Bear-Hug Test, a New Test for Subscapularis Tear

Subscapularis muscle is part of the rotator cuff muscles and the largest. It is also the main
internal rotator of shoulder joint. The current tests to evaluate subscapularis tears have been under
scrutiny since they are still inadequate preoperatively. Barth et al in 2006 devised a new test called
bear-hug test as a special test for accurately diagnosing a subscapularis tear. For a surgeon, it would
be advantageous to be able to diagnose a subscapularis tear clinically before surgery.

The two most frequently used subscapularis test, the lift-off test and the belly-press test are
sometimes difficult to perform, as patient has to bring arm into starting position which may be
limited by both pain and reduce mobility of shoulder joint. Belly-press test requires the patient to
actively internal rotate the shoulder and maintain the wrist in neutral position. As for lift-off test, if
there are additional problems such as impingement or arthritis, exacerbation of pain occurs due to
extreme abduction and internal rotation while performing the test.

In literatures, starting with Codman back in 1934, found that there is an incidence of 3.5% of
subscapularis tear. In 1992, Frankel et al reported the occurrence of 8% of patients with rotator cuff
tears having subscapularis tears. Lately Barth et al in 2006 in their arthroscopic studies reported a
prevelance of 29.4%.

In previous literatures, it was noted that belly press test activates more of the upper
subscapularis muscle, and lift off test activates lower muscles. This is due to the fact the recruitment
of upper subscapularis muscle is increased in active internal rotation when the elbow is in a more
anterior position (belly press test) compared to the elbow posterior to midline (lift-off test).
Recently, Chao et al in 2008 using the fine wire electromyography concluded that belly press test
actually activates both upper and lower subscapularis equally, and there is no statistically difference
in activation between them.

Barth et al describes a bear hug test as it uses the resisted internal rotation of shoulder, as
the palm is held on the opposite shoulder while the elbow is in a position of maximal anterior
translation. The fingers are in extension, and then the patient is told to hold that position while the
physician tried to pull the patient’s hand from the shoulder with an external rotation force applied
perpendicular to the forearm. It is positive if the patient could not hold the hand against the
shoulder or weakness in resisted internal rotation compared to the opposite side. A painful bear hug
test without weakness is considered negative
 A time frame of 3 months, from January 2004 till March 2004, with patients recruited for this
study totalled to 68 people. 4 special tests were evaluated; belly-press test, lift-off test, Napoleon
test and bear-hug test. One author does the prospective study of patients, including the tests, while
another author does the arthroscopic procedure. In this article, it is not stated in the methodology
whether the author doing the diagnostic arthroscopic knows the result of the subscapularis test
done by the other author to reduce bias (i.e. double blind), and also no data concerning intra- or
interobserver reliability.

Strength is measured using an electronic digital tensiometer. 34 patients were diagnosed

with rotator cuffs tear during the diagnostic arthroscopy, including 20 subscapularis tears. This
amounts to 58.8%, while the prevalence is 29.4%. The result of each test is in table 1

Bear-Hug Test Belly-Press Test Lift-Off Test Napoleon Test

Sensitivity (%) 60 40 17.6 25
Specificity (%) 91.7 97.9 100 97.9
PPV (%) 75 88.9 100 83.3
NPC (%) 84.6 79.7 76.7 75.8
Table1. Sensitivity, Specificity, PPV and NPV of each test

The bear-hug test is the most sensitive among the entire test, but even so it is low
sensitivity. It is highly specific, comparable to other test. Lift-off test is the highest specificity with
100%. But the authors concluded in their study that lift-off test will only be positive if there is ≥75%
tear, and it is difficult to conduct the test because of the pain and inability of the patients to
internally rotate the shoulder posteriorly to midline. None of the patients could even reach above
level S1. As for Napoleon test, it would only be positive if there is ≥50% tear.

As for the bear-hug and belly-press test, they would be positive even if at least 30% tear.
Thus it is most sensitive amongst the test. However, 40% of subscapularis tears were missed
clinically, therefore it is concluded that in shoulder examination, lift-off test, Napolean test, bear-hug
test and belly-press test should be carried out to optimize the probability to diagnose a subscapularis
tear.

Chao at al (2008) conducted a study to assess of 5 subscapularis test (belly-press test, lift-off
test and bear-hug test with 0⁰, 45⁰ and 90⁰ of elbow in anterior translation) and activity of 3
shoulder joint internal rotators (subscapularis, pertoralis major, and latissimus dorsi) using
electromyography (EMG). They reported that bear-hug test at 45⁰ shoulder flexion activates both
upper and lower subscapularis muscle, significantly greater as compared to pectoralis major and
latissimus dorsi. This shows that bear-hug test at 45⁰ shoulder flexion isolate subscapularis complex
as a unit.

Bear hug at 0⁰ Bear hug at 45⁰ Bear hug at 90⁰

 Other results in their study also concluded that bear-hug test at 90⁰ shoulder flexion
activates greater lower subscapularis muscle compared to upper subscapularis, pectoralis major and
latissimus dorsi. This test may be of importance for surgeons since the lower subscapularis is not an
easy region to explore with arthroscopy, thus an open surgery may be warranted.

Bear-hug test at 0⁰ degree shoulder flexion, the study reported that it does not differentiate
the activation of subscapularis complex with pectoralis major during internal rotation. This test may
not be significant in testing subscapularis muscle.

The lift-off test showed that it does not isolate the subscapularis complex, and there is no
difference in activation of upper subscapularis, lower subscapularis and latissimus dorsi.

As for belly-press test, it has a greater activation of both upper and lower subscapularis
complex than pectoralis major and latissimus dorsi. The activation is lower for belly press compared
to bear-hug test at 45⁰ shoulder flexion (activation upper subscapularis 78% VS 108%; activation
lower subscapularis 72% VS 86%)

The new bear-hug test does not replace any of the other known tests for subscapularis tear.
It is moreover to compliment other existing tests since it is currently the most sensitive, albeit it is
only 60% sensitivity. By doing the bear-hug test at 45⁰ shoulder flexion, it optimizes the chance of
detecting a tear in the subscapularis complex, and useful in identifying a relative small tear size
(30%).

REFERENCES

Barth JRH, Burkhart S, De Beer JF. The bear-hug test: A new and sensitive test for diagnosing a subscapularis tear. Arthroscopy
2006;22:1076-1084

Simon Chao, Stephen Thomas, David Yucha, John D. Kelly IV, Jeff Driban, Kathleen Swanik. An Electromyographic Assessment of the “Bear
Hug”: An Examination for the Evaluation of the Subscapularis Muscle. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
24, No 11 (November), 2008: pp 1265-1270