Comparative effectiveness of strengthening-focused exercise versus other conservative treatments for rotator cuff pathology: a systematic review and meta-analysis of randomized controlled trials

To compare strengthening-focused exercise therapy with other conservative interventions for activity-related pain, shoulder disability/function, and shoulder range of motion (ROM) in adults with rotator cuff pathology. We searched seven databases (PubMed, Embase, Cochrane, PEDro, Scopus, Ovid, Web of Science) from inception to 28 November 2025 (PROSPERO: CRD420251246846) for randomized controlled trials comparing strengthening-focused exercise with other conservative treatments. Two reviewers independently screened studies, extracted data, and assessed risk of bias (RoB 2). Random-effects meta-analyses were conducted in RevMan 5.3 within prespecified follow-up windows; certainty of evidence was assessed using GRADE. Fifteen trials ( N = 1084) were included. Ultra-short term (≤ 3 weeks): pain favored other conservative treatments (MD 1.54, 95% CI 1.19 to 1.90; I 2 = 30%; moderate certainty). Short term (4–12 weeks): effects were uncertain for pain (MD 0.88, 95% CI − 0.20 to 1.96; I 2 = 97%; very low certainty) and disability/function (SPADI: MD − 0.75, 95% CI − 9.83 to 8.34; I 2 = 93%; very low certainty). Mid-term (> 12 weeks to < 6 months): strengthening improved ROM in flexion (MD 10.22°, 95% CI 4.14° to 16.29°; I 2 = 67%), abduction (MD 25.23°, 95% CI 21.78° to 28.68°; I 2 = 43%), and extension (MD 2.80°, 95% CI 1.48° to 4.11°; I 2 = 26%) (moderate certainty). Other conservative modalities may provide greater ultra-short-term pain relief than strengthening-focused exercise, whereas short-term comparative effects on pain and disability/function remain highly uncertain because of substantial comparator heterogeneity and very low-certainty evidence. Strengthening-focused exercise may be associated with greater mid-term improvements in selected ROM planes, while evidence for rotation planes remains uncertain. Future trials should use clearly defined comparator categories, standardize intervention reporting, and measure core outcomes consistently across clinically relevant follow-up periods.