The surgical management of rotator cuff (RC) tears has progressed considerably in recent decades. Arthroscopic procedures now represent the mainstay of contemporary treatment approaches. The success of repair is predicated upon the achievement of a secure, durable repair that promotes tendon-to-bone healing. Both single and double row (DR) suture anchor configurations have been described to achieve stable fixation. Although consensus is lacking with regard to the clinical superiority of one configuration over another, trends in the literature suggest that DR repairs may optimize the likelihood of tendon healing and restoration of shoulder strength. In cases of truly irreparable RC tears, superior capsular reconstruction is a promising alternative to open tendon transfer and arthroplasty procedures. The purposes of this concise review are to: (1) explain our preference for a DR repair configuration in almost all circumstances; and (2) advocate superior capsular reconstruction as a viable treatment tactic for truly irreparable RC tears in the absence of significant glenohumeral arthritis.