Several studies have documented high success rates following the surgical treatment of full-thickness rotator cuff tears. Historically, however, less favorable and predictable results have been found in the treatment of massive tears (>5 cm) compared with small and medium sized tears. Determining the most appropriate treatment for a patient with a massive rotator cuff tear can be challenging because of inconsistent outcome results. Some patients function well with nonsurgical treatment of massive tears, some have initially favorable results from surgical débridement of tears without repair that then deteriorate over time, and other patients who are surgically treated continue to maintain good function despite documented retears. Nonsurgical treatment of massive rotator cuff tears may be suitable for elderly patients with chronic tears and limited functional goals below shoulder level. Surgical débridement without repair of the tear may be considered for patients with low physical demands whose predominant symptom is pain. Surgical repair is recommended for patients who require maximal postoperative function, particularly for overhead activities. Open repairs have a lower rate of rerupture than arthroscopic repairs; however, arthroscopic repair offers the benefits of decreased morbidity and decreased risk of postoperative deltoid detachment. Early studies of arthroscopic repairs have shown good functional results; however, there has been a high incidence of retears. Tendon transfers and other reconstruction techniques may offer improvements in certain salvage cases, but results of these procedures are inferior to those for primary repair. Preservation of the coracoacromial arch should be considered in all forms of treatment of massive rotator cuff tears to avoid the devastating complication of superior humeral head escape.