Although many definitions have been used to define massive rotator cuff tears, a tear is generally considered massive if it is greater than 5 cm in diameter. Most massive rotator cuff tears are chronic, and patients commonly present with an insidious onset of gradually worsening pain and weakness in the involved shoulder. In rare situations, patients without preexisting rotator cuff disease may experience an acute injury and present with a massive rotator cuff tear. A thorough history and physical examination is important to establish the diagnosis and determine the most appropriate treatment. Because most massive rotator cuff tears are chronic in nature, the quality of the underlying rotator cuff tissue is often poor, making repair difficult. Other treatment options include physical therapy, biceps tenotomy or tenodesis, suprascapular nerve release, rotator cuff repair with tissue augmentation, tendon transfer, and reconstruction with hemiarthroplasty or reverse shoulder arthroplasty. Integrating findings from the history, physical examination, and diagnostic imaging is the basis of clinical decision making.