Conservative management of degenerative rotator cuff tears: A systematic review of long-term clinical outcomes and cost effectiveness

Background: Degenerative rotator cuff tears are a prevalent cause of shoulder dysfunction in adults. The choice between conservative management and surgical repair remains controversial, particularly in older patients and those with partial-thickness tears. This systematic review evaluates the long-term outcomes and cost-effectiveness of conservative treatment strategies compared with surgical repair. Methods: A comprehensive literature search was conducted across PubMed, Embase, Cochrane Library, and Scopus databases, covering publications from 2010 to 2025. Only randomized controlled trials (RCTs) and cohort studies comparing conservative and surgical interventions for degenerative rotator cuff tears were included. Methodological quality was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool and the ROBINS-I tool for cohort studies. Due to heterogeneity in study design and outcome measures, a meta-analysis was not feasible; instead, a structured narrative synthesis was performed to highlight consistent trends. This review integrates recent evidence, reflecting the increasing prevalence of degenerative tears in aging populations and evaluating novel conservative options such as PRP and ESWT. Results: 16 high quality peer reviewed studies involving a total of 893 patients were included. Conservative treatment, primarily physiotherapy-based, demonstrated comparable outcomes to surgery in partial-thickness tears or low-demand individuals. For full-thickness tears, surgical repair yielded superior long-term improvements in Constant-Murley Score (CMS), Visual Analogue Scale (VAS) pain scores, American Shoulder and Elbow Surgeons (ASES) scores, and patient satisfaction. Although surgical groups demonstrated structural re-tears, these did not consistently correlate with deterioration in clinical function, suggesting that anatomical failure may not always equate to functional decline. Across multiple studies, conservative management was consistently associated with lower direct and indirect healthcare costs. Novel adjunctive therapies such as extracorporeal shockwave therapy (ESWT) and platelet-rich plasma (PRP) also showed promising results in selected populations. Conclusion: Conservative management appears as a clinically effective and cost-efficient first-line approach for degenerative rotator cuff tears, particularly for partial tears and elderly patients. However, surgical is associated with superior long-term functional outcomes in full-thickness tears. Emerging nonoperative technologies further strengthen the role of conservative care. Treatment should be individualized based on tear severity, patient activity level, and therapeutic goals.