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Superior Capsular Reconstruction and Subacromial Balloon

Some massive tears of the rotator cuff are so large and associated with such a degree of muscle and tendon degeneration that they are considered damaged beyond repair, also known as irreparable.  Irreparable tears are diagnosed by a combination of imaging findings coupled with an examination of the arm.  Sometimes the diagnosis of an irreparable tear is not clear until the time of surgery where it is seen that the rotator cuff tendon is simply too badly injured to be repaired back to the bone.   If the tear in the rotator cuff is considered irreparable, it is important to know your options because the outcomes of surgery are sometimes not optimal.

What is the Spectrum of Choices for an Irreparable Tear?

Choices for this diagnosis include arthroscopic debridement or partial repair (with or without removing the spur at the top of the shoulder called a subacromial decompression), patch grafting, tendon transfers, and reverse total shoulder replacement.  Partially repairing the tendon can improve pain but has limitations regarding improvement in weakness and motion impairment(1).  Reverse shoulder arthroplasty is not an optimal option for younger patients with irreparable tears, particularly those under the age of 60, with a high failure and complication rate in this population(2).  While older patients can do well with reverse shoulder replacement, the treatment of choice for younger patients with these tears continues to be debated.

What is the Superior Capsular Reconstruction and the Subacromial Balloon?

A procedure called the Superior Capsular Reconstruction (SCR) was introduced in Japan using tissue introduced into the shoulder to supplement and to compensate for the deficient, rotator cuff tendon.  The concept behind this procedure was to sew a tissue that would hold down and center the humeral head which “escapes” or slides up and out of the socket during arm activities(3).  While the results of the original series of patients receiving the SCR in Japan were very favorable, the results in patients undergoing this procedure in North America have been less promising.  Risk factors for doing poorly with the SCR include profound weakness (pseudoparalysis) and a massive tear that involves the front rotator cuff tendon called the subscapularis.  The SCR originally was gaining popularity in the United States but due to overall limited success, unpredictability of functional outcome, and a concerning number of clinical failures, the enthusiasm for the SCR has waned over the last several years as experience with the procedure has gained.   For these reasons, the SCR is being far less commonly in the United States.

Due to the limitations with the SCR, and the persistent challenges with managing the young patient with an irreparable tear, a procedure called the subacromial balloon spacer was introduced in the United States with Food and Drug Administration (FDA) approval in 2021.  The concept behind this device, which is indicated for patients with an irreparable cuff, an intact subscapularis, and ability to lift the arm (not pseudoparalysis), was that by inflating a saline-filled balloon under the acromion, the humeral head could be pushed down into the socket and recentered, thereby improving the pain and functional loss from the irreparable tear.  Despite the initial enthusiasm for this device, enthusiasm has also waned, as recent reports suggesting the balloon spacer is inferior to debridement only in this patient population(4).

Given the Limitations of the SCR and the Subacromial Balloon, Which Procedure Should I Have?

It is important to have a discussion with experienced shoulder surgeon Dr. Thomas Obermeyer regarding your options if you are a young active patient and have been diagnosed with an irreparable rotator cuff tear.  While innovations in shoulder surgery continue to arrive at a fast pace, it is important to know what these procedures can offer in your specific individual circumstances, so you can have realistic expectations about the results of your treatment.  Since Dr. Obermeyer specializes in and offers the entire spectrum of shoulder procedures, he can offer an unbiased opinion about the likelihood of success and help to guide you on which procedure, if any, is best in your case.

Schedule a shoulder consultation

If you’ve suffered a massive rotator cuff tear, we’re here for you. Call our office or book an appointment with shoulder surgeon Dr. Thomas Obermeyer. Dr. Obermeyer specializes in diagnosing and treating massive rotator cuff injuries. Dr. Obermeyer has orthopedic offices in Schaumburg, Bartlett, and Elk Grove Village, Illinois. Dr. Obermeyer regularly sees patients from throughout Illinois including Hoffman Estates, Palatine, Elgin, Streamwood, Arlington Heights, and Roselle communities.


  1. Berth A, Neumann W, Awiszus F, Pap G. Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair. J Orthop Traumatol. 2010 Mar;11(1):13-20. doi: 10.1007/s10195-010-0084-0. Epub 2010 Mar 3. PMID: 20198404; PMCID: PMC2837810.
  2. Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, Verma NN, Romeo AA, Nicholson GP. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg. 2014 Mar;23(3):395-400. doi: 10.1016/j.jse.2013.07.047. Epub 2013 Oct 12. PMID: 24129052.
  3. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012 Oct;40(10):2248-55. doi: 10.1177/0363546512456195. Epub 2012 Aug 10. PMID: 22886689.
  4. Metcalfe A, Parsons H, Parsons N, Brown J, Fox J, Gemperlé Mannion E, Haque A, Hutchinson C, Kearney R, Khan I, Lawrence T, Mason J, Stallard N, Underwood M, Drew S; START:REACTS team. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial. Lancet. 2022 May 21;399(10339):1954-1963. doi: 10.1016/S0140-6736(22)00652-3. Epub 2022 Apr 21. PMID: 35461618.
At a Glance

Dr. Thomas Obermeyer

  • 15+ years of training and experience treating complex shoulder and sports medicine conditions
  • Expert subspecialized and board-certified orthopedic care
  • Award-winning outstanding patient satisfaction scores
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