Abstract
Purpose
To investigate the performance of the bear hug (BH) and belly press (BP) tests in diagnosing tears of the subscapularis (SSC).
Methods
A retrospective review was conducted on prospectively maintained data on patients who underwent arthroscopic rotator cuff repair (ARCR) of SSC tears between 2011 and 2021. A control group also was obtained of ARCRs with an intact SSC tendon. All examinations and ARCRs were performed by one high-volume shoulder surgeon. The BH test and BP test results were compared with arthroscopic findings as the gold-standard diagnostic modality. Tear type was classified based on the Lafosse classification. Sensitivity, specificity, positive and negative predictive values, false-positive and false-negative rates, and accuracy were calculated for both tests.
Results
A total of 1,122 patients were included for analysis, 866 with intraoperatively confirmed SSC tears (77%) and 256 without (23%). The BH test diagnosed SSC tears with a sensitivity of 46.1% and a specificity of 83.2%, whereas the BP test diagnosed tears with a sensitivity of 23.3% and a specificity of 93.4%. Overall, both tests missed SSC tears in 42.3% (n = 475) of cases. The BH test had accuracy rates of 25.9% for SSC type I tear, 48.7% for type II tear, 65% for type III tear, and 81.7% for type IV-V tear. In contrast, the BP test had accuracy rates of 7.6% for type I tear, 14.7% for type II tear, 42% for type III tear, and 68.7% for type IV-V tear.
Conclusions
The BH test had greater sensitivity than the BP test in identifying SSC tears. Both tests showed low accuracy in identifying SSC tears as tear size decreased. Combining both tests did not provide any additional benefits over using the BH test alone.
Level of Evidence
Level III, diagnostic study.
The subscapularis (SSC) muscle is the strongest of the 4 rotator cuff muscles and is responsible for internal rotation and stabilization of the humeral head.1, 2, 3, 4 Although SSC tendon tears are less common than other rotator cuff tears, their recognition has increased since the advent of arthroscopy. Compared with the other rotator cuff tendons, physical examination tests and imaging modalities are not as accurate for preoperative diagnosis of SSC tears.5, 6, 7
Several maneuvers have been described to detect SSC tears, including the lift-off,8 internal rotation lag sign,9 belly press (BP),4 and bear hug (BH) tests.10, 11, 12 However, their sensitivities can vary significantly, and they may not always accurately diagnose the condition.13 The BH and BP test are used frequently in clinical practice, but limited high-quality studies have been conducted to investigate their diagnostic accuracy.10,14, 15, 16, 17, 18, 19 Moreover, the available studies evaluating these tests were conducted with small patient cohorts, highlighting the need for further investigation with larger sample sizes to determine their true diagnostic performance.
The purpose of this study was to investigate the performance of the BH and BP tests in diagnosing tears of the SSC. We hypothesized that the accuracy of the BH and BP tests for diagnosing SSC tears would decrease with smaller tears.
Methods
Study Design
A retrospective review was conducted on prospectively maintained data of patients who underwent arthroscopic rotator cuff repair (ARCR) at a single center between 2011 and 2021. The inclusion criteria were a preoperative physical examination documenting the BH and BP tests and an arthroscopically confirmed SSC tendon tear of any size. Patients were excluded if there was a history of previous ipsilateral shoulder surgery, proximal humerus fracture or glenoid fracture, adhesive capsulitis, inability to participate in the physical examination, or incomplete intraoperative documentation. This study has been exempted by the local ethical committee (approval date: June 1, 2023).
Physical Examination Tests
One high-volume fellowship-trained shoulder surgeon (P.J.D.) conducted all of the physical examination tests (i.e., BH and BP) at the time of the appointment before interpreting a magnetic resonance imaging (MRI). The BP test4 was conducted with the patient’s arm at the side and the elbow flexed, with the patient internally rotating the shoulder to press the palm into his or her abdomen. The test was considered positive if the palm was easily lifted from the abdomen or if the hand remained on the belly while flexing the wrist.
