Rotator Cuff-Related Shoulder Pain

Who: Middle-aged adults and loaded overhead athletes. Atraumatic or load-related onset.
What: Lateral or anterior shoulder pain, often referring to the deltoid insertion. Rarely below the elbow.
How it behaves: Load-sensitive and mechanical. Painful arc roughly 70–120°. Worse overhead, reaching behind, lifting. Worse lying on that side.

The numbers that matter:

([1]. Higher in women, and higher in high-income countries.)

The rotator cuff is the structure most often implicated in shoulder pain presenting to primary care [2]. On a five-week MSK block it will be your most common shoulder presentation, comfortably.

RCRSP is an umbrella, not a structure. Tendinopathy, subacromial pain, bursitis and symptomatic partial-thickness tears all sit under it, because we cannot reliably separate them clinically and separating them rarely changes what you do [3][4].

⚠️ The only Australian guideline is old: the RACGP- and APA-endorsed rotator cuff syndrome guideline, written for working adults and predating the trials below. Anchored to the JOSPT Rotator Cuff Tendinopathy Clinical Practice Guideline [5]. The closest Australian reference point is Crookes et al., Aust J Gen Pract 2023 [6] — a general-practice review, not a standard.

Pattern > Label. Nobody is grading you on whether you said "bursitis" or "tendinopathy". They're grading you on whether you sorted load-sensitive cuff pain vs tear vs stiff-and-global vs not-the-shoulder-at-all.

Five stages, in the order your course teaches them. Insidious onset → run BEHAVIOUR before HISTORY. Traumatic onset → flip them, because the mechanism is the story.

MAIN PROBLEM

"What's the main problem for you today?" Then stop talking. You want the function they've lost, not the pain score. Reaching the top shelf. Washing their hair. Serving. Sleeping on that side.

BODY CHART

Chart interpretation: Upper-arm referred discomfort and distal neurological warning features are distinct. Prominent hand tingling or progressive neurological loss warrants broader assessment.

• Lateral and anterior shoulder, often pointing to the deltoid insertion with a whole hand rather than one finger.
• Rarely below the elbow. Pain into the hand is a cervical question until you've cleared it.
• Clear what you're not treating. Cervical spine, thoracic spine, elbow, and both upper limbs for neurological symptoms.
• Type: ache, catching, sharp on a specific arc. Usually intermittent early, more constant as it gets irritable.

BEHAVIOUR

• Aggs: overhead reaching, reaching behind (seatbelt, back pocket, bra strap), carrying, lifting away from the body, sustained arm-out postures, lying on it.
• Eases: arm supported and by the side, changing position, heat, unloading the arm. If nothing eases it, question the label.
• 24-hr pattern: stiff and sore first thing, easing with gentle movement, building again with a day of use. Morning stiffness < 30 min = M. > 30 min = In — a prompt to screen inflammatory, not a diagnosis.
• Night: wakes on rolling onto it, settles once they move off it. Position-easable night pain is mechanical. Unremitting night pain is not.
• Severity: VAS 0–10 at best / at worst / right now.
• Irritability: the vigour of the provoking activity, the severity of what's provoked, and the time to settle. All three. This decides whether your O/E is LIMITED or FULL, and it decides your starting exercise dose.

HISTORY

• Onset: gradual load change (new job, new program, painting the house, pre-season) or a specific event.
• The question that changes the pathway: was there trauma, and could they lift the arm afterwards? A fall or a heavy lift in someone over 40–50, followed by real weakness, is a different conversation (§3).
• Previous episodes, previous imaging, previous injection, what they were told it was. Half the fear in the room came from the word "tear".
• Work and sport demands — overhead load, repetition, and how much control they have over it ([7], which is the guideline that actually covers return to work).

SPECIAL / SCREENING QUESTIONS

General health, weight loss, night sweats, fever, malignancy history, inflammatory features, medications including corticosteroids, and any neurological symptoms in the arm. See §4.

Irritability — the bit that actually sets your plan

Say out loud which one you chose and why. That sentence is what your educator is marking.

Top competing patterns, one discriminating feature each. Rank them — then rule out the dangerous one first.

Compare active and passive elevation to inform the differential. Preserved passive range does not establish an intact or torn cuff; pain inhibition, neurological findings and stiffness also matter.

Jones' hypothesis categories that actually change your plan here: sources of symptoms (cuff vs capsule vs neck), impairments (which is the load-sensitive direction), precautions (what irritability lets you do today), and contributing factors (work and sport load, and what they believe about their scan).

Consistency = confidence. If the history says load and the objective says load, you're done deciding.