Original article
The Bear-Hug Test: A New and Sensitive Test for Diagnosing a Subscapularis Tear

https://doi.org/10.1016/j.arthro.2006.05.005Get rights and content

Purpose: It was our intent to devise a new clinical test that would more accurately diagnose subscapularis tears than the current clinical tests. This new test is called the bear-hug test. The purpose of this study was to assess the bear-hug test and compare it with the current tests of subscapularis function (lift-off, belly-press, and Napoleon tests). Methods: Between January 2004 and March 2004, 68 consecutive patients scheduled for an arthroscopic procedure were evaluated preoperatively; the preoperative clinical examination findings were then correlated with arthroscopic findings. Lift-off, belly-press, Napoleon, and bear-hug tests were included in the examination. Furthermore, for the belly-press and bear-hug tests, the strength was precisely quantified by means of an electronic digital tensiometer (Kern HBC). Diagnostic arthroscopy was the reference that determined the actual pathologic lesions. Results: Subscapularis tears occurred with a prevalence rate of 29.4%. Of the subscapularis tears, 40% were not predicted by preoperative assessment by use of all of the tests. The bear-hug test was found to be the most sensitive test (60%) of all of those studied (belly-press test, 40%; Napoleon test, 25%; and lift-off test, 17.6%). In contrast, all 4 tests had a high specificity (lift-off test, 100%; Napoleon test, 97.9%; belly-press test, 97.9%; and bear-hug test, 91.7%). No statistically significant difference was found between the area under the receiver operating characteristic curve of the bear-hug test and that of the belly-press test in diagnosing a torn subscapularis. However, the areas under the receiver operating characteristic curve for both the bear-hug test and the belly-press test were significantly greater than those for the lift-off and Napoleon tests (P < .05). Positive bear-hug and belly-press tests suggest a tear of at least 30% of the subscapularis, whereas a positive Napoleon test indicates that greater than 50% of the subscapularis is torn. Furthermore, a positive lift-off test is not found until at least 75% of the subscapularis is torn. Conclusions: The bear-hug test optimizes the chance of detecting a tear of the upper part of the subscapularis tendon. Moreover, because the bear-hug test represents the most sensitive test, it can be considered to be the most likely clinical test to alert the surgeon to a possible subscapularis tear. Performing all of the subscapularis tests is useful in predicting the size of the tear. Level of Evidence: Level I, diagnostic study: testing of previously developed criteria in a series of consecutive patients with arthroscopy used as the criterion standard.

Section snippets

Methods

The junior author (J.R.H.B.) undertook a prospective study involving all of the patients scheduled to undergo an arthroscopic procedure by one of the senior authors (S.S.B.) during a period of 3 months (from January 2004 to March 2004). Previously operative shoulders and stiff shoulders scheduled for a capsular release and lysis of adhesions were excluded from the study group. After exclusion of these patients, the study group comprised 68 shoulders. The mean age of the patients was 45.1 ± 14.7

Results

During diagnostic arthroscopy, we found 34 torn rotator cuffs, including 20 subscapularis tears (5 isolated subscapularis tears), 19 SLAP lesions, 4 anterior Bankart lesions, 4 posterior Bankart lesions, and 19 cases of pathologic biceps (13 requiring biceps tenodesis, 3 requiring biceps tenotomy, 1 requiring biceps debridement, and 2 that had chronic complete ruptures). The prevalence rate of subscapularis tears in our study group was 29.4% (20 of 68). A pathologic biceps was found in 14

Discussion

Of the 34 torn rotator cuffs in this study, 20 had a subscapularis tear (58.8%). The prevalence of subscapularis tears in this study (29.4%) was much greater than that reported in some previous studies in the literature (3.5% reported by Codman8 and 4% reported by Deutsch et al.9). This discrepancy deserves an explanation. The aforementioned studies were both clinical studies, with subscapularis tears being discovered at the time of open surgery. In contrast, an anatomic cadaveric study by

Conclusions

The bear-hug test is the most sensitive clinical test for subscapularis function. Clinical examination should include the lift-off test, belly-press test, Napoleon test, and bear-hug test to optimize the chance of detecting and predicting the size of a subscapularis tear. Positive bear-hug and belly-press tests suggest a tear of at least 30% of the subscapularis, whereas a positive Napoleon test indicates that greater than 50% of the subscapularis is torn. Furthermore, a positive lift-off test

Acknowledgment

The authors thank John D. Schoolfield, M.S., for his assistance with the statistical and data analysis in this study.

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