To conduct the BH test,10 the patient’s palm was placed on the opposite shoulder with the fingers extended, the arm forward flexed 45°, and the elbow positioned anterior to the body to prevent the patient from grabbing the shoulder. Next, the physician applied an external rotation force perpendicular to the forearm while the patient resisted by holding the position (i.e., resisted internal rotation). A positive result was indicated when the position was not maintained or there was a wrist break. Conversely, a negative result was recorded if the position was preserved, strength was similar to the opposite side, and no pain was experienced.
To compare physical examination tests (i.e., BH and BP), a group of patients without SSC tears were selected as a control group. When combining tests, the BH and BP tests were calculated as “positive” when at least one test was positive, and “negative” if both of tests were negative. These tests were extracted from the medical records and correlated with intraoperative arthroscopic findings.
Surgical Technique and Arthroscopic Findings
All arthroscopic procedures were performed by a single surgeon (P.J.D.). Patients were positioned in the lateral decubitus position, and conventional portals were used (i.e., posterior, anterosuperior and lateral). SSC tendon integrity was evaluated with 30° and 70° arthroscopes inserted through the posterior portal. Intraoperatively, SSC tear type was documented according to the Lafosse classification20,21 and SSC tear size as a percentage (i.e., % cephalad to caudal). The Lafosse classification divides tears as partial (i.e., type I), upper-border full thickness (i.e., type II-III), and complete (i.e., type IV-V).22, 23, 24 In addition, supraspinatus and infraspinatus tear types (i.e., intact, partial, or full), and long head biceps tendon (LHBT) integrity (i.e., intact, subluxated, partial tear, or completed tear) were reported.20,21
Statistical Analysis
A power analysis was performed with the sensitivity and specificity rate using the GPower 3.1 program, with the following parameters: BH test sensitivity was 0.52-0.74 and specificity was 0.80-0.99, α error probe of 0.05, and a power (1 – β) of 0.957.10,15,16,19 A minimum sample size of 210 was determined, in comparison with 866 patients with SSC tears. Therefore, a control group of 256 patients that had undergone ARCR but had an intact SSC tendon was randomly selected from the same study period. Categorical data were described using absolute and proportional frequencies. Arthroscopy was used as the gold-standard for accuracy and to determine sensitivity, specificity, and positive and negative predictive values. Receiver operating characteristic curves were plotted to calculate clinical test performance in distinguishing the presence or absence of SSC tears. The area under the receiver operating characteristic (AUROC), which ranges from 0.50 to 1.0, was used as a measure of discrimination. Although an AUROC of 0.50 indicates a test performance no better than chance, an AUROC of 1.0 indicates perfect discrimination.25,26 The Cohen kappa coefficient was used to measure intertest reliability for qualitative, or categorical, variables. The study used the Cohen kappa test, a 2 × 2 contingency test, to evaluate the agreement between the BH test and BP test, BH test and arthroscopic findings, and BP test and arthroscopic findings for both intact and torn tendons. The Cohen kappa coefficient was used to interpret the results, with values ≤0 indicating no agreement to 0.81-1.00 indicating nearly perfect agreement. The study also employed backward model binary logistic regression to analyze the ability of the BH test and BP test to diagnose intact (coded as 0) and tear (coded as 1) tendons, with independent variables including age, sex, body mass index (BMI), duration of symptoms, dominant side, LHBT pathology, and rotator cuff integrity. The SPSS 25 program (IBM Corp., Armonk, NY) was used to evaluate the data. A threshold of .05 was used to denote statistical significance.
Results
A total of 2,480 ARCRs were performed during the study period, of whom 866 patients met the study criteria for the SSC group. The control group comprised 256 patients with an intact SSC. Baseline characteristics of the 2 cohorts are summarized in Table 1. In the SSC tear cohort, there were partial tears in 42.7% (n = 370) of cases and associated full-thickness posterosuperior cuff tears in 41.7% (n = 468) of cases. As compared with patients with intact SSC, there were more massive cuff tears in the SSC tear cohort (29.6% vs 22.6%; P < .001).
