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Minimally invasive arthroscopic techniques for rotator cuff tears have been greatly advanced during the past decade. It is important to review the clinical presentation and common physical findings of a large or massive rotator cuff tear, essential preoperative imaging, and the principles and technical aspects of all-arthroscopic repair. An anatomic repair of the footprint must begin with an understanding of the three-dimensional morphology of the rotator cuff tear and an accurate reduction of the tear. A contracted, immobile massive rotator cuff tear is challenging. Advanced arthroscopic mobilization techniques and margin convergence principles may allow repair of an otherwise irreparable tear. Failure of tendon healing is common but can be minimized by using dual-row, transosseous-equivalent techniques. A relatively slow rehabilitation program is paramount to protect the repair. The result of using arthroscopic techniques for a large or massive rotator cuff tear is comparable to that of a traditional open repair. Pain relief has been a far more reliable result than gains in function or strength.