Abstract
Background: Different physical examination tests have been used to preoperatively determine both the presence and size of a primary subscapularis tear. On the contrary, no clinical trial has yet been published to assess the diagnostic validity of the aforementioned tests in diagnosing subscapularis retears after arthroscopic subscapularis repair. Objective: To investigate the diagnostic value of the most commonly used clinical tests in the diagnosis of subscapularis tendon retears after arthroscopic repair. Methods: A retrospective (prospectively collected data) case series involving 37 patients who were suffering from symptomatic complete subscapularis tendon tear was conducted. All patients underwent an all-arthroscopic subscapularis repair with the same operative technique. They were postoperatively evaluated (final end point of follow-up: 12 months) with the use of ultrasound, Constant-Murlay score (CS), bear hug test, internal rotation lag sign, Napoleon test and lift-off test. Sensitivity, specificity, accuracy, positive and negative prognostic values were calculated for each test. Results: Shoulder function was significantly improved according to the final CS. The internal rotation lag sign was the most sensitive for the diagnosis of postoperative subscapularis retears, while the Napoleon sign had the highest specificity. Although postoperative clinical tests yielded no false negative findings, they were poorly predictive as for new ruptures. Ten patients (27%), who were found with a positive (for re-rupture), postoperative, clinical test, had a sonographically intact subscapularis tendon repair. Conclusion: We strongly support the use of subscapularis-specific clinical tests as a composite, in combination with a specific interpretation of their results. If all tests are found negative for retear, then we could assume that the arthroscopic repair remains intact and no further diagnostic examination might be necessary. On the contrary, if at least one subscapularis-specific clinical test is positive for retear, then the patient will likely require additional imaging control for definite diagnosis.
Highlights
The subscapularis is the largest and most powerful of the rotator cuff muscles5 and is more important for arm elevation than either the supraspinatus or infraspinatus [1]
If all tests are found negative for retear, we could assume that the arthroscopic repair remains intact and no further diagnostic examination might be necessary
If at least one subscapularis-specific clinical test is positive for retear, the patient will likely require additional imaging control for definite diagnosis
Summary
The subscapularis is the largest and most powerful of the rotator cuff muscles and is more important for arm elevation than either the supraspinatus or infraspinatus [1]. It has been suggested that the Napoleon test as well as the bear hug test, the internal rotation lag sign and the lift-off test are all specific for the examination of subscapularis tendon and its pathology [7 - 11]. The sensitivity of physical examination as a whole in diagnosing primary subscapularis tears was 81% [7]. Schiefer et al illustrated that the bear hug test had the highest sensitivity and negative predictive values in diagnosing primary subscapularis tears, when compared with the Napoleon test, the belly press and lift-off tests [9]. Different physical examination tests have been used to preoperatively determine both the presence and size of a primary subscapularis tear. No clinical trial has yet been published to assess the diagnostic validity of the aforementioned tests in diagnosing subscapularis retears after arthroscopic subscapularis repair
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