Table 1.
Descriptive Analysis of Patients With Intact Versus Torn Subscapularis Tendons
| Patients With Intact SSC, n = 256 | Patients With SSC Tendon Tear, n = 866 | P Value | |
|---|---|---|---|
| Age, y | .005∗ | ||
| Median | 61 | 62 | |
| Range | 20-82 | 31-88 | |
| Sex | <.001† | ||
| Male | 132 (51.6%) | 586 (67.6%) | |
| Female | 124 (48.4%) | 280 (32.3%) | |
| BMI ± SD | 29.7 ± 5.7 | 29.2 ± 5.6 | .190‡ |
| Dominant | .051† | ||
| Yes | 158 (61.7%) | 591 (68.2%) | |
| No | 98 (38.3%) | 275 (31.8%) | |
| Duration of symptoms, mo | <.001∗ | ||
| Median | 12 | 8 | |
| Range | 1-240 | 0.25-180 | |
| Intact posterosuperior cuff | N/A | 137 (15.8%) | <.001† |
| Partial posterosuperior cuff tear | 59 (23%) | 144 (16.6%) | |
| Full-thickness posterosuperior cuff tear | 139 (54.3%) | 329 (38%) | |
| Massive rotator cuff tear | 58 (22.7%) | 256 (29.6%) | |
| LHBT intact | 130 (50.8%) | 231 (26.7%) | <.001† |
| LHBT subluxation or dislocation | 31 (12.1%) | 198 (22.9%) | |
| LHBT partial tear | 84 (32.8%) | 302 (34.9%) | |
| LHBT complete or retracted tear | 11 (4.3%) | 135 (15.6%) | |
| Mean size of torn SSC tendon (% cephalad to caudal) | N/A | 49.9% | |
| Intact SSC tendon | 256 | N/A | |
| Partial SSC tear | N/A | 370 (42.7%) | |
| Full-thickness upper border SSC tear | N/A | 381 (44%) | |
| Complete SSC tear | N/A | 115 (13.3%) |
BMI, body mass index, LHBT, long head biceps tendon, N/A, not applicable; SD, standard deviation; SSC, subscapularis.
Mann–Whitney U test.
χ2 test.
Independent t test.
The BH test had a sensitivity of 46.1% and specificity of 83.2% for diagnosing SSC tears, whereas the BP test had a sensitivity of 23.3% and specificity of 93.4%. The test combination had a sensitivity of 46.7% and specificity of 81.6%. The AUROC curves for the BH test, BP test, and test combination were 0.65 (95% confidence interval [CI] 0.61-0.68), 0.58 (95% CI 0.55-0.62), and 0.64 (95% CI 0.61-0.68), respectively (Table 2). As tear size increased, the accuracy of diagnosis improved, with the BH test detecting 25.9% of partial tears and 81.7% of complete tears, the BP test detecting 7.6% and 68.7%, and the combination of both tests detecting 26.2% and 82.6%, respectively (P < .001) (Table 3). The overall the rate of missing SSC tears in both tests was 42.3% (n = 475). Combining both tests did not provide any advantages over using the BH test alone (P = .5).
Table 2.
