Purpose <p>The aim of this study was to evaluate the outcomes of bioinductive collagen implant (BCI) augmentation after arthroscopic repair of rotator cuff tear with incomplete footprint coverage.</p> Methods <p>This was a prospective single-centre, single-surgeon case series. 27 patients with posterosuperior tears (10 -isolated SST, 14 SST with IST) were enrolled with 24 patients completing the entire follow-up. All patients were treated using arthroscopic double row technique with BCI augmentation. BCI was applied when complete tendon repair was possible, but footprint coverage was incomplete. Patients were assessed preoperatively, then at four, six and 12-months postoperatively. Each evaluation included a clinical assessment using shoulder specific outcome measures (ASES, Simple Shoulder Test, UCLA, Constant), isokinetic strength testing, and tendon healing assessment via magnetic resonance imaging (MRI).</p> Results <p>Retear rate for isolated SST was 30%. For massive rotator cuff tears (SST + IST), retear rate of SST was 42% and IST was 14%. Six SST retears were type 1 and three were type 2. In ten patients who healed, complete footprint coverage was observed on MRI despite an intraoperative defect in footprint coverage. PROMs and range of motion improved significantly throughout follow-up. There were no significant differences in final clinical scores between SST tears and SST + IST tears. However, patients with isolated SST tear had better strength parameters (Peak Torque/Body Weight and Total Work deficit).</p> Conclusions <p>Arthroscopic repair of “difficult” rotator cuff tears of poor tissue quality with the use of bioinductive implant is associated with significant clinical, biomechanical and radiological improvements. IST retear was very low despite risk factors. Patients with SST and massive SST + IST rotator cuff tears had similar clinical results but massive had less shoulder strength and endurance. The BCI appears to reduce the incidence of type 2 retears and may promote tendon regeneration.</p>