Etiology — what causes it

Pain related to the rotator cuff and surrounding tissues, which may include tendinopathy, bursal irritation, partial-thickness tearing, and biomechanical contributors (scapular control deficits, posterior capsule tightness, deltoid–cuff force-couple imbalance). The older 'impingement' model has been replaced by a load-tolerance framework.

Epidemiology — who gets it

Shoulder pain affects 18–26% of adults at any given time (Luime et al., Scand J Rheumatol). RCRSP is the most common cause across the lifespan, with peak incidence between ages 45–65. Common in overhead athletes and manual workers.

Clinical signs

Painful arc (60–120° abduction), positive Hawkins–Kennedy, Neer, Jobe (empty can), and Hornblower in various combinations, scapular dyskinesis, posterior capsule tightness, and reduced shoulder external rotation strength. Importantly, no single test rules in or out the diagnosis.

Symptoms

Anterolateral or deltoid-region shoulder pain, worse with overhead reaching, lying on the affected side, and resisted abduction or external rotation. Often progressive onset. Night pain in moderate-to-severe cases.

Best evidence for chiropractic treatment

BJSM consensus on RCRSP (Lewis, 2018) and the CSAW trial (Beard et al., Lancet 2018) support progressive loading as first-line care, with comparable outcomes to subacromial decompression surgery in many patients. Ketola et al. (BJSM 2017) showed equivalent outcomes at 5 years between surgical and exercise-only groups. The cornerstone is progressive load — heavy slow resistance, isometric, and eccentric work tailored to symptom irritability. Manual therapy is a useful short-term adjunct. Corticosteroid injection provides short-term relief but doesn't outperform exercise at 6 months.

Subtypes

  • Reactive cuff tendinopathy. Pain with overhead and resisted use; structural changes are minimal. Early-phase load tolerance is the key.
  • Degenerative cuff tendinopathy. Older population; pain with sustained loading. Progressive heavy slow resistance is well-supported.
  • Partial-thickness tear with RCRSP. Tear is incidental in many cases; rehab is similar to tendinopathy.

When to seek emergency care

Some symptoms need urgent medical attention — not a chiropractic visit. Call 911 or go to the nearest emergency department for: progressive limb weakness, loss of bowel or bladder control, saddle anesthesia (numbness in the groin/inner thighs), severe unrelenting pain unrelieved by position, signs of fracture after significant trauma, chest pain, stroke-like symptoms (face drooping, arm weakness, speech changes), or any rapidly worsening or unusual symptom.

Bottom line

Most rotator cuff related shoulder pain responds to progressive loading over 12 weeks. Surgery is rarely the first answer — strength and capacity are.