The normal rotator cuff tendon to bone insertion site is not recreated after repair. Instead of the normal fibrocartilaginous transition zone, repaired tendons heal with a layer of interposing scar tissue. This alteration in the biology makes rotator cuff repairs prone to failure. Various methods have been proposed to biologically augment rotator cuff repairs including platelet-rich plasma, patches, stem cells, and molecular factors such as cytokines. Currently, there is insufficient evidence in the literature to support platelet-rich plasma as an augment for rotator cuff repair. Patches should only be used as an augment and are not recommend as a gap-spanning instrument. Stem cells and cytokines have promising animal data but sparse data in humans suggestive of positive outcomes. Newer possibilities include combinations of the above methods as well as gene therapy. Modifiable patient factors such as smoking cessation, glycemic control in diabetics, and limiting the use of anti-inflammatories may be the most readily available ways to improve the biology of rotator cuff healing. Goals of further research should build on preclinical work and successes as well as find novel ways to enhance biology of the repair site to improve healing and reduce retears.