Tears of the rotator cuff can be very challenging for the surgeon. He should be aware of the variations in the pathologic lesions that can be encountered and should understand the functions of the cuff-capsule mechanisms so that deficiencies can be appropriately defined and treated. A definite diagnosis, based on the history, physical examination, roentgenography, and arthrography, should be made. In some patients with acute tears of the rotator cuff, early operative treatment is warranted. Chronic cuff disease is often treated conservatively. When operative invervention is justified, the anterior or anterosuperior surgical approach is most useful, and the classic plastic surgery flap techniques provide a model for planning and executing the repair. Postoperative external support and the physical therapy program should be tailored to the complexity and the security of the cuff repair.