MSCs are thought to mediate therapeutic functions in a paracrine manner in addition to their multipotent differentiation capacity and direct intercellular interactions. In the example of a rotator cuff injury model, conditioned medium (CM) of human bone marrow-derived stem cells promotes rotator cuff healing by increasing histologic score, bone mineral density and biomechanical tensile after surgery (; ). To search for the therapeutically active components, Bruno and colleagues successfully fractioned CM of MSCs by ultracentrifugation and discovered the therapeutic vesicular structures (). Collectively, these nano-sized particles with a lipid bilayer, naturally released by cells, are called extracellular vesicles (EVs) (). They can be categorized into exosomes, microvesicles, and apoptotic bodies according to their cellular origins. Exosomes are the smallest vesicle types (40–120 nm), and they originate from the inward budding of late multivesicular endosomes (MVEs) and are released upon fusion of MVEs with the plasma membrane. Meanwhile, microvesicles are formed by budding from the plasma membrane, and their size can vary from 50 nm to 1 μm. Unlike exosomes and microvesicles, which are released by all cells, apoptotic bodies are vesicles (50 nm–5 μm) produced by cells undergoing apoptosis. EVs have become an attractive approach in regenerative medicine because they exert biological activities like those of stem cells and overcome the shortages of cell-based therapy, such as cell expansion, low survival rate, and potential immunological rejection (; ). It is believed that MSCs cultured in chemically defined serum-free media may be more suitable for the manufacture of EVs. The methods of separation and concentration may vary depending on the size of EVs and the purpose of end-use. According to a worldwide ISEV survey in 2015, ultracentrifugation was the most widely used primary EV separation and concentration technique (). A variety of techniques have also been developed to achieve better specificity of separation, such as density gradients and size-exclusion chromatography (). However, there are currently no accepted metrics for assessing the purity or degree of purity in EV preparation (). Although the mechanism of EVs is not fully understood, it is believed that EVs secreted by stem cells can promote tissue repair and regeneration by inducing the proliferation of cells, promoting angiogenesis, modulating the inflammation process, and affecting cell apoptosis (). The therapeutic effects of MSC-EVs for rotator cuff injuries are summarized in and ., In this review, we summarize the advances of stem cells and stem cell-derived extracellular vesicles in rotator cuff repair, gene therapy, and their biomaterial delivery systems. 2 Rotator Cuff Structure and Healing, Stem cell therapy is an up-and-coming treatment with proven efficacy in relieving symptoms associated with a wide range of orthopedic injuries and conditions. Shoulder osteoarthritis and rotator cuff tears are among the shoulder issues which may be treated using stem cell therapy..