The cause of the high failure rates often observed following rotator cuff tendon repairs, particularly massive tears, is not fully understood. Collagen structural changes have been shown to alter tendon thermal and mechanical properties. This study aimed to form a quantitative rather than qualitative assessment, of whether differences in collagen structure and integrity existed between small biopsies of normal, small, and massive rotator cuff tears using differential scanning calorimetry. Thermal properties were measured for 28 human biopsies taken intra-operatively from normal, small, and massive rotator cuff tendon tears in this powered study. Denaturation temperatures are represented by T onset (8C) and T peak (8C). The T onset is proposed to represent water-amide hydrogen bond breakage and resulting protein backbone mobility. T peak reportedly corresponds to the temperature at which the majority of proteins fall out of solution. Denaturation enthalpy (DH) should correlate with the amount of triple helical structure that is denatured. Fluorescence and confocal microscopy allowed quantitative validation. Small and massive rotator cuff tears had significantly higher T onset , T peak , and DH compared to controls. Polarized light microscopy of torn tendons confirmed greater collagen structural disruption compared to controls. These novel findings suggest greater quantifiable collagen structural disruption in rotator cuff tears, compared to controls. This study offers insight into possible mechanisms for the reduced strength of torn tendons and may explain why repaired tendons fail to heal. ß 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:1938Res 29: -1943Res 29: , 2011.Keywords: shoulder; rotator cuff; tendon; collagen denaturation; imaging American census data estimates that 17 million people potentially face the risk of disability from rotator cuff failure. 1 As rotator cuff tears become more prevalent with age, 2 an increasingly aging population means that the healthcare costs are likely to become greater for this disorder.Repairs of massive rotator cuff tendon tears have higher failure rates than small tears. 3 A multistage model of rotator cuff tears has been suggested, wherein tear size has been shown to affect both the cellular and extracellular matrix composition of the torn tendon edge. 4 Further understanding of changes in the extracellular matrix composition of rotator cuff tendon tears may offer insight into differences in healing and failure rates, and help to guide research into treatment strategies. Characterizing human rotator cuff tears can enhance our understanding of the complex degeneration occurring in chronic tears, which animal models cannot fully replicate.Differential scanning calorimetry (DSC) is a useful technique to characterize structural properties of very small (0.5 mg, approximately 2 Â 2 Â 2 mm) human tendon biopsies that are sampled intraoperatively as thermal properties are inherent to a material and hence much less affected by ...