Massive, irreparable rotator cuff tears remain a clinical challenge. In low-demand patients, debridement of the tear may relieve pain. Partial repair using the technique of margin convergence decreases the size of the tear gap and reduces strain. Biceps tenotomy or tenodesis has a role in providing pain relief in massive rotator cuff tears. Tendon transfers offer good results in patients with massive, irreparable rotator cuff tears. The treatment modality specifically chosen for the massive, irreparable rotator cuff tear must be tailored to the individual patient, their needs and expectations, and their ability to comply with intensive rehabilitation.