Nonoperative Management: Who, When, and What?

Disorders of the rotator cuff are among the most common shoulder pathologies encountered by orthopedic surgeons. Although both acute and chronic tears of the rotator cuff are recognized and traditionally classified based on tear size, the increasing appreciation of asymptomatic tears in population studies challenges our current treatment algorithms. Conventionally, nonoperative treatment has been reserved for patients who do not have significant pain, including those with massive tears. Recent studies demonstrating successful treatment of various cuff tear morphologies using nonoperative modalities have increased interest in conservative management. Presently, nonoperative options include exercise/physical therapy, corticosteroid injections, oral anti-inflammatory medications, and autologous biological administration. However, it is unclear at this time which patient populations benefit most among the nonoperative treatment options, as the literature to date represents heterogeneous cohorts of tear types, symptom duration, as well as varied treatment modalities. Any further comparison between operative and nonoperative outcomes necessitates prospective studies with rigorous inclusion/exclusion criteria and standardized interventions.