Diagnostic values of Bear Hug Test, Belly Press Test, and Test of Combination for Detecting Subscapularis Tears
| Bear Hug∗ | Belly Press† | Test Combination | Cohen Kappa, P Value | |
|---|---|---|---|---|
| Sensitivity | 46.1% (399/866) | 23.3% (202/866) | 46.7% (404/866) | <.001 |
| Specificity | 83.2% (213/256) | 93.4% (239/256) | 81.6% (209/256) | <.001 |
| Positive predictive value | 90.3% (399/442) | 92.2% (202/219) | 89.6% (404/451) | <.001 |
| Negative predictive value | 31.3% (213/680) | 26.5% (239/903) | 31.1% (209/671) | <.001 |
| Accuracy | 54.5% (612/1122) | 39.3% (441/1122) | 54.6% (613/1122) | <.001 |
| False-positive rate | 16.8% (n = 43) | 6.6% (n = 17) | 18.4% (n = 47) | |
| False-negative rate | 53.9% (n = 467) | 76.7% (n = 664) | 53.3% (n = 462) | |
| AUROC curve | 0.646 (95% Cl 0.610-0.682) | 0.583 (95% Cl 0.546-0.620) | 0.641 (95% Cl 0.605-0.678) |
NOTE. Test of combination versus bear hug test versus belly press test Cochran’s Q test 282.04, P < .001. Pairwise comparisons: test of combination versus bear hug test, P = .478; test of combination versus belly press test, P < .001; bear hug test versus belly press test, P < .001.
AUROC, area under the receiving characteristic curve; CI, confidence interval.
Bear hug test versus belly press test Cohen’s kappa value: 0.51 is substantial. T = 19.07, P < .001.
Arthroscopic diagnosis versus bear hug test Cohen kappa value: 0.19 is slight. T = 8.42, P < .001.
Arthroscopic diagnosis versus belly press test Cohen’s kappa value: 0.09 is slight. T = 5.91, P < .001.
Table 3.
Diagnostic Values of Bear Hug Test, Belly Press Test, and Test Combination for Detecting Subscapularis Tears
| Subscapularis Tear Types |
|||||||
|---|---|---|---|---|---|---|---|
| Intact, n (%) | Type I, n (%) | Type II, n (%) | Type III, n (%) | Type IV-V, n (%) | χ2 P Value |
||
| Bear hug | Negative | 213 (83.2) | 274 (74.1) | 122 (51.3) | 50 (35) | 21 (18.3) | 217.2 |
| Positive | 43 (16.8) | 96 (25.9) | 116 (48.7) | 93 (65) | 94 (81.7) | <.001 | |
| Belly press | Negative | 239 (93.4) | 342 (92.4) | 203 (85.3) | 83 (58) | 36 (31.3) | 287.1 |
| Positive | 17 (6.6) | 28 (7.6) | 35 (14.7) | 60 (42) | 79 (68.7) | <.001 | |
| Test combination | Negative | 209 (81.6) | 273 (73.8) | 122 (51.3) | 47 (32.9) | 20 (17.4) | 217.3 |
| Positive | 47 (18.4) | 97 (26.2) | 116 (48.7) | 96 (67.1) | 95 (82.6) | <.001 | |
| Total | 256 (100) | 370 (100) | 238 (100) | 143 (100) | 115 (100) | ||
χ2, chi-square test.
Bold values indicate clinical tests with the highest negative and positive rates.
When we evaluated clinical test performance with concomitant pathologies, the BH test had 25% accuracy in detecting isolated SSC tears, whereas the BP test 5% accuracy for the same condition. However, when SSC tears were accompanied by other pathologies such as supraspinatus tear, infraspinatus tear, and LHBT pathology, the accuracy of both tests improved. The most accurate diagnosis was obtained when SSC tear was associated with LHBT pathology (Table 4 and Fig 1).
Table 4.
