Diagnostic Value of the Supine Napoleon Test for Subscapularis Tendon Lesions

Diagnostic Performance of Belly-Press Angle in Predicting the Severity of Subscapularis Tear

BACKGROUND

Neglected partial subscapularis tears often cause functional impairment even after repair of the supraspinatus and infraspinatus tear is done. Numerous physical examinations for detecting partial subscapularis tears have been described in previous studies.

PURPOSE

To analyze the relationship between the preoperative clinical features and the severity of a partial subscapularis tear and to provide diagnostic clues for patients requiring subscapularis repair.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This retrospective study included 286 patients who underwent arthroscopic shoulder surgery between 2020 and 2022. Preoperative clinical features, including range of motion, functional scores, muscle strength ratio, modified belly-press test (measuring belly-press angle), and bear-hug test, were collected. Magnetic resonance imaging (MRI) evaluation was done according to the Yoo and Rhee classification. Types of subscapularis tear, supraspinatus lesion, and biceps lesion were recorded during arthroscopic surgery. A comparison of preoperative clinical features between the no-repair group (type 2A or less) and surgical repair group (type 2B or more) was done. The optimal cutoff value of the belly-press angle was determined and the diagnostic performance of the belly-press angle, bear-hug test, and MRI were evaluated using the receiver operating characteristic curve.

RESULTS

Among 286 patients, 189 (66.1%) had subscapularis tears with type 2A or more. There was a significant difference in muscle strength ratio of the belly-press (P < .001), belly-press angle (P < .001), and bear-hug test (P < .001) between the no-repair group (type 2A or less) and the surgical repair group (type 2B or more). With a belly-press angle of 15° as a new cutoff value, the modified belly-press test showed 67.6% sensitivity, 73.9% specificity, and 69.6% accuracy in detecting type 2B or higher subscapularis tear.

CONCLUSION

Patients with type 2A and 2B subscapularis tears (according to the Yoo and Rhee classification) showed differences in belly-press strength ratio, belly-press angle, and bear-hug test. The cutoff value of the 15° belly-press angle showed an accuracy of 69.6% in detecting subscapularis tears with type 2B or higher.

Subscapularis tendon tear classification and diagnosis: A systemic review and meta-analysis

Background

In the current study, we performed a systematic review and meta-analysis regarding the comparison of accuracy, sensitivity, and specificity of the techniques in diagnosing SSC tendon tears. Also, we performed a systematic review of the classification of SSC tendon tears.

Methods

English language, peer-reviewed journal publications from the first date available to March 2022 were extracted by searching PubMed and Web of Science databases. A forest plot was used to graphically show the results of pooled sensitivity, specificity, and accuracy of different diagnostic modalities.

Results

There were six studies on using MRI to diagnose subscapularis tendon tears, five studies on MRI, four studies on clinical examination, one on ultrasonography, and one on CT arthrography. Pooled sensitivity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.71 (CI: 0.54; 0.87), 0.83 (0.77; 0.88), 0.49 (0.31; 0.67), 0.39 (0.29; 0.51), and 0.90 (0.72–0.97), respectively. The pooled specificity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.93 (CI: 0.89; 0.96), 0.86 (0.75; 0.93), 0.89 (0.73; 0.96), 0.93 (0.88; 0.96), and 0.90 (0.69; 0.98), respectively. The pooled diagnostic accuracy values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.84 (CI: 0.80; 0.88), 0.85 (0.77; 0.90), 0.76 (0.66; 0.84), 0.76 (0.70; 0.81), and 0.90 (0.78; 0.96), respectively.

Conclusion

According to our systematic review and meta-analysis, MR arthrography was the most accurate in diagnosing subscapularis tears. MR arthrography was the most sensitive, and MRI and ultrasonography were the most specific in detecting subscapularis tears.

Correlation between preoperative clinical examination and intraoperatively found subscapularis tendon tear

PURPOSE

Analyze the diagnostic value for subscapularis (SSC) tendon tears, their correlation between pain and strength on clinical tests, and compare them with intraoperative arthroscopic findings to prove their diagnostic value.

METHODS

110 consecutive patients undergoing arthroscopic rotator cuff repair were reviewed and allocated to isolated SSC (n = 39) and combined anterosuperior tendon tear (n = 71) groups and analyzed. Preoperative clinical testing included belly press (BPT), bear hug (BHT), lift-off (LOT), palm-up (PUT), and Jobe test (JT). All tests were performed in two categories: pain (in 4 categories: 0, 5, 10, and 15) and strength (from 0 to 5). The tendon tears were intraoperatively reviewed and classified.

