Review Reports - Rotator Cuff Disorders: Practical Recommendations for Conservative Management Based on the Literature

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Weak 'Methods' section. Authors state the protocol is a "narrative synthesis" and "does not follow a systematic review methodology". You must explain how you chose your references to prove this is scientifically rigorous.
No visual flowchart. You describe a "stepwise approach" and "roadmap", but there is no figure or diagram. A practical protocol needs a visual flowchar
Underdeveloped "Discussion". The discussion is too short (only one paragraph). It does not compare your protocol to existing guidelines or explain why your specific approach is better. Please expand
Missing "Limitations" section. You do not mention the weaknesses of your study? You must admit that this is a theoretical protocol that has not yet been validated by a clinical trial...
"Systematic" xrays need justification. You recommend xrays "systematically" for all patients. This is controversial due to radiation exposure; you need strong evidence to justify this routine use.
Your protein recommendation (-1.6 g/kg) is general sports advice. You should clarify if there is specific evidence linking this dosage to tendon healing.
You include "Stromal vascular fraction" and "nanofat" in the results. Since you admit these are "experimental", move them to a "Future Directions" section to avoid confusion.
You mention "sufficient strength" but give no numbers. To be "pactical", you must provide specific passing scores for example >90% symmetry
Contradictory advice on corticosteroids: you recommend injections for pain but later warn of "catabolic effects". You must specify exactly when to inject to avoid these risks
You classify partial tears as "borderline". Many surgeons consider this a surgical indication. You should acknowledge this controversy in the text and discuss further in the section dedicated to discussions
You should explicitly mention the three prognostic categories (good, borderline, poor) in the abstract.
The paper ends with the "Discussion" and jumps to "Funding". You need a specific "Conclusions" paragraph...
Incorrect citation style.
Title vs. Content mismatch. The title claims "Practical Suggestions", but the text is mostly a literature review?

Author Response

I thank the reviewer for the constructive and pertinent comments, which helped improve the clarity and rigor of the manuscript.

C1: Weak 'Methods' section. Authors state the protocol is a "narrative synthesis" and "does not follow a systematic review methodology". You must explain how you chose your references to prove this is scientifically rigorous.

R1 : The Methods section has been revised to clarify the reference selection process. References were selected through targeted searches of major medical databases, prioritizing widely cited clinical trials, systematic reviews, and international guidelines relevant to conservative management of rotator cuff disorders. The narrative and non-systematic nature of the article is now explicitly stated.

C2 : No visual flowchart. You describe a "stepwise approach" and "roadmap", but there is no figure or diagram. A practical protocol needs a visual flowchart

R2 : A visual flowchart summarizing the stepwise clinical approach has been added as Figure 1. The figure provides an overview of the proposed protocol and illustrates the main stages from clinical assessment to rehabilitation, follow-up, and treatment adaptation.

C3 : Underdeveloped "Discussion". The discussion is too short (only one paragraph). It does not compare your protocol to existing guidelines or explain why your specific approach is better. Please expand.

R3 : The Discussion section has been expanded to compare the proposed protocol with existing guidelines and to clarify its specific contribution, particularly regarding longitudinal follow-up, treatment adaptation, and structured clinical reasoning in conservative care.

C4 : Missing "Limitations" section. You do not mention the weaknesses of your study? You must admit that this is a theoretical protocol that has not yet been validated by a clinical trial...

R4 : A dedicated Limitations section has been added. The manuscript now explicitly states that the protocol represents a theoretical, experience-informed approach derived from the clinical reasoning of a single clinician and has not been validated by prospective clinical trials.

C5 : "Systematic" xrays need justification. You recommend xrays "systematically" for all patients. This is controversial due to radiation exposure; you need strong evidence to justify this routine use.

R5 : The protocol has been revised to clarify the rationale for systematic baseline radiographs. The recommendation has been reformulated to justify their use primarily to assist in differential diagnosis, while intentionally avoiding excessive detail in order to preserve clinical judgment and allow clinicians to adapt imaging decisions to individual patient contexts.

C6 : Your protein recommendation (-1.6 g/kg) is general sports advice. You should clarify if there is specific evidence linking this dosage to tendon healing.

R6 : The recommendation has been reformulated in the protocol, and a key reference supporting the role of adequate protein intake in rotator cuff tendon recovery has been added.

C7 : You include "Stromal vascular fraction" and "nanofat" in the results. Since you admit these are "experimental", move them to a "Future Directions" section to avoid confusion.

R7 : The protocol has been clarified. Stromal vascular fraction and nanofat injections are now explicitly described as strictly experimental, with wording revised in both the protocol and Table 5 to avoid any confusion regarding their clinical validation status.

