Synopsis Progressive resistance exercise, in isolation or in combination with other noninvasive therapies such as therapeutic touch, is the first-line approach to managing nontraumatic rotator cuff–related shoulder pain (RCRSP). Resistance exercise may be effective for people with RCRSP secondary to improving mechanical features of the shoulder, including strength, kinematics, and muscle timing and activation. However, strength gains are often small and clinically unimportant when measured during clinical trials. In this Viewpoint, we argue that clinicians should (1) continue to prescribe resistance exercise when managing RCRSP, and (2) embrace the broad biological mechanisms underpinning the efficacy of resistance exercise. Any benefit is governed by more than simple mechanical changes. The clinical message must go beyond the idea that the patient's weak, deconditioned, or frail shoulder is the basis of his or her pain, and all the patient needs to do is to get strong. J Orthop Sports Phys Ther 2021;51(4):156–158. doi:10.2519/jospt.2021.10199

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Objective Rotator cuff-related shoulder pain is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for rotator cuff-related shoulder pain. However, the causal mechanisms underpinning the beneficial effects of exercise for rotator cuff-related shoulder pain are not well understood. Moreover, how individuals with lived experience of rotator cuff-related shoulder pain believe exercise helped or did not help is unknown. This study aimed to gain insights into how individuals with rotator cuff-related shoulder pain believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs. Methods This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semistructured interview. The data were coded by 2 members of the research team (JKP & NC) and verified by a third (BS). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations. Results Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psycho-emotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress. Conclusions Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with rotator cuff-related shoulder pain was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself. Impact Exercise is a recommended primary, first-line intervention to manage rotator cuff-related shoulder pain. The results of this study suggest that a positive experience and outcome with exercise for rotator cuff-related shoulder pain is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context an exercise program is prescribed and delivered should be considered by clinicians.

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Physiotherapists nearly always prescribe exercise for rotator cuff-related shoulder pain; but why? A cross-sectional international survey of physiotherapists. Musculoskeletal Care.