From Imaging to Function: Contemporary Evidence-Based Management of Subacromial Pain and Rotator Cuff-Related Shoulder Disorders

Background: Subacromial pain syndrome (SAPS) and rotator cuff–related shoulder disorders are among the most common causes of shoulder pain. Historically, management was driven by structural abnormalities identified on imaging, but contemporary evidence supports a clinically led, function‑focused approach. Methods: This narrative clinical review synthesizes current evidence from high‑quality clinical practice guidelines, systematic reviews, and randomized controlled trials. Key themes include diagnostic reasoning, imaging indications, tear classification, rehabilitation strategies, injection therapy, surgical decision‑making, and de‑implementation of low‑value procedures. Results: Clinical assessment remains the cornerstone of diagnosis. Early imaging is discouraged in typical atraumatic presentations. Progressive exercise therapy is the most consistently supported intervention. Corticosteroid injections provide short‑term relief but do not modify disease progression. Arthroscopic subacromial decompression offers no clinically meaningful benefit over placebo surgery or structured rehabilitation. Rotator cuff repair is appropriate for selected patients, particularly those with traumatic onset, pseudoparesis, or persistent functional impairment despite conservative treatment. Conclusion: A clinically led, stepped‑care pathway emphasizing rehabilitation‑first management, selective imaging, and individualized surgical referral / intervention aligns with contemporary evidence and reduces low‑value interventions.