Massive rotator cuff tears (MRCTs) can be classified by their size, number of tendons involved, type of onset, and patient shoulder function. MRCTs’ management has to take into consideration: patient age, motivation and expectations, pain, the clinical exam, the type and onset of the lesion, the static upward migration and arthritic changes of the humeral head, the presence of muscle atrophy, and fatty degeneration of the muscles involved. Surgical repair may be complete, if needed using interval slide and margin convergence techniques or, partially complete. If repair is not possible, techniques like debridement with long head of the biceps tenotomy and arthroscopic reversed subacromial decompression may be used in some specific patients. Interposition techniques like a subacromial balloon and superior capsular reconstruction using fascia lata, human acellular dermal matrix, and more recently the long head of the biceps have been developed in order to increase range of motion and reduce pain. Tendon transfers might be a valuable option. For anterosuperior tears, pectoralis major is a classic option but latissimus dorsi has the same vector as subscapularis. For posterosuperior tears, latissimus dorsi transfer is the classic approach but lower trapezius in spite of the need of elongation has good results in selected patients. The best results are obtained if complete repair and healing is possible; all the other techniques may be of value if treatment indication is correct.