**4. Clinical examination**

On examination there will be increased passive external rotation, Loss of active internal rotation strength.

Lift-off, belly-press, Napoleon and bear-hug are specific tests to assess the subscapularis tendon.

**The lift-off test**: This test has 15–20% sensitivity and almost 100% specificity (Barth et al.) [9]. This test is carried out in sitting or in standing position. The patient's arm is kept in internal rotation with the hand is placed at the back at lumbar spine level. In this position patient tries to move the hand away from back by further extending arm and in internal rotation. Now if this movement is possible, examiner can check by providing resistance. The test is positive when the patient is unable to lift the hand away from back indicative of tear of subscapularis. The degree of weakness and pain are indicative of the degree of the lesion (**Figure 3**).

**The belly-press test**: It is one of the most commonly performed and accurate clinical test for subscapularis tear with sensitivity of 40% and specificity of 97.3%.It is also called as abdominal compression test, In this test patient attempts to press the hand against the belly with

**Figure 3.** Lift off test.

the arm rotated internally [10].The examiner places hand on the abdomen so he can feel the how much pressure patient is applying. The test is considered positive if the pressing force is weaker or if the pressing movement of the hand against the belly is possible only with the elbow extension and shoulder extended. This indicates a deficiency of the subscapularis tendon tear or dysfunction (**Figure 4**).

**Figure 4.** Belly press test.

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**Figure 5.** Bear hug test.

**The Napoleon test**: It is similar to belly press test also called as modified belly press test. The patient hand is placed on abdomen with hand wrist and elbow in straight line. Now patient has to press down on the abdomen negative test indicates wrist at 0° suggestive of normal subscapularis. Positive test indicates patient can press on the belly by flexing wrist at 90° and intermediate result when wrist flexed 30–60° suggestive of partial function of subscapularis. It has sensitivity of 25% and specificity of 97.3%.

**The bear-hug test**: This test is most sensitive (60%) and with specificity >90%, can be considered single most accurate test for subscapularis injuries [11]. In this test patient has to place his hand on the opposite shoulder with the elbow anterior to the body. The examiner then applies an external rotation force while the patient attempts to maintain the hand on the shoulder. Positive test indicates patient cannot maintain the hand against the shoulder as examiner applies external rotation force (**Figure 5**).

**Figure 4.** Belly press test.

the arm rotated internally [10].The examiner places hand on the abdomen so he can feel the how much pressure patient is applying. The test is considered positive if the pressing force is weaker or if the pressing movement of the hand against the belly is possible only with the elbow extension and shoulder extended. This indicates a deficiency of the subscapularis ten-

**The Napoleon test**: It is similar to belly press test also called as modified belly press test. The patient hand is placed on abdomen with hand wrist and elbow in straight line. Now patient has to press down on the abdomen negative test indicates wrist at 0° suggestive of normal subscapularis. Positive test indicates patient can press on the belly by flexing wrist at 90° and intermediate result when wrist flexed 30–60° suggestive of partial function of subscapularis.

**The bear-hug test**: This test is most sensitive (60%) and with specificity >90%, can be considered single most accurate test for subscapularis injuries [11]. In this test patient has to place his hand on the opposite shoulder with the elbow anterior to the body. The examiner then applies an external rotation force while the patient attempts to maintain the hand on the shoulder. Positive test indicates patient cannot maintain the hand against the shoulder as

don tear or dysfunction (**Figure 4**).

**Figure 3.** Lift off test.

44 Advances in Shoulder Surgery

It has sensitivity of 25% and specificity of 97.3%.

examiner applies external rotation force (**Figure 5**).

**Figure 5.** Bear hug test.

All these tests allow diagnosing a partial tear in 30% of cases. More than 50% of tendon thickness is torn when the Napoleon test is positive; more than 75% when the lift-off test is positive.
