The Superior Capsular Reconstruction

Lessons Learned and Future Directions

John M. Tokish, MD; Justin L. Makovicka, MD


J Am Acad Orthop Surg. 2020;28(13):528-537. 

In This Article

Abstract and Introduction


The ideal solution for the irreparable rotator cuff tear remains in question. A recent innovative technique, superior capsular reconstruction (SCR), has demonstrated promising results with some early clinical outcomes demonstrating statistically notable improvements in active forward flexion and American Shoulder and Elbow Surgeons scores. Multiple biomechanical studies have also demonstrated its ability to reduce superior translation of the humerus after massive rotator cuff tear. Even so, these results are still early and durability of the reconstruction over time needs to be determined. Although more than 15,000 SCRs have been done worldwide, there remains a paucity of outcome data and one must be vigilant to not allow enthusiasm to overtake critical evaluation. The potential mechanisms of action, including tenodesis effect, force coupler, or subacromial spacer, need further elucidation and the ideal indications for this procedure, as well as its technical optimization, and limitations have yet to be fully determined. The purpose of this review is to critically evaluate the biomechanical and clinical literature that has assessed SCR, along with the controversies and considerations encountered with this procedure.


Massive rotator cuff tears can be devastating problems to patients because they often cause pain and notable losses in range of motion and function that affect quality of life.[1] In severe cases, this loss of function may be profound with complete loss of active shoulder elevation (0°; pseudoparalysis) or some retention of active elevation may remain (<90°; pseudoparesis).[1,2] Even in these cases, shoulder function can be reestablished if complete repair of the torn tendon can be accomplished.[3] By contrast, some massive rotator cuff tears are irreparable and persist as challenging problems for both patients and surgeons alike. These cuff tears remain difficult to treat because of the chronicity of the tear leading to tendon retraction and inelasticity, which limits excursion during attempted repair.[4,5] In addition, with time, the rotator cuff muscles may atrophy and can become infiltrated with fat, which[4–7] contribute to the decreased healing and functional potential seen after primary or revision repair of these conditions.

Treatment options for massive, irreparable rotator cuff tears are dependent on a multitude of factors including the patient's age, activity level, degree of joint arthropathy, and extent of disability caused by the tear.[8] Multiple approaches have been developed to address these tears including partial or complete repair, tendon transfer, and reverse total shoulder arthroplasty (RSA).[1] The partial repair of irreparable rotator cuff tears, popularized by Burkhart, demonstrated improvements in functional outcomes, but the risk of recurrent tear has been found to be as high as 52%.[9,10] Reverse total shoulder arthroplasty has demonstrated satisfactory results in older patients with massive rotator cuff tears; however, results have not been as promising in younger patients. When RSA was done in patients younger than 60 years, Sershon et al[11] found a statistically notable improvement in American Shoulder and Elbow Surgeons (ASES) scores (31 to 66), but reported a failure rate of 25% at 3-year follow-up. In addition, complications seen with this procedure increase when used in younger patients.[12] No one treatment has proven to be an optimal solution, especially in younger, more functionally active patients. In addition, comparison of treatment options is difficult because current literature has not stratified results between pseudoparalytic and pseudoparetic patients, as a patient with pain and true dysfunction is a much more difficult clinical scenario to address than one with preserved function.

One recent approach to massive, irreparable tears that has gained popularity recently is that of superior capsular reconstruction (SCR). Originally described in biomechanical work by Mihata et al[13] in 2012, reconstruction of the superior capsule is proposed as a means to restore the humeral head depressor effect of the capsule, improve the concavity compression effect of the rotator cuff, and help balance force couples between the anterior and posterior cuff structures.[14,15] Several series have since been published on the biomechanical and clinical outcomes after SCR. Early clinical results have demonstrated an almost doubling of active forward flexion and quadrupling of ASES scores.[14] Although these initial results are promising, they are early and some series have cautioned against the use of SCR as a panacea in all cases of irreparable rotator cuff tears.[16] The purpose of this article is to critically evaluate the biomechanical and clinical literature that has assessed SCR, along with the controversies and considerations encountered with this procedure.