Do patients with rotator cuff pain need to lift heavier?

By Josh Naunton (B. Physio, M. Sports Physio, Sports and Exercise Physiotherapist (APA))

Twitter @JoshNaunton

Rotator cuff related shoulder pain is often challenging for both clinicians and patients to manage.1,2 The vast and varied opinions on the underlying cause or mechanisms may partly contribute to the confusion or to inappropriate recommendations and low value care being sought.2,3

Patients with rotator cuff pain often experience pain lying on their shoulder at night, difficulty dressing and are significantly limited in their work or recreational pursuits, as lifting their arm overhead is usually painful and restricted. While we know significant improvement is made through natural history and time alone, many patients experience ongoing symptoms for months or even years.4

Current best practice guidelines recommend 12 weeks of exercise and activity modification as first line treatment.5,6 However, we have very little evidence concerning the type of exercise. Is it enough to get the shoulder moving, doing any exercise? Or is it possible that some exercise offers greater benefit than others?

It is clear that our body adapts to the activity and demands that are placed on it.7 For example, working out at the gym increases our muscle size and strength; running regularly improves our fitness.  This correlation between the intensity of exercise and the potential benefit for improvement is demonstrated in a wide variety of health improvements, such as cardiovascular health, cognitive function, strength gains, osteoarthritis and athletic performance.7-10

Consequently, we must ask the same question for rotator cuff related shoulder pain. If patients lift heavier, with greater intensity is there greater improvement in pain or function?

Our work investigated this question with two recent systematic reviews.11,12 The first made two comparisons:

  1. Progressive and resisted exercise compared with no treatment or placebo.
  2. Non-progressive or non-resisted exercise compared with no treatment or placebo.

While a comparison between progressive and resisted exercise and non-progressive or non-resisted exercise is not directly made; progressive and resisted exercise appears to have greater benefit in comparison to placebo or no-treatment.

Our second review investigated the effect of higher load or volume exercise for rotator cuff pain compared with lower load or volume exercise. This review found function outcomes may be clinically important in favour of greater exercise load or volume after 3 or more months.

It’s important to remember that there was low certainty in this evidence due to the quality of the trials included in these reviews.

For more information please be sure to check out the infographic below or read the full text at the links below.

1. Smythe A, Rathi S, Pavlova N, et al. Self-reported management among people with rotator cuff related shoulder pain: An observational study. Musculoskelet Sci Pract. 2021;51:102305.

2. Smythe A, White J, Littlewood C, Bury J, Haines T, Malliaras P. Physiotherapists deliver management broadly consistent with recommended practice in rotator cuff tendinopathy: An observational study. Musculoskeletal Science and Practice. 2020;47:102132.

3. Buchbinder R, Staples MP, Shanahan EM, Roos JF. General practitioner management of shoulder pain in comparison with rheumatologist expectation of care and best evidence: an Australian national survey. PLoS One. 2013;8(4):e61243.

4. Ottenheijm RP, Joore MA, Walenkamp GH, et al. The Maastricht Ultrasound Shoulder pain trial (MUST): Ultrasound imaging as a diagnostic triage tool to improve management of patients with non-chronic shoulder pain in primary care. 2011;12(1):154.

Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322.

6. Hopman K, Lee KS, Lukersmith S, McColl A, Vine K. Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace. Port Macquarie (Australia): The University of New South Wales; 2013.

7. Schoenfeld BJ, Wilson JM, Lowery RP, Krieger JW. Muscular adaptations in low- versus high-load resistance training: A meta-analysis. European Journal of Sport Science. 2016;16(1):1-10.

8. Lesinski M, Prieske O, Granacher U. Effects and dose–response relationships of resistance training on physical performance in youth athletes: a systematic review and meta-analysis. British Journal of Sports Medicine. 2016;50(13):781-795.

9. Galloway M, Marsden DL, Callister R, Erickson KI, Nilsson M, English C. What Is the Dose-Response Relationship Between Exercise and Cardiorespiratory Fitness After Stroke? A Systematic Review. Physical Therapy. 2019;99(7):821-832.

10. Jönsson T, Nero H, Dahlberg LE. Exercise dose-response in individuals participating in a supported osteoarthritis self-management program; an observational register study. Osteoarthritis and Cartilage. 2018;26:S322-S323.

11. Malliaras P, Johnston R, Street G, et al. The Efficacy of Higher Versus Lower Dose Exercise in Rotator Cuff Tendinopathy: A Systematic Review of Randomized Controlled Trials. Archives of physical medicine and rehabilitation. 2020.

12. Naunton J, Street G, Littlewood C, Haines T, Malliaras P. Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation. 2020.