Subacromial Balloon Spacer
Original Editor - Jessica Galasso
Top Contributors - Emily McPherson, Jessica Galasso, Vidya Acharya and Alexandra Stead
Introduction
Subacromial balloon spacers are a relatively recent intervention for patients with massive irreparable rotator cuff tears.[1] [2] This minimally invasive surgical technique was first described in 2012.[3] The surgical procedure of a subacromial balloon spacer is typically performed arthroscopically through the lateral shoulder.[3] The goal of the spacer is to decrease pain and improve function by decreasing friction in the subacromial space by depressing the humeral head.[1][3] The balloon spacer is biodegradable after about 6-12 months.[3][4]
There is no gold standard treatment in this patient population so interventions must be selected based on factors such as tear characteristics and patient goals.[1] [3][4] Some research indicates limited clinical benefit as compared to shoulder debridement, so a thorough history and discussion with a surgeon is important.[5][6] Other interventions for massive irreparable rotator cuff tears include nonoperative treatment or operative management such as subacromial decompression, partial tendon repairs, biceps tenodesis, and reverse total shoulder arthroplasty.[3]
Indication for Use
Subacromial balloon spacers are indicated in individuals with massive irreparable rotator cuff tears.[2][3] A massive rotator cuff tear is considered a tear ≥5 cm or involving 2 or more tendons.[3] Irreparable rotator cuff tears will have fatty infiltration into 50% or greater of the musculature, static superior migration of the humeral head, and a decreased or absent acromiohumeral interval.[3][7] Typical MRI findings in candidates for a subacromial balloon spacer include a full-thickness supraspinatus tear with a partial-thickness infraspinatus tear.[8]
The subacromial balloon spacer can be used in younger patients to allow for additional time before a more radical procedure is performed, like shoulder arthroplasty.[7] In individuals that are not appropriate for extended procedures, the balloon spacer can be a terminal intervention.[7] Some research suggests that subacromial balloon spacer should only be considered in elderly patients as outcomes are similar to that of shoulder debridement.[5][6]
It is important to select appropriate individuals when considering a subacromial balloon spacer. Individuals with reparable rotator cuff tears, axillary nerve palsy, advanced glenohumeral arthritis, irreparable subscapularis tears, active infections, and those with allergies to the device materials would not be appropriate candidates for the subacromial balloon spacer.[8]
Clinical Presentation
Clinically, patients must have an intact subscapularis and teres minor and have appropriate deltoid muscle function.[8] Appropriate patients will report primary complaint of pain and the ability to perform forward elevation to 90°.[8][9]
The subacromial balloon spacer functions to restore normal biomechanics to the shoulder.[2][8] The spacer depresses the humeral head so that it has a more centralised position in the glenoid cavity.[7] This restores the coupling forces between the subscapularis and teres minor, as well as improves the function of the deltoid.[7][8] This improves abduction and pain-relief by reducing impingement. The balloon spacer also reduces friction, redistributes forces, and facilitates smooth gliding of the humeral head.[7]
Diagnostic Tests
MRI and X-rays are typically used to determine diagnosis and extent of shoulder damage.[8] This will assist with determining the appropriate intervention is for the patient.
Rehabilitation Considerations
Rehabilitation is commonly performed both before and after surgery. Listed below are the considerations for physical therapy both pre- and post-operatively.
Pre-Op
Many patients will undergo physical therapy prior to deciding to have surgery.[10] Physical therapy focuses on improving range of motion and decreasing pain.[11] Despite tears on imaging, many individuals will demonstrate clinical improvements and improved functional outcomes.[10] However, tear pattern is an important consideration in whether physical therapy will be successful.[10] Other conservative treatments include corticosteroid injections.[9] If conservative interventions fail, then the patient will undergo a surgical consult to discuss what the best course of action is for that individual patient.[3]
Post-Op
As subacromial balloon implantation is minimally invasive, rehabilitation afterwards tends to be well tolerated. After surgery, the spacer remains inflated for 6-12 months.[3][7] This allows for the retraining of the muscles around the shoulder joint to improve muscle balance and biomechanics.[7]
Complication rates range from 2-16.7%.[7] The most common complication is spacer migration.[7] The most common next surgical intervention is a reverse total shoulder arthroplasty.[7]
There is currently no standard rehabilitation protocol for optimal management of a post-operative subacromial balloon spacer. The physical therapist should always discuss surgical precautions with the referring physician. A general protocol is provided below. Always check with your referring surgeon on specifics for each individual patient.
