Rotator cuff (RC) repair is a common procedure, which provides high patient satisfaction. Despite advances in surgical techniques, the RC repair failure rate is still high. Alterations in glenohumeral and scapulothoracic kinematics and a decreased acromiohumeral distance are related to an inferior clinical outcome after RC repair. To evaluate the reparability of large and massive RC tears, several factors should be taken into account. Patients’ age, comorbidities, and poor tendon and muscle quality lead to higher failure rates. If fatty infiltration grades 3 and 4 according to Goutallier and significant muscle atrophy and tear gaps of >3.5 cm with contracted and immobile tendons are present, an RC tear should primarily be considered as not repairable. In such cases, a partial repair or a tendon transfer technique is recommended. However, if patients have an advanced cuff arthropathy with acetabularization and glenohumeral osteoarthritis, an inverse shoulder arthroplasty could be performed instead of an RC repair.