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Most studies of rotator cuff repairs report high success rates. However, the majority of these studies combine the results of surgical management of rotator cuff tears of various sizes; few published reports specifically evaluate the management of chronic massive tears. Chronic massive rotator cuff tears may be acute traumatic, chronic atraumatic, or acute-on-chronic. A detailed history and thorough physical examination often are sufficient to establish the diagnosis. Radiographic evaluation can reveal osseous changes suggestive of pathology. Magnetic resonance imaging can determine the size of rotator cuff tears and status of the muscles but generally is not necessary for patients who are not candidates for surgery. Chronic massive rotator cuff tears without glenohumeral arthritis can be managed nonsurgically or with subacromial débridement, rotator cuff repair, or rotator cuff reconstruction. However, treatment of these patients is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears.