Subscapularis, The Forgotten Rotator Cuff Muscle - PRESENTED BY: YARA HARB COLLABORATORS: ANDREW KIM AND MITCHELL STARKMAN - 2019 Orthopaedic ...
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Subscapularis, The Forgotten Rotator Cuff
Muscle
PRESENTED BY: YARA HARB
COLLABORATORS: ANDREW KIM AND MITCHELL STARKMAN
Work Source
v Introduction to Clinical Research to Support Evidence Based Practice
in Manual Therapy Course
v Requirement for the Diploma of Advanced Orthopaedic Manual and
Manipulative Physiotherapy
Outline v Introduction v Diagnostic Imaging Accuracy v Case History v Typical Clinical Presentation v Clinical Question and Critical Appraisal of included studies v Implications on Clinical Practice v Application to Case History v Directions for Future Research
Introduction HISTORY, ANATOMY AND BIOMECHANICS
History
v First described by cadaver studies in 1834 (Smith, 1834)
v Evidence of isolated subscapularis tears (Gerber et al., 1996)
v First series of arthroscopic repairs in 2002 (Burkhart et al., 2002)
v Subscapularis tears are more common than previously thought
(Narasimhan et al., 2016)
v 25-59% of arthroscopic shoulder procedures
v No longer the forgotten rotator cuff muscle
Anatomy
v 53% of Rotator Cuff (RC) muscle bulk
v Origins and Insertions: subscapular fossa
and lesser tuberosity of the humerus
v Intimately related to the Long Head of
Biceps (LHB) and its sheath
v Interdigitates with the supraspinatus fibers
Biomechanics
v Internal rotation of the glenohumeral joint (GHJ)
v Stabilization of the GHJ in abduction and external rotation
v Force couple with the infraspinatus and teres minor for transverse
stabilization of the GHJ
v Opposes the upward pull of the deltoid with humeral abduction and
elevation
Diagnostic Imaging
v Arthroscopy is the Golden Standard
v MRI - lower diagnostic accuracy of subscapularis tears vs. other RC tears
(Malavolta et al., 2018)
v Full thickness (93% Sensitivity, 97% Specificity)
v Partial Tears (74% Sensitivity, 88% Specificity)
v Ultra-sound – high likelihood of false negatives (Narasimhan et al., 2016)
v 39% Sensitivity, 93.1% Specificity
v Lower values for partial tears
Case History
Case History - Subjective
v Background: Works in IT, desk worker, plays tennis
1-2x/week.
v History: 2 year, gradual onset right shoulder pain.
No MOI
v Pain Descriptors: Intermittent. Sharp. Worsening.
0-6/10 on NPRS. Aggravated by reaching back,
lifting and cross-body motionsCase History - Objective
v ROM: Pain end range of flexion, horizontal adduction, combined
extension and external rotation
v Scapular position: right sided protraction and anterior tilt. Scapular
dyskinesia observed with scapular plane elevation.
v Strength: Pain with resisted abduction (in 90° of flex/abd/ER). Pain
limited weakness in shoulder IR .
v Tests: (+) Hawkins Kennedy Test
v Slap Tests:(-) Jobe Relocation Test, Active Compression Test and
Biceps Load Test
v Imaging: MRI (6 weeks into care) showed 1 cm subscapularis tear.Typical Clinical Presentation
Typical Clinical Presentation
v Predominantly degenerative
v Traumatic injuries more common in the younger age group
v Most common MOI: Hyperextension and external rotation
v Some association with anterior shoulder dislocation or LHB pathologies
v In cases of complete tear: increased passive ER and marked IR weakness
v Weakness and difficulty with activities involving pushing inward
(Lyons et al., 2005, Lee et al., 2018)Typical Clinical Presentation
v Pain that is more anterior and
may involve the arm.
v Night pain.
v Myofascial Pain Pattern
(Simons et al., 1999)Clinical Question
IN PATIENTS WITH SUSPECTED ROTATOR CUFF
PATHOLOGY WHICH CLINICAL TESTS COULD
ACCURATELY PREDICT A SUBSCAPULARIS
INVOLVEMENT WHEN COMPARED WITH
ARTHROSCOPY?Article Summary Table – Internal Validity
Schiefer et al. Lin et al. (2015) Kappe et al. (2018) Takeda et al.
