes criteria-based progression.
Clinicians should assess:
Shoulder and rotator cuff load capacity
Functional performance and control
Patient confidence, readiness, and outcome measures
8. What This Means for Clinicians
For health professionals, this guideline confirms the direction modern MSK care is heading:
Lead with assessment, not imaging
Educate and empower early
Prescribe active, progressive rehab
Integrate psychosocial care
Communicate clearly and collaboratively
9. What This Means for Patients
Recovery isn’t about “healing a tear.” It’s about restoring strength, control, and confidence in your shoulder.
If you’re dealing with shoulder pain, here’s what the evidence now says:
You don’t need an MRI first.
Exercise — not rest — is your best medicine.
Injections may help temporarily, but they’re not a fix.
You can regain full function with consistency and guided movement.
Reference:
Desmeules F, Roy J-S, Lafrance S, et al. Rotator Cuff Tendinopathy: Diagnosis, Nonsurgical Medical Care, and Rehabilitation – A Clinical Practice Guideline. J Orthop Sports Phys Ther. 2025;55(4):235–274.