Subgroup Analysis of Physical Examination Tests According to Pathologies Accompanying Subscapularis Tear
| Bear Hug |
Belly Press |
Test Combination |
||||
|---|---|---|---|---|---|---|
| Negative, n (%) | Positive, n (%) | Negative, n (%) | Positive, n (%) | Negative, n (%) | Positive, n (%) | |
| SC torn group | ||||||
| Isolated SSC | 30 (75) | 10 (25.0) | 38 (95.0) | 2 (5.0) | 30 (75.0) | 10 (25.0) |
| SSC + SS | 86 (64.2) | 48 (35.8) | 109 (81.3) | 25 (18.7) | 85 (63.4) | 49 (36.6) |
| SSC + SS + IS | 31 (54.4) | 26 (45.6) | 40 (70.2) | 17 (29.8) | 30 (52.6) | 27 (47.4) |
| SSC + LHBT | 41 (42.3) | 56 (57.7) | 66 (68.0) | 31 (32.0) | 41 (42.3) | 56 (57.7) |
| SSC + SS + LHBT | 174 (53.7) | 150 (46.3) | 262 (80.9) | 62 (19.1) | 174 (53.7) | 150 (46.3) |
| SSC + SS + IS + LHBT | 105 (49.1) | 109 (50.9) | 149 (69.6) | 65 (30.4) | 102 (47.7) | 112 (52.3) |
| SSC intact group | ||||||
| Isolated SS | 88 (86.3) | 14 (13.7) | 96 (94.1) | 6 (5.9) | 87 (85.3) | 15 (14.7) |
| SS + IS | 23 (82.1) | 5 (17.9) | 25 (89.3) | 3 (10.7) | 22 (78.6) | 6 (21.4) |
| SS + LHBT | 71 (79.8) | 18 (20.2) | 83 (93.3) | 6 (6.7) | 70 (78.7) | 19 (21.3) |
| SS + IS + LHBT | 31 (83.8) | 6 (16.2) | 35 (94.6) | 2 (5.4) | 30 (81.1) | 7 (18.9) |
| Total | 680 (60.6) | 442 (39.4) | 903 (80.5) | 219 (19.5) | 671 (59.8) | 451 (40.2) |
IS, infraspinatus; LHBT, long head biceps tendon; SS, supraspinatus; SSC, subscapularis.
Bold values indicate clinical tests with the highest negative and positive rates.
Fig 1.
Physical examination tests positivity rate based on concomitant pathologies. (IS, infraspinatus; LHBT, long head biceps tendon; SS, supraspinatus; SSC, subscapularis.)
Accompanying lesions did not significantly affect the accuracy of the physical examination tests. Age and BMI were observed to have a significant impact on the test results (P < .001). With advanced age, the BH and BP tests had increased likelihoods of testing positive for the condition (regression coefficients [B]: 0.025; odds ratio: 1.026; P < .001). Similarly, the probability of testing positive in the BP test tended to increase with age (B: 0.018; odds ratio: 1.018; P = .04), whereas an increase in BMI was associated with a lower probability of testing positive for the condition (B: –0.06; odds ratio: 0.948; P < .001).
Discussion
The most important findings of this study were that the BH test was twice as sensitive as the BP in identifying SSC tears and there was no advantage in combining the 2 tests to accurately diagnose SSC tears. The BH test correctly identified 54.5% of SSC tears, whereas the BP test correctly identified only 39.3% of SSC tears. As the size of the SSC tear increased, both the BH and BP tests demonstrated improved accuracy, with the BH test detecting 25.9% of SSC type I tears, 48.7% of type II tear, 65% of type III tear, and 81.7% of type IV-V tears, and the BP test detecting 7.6%, 14.7%, 42%, and 68.7%, respectively.
The BH and BP tests are frequently employed for diagnosing SSC tears through physical examination. The sensitivity of these tests has been reported to vary significantly in previous studies, with the BH test's sensitivity ranging from 19% to 74% and the BP test’s sensitivity ranging from 30% to 88%.10,14, 15, 16, 17, 18, 19 In this study, the sensitivity of both tests was less than 50%, whereas the specificity remained constant in line with previous research.10,13, 14, 15, 16, 17, 18, 19 These findings demonstrate that relying solely on clinical examination is inadequate for accurately diagnosing SSC tears. Imaging methods such as MRI also exhibit low diagnostic accuracy for SSC tears. In a recent meta-analysis by Malavolta et al.,27 MRI had a sensitivity of 68% (95% CI 0.64-0.72) and specificity of 90% (95% CI 0.89-0.92) for diagnosing SSC tears. Based on the low sensitivity of current physical examination maneuvers as well as MRI, a systematic arthroscopic examination is often required to detect of SSC tears, particularly partial articular-sided tears.6
Interestingly, the combination of both physical examination tests did not provide any added benefit over using the BH test alone. Both tests missed 73.8% (n = 273) of partial SSC tears, and 44.4% (n = 169) of full-thickness upper border tears. This indicates that neither test should be solely relied upon for the diagnosis of SSC tears. A possible explanation for this observation is that the BH test is more effective in detecting SSC tears than other physical examination tests, such as the BP test, lift-off test, and internal rotation resistance test, as evidenced by a recent meta-analysis study.13 Consequently, if the BH test is employed to diagnose SSC tears, there may be no need for additional physical examination tests. However, the results also emphasize there may be value in developing a new physical examination test.
