Few previous studies have investigated the pathomechanism and managements of rotator cuff lesions with shoulder stiffness. Based on observations by Codman in 1934, frozen shoulder presumably relates to rotator cuff tendenitis. In the past six decades, tended to discriminate primary frozen shoulder from secondary shoulder stiffness due to shoulder disorders such as rotator cuff lesions or trauma. Intrinsic degeneration and outlet acromial spur impingement are reported as pathogenic causes of rotator cuff lesion. Although patients with rotator cuff lesions with shoulder stiffness or adhesive capsulitis (frozen shoulder) may have similar complaints about pain and motion limitation, the pathological reactions in these disorders remain unclear. In our investigation of clinical vignettes of shoulder stiffness, inflammation-mediated adhesions in the subacromial bursa in rotator cuff lesions, and changes in inflammatory cytokine levels have been linked to myofibroblast recruitment in the subacromial bursa. Our study provides the first indication that increased interleukin -1β expression and myofibroblast recruitment in the subacromial bursa are correlated with rotator cuff lesions with shoulder stiffness. Increased inflammatory cytokine concentrations in the lesions also provide new molecular insight into the pathological role of the subacromial bursa in the development of shoulder stiffness in rotator cuff lesions. Although rotator cuff repair is a shoulder-tightening procedure and is not recommended until resolution of the shoulder stiffness in rotator cuff lesions with stiff shoulder, our clinical evidence-based survey suggests that a combined procedure of manipulation, lysis of adhesions, acromioplasty, and rotator cuff repair is a useful procedure if the symptoms do not improve 3 months of aggressive rehabilitation.