The Diagnostic Value of Subscapularis Clinical Tests in the Postoperative Diagnosis of Subscapularis Retears: An Ultrasound-Comparative Trial



Emmanouil Fandridis1, Michael-Alexander Malahias1, *, Athena Plagou1, Antonio Orgiani2, Flaviis Luca3, Alessandro Castagna2
1 Hand-Upper Limb and Microsurgery Department, Hospital KAT, Athens, Greece
2 Istituto Clinico Humanitas, Milano, Italy
3 Studio di Radiologia De Flaviis, Milano, Italy


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Creative Commons License
© 2019 Fandridis et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Hand-Upper Limb and Microsurgery Department, Hospital KAT, Athens, Greece;
Tel: +30 213 – 20.86.374; E-mail: alexandermalahias@yahoo.gr


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.

Keywords: Subscapularis tendon, Bear hug test, Napoleon test, Lift-off test, Internal rotation lag sign, Arthroscopic subscapularis repair, Shoulder ultrasound.