C8 : You mention "sufficient strength" but give no numbers. To be "pactical", you must provide specific passing scores for example >90% symmetry

R8 : A quantitative example has been added to the protocol, specifying a limb symmetry index ≥90% as a pragmatic reference to define sufficient strength, while maintaining functional and clinical context.

C9 : Contradictory advice on corticosteroids: you recommend injections for pain but later warn of "catabolic effects". You must specify exactly when to inject to avoid these risks

R9 : The protocol has been clarified to explicitly state that corticosteroid injections are intended for short-term pain control when pain significantly limits rehabilitation. I agree with the reviewer’s concern, and this clarification was added to further improve readability, while the overall clinical rationale was already explained in the protocol.

C10 : You classify partial tears as "borderline". Many surgeons consider this a surgical indication. You should acknowledge this controversy in the text and discuss further in the section dedicated to discussions

R10 : The Discussion section has been revised to explicitly acknowledge this controversy. I now clarify that, although partial-thickness tears >50% are often considered surgical indications, especially in young & active patients, published data show that conservative treatment can still lead to favorable outcomes in selected patients (refs 1 & 2), supporting their classification as a borderline category in this protocol.

C11 : You should explicitly mention the three prognostic categories (good, borderline, poor) in the abstract.

R 11 : The abstract has been revised to more clearly emphasize the three prognostic categories (good, borderline, and poor) and improve their visibility for the reader.

C12 : The paper ends with the "Discussion" and jumps to "Funding". You need a specific "Conclusions" paragraph...

R 12 : A Conclusions section has been added.

C13 : Incorrect citation style.

R 13 : The reference list and in-text citations have been reformatted according to the MDPI citation style, which was downloaded and applied using EndNote.

C14 : Title vs. Content mismatch. The title claims "Practical Suggestions", but the text is mostly a literature review?

R 14 : The title has been revised to better reflect the nature of the manuscript, emphasizing that the practical recommendations are derived from a narrative review of the literature.

Reviewer 2 Report

Comments and Suggestions for Authors

Narrative review of nonoperative treatment of rotator cuff pathology. Lacking in background and discussion of management - provides a list, but no in-depth discussion of timing, effectiveness of each of these modalities described in literature.

TITLE:

No major changes.

ABSTRACT:

No major changes.

INTRODUCTION:

Would provide at least a paragraph of background to provide historical context and need for a narrative review such as this, and what this narrative review set to achieve.

MATERIALS AND METHODS:

How recent of evidence, i.e. within last 5, 10, 20 years?

RESULTS:

Would probably place the protocol under results section with sub-headings.
MR arthrogram preferred based on what evidence for cuff pathology?
Timing from injury or evaluation for all of these phases of rehab?

DISCUSSION:

Would at least briefly divide into a discussion section, discussing prior work and what this review accomplishes.

CONCLUSIONS:

Missing.

REFERENCES:

No major changes.

FIGURES AND TABLES:

No major changes.

Author Response

I thank the reviewer for the constructive comments, which helped improve the clarity and structure of the manuscript.

C1 : Narrative review of nonoperative treatment of rotator cuff pathology. Lacking in background and discussion of management - provides a list, but no in-depth discussion of timing, effectiveness of each of these modalities described in literature.

R1 : The Introduction and Discussion sections have been revised to strengthen the clinical background and to clarify the rationale of the proposed approach, with particular emphasis on longitudinal clinical follow-up and treatment adaptation, aspects that are often insufficiently addressed in existing guidelines and medical training.

C2 : How recent of evidence, i.e. within last 5, 10, 20 years?

R2 : The Methods section has been clarified to indicate that most references were selected from literature published within the last 10 years, with earlier publications included when they remain relevant to current clinical practice.

C3 : Would probably place the protocol under results section with sub-headings.

R3 : The protocol was intentionally kept as a distinct and self-contained section or appendix to allow it to be used independently from the narrative text. Its structure and positioning were considered appropriate for a practice-oriented review, and the Results section explicitly refers to the protocol and its stepwise organization.

C4 : MR arthrogram preferred based on what evidence for cuff pathology?

R4 : The protocol has been clarified to indicate that MR arthrography is not a first-line examination. It may be considered in selected cases, particularly when surgical management is being considered or when the diagnosis remains uncertain after radiography and ultrasound.

C5 : Timing from injury or evaluation for all of these phases of rehab?

R5 : The protocol intentionally avoids fixed time-based rehabilitation phases, with progression guided by clinical and functional criteria, symptom evolution, and tolerance to load rather than predefined timelines. This rationale has been clarified and further discussed in the Discussion section.

C6 & 7 : Would at least briefly divide into a discussion section, discussing prior work and what this review accomplishes. CONCLUSIONS : missing

R6 & 7 : The Discussion section has been expanded to compare the proposed approach with existing literature and guidelines and to clarify the specific contribution of this review. In addition, the Conclusions section explicitly state what this narrative review accomplishes in terms of practical clinical application.