Comparative effectiveness of physical therapy interventions in adults with rotator cuff tendinopathy: a systematic review and network meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract; CIs for primary comparisons do not cross zero, suggesting statistical significance at α=0.05

• Effect Size: Shoulder exercises vs. no treatment: pain SMD −0.79 (moderate effect); function SMD 0.74 (moderate effect). Exercises + percutaneous electrolysis vs. comparator: pain SMD −1.58 (large effect). Exercises + trigger point dry needling vs. comparator: function SMD 3.10 (very large effect, but very wide CI)

• Primary Outcome: Pain and physical function at end of treatment, assessed across multiple physical therapy intervention comparisons via network meta-analysis

• Nnt Or Sensitivity: NNT not calculable from SMD data without assumed baseline SD and MCID threshold. The SMD of −0.79 for pain with shoulder exercises represents a clinically meaningful effect using Cohen's convention (medium-large), but GRADE certainty is very low, limiting clinical translation

• Confidence Interval: Shoulder exercises pain: 95% CI −1.33 to −0.26; function: 95% CI 0.34 to 1.14. Exercises + percutaneous electrolysis pain: 95% CI −2.68 to −0.48. Exercises + trigger point dry needling function: 95% CI 1.99 to 4.22

Clinical Application

Shoulder-targeted exercise therapy is widely available, low-cost, and feasible in Australian primary care and physiotherapy settings without specialist referral. Percutaneous electrolysis and trigger point dry needling require trained practitioners and specific equipment; availability varies across metropolitan and regional Australia. These adjunct interventions are not universally covered by private health insurance and are not PBS-listed. RACGP guidelines and Musculoskeletal Australia support exercise-based management as first-line for shoulder tendinopathy, consistent with this review's conclusions. Physiotherapy is accessible via Medicare-funded chronic disease management plans (up to 5 allied health visits per year under a GP Management Plan). Corticosteroid injections, often used in Australian practice, were not the focus of this review. The TGA has not specifically approved any physical therapy device for RC tendinopathy, but dry needling and electrophysical agents are within the scope of practice of AHPRA-registered physiotherapists. The 'very uncertain' GRADE evidence should temper enthusiasm for adopting combination therapies (percutaneous electrolysis, dry needling) as standard care without further high-quality Australian RCTs. Adults with rotator cuff tendinopathy presenting to physiotherapy, sports medicine, or primary care settings. Applicable across a spectrum of chronicity and severity, though subgroup-specific data are not available from this review.

Abstract

OBJECTIVE: To compare the effects of different physical therapy interventions and identify the most effective intervention on pain, function, quality of life (QoL) and adverse events (AEs) in adults with rotator cuff (RC) tendinopathy. DESIGN: Systematic review and network meta-analysis (NMA) of randomised clinical trials (RCTs). DATA SOURCES: Seven databases and two trial registries were searched up to March 2024. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: RCTs comparing physical therapy interventions to any other physical therapy intervention, sham, placebo, waiting list or no treatment on pain, function, QoL and AEs in adults with RC tendinopathy. DATA SYNTHESIS: A frequentist NMA using a random-effects model was performed. Risk of bias and certainty of the evidence were assessed using the revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluation approach, respectively. RESULTS: 89 RCTs (5532 participants) were included. Exercises targeting the shoulder muscles may reduce pain (standardised mean difference (SMD) -0.79, 95% CI -1.33 to -0.26) and improve function (SMD 0.74, 95% CI 0.34 to 1.14) compared with no treatment but the evidence is very uncertain. Exercises targeting shoulder and scapular muscles in addition to percutaneous electrolysis (SMD -1.58, 95% CI -2.68 to -0.48) and to trigger point dry needling (SMD 3.10, 95% CI 1.99 to 4.22) seem to be the most effective interventions on pain and function at the end of treatment, respectively. CONCLUSION: Most of the interventions identified may not be superior to isolated shoulder exercises alone, which might be considered a reasonable first-line approach, but the evidence is very uncertain and most interventions are informed by limited data. High-quality research is needed to improve evidence of physical therapy interventions in adults with RC tendinopathy. PROSPERO REGISTRATION NUMBER: CRD42024527176.

References

1. 1.Lazzarini, S. G., Bettariga, F., Mosconi, B., Maestroni, L., Cordani, C., Bandini, E., Dal Farra, F., Lopez, P., & Arienti, C. (2026). Comparative effectiveness of physical therapy interventions in adults with rotator cuff tendinopathy: a systematic review and network meta-analysis. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2025-110024