Proprioception vs Strengthening: what works best for rotator cuff–related shoulder pain?
What is rotator cuff-related shoulder pain?
The rotator cuff is comprised of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis), whose primary role is to provide stability to the shoulder joint. Let’s put it this way: your shoulder joint is inherently the most unstable joint in the body, as it’s a ball-and-socket joint that is analogous to a golf ball on a tee. With that said, these four muscles of the rotator cuff must be not only be strong individually, but also as a unit that coordinates as a team to provide both static and dynamic stability to the shoulder as you move your arm about. Injury to one or more of these muscles can affect your arm’s ability to move in a bio-mechanically sound manner, translating to pain with movement over time.
What’s the difference between proprioception and strengthening?
Proprioception is your body’s ability to perceive joint awareness in space. Your central nervous system processes somatosensory input from receptors in your joints to produce motor output. This, for example, would allow you to catch yourself from rolling your ankle on some unforeseen rock while hiking on a trail.
Strengthening, on the other hand, is providing a resistive stimulus that promotes increased force production through adaptation. When your muscle is physically taxed repeatedly over time, it will adapt and grow stronger to conform to demands.
Research has shown favorable outcomes with incorporating both proprioceptive and strength training for patients with osteoarthritis or ankle sprains. This following study looks to see whether the same applies for rotator cuff-related shoulder injuries, which may shine some light on the most efficient physical therapy protocols for shoulder rehab.
The study
A Buccioli et al in this 2025 study looks at whether there are any advantages of a combinatory program of proprioceptive and strength training versus strength training alone for subjects with rotator cuff-related shoulder pain (RCRSP). The study was a randomized controlled trial with two primary groups:
Group 1 was given strengthening exercises alone (the control).
Group 2 was given strengthening exercises plus proprioceptive training (the experimental).
Both groups underwent training over the course of 8 weeks, with data collected at start of treatment, followed by 2 months and 5 months from start of intervention.
Outcome measures included Shoulder Pain and Disability Index (SPADI), pain (Visual Analog Scale), range of motion (ROM), isometric strength, and joint position sense (JPS).
The results
Both groups improved significantly in all outcomes measures, including SPADI, pain, ROM, strength and joint position sense
Limitations: 1) The study didn’t include a non-intervention control group, which would have been nice to see whether the favorable outcome measures were indeed due to the allocated intervention versus just the natural healing progression of time. 2) The same physical therapist was used to treat both groups, increasing the risk for performance bias. However, since the hypothesis that proprioceptive training would yield better outcome measures was disproved based on the data of this study, it’s likely this bias was controlled to some degree. 3.) The 5-month follow-up had a 26% decreased follow-up in the control group, and 29% in the experimental group.
Clinical implications for physical therapists
For a more efficient treatment approach, it may suffice to focus on the strength training rather than dividing time between strength and proprioceptive training. By all means, though, this doesn’t undermine the importance of proprioceptive training. Rather yet, enhanced proprioception may occur while performing strength training, so it may be a two-birds-one-stone scenario. Put it this way: changes in motor output following proprioceptive exercise may either result from enhanced somatosensory information (which in turn improved motor output) or improved sensorimotor integration. Since the data from both groups shows increased proprioception post-intervention, it is possible that shoulder strengthening exercises alone can improve sensorimotor integration, which increases proprioception.
Citations
1.) Buccioli V, van de Water A, van den Noort JC, et al. Proprioceptive exercises combined with strengthening exercises are not superior to strengthening exercises alone for shoulder pain and disability in individuals with chronic rotator cuff-related shoulder pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2025;55(7):495–511. https://www.jospt.org/doi/10.2519/jospt.2025.13097.
2.) Aman JE, Elangovan N, Yeh IL, Konczak J. The effectiveness of proprioceptive training for improving motor function: a systematic review. Front Hum Neurosci. 2015;8:1075. https://doi.org/10.3389/fnhum.2014.01075.