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Tears of the rotator cuff, both partial, and less commonly, full thickness, are relatively common in the throwing athlete. The rotator cuff is subjected to enormous stresses during repetitive overhead activity. The supraphysiological strains, especially when combined with pathology elsewhere in the kinetic chain, can lead to compromise of the cuff fabric, most commonly on the undersurface where tensile overload occurs. Exacerbation by a tight posterior capsular, anterior instability, and internal impingement render the cuff progressively compromised, with intrinsic shear stresses and undersurface fiber failure. Advances in imaging technology, including contrast magnetic resonance imaging, dynamic ultrasound, and arthroscopic visualization have enhanced our understanding of cuff pathology in this athletic population. Unfortunately, this has not yet translated into how to best approach these athletes to return them to their previous level of activity. Nonoperative management remains the mainstay for most throwers, with arthroscopic debridement an effective surgical option for those with refractory symptoms. Despite technological advances in cuff repair in the general population, comparable outcomes have not been achieved in high-level throwers. Widespread appreciation that securing the cuff operatively will likely end an athletes’ throwing career has led to adopting a surgical approach that emphasizes debridement over repair for nearly all partial and full-thickness tears. Whether advances in surgical technique will ultimately permit definitive and lasting repairs that allow overhead throwers to return to their previous level of sports remains unknown at this time.