Rotator Cuff Tendinopathy: Clinical Best Practices for Outpatient Rehabilitation

Rotator cuff tendinopathy is one of the most common causes of shoulder pain in adults, accounting for a significant share of musculoskeletal complaints in outpatient rehabilitation. As the population ages and maintains high activity levels, this condition becomes increasingly prevalent—and often progressive.

While many cases respond to conservative treatment, tendinopathy is not always static. Studies have shown that a substantial portion of individuals with symptomatic rotator cuff tendinopathy will experience structural progression over time, with nearly 40 percent developing a partial or full-thickness tear within just a few years. Alarmingly, the risk of degeneration increases with time, rising to over 50 percent beyond five years.¹

This trajectory highlights a critical window for intervention. Left unaddressed, rotator cuff tendinopathy can evolve into more complex, treatment-resistant presentations. Early, evidence-based care—delivered through a personalized and engaging clinical approach—can not only reduce pain and restore function but may also help slow this structural decline.

This article outlines practical, evidence-based strategies, from assessment to treatment, designed to help rehabilitation specialists manage rotator cuff tendinopathy more effectively. These approaches are drawn from the 2025 Clinical Practice Guideline on rotator cuff tendinopathy and emphasize patient engagement techniques that foster adherence, support shared decision-making, and promote long-term recovery. Plus, we’ll show you how tools like the PROMIS questionnaire can help align care with patients’ functional goals and track meaningful progress throughout the rehabilitation journey.

The role of PROMIS CAT in rotator cuff tendinopathy management 

For patients with rotator cuff tendinopathy, shoulder pain often limits daily function in ways that may not be immediately visible during clinical exams. Patient-reported outcome measures like the PROMIS CAT Physical Function and Pain Interference Questionnaires offer efficient ways to quantify function and the impact of pain as well as help clinicians track progress over time. 

How PROMIS CAT works 

PROMIS CAT Physical Function and Pain Interference Questionnaires are two PROMIS scales that are clinically validated and are designed to gather the most critical information with the fewest questions possible. PROMIS CAT asks patients four to eight questions that assess:

• Physical Function: A patient’s self-reported capability to do functional activities, such as activities of daily living (ADLs) and activities in the community. A higher score indicates better function.

• Pain Interference: A patient’s self-reported impact of pain on their social, cognitive, emotional, physical, and recreational activities. A lower score indicates less pain interference.

Patients rate each question on a five-point scale. The tool adapts based on each patient’s answer, determining which questions will follow as well as when to stop the assessment. Patients’ total scores are reported on a T-score scale, ranging from 20 to 80. 

To learn more about how this validated, patient-friendly tool enhances assessment and care, check out our article on PROMIS CAT.

Assessment and evaluation of rotator cuff tendinopathy

Effective, patient-centered care for rotator cuff tendinopathy begins with a comprehensive assessment. Beyond symptom management, this process informs clinical decision-making, builds trust, and ensures care aligns with each patient’s goals from the very first visit.

The following assessment strategies are drawn from the 2025 Clinical Practice Guideline and can help you guide targeted interventions and strengthen patient engagement from the start:

1. Conduct a thorough subjective and objective evaluation

(B-level recommendation: Identify factors influencing prognosis)

Begin with a detailed patient history to understand symptom onset, aggravating activities, functional limitations, and psychosocial or occupational contributors. Promptly screen for red flags (e.g., acute trauma, systemic illness) and yellow flags such as fear-avoidance behaviors or low self-efficacy that may impact recovery.

2. Use evidence-based clinical tests to confirm or rule out diagnosis

(B-level recommendation: Painful arc to confirm, Hawkins-Kennedy to rule out)

While no single test can definitively diagnose rotator cuff tendinopathy, combining tests with clinical reasoning improves diagnostic accuracy. The painful arc test has the highest value for confirming the diagnosis, while the Hawkins-Kennedy test can help rule it out. However, these should always be interpreted in the context of the patient’s full clinical presentation.