RESULTS

Mean age was 59 years (SD 10). The sensitivity of the BHT was 88.2% and 74.5% for BPT, while specificity was only 41.9% for BHT and 45% for BPT. Sensitivity of JT was 90.5% and 87.5% for PUT, while specificity was only 41% for JT and 28.2% for PUT. A low positive correlation for an intraoperative SSC lesion and the strength of BPT (Spearman rank correlation  - 0.425; p value < 0.0001) and the strength of BHT ( - 0.362; p value = 0.001) could be found. With linear regression analysis estimated by ordinary least squares, a correlation between BPT strength and surgical grade of SSC lesion (- 0.528; 95% CI, - 0.923 to - 0.133; pvalue < 0.01) was found.

CONCLUSION

The BHT showed a higher sensitivity for a SSC lesion, while the BPT had a higher correlation between preoperative testing, most notably internal rotation strength, and intraoperative surgical grade of the SSC tendon lesion.

LEVEL OF EVIDENCE

Level II, Prospective cohort study for Diagnostic tests.

The influence of testing positions and resistance locations on muscle activities during shoulder internal rotation strength measurements in young healthy adults

BACKGROUND

Although some tests of shoulder internal rotator strength including subscapularis are commonly used in clinical practice, the differences in shoulder muscle activities other than subscapularis muscle among those tests are not well understood. The purpose of this study was to examine the activities of the superficial shoulder muscles in addition to internal rotation strength during two belly-press and three lift-off test positions.

METHODS

Thirteen healthy young adult men (age 29.5 ± 5.4 years) were recruited for the present study. They performed isometric shoulder internal rotation against manual resistance during the belly-press test positions with two different resistance locations and the lift-off test with three different arm positions. The surface electromyographic activities of the superficial shoulder muscles, including the deltoid (anterior, middle, posterior), pectoralis major, long head of triceps and latissimus dorsi muscle, were collected and compared between the two belly-press tests, and among the three lift-off test positions (P < 0.05).

RESULTS

The belly-press test position with resistance to elbow showed significantly greater activities of the anterior and middle deltoid muscle than the original belly-press test; but showed significantly smaller activities of pectoralis major, triceps and latissimus dorsi muscle than the original belly-press test. Among the three lift-off tests, all muscle activities, except for the pectoralis major, were greater in the lift-off at L4/5 than in the lift-off at buttock and thigh. Lift-off at thigh showed significantly smaller activity of pectoralis major than the lift-off at L4/5 and buttock.

CONCLUSIONS

The findings of the present study suggest that clinician should give attention to compensatory motions by excessive shoulder extensor and adductor muscle activities for the original belly press test, by excessive deltoid muscle activities for the modified belly-press, and by excessive shoulder extensor muscle activities for the lift off test in the inferior arm positions.

The scissors sign: a provocative test for detecting the leading-edge tear of subscapularis tendon: a diagnostic study

BACKGROUND

Several physical examination tests and signs have been described to aid in the diagnosis of subscapularis (SSC) tear, but have limitations and variable sensitivity. This study aimed to introduce a novel test for detecting a leading-edge tear of the subscapularis (LETS), the most important tendinous portion of SSC.

METHODS

A total of 233 patients who underwent arthroscopic repair for anterior and superior cuff tears between January 2018 to September 2019 were retrospectively reviewed. The provocative test we have coined as the "scissors sign" and the other related clinical tests (i.e., belly press, belly off, Napoleon, lift off, internal rotation lag, bear hug tests) were performed preoperatively. Whether the patient has a LETS or the complete tear of the SSC (CTS) was confirmed by arthroscopic findings. Sensitivity, specificity, and areas under the receiver operating characteristic curve were calculated for each test.

RESULTS

In patients who had LETS with or without supraspinatus tear, the scissors sign showed the highest sensitivity (91.4%) with a specificity of 81.6%, positive predictive value (PPV) of 80.2%, and negative predictive value (NPV) of 92.1%. In patients with isolated LETS, the scissors sign also showed the highest sensitivity (90.3%) with a specificity of 81.6%, PPV of 57.1%, and NPV of 96.8%. The scissors sign for the complete tear of the subscapularis (CTS) with or without supraspinatus tear and the isolated CTS had a sensitivity of 73.1 and 75%, respectively.

CONCLUSIONS

The scissors sign is a novel provocative test that can be helpful in the diagnosis of subscapularis tears, especially LETS, with its high sensitivity and diagnostic accuracy. In combination with other tests, the scissors sign will be a good screening tool.

Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis

Background:

Previous systematic reviews and meta-analyses on the diagnostic accuracy of shoulder clinical tests do not reach conclusions regarding subscapularis tears.

Purpose:

To compare the diagnostic accuracy of commonly used clinical tests for subscapularis tears.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

An electronic literature search was conducted using Medline, Embase, and the Cochrane Library/Central. Eligibility criteria were original clinical studies reporting the diagnostic accuracy of clinical tests to diagnose the presence of rotator cuff tears involving the subscapularis.

