Background <p>Opioids are commonly used for postoperative analgesia after arthroscopic rotator cuff repair; however, they pose an increased risk of postoperative nausea and vomiting. Therefore, multimodal analgesia using non-opioid analgesics is recommended. However, the efficacy of postoperative opioid-free analgesia, including acetaminophen, has not been fully elucidated. Therefore, this study aimed to assess the effect of postoperative opioid-free, acetaminophen-containing analgesia on postoperative outcomes in patients undergoing arthroscopic rotator cuff repair.</p> Methods <p>Patients who underwent arthroscopic rotator cuff repair at Rakuwakai Marutamachi Hospital between June 2022 and May 2025 were included. The patients were divided into postoperative opioid and opioid-free groups. Propensity score matching was used to balance baseline characteristics. The postoperative outcomes, including pain scores, incidence of nausea and vomiting, use of additional analgesics, and length of postoperative hospital stay, were compared between the groups.</p> Results <p>After propensity score matching, 78 patients were assigned to each group. Postoperative pain scores did not significantly differ between the groups. However, the postoperative opioid-free group had a significantly lower incidence of nausea and vomiting (5.1% vs. 20.5%, <i>p</i> &lt; 0.05) and use of additional analgesics (5.1% vs. 20.5%, <i>p</i> &lt; 0.05). The length of postoperative hospital stay did not differ significantly between the groups (13 days vs. 11.5 days, <i>p</i> = 0.268).</p> Conclusions <p>Postoperative opioid-free analgesia, including acetaminophen, may provide pain control comparable to conventional opioid-based strategies, reduce the incidence of postoperative nausea and vomiting, and represent a safe and effective approach for postoperative analgesia after arthroscopic rotator cuff repair.</p>