3. Incorporate objective measurement tools

(A-level recommendations: Use goniometers, dynamometers, and validated questionnaires)

Functional impairments such as reduced range of motion (ROM) or muscle strength should be measured objectively to inform care and track change over time. The Clinical Practice Guideline recommends using:

• Inclinometers or goniometers for assessing shoulder range of motion.

• Handheld dynamometers for measuring isometric strength of the rotator cuff.

• Validated questionnaires like the QuickDASH to determine pain and functional limitation.

4. Identify baseline function and monitor change with outcome measures

(A-level recommendation: Use MCIDs to guide interpretation)

Validated patient-reported outcome measures help establish meaningful baselines and ensure care stays responsive to patient needs. The PROMIS-CAT Physical Function and Pain Interference Scales offer clear insights into pain and function, supporting informed decisions about care adjustments. Using PROMIS-CAT to establish a patient’s baseline and then regularly review their plan of care can help you determine whether patients are progressing and when it’s time to update their plan. 

Evidence-based best practices for managing rotator cuff tendinopathy

Once assessment and diagnosis are complete, the next step is implementing an individualized, evidence-informed treatment plan to reduce pain, restore function, and support long-term recovery. The 2025 Clinical Practice Guideline outlines several high-value interventions that clinicians can use to guide rehabilitation, and the following strategies reflect those with the strongest levels of evidence and recommendation:²

1. Prescribe a structured, progressive exercise program

(A-level recommendation: Therapeutic exercise)

Exercise is the foundation of nonoperative management for rotator cuff tendinopathy. Targeted rehabilitation can reduce pain, improve neuromuscular control, and build load tolerance in the rotator cuff and surrounding structures. 

Programs may include concentric and eccentric strengthening, motor control strategies, scapular stabilization, and whole-body conditioning. Empowering patients with home exercise programs that progress over time is strongly recommended as part of an active rehabilitation plan that effectively reduces pain.

Clinical application:

• Begin with low-load resistance or isometric exercises for patients with high irritability.

• Integrate scapular-focused and motor control exercises to enhance dynamic shoulder stability.

• Progress patients to higher-load resistance training or functional tasks as tolerated.

• Emphasize consistency over intensity to reduce symptom flares and improve adherence.

2. Deliver individualized patient education

(C-level recommendation: Patient education and self-management)

Empowering patients with clear, relevant, comprehensive education supports self-efficacy and long-term management. A patient-centered approach should include discussions about pain mechanisms, expected recovery timelines, and appropriate activity modifications. Education also lays the foundation for shared decision-making and stronger patient-provider trust.

Clinical application:

• Educate patients on symptom behavior, rotator cuff function, and the role of exercise.

• Discuss goal setting and how progress will be measured (e.g.,PROMIS-CAT, ROM, strength).

• Reinforce the difference between discomfort and harm to reduce fear-avoidance.

• Use handouts, visual models, or videos to align with patients' learning styles.

3. Integrate manual therapy to reduce pain and support mobility

(B-level recommendation: Manual therapy as an adjunct)

Manual therapy can improve short-term pain and function, especially when combined with exercise. Techniques may include soft tissue release, mobilization of the glenohumeral or thoracic spine, and stretching.

Clinical application:

• Use joint mobilization to address capsular stiffness or improve tolerance to loading.

• Apply soft tissue techniques to reduce guarding or myofascial restrictions.

• Follow manual therapy immediately with active exercise to reinforce gains.

4. Consider pain management strategies within scope

(B- and C-level recommendations: NSAIDs, acetaminophen, corticosteroid injections)

In some cases, short-term pharmacological support may be beneficial—particularly when pain limits exercise tolerance. While PTs may not directly prescribe in all settings, they can collaborate with providers or make informed recommendations.

Clinical application:

• Suggest a conversation with a prescribing provider about nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with moderate pain and no contraindications.

• Educate patients on the short-term benefits and risks of corticosteroid injections.

• Refer patients with calcific tendinopathy unresponsive to rehab for potential imaging-guided lavage.

