Innovation in rotator cuff repair technique has driven our understanding of the biomechanical attributes necessary for optimizing tendon-bone healing. Despite these advances, rotator cuff repair failure and retear rates still remain high. With the evolution of arthroscopic technique and instrumentation, transosseous, single-row, double-row, and transosseous-equivalent repair configurations have all been shown to be effective clinically. Biomechanical studies have identified significant strengths and weaknesses when comparing current repair configurations. Limitations do exist when extrapolating laboratory data and correlating clinically. The biological milieu at the tendon-bone interface and patient-specific factors out of the surgeon’s control can determine the successful healing of a rotator cuff repair. Ultimately, the goals of rotator cuff repair include identifying the superior construct to provide the biomechanical environment to optimize biological healing within the constraints of the underlying pathology.