Rotator cuff tears are common and multifactorial in etiology. Natural history studies suggest that following initiation of a tear, rotator cuff disease may advance along a continuum of tear enlargement and symptom progression, muscular degeneration and fatty infiltration, and glenohumeral arthritis. Patient- and tear-specific features influence both the risk of clinical progression and the potential for tendon healing following a repair. General guidelines regarding management of rotator cuff tears are influenced by a patient’s symptoms, risk of clinical progression, and potential for biologic healing.