Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms postoperatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge. A thorough patient history, physical examination, and imaging studies (eg, plain radiography, MRI, magnetic resonance arthrography, ultrasonography) are required for diagnosis. Management is determined based on patient age, functional demands, rotator cuff competence, and the presence or absence of glenohumeral arthritis. Treatment options include revision repair, nonanatomic repair with or without biologic or synthetic augmentation, tendon transfer, and arthroplasty.