Millions of adults face shoulder pain from degenerative rotator cuff tears, often assuming surgery is inevitable. This comprehensive evidence review challenges that assumption, revealing when non-surgical approaches deliver equivalent outcomes while avoiding operative risks and recovery time. The analysis synthesized 16 high-quality studies tracking 893 patients over multiple years, comparing physiotherapy-based conservative care against surgical repair. For partial-thickness tears and older or less active individuals, conservative management achieved comparable functional improvements to surgery. The evidence particularly favored non-surgical approaches for patients over 60 and those with sedentary lifestyles, where healing demands are lower and surgical complications more concerning. Conservative protocols centered on structured physiotherapy programs, with emerging treatments like platelet-rich plasma (PRP) injections and extracorporeal shock wave therapy showing promise as adjunctive options. Cost analyses revealed conservative care delivered substantial savings compared to surgical pathways, factoring in procedure costs, rehabilitation duration, and time away from work. This systematic review fills a critical gap in orthopedic decision-making by providing robust comparative data across tear severity and patient demographics. The findings suggest many patients could avoid surgery while achieving similar pain relief and function restoration. However, the research confirms full-thickness tears in younger, active individuals still benefit more from surgical repair. For healthcare systems grappling with rising orthopedic costs and aging populations, these insights support more selective surgical criteria and expanded conservative treatment protocols.