Phase I (Day 0-4 weeks):
- Use of immobilising sling for 10-14 days[8][10]
- Modalities as needed
- Passive range of motion (PROM) to promote mobility and decrease stiffness at 2-4 weeks[8]
Phase II (4-6 weeks):
- Active-assisted range of motion (AAROM) and active range of mion (AROM) exercises to maximize range of motion[8]
- Gradual reintroduction of operative arm in activities of daily living (ADLs)[8]
- Isometric exercises of shoulder[10]
Phase III (6-12 weeks):
- Dynamic strengthening with emphasis on deltoid, rotator cuff, and periscapular musculature at 6-8 weeks[8][10]
Phase IV (12+ weeks)
Summary
A subacromial balloon spacer can be a useful tool for those with massive, irreparable rotator cuff tears in order to improve their function and decrease pain.[1][3] The spacer degrades after about 6-12 months, which allows time for retraining the shoulder musculature.[7] Frequently, the spacer is used to improve function prior to another surgery, but it can also be used as a terminal intervention.[7] Consideration of all factors is important as some research indicates little benefit of the subacromial balloon spacer when compared to shoulder debridement.[5] [6] Physical therapy is typically performed both before and after surgery in order to maximize strength and range of motion.[8] [10]
References
- ↑ 1.0 1.1 1.2 1.3 Wright MA, Abboud JA, Murthi AM. Subacromial balloon spacer implantation. Current Reviews in Musculoskeletal Medicine. 2020 Oct;13(5):584-91.
- ↑ 2.0 2.1 2.2 Piekaar RS, Bouman IC, Van Kampen PM, Van Eijk F, Huijsmans PE. Early promising outcome following arthroscopic implantation of the subacromial balloon spacer for treating massive rotator cuff tear. Musculoskeletal surgery. 2018 Dec;102(3):247-55.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Stewart RK, Kaplin L, Parada SA, Graves BR, Verma NN, Waterman BR. Outcomes of subacromial balloon spacer implantation for massive and irreparable rotator cuff tears: a systematic review. Orthopaedic Journal of Sports Medicine. 2019 Oct 11;7(10):2325967119875717.
- ↑ 4.0 4.1 Johns WL, Ailaney N, Lacy K, Golladay GJ, Vanderbeck J, Kalore NV. Implantable subacromial balloon spacers in patients with massive irreparable rotator cuff tears: a systematic review of clinical, biomechanical, and financial implications. Arthroscopy, sports medicine, and rehabilitation. 2020 Dec;2(6):e855-72.
- ↑ 5.0 5.1 5.2 Albishi W, Alanezi M, Alnasser N, Murrad K, Elansary E, Alaseem A. Limited Clinical Benefit of the Subacromial Balloon Spacer in Massive Irreparable Rotator Cuff Tears: A Comprehensive Review of Clinical Outcomes and Cost-Effectiveness. Jbjs Reviews. 2026 Feb 25;14(2):e25-00231.
- ↑ 6.0 6.1 6.2 Haque A, Parsons H, Parsons N, Mason J, Khan I, Stallard N, Underwood M, Hutchinson C, Lawrence T, Drew S, Kearney R. Two-year follow-up of a group-sequential, multicenter randomized controlled trial of a subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START: REACTS). The American Journal of Sports Medicine. 2025 May;53(6):1291-8.
- ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 Knapik DM, Williams BT, Verma NN. Balloon spacers in the management of massive rotator cuff tears: a focus on clinical outcomes. Annals of Joint. 2021 Apr 15;6.
- ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 Boufadel MP, Khanna BA, Suarez MJ, Stadler BR, Fares MM, Abboud MJ. The subacromial balloon spacer: Adhering to indications and clinical outcomes. Journal of Hand and Microsurgery. 2025 Sep 1;17(5):100330.
- ↑ 9.0 9.1 Dasari SP, Khan ZA, Swindell HW, Mehta N, Kerzner B, Verma NN. Subacromial balloon spacer: indications, rationale, and technique. JBJS Essential Surgical Techniques. 2022 Jun 20;12(2):e21-00069.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Sewpaul Y, Sheean AJ, Rashid MS, Hartzler RU. Subacromial balloon spacer for the massive irreparable cuff tear. Current Reviews in Musculoskeletal Medicine. 2024 Feb;17(2):47-57.
- ↑ Yallapragada RK, Apostolopoulos A, Katsougrakis I, Selvan TP. The use of a subacromial spacer-inspace balloon in managing patients with irreparable rotator cuff tears. Journal of Orthopaedics. 2018 Sep 1;15(3):862-8.