Comparison of Clinical Examination Tests, Ultrasonography, Mri, and Arthroscopy Findings in Subscapularis Tear Diagnosis

To evaluate and compare the diagnostic accuracy of specific physical examination tests, ultrasonography (USG), and magnetic resonance imaging (MRI) in detecting subscapularis (SSC) tears, using shoulder arthroscopy as the gold standart. In this prospective study, patients who scheduled for shoulder arthroscopy between one year period were enrolled. Patients with prior shoulder fractures, surgery, cervical disc pathology, neurological findings, recurrent shoulder instability, or rheumatologic diseases were excluded. Two clinicians (C1, C2) performed preoperative SSC tests on each patient, including Lift-Off (LO), Belly Press (BP), Belly Off (BO), Bear Hug (BH), Napoleon (N), and Internal Rotation Lag Sign (IRLS). Each patient was also assessed by two musculoskeletal radiologists using USG, and MRI scans were reviewed independently. Test combinations of three were evaluated across six configurations: Combination I (BH, BP, BO), Combination II (BH, BP, LO), Combination III (BH, BP, N), Combination IV (BH, BF, IRLS), Combination V (BP, BO, LO), Combination VI (BH, N, IRLS). Each combination was considered positive if two or more of the three tests yielded positive results. Sensitivity, specificity, accuracy, positive predictive value, and agreement with arthroscopy (gold standard) were calculated for individual tests, test combinations, USG, and MRI findings. Inter-clinician agreement was also assessed. Arthroscopy revealed SSC tears in 14 of 21 patients, with 1 full-thickness tear and 13 partial tears (Six Lafosse Type 1 and Seven Lafosse Type 2). USG correctly diagnosed SSC tears in 12 cases by Clinician 1 (C1) and in 13 cases by Clinician 2 (C2), with sensitivities of 85.71% and 92.86%, respectively (p 0.05). Among individual tests, the Lift-Off test had the lowest specificity (43%) but highest sensitivity (100%), with an accuracy of 81%. The highest accuracy was observed with Bear Hug and Napoleon tests (85.7%), while Belly Press had the lowest accuracy (61.5%). The highest combination accuracies were seen in Combination III (BH, BP, N) and Combination V (BP, BO, LO) at 90.5%. Significant agreement (p 0.05). Figure 1. Shoulder ultrasonography (a), MRI (b), and arthroscopic evaluation (c) of the same patient. Visualization of the subscapularis tendon with ultrasound (blue star) and observation of the tear starting at the tendon insertion site (yellow arrow). Examination and observation of the tear arthroscopically with a probe (c). The accurate diagnosis and treatment of subscapularis tears, which are often overlooked and frequently neglected, pose significant challenges for both patients and clinicians. This study highlights that the combined use of specific clinical examination tests for SSC tears, along with dynamic imaging methods such as ultrasonography, offers a more reliable and accurate diagnostic approach than magnetic resonance imaging. For any figures or tables, please contact the authors directly.