QUESTIONS: To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs). DESIGN: Systematic review with meta-analysis of randomised controlled trials (RCTs). PARTICIPANTS: Adults with L-MRCTTs defined as; > 5 cm, 2 or more tendons. INTERVENTION: Exercise as an intervention for L-MRCTTs. OUTCOME MEASURES: Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07 to 0.88, I2 = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9 degree (95% CI 2.16 to 16.22, I2 = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4 to 12). The certainty of evidence was low or very low across all outcomes. CONCLUSION: A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.

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