(2015) (2016)
Study Design and Diagnostic Study, Level I
Level
Population 49 patients 235 patients 106 patients 130 patients
scheduled for scheduled for scheduled for scheduled for
Arthroscopy Arthroscopy Arthroscopy Arthroscopy
Clinical Tests Lift-Off, Belly Lift-Off, Belly Lift-Off, Belly Press, Lift-Off, Belly Press,
(Intervention) Press, Bear Hug Press, IRLS, Bear Belly Off, IRLS, Bear Bear Hug, Supine
Hug, IRRT0, IRRTM Hug Napolean
Comparison Arthroscopy
Outcome Diagnostic Quality Measures (Sensitivity, Specificity, Likelihood Ratios)
Reproducibility Sufficient details of clinical tests and methods
IRLS: Internal Rotation Lag Sign, IRRT0: Internal Rotation Resisted Test at 0⁰ abduction, IRRTM: Internal Rotation Resisted Test MaxArticle Summary Table – External
Validity
Schiefer et al. Lin et al. (2015) Kappe et al. Takeda et al.
(2015) (2018) (2016)
Applicability Strong. Subscapularis tears are more common than previously
thought
Feasibility All tests are feasible to perform
Influence on Single clinical test has poor accuracy; combined tests
patient recommended to improve diagnosis.
Management Early diagnosis = better prognosisResults
Lift-Off Test Diagnostic Lin et al. Schiefer et Kappe et al. Takeda et al. Measure (2015) al. (2015) (2018) (2016) Sensitivity 59.8% 25% 35% 65.2% Specificity 68.5% 92% 98% 94.5% +LR 1.90 3.13 17.5 11.85 -LR 0.59 0.82 0.66 0.37
Belly Press Test Diagnostic Lin et al. Schiefer et Kappe et al. Takeda et al. Measure (2015) al. (2015) (2018) (2016) Sensitivity 64.4% 45% 34% 62.7% Specificity 79.7% 92% 96% 89.7% +LR 3.17 5.63 8.5 6.09 -LR 0.44 0.60 0.69 0.42
Bear Hug Test Diagnostic Lin et al. Schiefer et Kappe et al. Takeda et al. Measure (2015) al. (2015) (2018) (2016) Sensitivity 70.2% 75% 52% 73.7% Specificity 79.9% 56% 85% 97.4% +LR 3.49 1.70 3.47 28.35 -LR 0.37 0.45 0.56 0.27
Internal Rotation Lag Sign Diagnostic Lin et al. Kappe et al. Measure (2015) (2018) Sensitivity 31.6% 41% Specificity 92.5% 91% +LR 4.21 4.56 -LR 0.74 0.65
Internal Rotation
Resisted Tests
IRRTM Diagnostic Lin et al.
Diagnostic Lin et al. Measure (2015)
Measure (2015) Sensitivity 76.5%
Sensitivity 62.7%
Specificity 80.4%
Specificity 76.3%
+LR 3.9
+LR 2.65
-LR 0.29
IRRT0 -LR 0.49Belly Off
Test
Diagnostic Kappe et al.
Measure (2018)
Sensitivity 31%
Specificity 97%
+LR 10.33
-LR 0.71Supine
Napolean
Diagnostic Takeda et al.
Measure (2016)
Sensitivity 84.3%
Specificity 96.2%
+LR 22.18
-LR 0.16Implications on Clinical Practice
v Overall poor accuracy of clinical tests
v Compensation
v Familiarity with all subscapularis tests is important
v Subjective information are needed to provide a better clinical
picture
v Mechanism of injury
v Pain behaviour and location
v A stronger diagnosis toolbox = reduced rehab times and better
functional outcomes
v Proposed test cluster may provide a higher cumulative probability
of diagnosisProposed Test Cluster
Lift-Off, Belly Press,
To Rule
+LR>5 Belly Off Sign, Supine
In Napolean
To Rule Bear Hug, IRRTM,
-LRApplication
to Case
History
v Fagan’s Nomogram
v Example: Belly Press
Test (Takeda et al.,
2016)
v Pre-Test Probability
(42%)
v +LR = 6.09
v Post-Test Probability
(82%)Directions for Future Research
v Understanding anatomical basis of clinical tests for subscapularis
pathology may improve accuracy for development of accurate clinical
tests
v Electromyographic studies of subscapularis activity with the different tests
v Conduct a systematic review specific to subscapularis clinical tests
v Development of a clinical cluster involving subjective and objective tests
and measuring its diagnostic accuracyReferences
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