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

Abstract

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.

Figure 1.

QUADAS-2 (Quality Assessment on Diagnostic Accuracy Studies–Revised) critical appraisal of included studies.

Figure 2.

Statistical analyses for series and parallel testing methods.

Figure 3.

Statistics formula to create posttest probabilities.

Figure 4.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) systematic review diagram, which displays the process and rationale for study omission for the systematic review.

Figure 5.

(a) Statistical characteristics of optimized special test combinations performed in series. (b) Statistical characteristics of optimized special test combinations performed in parallel.