Right Shoulder Pain with Positive Lift-Off Test
A positive lift-off test indicates a subscapularis tendon tear, most likely a full-thickness or severe partial-thickness tear involving at least 75% of the tendon, and warrants initial plain radiography followed by MRI without contrast to characterize the tear and guide surgical planning. 1, 2
Diagnosis: Subscapularis Tendon Tear
The lift-off test is the most specific clinical examination for subscapularis pathology, with 100% specificity for detecting full-thickness tears. 1 When this test is positive, it reflects severe internal rotation strength loss (mean 72.2% deficit) and indicates substantial tendon damage. 1
Key Diagnostic Features
The lift-off test becomes positive only when at least 75% of the subscapularis tendon is torn, making it highly specific but relatively insensitive (sensitivity 17.6% for any tear, but increases to 32-35% for full-thickness tears). 1, 3, 4
A positive lift-off test is highly predictive of severe fatty degeneration of the subscapularis muscle, which has important prognostic implications for surgical repair outcomes. 1
Pain is typically located anteriorly in the shoulder, and patients report difficulty with lifting movements across the chest or twisting inward motions that interfere with activities of daily living. 2
Additional Clinical Testing to Perform
Perform the bear-hug test, belly-press test, and internal rotation lag sign to further characterize the extent of subscapularis involvement, as the number of positive tests correlates with tear severity. 4, 5
The bear-hug test has the highest sensitivity (52-72%) for subscapularis tears, particularly for upper tendon border involvement, and should be performed even when the lift-off test is positive. 3, 4
Assess for increased passive external rotation compared to the contralateral side, which suggests loss of the subscapularis' restraining function. 5
Evaluate for biceps tendon pathology using the Palm-Up test, as biceps involvement occurs frequently with subscapularis tears due to disruption of the biceps pulley. 5
Imaging Pathway
Initial Imaging: Plain Radiography
Obtain standard shoulder radiographs (anteroposterior views in internal and external rotation plus an axillary or scapula-Y view) as the first imaging study. 6, 7
Plain radiographs rule out fracture, dislocation, significant arthritis, or calcific tendinitis before proceeding to advanced imaging. 8
Radiographs should be performed with the patient upright, as supine positioning underrepresents shoulder malalignment. 7, 8
Advanced Imaging: MRI Without Contrast
MRI of the shoulder without intravenous contrast is the preferred next imaging modality for characterizing subscapularis tears and planning surgical intervention. 6, 7
MRI has 90-95% sensitivity and 90-95% specificity for detecting full-thickness rotator cuff tears, including subscapularis pathology. 6, 7
MRI provides critical information beyond tear detection: tendon retraction, muscle atrophy, and fatty infiltration, which guide decisions between conservative versus operative repair and predict postoperative prognosis. 6, 7
No intravenous contrast is needed for initial evaluation of rotator cuff tears; MR arthrography is reserved for equivocal cases where distinguishing partial from full-thickness tears would alter management. 6, 7
Alternative Imaging: Ultrasound
Ultrasound is an acceptable alternative when performed by experienced operators, particularly in patients with contraindications to MRI or when proximal humeral hardware would cause artifact. 6, 8
Ultrasound has 90-91% sensitivity and 93-95% specificity for full-thickness rotator cuff tears, comparable to MRI. 6
Ultrasound has limitations: variable interobserver agreement for partial-thickness tears and poor visualization of labral lesions and deep intra-articular structures. 6, 8
Management Algorithm
Conservative Management (Initial Trial)
Complete rest from aggravating activities (lifting across the chest, internal rotation movements) until the patient becomes pain-free. 6, 9
Relative rest and activity modification are the cornerstone of early conservative management for tendinopathy. 6, 9
NSAIDs for acute pain management and consideration of subacromial corticosteroid injections for more severe cases. 9
Physical therapy focusing on range of motion through stretching and mobilization, followed by rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved. 9
Surgical Referral Criteria
Orthopedic surgical referral is indicated for most patients with subscapularis tears because operative management is the only approach that allows restoration of subscapularis function. 2
Immediate surgical consultation is warranted when MRI demonstrates: full-thickness tear with tendon retraction, significant muscle atrophy, or fatty infiltration. 6, 7
A positive lift-off test combined with MRI confirmation of a full-thickness tear strongly indicates the need for surgical repair, as these tears rarely heal with conservative management alone. 1, 2
Arthroscopic repair can be safely and successfully performed with encouraging intermediate-term outcomes, comparable to open repair with very low complication rates. 2
Critical Pitfalls to Avoid
Do not rely solely on the lift-off test: 24-40% of subscapularis tears may be missed even when multiple clinical tests are performed, requiring a high index of suspicion. 3, 5
Do not assume normal radiographs exclude significant pathology: soft-tissue injuries remain the most frequent source of shoulder pain despite normal X-rays. 8
Do not proceed directly to advanced imaging without plain radiographs: this may miss fractures, dislocations, or bony abnormalities that fundamentally change management. 7, 8
Do not delay surgical referral in patients with full-thickness tears: early operative intervention optimizes functional outcomes and prevents progression of muscle atrophy and fatty infiltration. 2