Results:

The electronic literature search returned 2212 records, of which 13 articles were eligible. Among 8 tests included in the systematic review, the lift-off test was most frequently reported (12 studies). Four tests were eligible for meta-analysis: bear-hug test, belly-press test, internal rotation lag sign (IRLS), and lift-off test. The highest pooled sensitivity was 0.55 (95% CI, 0.28-0.79) for the bear-hug test, while the lowest pooled sensitivity was 0.32 (95% CI, 0.13-0.61), for the IRLS. In all tests, pooled specificity was >0.90.

Conclusion:

Among the 4 clinical tests eligible for meta-analysis (bear-hug test, belly-press test, IRLS, and lift-off test), all had pooled specificity >0.90 but pooled sensitivity <0.60. No single clinical test is sufficiently reliable to diagnose subscapularis tears.

Registration:

PROSPERO (CRD42019137019).

The Diagnostic Value of Subscapularis Clinical Tests in the Postoperative Diagnosis of Subscapularis Retears: An Ultrasound-Comparative Trial

Background:

Different physical examination tests have been used to preoperatively determine both the presence and size of a primary subscapularis tear. On the contrary, no clinical trial has yet been published to assess the diagnostic validity of the aforementioned tests in diagnosing subscapularis retears after arthroscopic subscapularis repair.

Objective:

To investigate the diagnostic value of the most commonly used clinical tests in the diagnosis of subscapularis tendon retears after arthroscopic repair.

Methods:

A retrospective (prospectively collected data) case series involving 37 patients who were suffering from symptomatic complete subscapularis tendon tear was conducted. All patients underwent an all-arthroscopic subscapularis repair with the same operative technique. They were postoperatively evaluated (final end point of follow-up: 12 months) with the use of ultrasound, Constant-Murlay score (CS), bear hug test, internal rotation lag sign, Napoleon test and lift-off test. Sensitivity, specificity, accuracy, positive and negative prognostic values were calculated for each test.

Results:

Shoulder function was significantly improved according to the final CS. The internal rotation lag sign was the most sensitive for the diagnosis of postoperative subscapularis retears, while the Napoleon sign had the highest specificity. Although postoperative clinical tests yielded no false negative findings, they were poorly predictive as for new ruptures. Ten patients (27%), who were found with a positive (for re-rupture), postoperative, clinical test, had a sonographically intact subscapularis tendon repair.

Conclusion:

We strongly support the use of subscapularis-specific clinical tests as a composite, in combination with a specific interpretation of their results. If all tests are found negative for retear, then we could assume that the arthroscopic repair remains intact and no further diagnostic examination might be necessary. On the contrary, if at least one subscapularis-specific clinical test is positive for retear, then the patient will likely require additional imaging control for definite diagnosis.

Diagnostic performance of clinical tests for subscapularis tendon tears

PURPOSE

Tears of the subscapularis (SSC) tendon constitute a diagnostic challenge. The purpose of the present study was to evaluate the diagnostic capabilities of five clinical SSC tests.

METHODS

Five established clinical tests were evaluated in 106 consecutive patients prior to shoulder arthroscopy. The tests included the Lift Off Test, Internal Rotation Lag Sign, Belly Press Test, Belly Off Sign, and Bear Hug Test. The integrity of the SSC tendon at surgery was used as the gold standard. Lesions to the SSC were graded according to Fox and Romeo.

RESULTS

There were 32 SSC lesions accounting for an incidence of 30.2%. The sensitivity for all tests was 0.66, while the specificity was 0.82. For all tests, positive tests results were found to be dependent on subscapularis integrity (p < 0.001, respectively). The sensitivity for any type of SSC lesion for the Lift Off Test, Internal Rotation Lag Sign, Belly Press Test, Belly Off Sign, and Bear Hug Test was 0.35, 0.41, 0.34, 0.31, and 0.52, respectively. Specificity was found to be 0.98, 0.91, 0.96, 0.97, and 0.85, respectively. If only grade 2-4 tears were analysed, sensitivity was 0.32, 0.42, 0.37, 0.37, and 0.72 and specificity 0.94, 0.86, 0.92, 0.94, and 0.84. A positive correlation was found between the number of positive tests and the severity of the SSC lesions.

CONCLUSION

In the present study, the Bear Hug Test was found to have the highest sensitivity of all tests studied, especially for tears of the upper tendon border. It appears advisable to perform more than one clinical subscapularis test to further improve sensitivity. Nevertheless, SSC tears may still escape clinical recognition. Therefore, a high index of suspicion has to be maintained in order not to miss SSC tears.

LEVEL OF EVIDENCE

Diagnostic study, Level I.