**1. Introduction**

Rotator cuff tears affect millions worldwide; given their age-dependent increase in prevalence, they pose a significant healthcare burden on today's aging population [1]. Chronic large to massive rotator cuff tears are often considered "irreparable" secondary to poor tissue quality, tendon retraction, and muscle atrophy and fatty infiltration [2]. Surgical options

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for treatment of these tears have not demonstrated consistently good outcomes [2–4]. These include attempts at relieving pain by way of debridement with or without biceps tenotomy; balancing the anterior/posterior force couples by way of partial repair; restoring cuff integrity by way of interpositional grafting; and tendon transfers. Reverse shoulder arthroplasty has been gaining popularity and demonstrates good outcomes as a treatment option for patients with rotator cuff arthropathy, but is typically reserved for the elderly patients. Massive and irreparable rotator cuff tears in younger and more active individuals, especially without significant arthritic changes of the glenohumeral joint, remain a clinical conundrum.

Recently, a new surgical procedure called superior capsular reconstruction (SCR) was described by Mihata et al., who reported promising short-term clinical outcomes in 24 shoulders (23 consecutive patients) with symptomatic irreparable rotator cuff tears [2]. Although the procedure has a strong appeal for physicians treating patients with this difficult problem and has been quickly gaining popularity, caution regarding widespread use is warranted, as large-scale and long-term data is still lacking. This chapter reviews the anatomy and function of the rotator cuff and shoulder capsule; patho-etiology of rotator cuff tears; and rationale, techniques, outcomes, and future direction of superior capsule reconstruction for irreparable tears.