The prevalence of SSC tears can be as high as 50%, with approximately 80% of them being partial and upper border tears.5,6,28 Previous studies have shown that clinical tests have much lower sensitivities for partial and small tears in the SSC than for medium and large tears.10,14,19 This study’s findings are consistent with these previous reports, with the BH test having an accuracy of 25.7% for SSC type I tears, and the BP test being about 3 times less accurate than the BH test. Although the accuracy of both tests improved with increasing tear size, the BH test exhibited significantly greater accuracy across all tear types compared with the BP test. The low accuracy observed in Lafosse type I and II tears can be attributed to the fact that clinical tests for SSC tears are primarily designed to identify weakness in internal rotational strength. Partial- or small full-thickness tears may not always manifest as significant weakness, leading to potential challenges in their detection through clinical examination alone.
Although SSC tears can occur in isolation, these tears are often associated with concomitant pathology.29, 30, 31 In this study, the majority of SSC tears were accompanied by other rotator cuff tears (84.5%) and more than 70% of SSC tears were accompanied by LHBT pathology. Although previous studies have reported similar findings, the impact of accompanying lesions on physical examination tests has not been thoroughly explored.10,16,19,32 This study found that the presence of accompanying pathology resulted in an increase of more than 25% in the accuracy of physical examination tests. However, the accuracy of physical examination tests was not influenced by accompanying pathologies. Despite the low sensitivity values, the BH and BP tests can still identify SSC tears when other pathologies are present. The accuracy of physical examination tests was also influenced by clinical factors such as age and BMI. As age increased, there was a greater likelihood of testing positive for an SSC tear in both tests, possibly due to the greater prevalence of shoulder pathologies in older individuals.33,34 Interestingly, greater BMI was associated with a decreased likelihood of testing positive for SSC tear with the BP test. This finding is important to consider when performing the BP test on obese patients.
Limitations
The study had several limitations. For instance, the patient population was assessed retrospectively via medical records, which may carry the risk of selection bias. Nevertheless, the researchers mitigated this limitation by including a large sample of patients with SSC tears (n = 866) and another group with intact SSC tendons (n = 256). Moreover, the study’s reliance on only 2 physical examination tests, i.e., the BH and BP tests, limited the assessment of other physical examination tests’ efficacy, such as the Lift-off and Napoleon tests. Also, the assessment of all patients was carried out by a single observer during the evaluation of physical examination tests, and quantifiable strength testing using a dynamometer or tensiometer was not employed. This may introduce potential bias and limit the generalizability of our findings. Lastly, the study did not consider preoperative patient-reported outcomes and magnetic resonance imaging findings to explore additional associations with clinical tests. The study solely examined the diagnostic accuracy of these tests and did not evaluate their clinical usefulness in guiding treatment decisions, which may be an avenue for further research.
Conclusions
The BH test had greater sensitivity than the BP test in identifying SSC tears. Both tests showed low accuracy in identifying SSC tears as tear size decreased. Combining both tests did not provide any additional benefits over using the BH test alone.
Disclosure
The authors report the following potential conflicts of interest or sources of funding: M.E.M. is a consultant for Arthrex. P.J.D is a consultant for Arthrex. All other authors (A.I.K., J.A., T.P.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
References
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