Single-row and double-row repair remain widely used approaches for arthroscopic rotator cuff surgery. This meta-analysis of randomized trials examined whether the choice of repair construct changes patient outcomes and tendon integrity. Across the included studies, standard functional scores such as the ASES, Constant and UCLA scales often did not differ substantially between techniques. However, imaging-based outcomes consistently favoured double-row repair, with lower structural re-tear rates and better tendon healing. This creates an important clinical nuance: a more anatomically robust repair does not necessarily produce a dramatic difference in short-term patient-reported function, particularly in smaller tears. The choice of construct should therefore consider tear size, tissue quality, tendon retraction, footprint restoration and surgeon experience rather than relying on a single universal rule. The study supports double-row or suture-bridge strategies when structural healing is a priority, especially in larger or more complex tears, while recognising that increased construct complexity and cost may not translate into large gains for every patient. For HCPs, the key point is to separate two goals—symptom and functional improvement versus structural integrity—and decide how much each matters in the individual surgical context.