Rotator cuff injury in athletes results from accumulation of microtrauma to both the static and dynamic stabilizers of the shoulder. Our classification of these injuries and treatment protocol is based on knowledge of the pathophysiology of events leading to rotator cuff failure. Rotator cuff disease is attributed to one of five different modes of failure: primary compressive disease, secondary compressive disease, primary tensile overload, secondary tensile overload, and macrotraumatic injuries. Although disease is categorized based on a single failure mode, there is often significant overlap between the mechanisms of injury leading to the disease. Categorization and, consequently, treatment of the injury rely upon proper identification of the primary pathology and an understanding of the causative factors leading to rotator cuff failure. In most cases conservative management is successful, but, in the refractory cases, minimally invasive surgical techniques have also been successful in returning most athletes to a premorbid level of function.