Diagnosing a Subscapularis Tear
Reference:Barth JR et al. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006Oct;22(10):1076-84.
Have you ever wondered if a patient post anterior dislocation has a subscapularis tear? If they do, they ideally should get an MRI and perhaps have arthroscopic surgery to repair the tear.
Here are 4 clinical tests that have pretty good diagnostic accuracy for detecting or excluding subscapularis tears.
Test #1: The “lift off” Test
The back of the hand is placed behind in the mid-lumbar spine and the patient is asked to lift the hand off the back. The test is considered positive if the patient is unable to lift the hand off the back or cheats by extending the shoulder. (I personally like to manually resist the “lift off” test.)
A positive “lift-off” test is not found until at least 75% of the subscapularis is torn with 100% specificity (Barth et al. 2006).
Test #2: The “Napoleon” Test
This test is named after Napoleon the French dictator as it involves being in the same position he held his hand for portraits. The patient is asked to push his/her hand into their belly and a test is negative if the wrist is maintained straight. A test is positive if the wrist flexes more than 30⁰.
A positive Napoleon test indicates that greater than 50% of the subscapularis is torn with 98% specificity (Barth et al. 2006).
Test #3: The “Belly Press” Test
The test is exactly as it sounds. It is the same as the Napoleon pose, where the patient is asked to push their palm into their stomach, but this time instead of just observation of the wrist position, the relative strength into internal rotation is measured and compared to the asymptomatic side.
A weak belly-press test suggests a tear of at least 30% of the subscapularis with 98% specificity (Barth et al. 2006).
Test #4: The “Bear-Hug” Test
The patient places his/her open palm on top of the opposite shoulder with the elbow positioned anterior to the body. The PT stands in front of the patient and attempts to pull the hand directly up and off the shoulder. The relative strength into internal rotation is measured and compared to the asymptomatic side.
Of the above tests, the “Bear-Hug” test has the highest sensitivity at 60% (Barth et al. 2006). In other words if the “Bear Hug” test is negative you may rule out a subscapularis tear.
Clinical Relevance: For a patient post anterior shoulder dislocation, assess the “Bear-Hug” test and the “Lift off” test and if both are positive, the patient is likely to have a subscapularis tear and so an MRI is indicated.
If a patient has a negative “Bear-Hug”, “Lift-off” and “Belly press” test, he/she likely does not have a significant subscapularis tear, no need for an MRI as they are not likely a surgical candidate.
Posted on: July 04, 2013
Categories: Shoulder
