Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review

Context: There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making.

Objective: To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology.

Data sources: PubMed, MEDLINE, Ovid, and Cochrane Reviews databases.

Study selection: Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination.

Study design: Systematic review.

Level of evidence: Level 2.

Data extraction: Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities.

Results: A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21).

Conclusion: The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

Keywords: diagnosis; physical examination; rotator cuff; shoulder examination; special tests; subscapularis.