5. Avoid routine use of passive modalities for non-calcific tendinopathy

(B-level recommendation: Do not use therapeutic ultrasound in non-calcific cases)

While modalities like ultrasound or shockwave therapy are common in some clinics, current evidence does not support their effectiveness in treating noncalcific rotator cuff tendinopathy.

Clinical application:

• Reserve physical modalities (e.g., laser, acupuncture) for select cases or when combined with active care.

• Use evidence discussions as a patient engagement tool to align treatment expectations and reduce dependency on passive care.

Real-world application: Patient scenarios in rotator cuff tendinopathy care

Putting the clinical guidelines into practice means adapting your approach to each patient’s context, goals, and presentation. The following three case examples illustrate how evidence-based strategies—paired with PROMIS-CAT—can drive meaningful outcomes across different rehabilitation settings.

Scenario 1: Middle-aged recreational athlete in outpatient PT

A 55-year-old recreational pickleball player presents with a six-month history of shoulder pain that worsens during overhead serves. His PROMIS-CAT Physical Function score at evaluation is 50, and he reports difficulty sleeping on his right side.

Approach:

• Assign a digital home exercise program to the patient that begins with low-load isometric exercises and motor control training to address pain and dynamic control, then introduce scapular stabilization when the patient is ready.

• Reassess after four weeks—his PROMIS-CAT improves to 65, and he reports improved tolerance with play.

• Progress to eccentric loading and resistance training, and set graded goals for return-to-sport.

Outcome: A clear, progressive plan combined with functional outcome tracking supports both physical recovery and motivation for continued care.

Scenario 2: Sedentary office worker with functional limitations

A 42-year-old administrative professional presents with gradual-onset shoulder pain affecting desk work, lifting groceries, and playing with her children. Her PROMIS-CAT Pain Interference score is 52, and she expresses frustration about limited productivity and fatigue during daily tasks.

Approach:

• Focus initial treatment on pain management, postural training, and motor control strategies targeting scapular mechanics.

• Provide ergonomics education and modify her workstation to reduce shoulder load.

• Use motivational interviewing to address perceived barriers and reinforce long-term goals (e.g., playing with her kids).

• Reassess at six weeks—her PROMIS-CAT Pain Interference score improves to 33, and she reports greater ease in daily activities.

Outcome: Patient-centered education, measurable progress markers, and real-world adaptations help sustain engagement and improve quality of life.

Scenario 3: Older adult in home health following acute flare-up

 A 70-year-old retired teacher with a history of rotator cuff tendinopathy experiences a recent flare-up after lifting luggage. She receives home health physical therapy due to mobility challenges and limited transportation. At intake, her PROMIS-CAT Pain Interference score is 61, and she avoids using the affected arm due to pain.

Approach:

• Initiate gentle range of motion exercises and isometric contractions to reduce pain and maintain mobility.

• Incorporate functional ADL-based tasks, like reaching into cabinets and folding laundry, as therapeutic activities.

• Provide education on symptom pacing and use visual charts to track daily movement goals.

• At reassessment after three weeks, her PROMIS-CAT Pain Interference score drops to 46, and she’s able to perform basic tasks independently again.

Outcome: A functional, home-based care plan with strong education and reinforcement strategies builds confidence and accelerates recovery—even in low-resource settings.

Advancing outcomes in rotator cuff tendinopathy care

Rotator cuff tendinopathy is a prevalent and often progressive condition that requires more than symptom management. With a notable risk of structural degeneration over time, early targeted intervention is key. By combining thorough assessment, tailored treatment strategies, and validated tools like the PROMIS-CAT, clinicians can deliver care that restores shoulder function and reinforces patient confidence throughout recovery.

Whether you're supporting recreational athletes, desk workers, or older adults at home, these approaches offer flexible, real-world solutions that can elevate care and drive long-term success.

Ready to take your practice further? Explore our continuing education courses and Pathways to stay current on evidence-based protocols and deliver exceptional care—anytime, anywhere.

References

1. https://www.sciencedirect.com/science/article/pii/S2666061X22000815

2. https://www.jospt.org/doi/10.2519/jospt.2025.13182