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Pain Management · 5 min read · September 27, 2026
From the course: Exercising Into Pain for Rotator Cuff-Related Shoulder Pain: A Six-Month Randomized Trial · 0.5 contact hours
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Does exercise for rotator cuff-related shoulder pain have to hurt to work? In a randomized controlled trial published in the Open Access Journal of Sports Medicine in 2024, Cavaggion and colleagues compared a 12-week program in which one exercise deliberately provoked moderate pain with a program kept at no more than mild discomfort. Both groups of adults with chronic rotator cuff-related shoulder pain improved substantially, and through six months no measure separated the two programs. The authors concluded that provoking pain during exercise does not appear necessary for a successful result in this population, and they limit that conclusion to people with long-standing symptoms and minimal pain at rest.
Exercise is the recommended first-line treatment for rotator cuff-related shoulder pain, and the authors note that no single exercise program has been shown to be better than another. That has turned attention to other parts of the prescription, including whether pain during exercise should be permitted or avoided. The widely used pain monitoring model, with its low, acceptable and high risk zones, traces back to one clinician's experience published in 1997. Surveys the authors cite show that tolerance for pain during shoulder exercise varies from country to country.
The team recruited adults aged 18 to 65 from one private physiotherapy clinic in Belgium. Each had pain in the front and outer shoulder region for at least three months, resting pain no higher than 2 out of 10, and at least three of five provocative tests positive: Neer, Hawkins-Kennedy, Jobe, a painful arc between 60 and 120 degrees, and resisted external rotation. A long exclusion list removed, among others, people with clinical signs of a full-thickness rotator cuff tear, frozen shoulder, a corticosteroid injection in the previous six weeks, or shoulder pain reproduced by neck movement. Only 13% of screened patients were enrolled.
Of the 43 people randomized, 41 were analyzed. Their average age was 47 years, just over half were female, and symptoms had been present for an average of 28 months.
Both groups had nine supervised sessions over 12 weeks, home exercise three times a week during the unsupervised weeks, posterior shoulder stretching at the start of each session, and the same education, lifestyle and ergonomic advice. The only planned difference was how much pain one of the four exercises in each session was allowed to provoke.
| Exercise into pain | Exercise without pain | |
|---|---|---|
| Pain allowed, weeks 1 to 9 | One exercise provoking pain rated 4 to 7 out of 10, plus three kept at 0 to 2 | All four exercises kept at no more than 2 out of 10 |
| Pain allowed, final three weeks | All exercises kept at 0 to 2 out of 10 | Unchanged |
| Exercises per session | Four, chosen from set categories and individualized | Four, chosen the same way |
The team's earlier feasibility study had used four painful exercises, and many patients did not stick with them, so this trial used only one. A single assessor, blinded to group assignment, measured outcomes before treatment and at 9 weeks, 12 weeks and 6 months.
No. The main outcome was a shoulder pain and disability questionnaire with five pain items and eight disability items. The authors found no clear difference between groups at any follow-up point, and the largest gap, which slightly favored the pain-free group, stayed below the 10-point difference they named as the smallest that would matter between groups. None of the other measures separated the groups either, including pain intensity, fear-avoidance beliefs, quality of life, strength, range of motion, adherence and satisfaction.
Both groups improved over time. With the groups combined, questionnaire scores were 21 points better by week 9 and 33 points better at six months, beyond the 20-point change the authors called clinically important. Seventy percent of the painful-exercise group and 84% of the pain-free group reached a clinically relevant change, and the comparison between those proportions showed no clear difference.
After clinic-based sessions, adverse effects were similar in the two groups. In each, 10% of patients reported four to seven episodes of lasting pain or fatigue. After home exercise, 14% of the painful-exercise group and 5% of the pain-free group reported that many episodes. Four patients in total had flare-ups the day after unsupervised exercise, which the authors say deserves closer monitoring in future work.
The authors also raise the possibility that the two programs were more alike than intended, which would have left too small a contrast to produce a group difference. Both groups progressed loads and repetitions on their comfortable exercises, and for six patients in the painful-exercise group the physiotherapists could not always find a movement that provoked pain and used a rating of perceived exertion instead.
The authors describe pain provocation during shoulder exercise as unnecessary for a successful result in chronic rotator cuff-related shoulder pain with low resting pain. They do not describe it as harmful, and allowing one painful exercise did not lead to worse adherence, more adverse effects or lower satisfaction than the pain-free program.
The authors cite two earlier randomized trials in similar patients in which painful and less painful conditions also produced no difference, although both treated patients more often than this trial did. For future trials, they recommend closer tracking of flare-ups after home exercise and an outcome assessor from outside the research team. They also suggest adding ultrasound imaging of the subacromial bursa, which was not evaluated in this trial and might help explain why some patients respond differently.
In the trial, the treating physiotherapists made the decisions about exercise selection and load progression, including when to switch a patient to an exertion rating. In US practice, those evaluation and plan-of-care judgments rest with the physical therapist, and physical therapist assistants deliver the interventions under that direction.
In the trial by Cavaggion and colleagues, a program with one exercise at moderate pain (4 to 7 out of 10) and a program kept at 2 out of 10 or less produced similar improvement through six months. The authors concluded that provoking pain does not appear necessary for a successful result in chronic cases with minimal pain at rest.
The authors did not conclude that painful exercise is harmful. Adverse effects after clinic sessions were similar in both groups, although more patients in the painful-exercise group reported repeated episodes of lasting pain or fatigue after home exercise.
No. Patients with acute symptoms or substantial pain at rest were screened out, and the authors limit their conclusions to chronic cases with minimal resting pain.
Cavaggion C, Luque-Suarez A, Voogt L, et al. Exercise into pain in chronic rotator cuff-related shoulder pain: a randomized controlled trial with 6-month follow-up. Open Access J Sports Med. 2024;15:181-196. doi:10.2147/OAJSM.S483272
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