探讨肩关节特殊体查试验在肩胛下肌腱撕裂诊断中的价值。

回顾性分析2021年1月1日至2022年12月31日以肩袖损伤为诊断入院行肩关节镜手术治疗的211例患者，术前分别行肩关节特殊体查试验：抬离试验、压腹试验、熊抱试验、内旋迟滞试验。以术中关节镜检查结果为金标准，通过对比分析四项体查试验诊断肩胛下肌腱损伤的敏感性、特异性、ROC曲线下面积等。

经关节镜检查证实，211例患者中有108例肩胛下肌腱完整，72例肩胛下肌腱部分撕裂（Lafossa I型），31例全层撕裂（Lafossa II-V型）。对Lafossa I-V型损伤，各项体查试验的敏感性为熊抱试验（81.6%）>抬离试验（71.8%）>压腹试验（68.0%）>内旋迟滞试验（48.5%），特异性为内旋迟滞试验（71.3%）>熊抱试验（63.0%）>抬离试验（50.0%）>压腹试验（46.3%），ROC曲线下面积为熊抱试验（0.609）>抬离试验（0.573） >压腹试验（0.568） >内旋迟滞试验（0.538）。对Lafossa II-V型损伤，各项体查试验的敏感性为熊抱试验（93.5%）>压腹试验（80.6%）>抬离试验（77.4%）>内旋迟滞试验（45.2%），特异性为内旋迟滞试验（62.8%）>抬离试验（57.8%）>熊抱试验（47.2%）>压腹试验（42.3%）。ROC曲线下面积为熊抱试验（0.682）>抬离试验（0.644）>内旋迟滞试验（0.599）>压腹试验（0.571）。上述各项试验并不具备区分肩胛下肌腱部分撕裂和全层撕裂的能力（P>0.05）。联合试验可提高特殊体查试验的敏感性（84.5%）和ROC曲线下面积（0.723）。

在纳入研究的四项肩关节特殊体查试验中，熊抱试验具有最高的诊断效能，特别是肩胛下肌腱全层撕裂的病例。同时也建议行四项体查试验联合检查，以进一步提高诊断效能。尽管如此，肩胛下肌腱撕裂仍有漏诊，尤其是部分撕裂。因此，为了防止肩胛下肌腱撕裂的漏诊，在关节镜手术过程中必须对肩胛下肌腱仔细探查。

Subscapularis muscle (SSc) is one of the critical components of rotator cuff muscles, the largest and strongest muscle in the rotator cuff muscle group, and the only rotator cuff muscle located in front. SSc is a robust internal rotator and dynamic anterior stabilizer of the glenohumeral joint, so the integrity of the SSc tendon is essential. However, SSc tendon injury is often overlooked, so it is named a "forgotten tendon". SSc tendon tear is not rare. According to previous literature reports on open shoulder surgery and cadaver studies, the prevalence of SSc tendon tear is 3.5%-29.4%. However, with the progress and widespread use of shoulder arthroscopy technology, the prevalence of SSc tendon tear is much higher than 29.4%. The incidence of SSc tear in arthroscopic rotator cuff surgery is 31.4%-69.5%. Missed diagnosis of SSc tendon tear can lead to postoperative symptom residue and poor functional recovery, which are potential risk factors for medical disputes. Therefore, accurate preoperative prediction of SSc tendon tear is significant for both patients and shoulder surgeons. Despite the breakthroughs in high-resolution magnetic resonance imaging technology, diagnosing SSc tendon tears is still challenging due to the relatively particular anatomical structure of the insertion site of the SSc tendon, especially in patients with partial or minor tears. In addition, MRI is currently one of the large-scale examinations that cost a lot of money and time in China; in primary hospitals, the conditions for high-resolution MRI examinations may not be available. Therefore, if there is an inexpensive, accurate, and repeatable physical examination of the shoulder joint that can detect SSc tendon tears early, it can reduce the waste of medical resources and the economic burden on patients. In foreign countries, there have been relevant special physical examination tests of the shoulder joint for the diagnosis of SSc tendon injuries, such as the lifting test, abdominal pressure test, bear-hug test, and internal rotation hysteresis test, etc., and have been confirmed to have high sensitivity and moderate specificity. However, most of these tests are carried out alone and have a small sample size. In addition, there has been no research report on the physical examination of the shoulder joint for the diagnosis of SSc tendon injuries in China.

To investigate the value of special physical examination tests for shoulder joints in diagnosing subscapular tendon tears.

A retrospective analysis was performed on 211 patients admitted to the hospital for shoulder arthroscopy treatment with rotator cuff injury from January 1, 2021, to December 31, 2022. Special physical examination tests for shoulder joints were performed before surgery: lifting test, abdominal compression test, bear-hug test, and internal rotation hysteresis test. With intraoperative arthroscopy results as the gold standard, the sensitivity, specificity, and area under the ROC curve of the four physical examination tests for diagnosing subscapular tendon injury were compared and analyzed.

Arthroscopy confirmed that 108 of the 211 patients had intact subscapular tendons, 72 had partial tears of the subscapular tendon (Lafossa type I), and 31 had full-thickness tears (Lafossa type II-V). For Lafossa type I-V injuries, the sensitivity of each physical examination test was bear-hug test (81.6%) > lifting test (71.8%) > abdominal compression test (68.0%) > internal rotation hysteresis test (48.5%), the specificity was internal rotation hysteresis test (71.3%) > bear-hug test (63.0%) > lifting test (50.0%) > abdominal compression test (46.3%), and the area under the ROC curve was bear-hug test (0.609) > lifting test (0.573) > abdominal compression test (0.568) > internal rotation hysteresis test (0.538). For Lafossa II-V injuries, the sensitivity of physical examination tests was bear hug test (93.5%) > abdominal compression test (80.6%) > lifting test (77.4%) > internal hysteresis test (45.2%), and the specificity was internal hysteresis test (62.8%) > lifting test (57.8%) > bear hug test (47.2%) > abdominal compression test (42.3%). The area under the ROC curve was the bear hug test (0.682) > lifting test (0.644) > internal hysteresis test (0.599) > abdominal compression test (0.571). The above tests could not distinguish between partial and full-thickness tears of the subscapularis tendon (P >0.05). Combined tests can improve the sensitivity (84.5%) and area under the particular physical examination tests' ROC curve (0.723) .

Among the 4 shoulder joint special physical examinations included in the study, the bear hug test has the highest diagnostic efficacy, especially for full-thickness tears of the subscapularis tendon. It is also recommended to perform a combined examination of the four physical examination tests to improve the diagnostic efficacy further. Despite this, there are still missed diagnoses of subscapularis tendon tears, especially for partial tears. Therefore, to prevent missed diagnoses of subscapularis tendon tears, it is necessary to explore the subscapularis tendon during arthroscopic surgery carefully.