Effectiveness of exercise therapy versus passive conservative treatments for rotator cuff-related shoulder pain: a systematic review and meta-analysis of randomized controlled trials

Background Exercise therapy is commonly recommended as first-line treatment for rotator cuff–related shoulder pain (RCRSP), yet its effectiveness versus passive conservative treatments is uncertain. Objectives To evaluate the effectiveness of exercise therapy versus passive conservative treatments in individuals with RCRSP. Methods Five databases were searched from inception to December 2025. Randomized controlled trials comparing exercise therapy with non-exercise-based conservative treatments were included. Random-effects meta-analyses were performed. Risk of bias and certainty of evidence were assessed using the RoB 2.0 tool and the GRADE approach. Results Of 10546 records identified, 19 studies (n = 1349) were included in the meta-analysis. No differences in pain (SMD, −0.14; 95% CI, −1.25 to 0.96) or disability (SMD, −0.06; 95% CI, −1.57 to 1.45) were observed between exercise therapy and passive physical therapy in the short term. Exercise therapy combined with passive physical therapy was not more effective for pain and disability than passive physical therapy (pain: SMD, 0.23; 95% CI, −0.88 to 1.33; disability: SMD, −0.44; 95% CI, −1.64 to 0.77) or injections alone (pain: SMD, 0.02; 95% CI, −1.12 to 1.17; disability: SMD, −0.36; 95% CI, −1.38 to 0.66) in the short term. Exercise therapy combined with education was not superior to education alone for disability in the short term (SMD, −0.36; 95% CI, −1.54 to 0.83). The certainty of evidence ranged from very low to low. Conclusion Exercise therapy, alone or in combination with other conservative treatments, may not be more effective than passive conservative treatments for managing RCRSP at short-term follow-up.