Bear Hug Test: Purpose, Procedure, Positive Result, and Diagnostic Accuracy

The Bear Hug Test is a clinical shoulder examination used to assess the integrity and function of the subscapularis tendon, one of the four tendons of the rotator cuff. It is particularly useful for detecting tears involving the upper portion of the subscapularis tendon, which may be difficult to identify using routine shoulder examination techniques.

The test evaluates the patient’s ability to maintain the hand against the opposite shoulder while the examiner applies an external rotational force. Pain, weakness, or an inability to maintain the position may indicate subscapularis tendon dysfunction.

The Bear Hug Test is a valuable component of a comprehensive shoulder examination, especially in patients with suspected rotator cuff injuries, anterior shoulder pain, or weakness during internal rotation. However, its results should be interpreted alongside other clinical tests, the patient’s history, and appropriate imaging when indicated.

What Is the Bear Hug Test Used For?

The Bear Hug Test is primarily used to assess subscapularis tendon tears, particularly tears affecting the upper portion of the tendon.

The subscapularis is the largest and one of the most powerful muscles of the rotator cuff. It originates from the anterior surface of the scapula and inserts onto the lesser tuberosity of the humerus. Its main function is to internally rotate the shoulder, while also contributing to dynamic stabilization of the glenohumeral joint.

Damage to the subscapularis tendon may result from acute trauma, repetitive overhead activity, degenerative changes, or an associated rotator cuff injury.

The Bear Hug Test may help clinicians evaluate patients with:

• Suspected partial or full-thickness subscapularis tendon tears.
• Weakness during resisted shoulder internal rotation.
• Anterior shoulder pain associated with rotator cuff pathology.
• Suspected upper subscapularis tendon injuries.
• Rotator cuff injuries involving more than one tendon.

The test is especially useful because some subscapularis tears may not be readily apparent on routine examination. Nevertheless, no single physical examination test can reliably identify every subscapularis tear.

Anatomy and Clinical Significance of the Subscapularis Muscle

The subscapularis muscle occupies the subscapular fossa on the anterior surface of the scapula. Its tendon passes anterior to the shoulder joint and attaches to the lesser tuberosity of the humerus.

Its primary actions include:

• Internal rotation: Rotates the humerus inward toward the body.
• Shoulder stabilization: Helps maintain the humeral head within the glenoid cavity.
• Dynamic joint control: Works with the other rotator cuff muscles to coordinate shoulder movement.

The upper portion of the subscapularis tendon plays an important role in shoulder stability and may be involved in tears associated with other shoulder abnormalities, including lesions of the long head of the biceps tendon.

Identifying subscapularis dysfunction is clinically important because untreated significant tears can contribute to persistent pain, weakness, and impaired shoulder function.

How to Perform the Bear Hug Test

The Bear Hug Test is performed with the patient in an upright position. The examiner compares the affected shoulder with the opposite shoulder to identify differences in strength, pain, or the ability to maintain the testing position.

Patient Position

1. Ask the patient to stand or sit upright with the shoulder relaxed.
2. Instruct the patient to place the palm of the affected hand on the opposite shoulder.
3. The fingers should remain extended, and the elbow should point forward, anterior to the body.
4. Ensure that the hand remains in contact with the opposite shoulder throughout the test.

Examiner Technique

1. Stand in front of the patient and grasp the wrist of the affected arm.
2. Ask the patient to maintain the hand against the opposite shoulder by actively resisting external rotation.
3. Apply an external rotational force to the patient’s arm, attempting to lift or pull the hand away from the shoulder.
4. Observe whether the patient can maintain the position against resistance.
5. Assess pain, weakness, or an inability to resist the examiner’s force.
6. Repeat the test on the unaffected side and compare the findings.

The examiner should apply controlled resistance and avoid excessive force, particularly when the patient has significant pain or a suspected acute shoulder injury.

What Is a Positive Bear Hug Test?

A positive Bear Hug Test is indicated by an inability to maintain the palm against the opposite shoulder while resisting the examiner’s external rotational force.

The main findings include:

• Muscle weakness: The patient cannot resist the examiner’s force as effectively as on the opposite side.
• Pain: The maneuver reproduces pain around the anterior shoulder.
• Loss of position: The hand lifts away from the opposite shoulder despite the patient’s effort to maintain contact.
• Side-to-side strength difference: The affected shoulder demonstrates reduced resistance compared with the unaffected shoulder.

These findings suggest possible subscapularis tendon dysfunction, particularly when weakness is more pronounced than would be expected from pain alone.

A commonly cited clinical finding is that internal rotation strength may be approximately 20% lower on the affected side than on the contralateral side. This should be interpreted as a reported comparative finding rather than a universal diagnostic threshold.

A positive test does not independently confirm a tendon tear. Pain, other shoulder disorders, limited movement, and patient effort may influence the result.

Bear Hug Test Accuracy

The Bear Hug Test has been evaluated as part of the clinical examination for subscapularis tendon tears.

Reported diagnostic performance includes:

• Sensitivity: 60%
• Specificity: 91%

Sensitivity describes the proportion of patients with a tendon tear who test positive. A sensitivity of 60% means that some patients with a subscapularis tear may have a negative test.

Specificity describes the proportion of patients without the condition who test negative. A specificity of 91% indicates that a positive result may be useful in raising suspicion for a tear, although false-positive results can still occur.

These values should be interpreted in the context of the population examined, the reference standard used, and the study methodology. Diagnostic accuracy may vary between clinical settings.

The Bear Hug Test should therefore be combined with other subscapularis examination maneuvers, such as the Lift-Off Test, Belly-Press Test, and Internal Rotation Lag Sign, rather than used in isolation.

Clinical Interpretation and Limitations

The Bear Hug Test is most useful when interpreted alongside the patient’s symptoms and other examination findings. A systematic review and meta-analysis found that the test’s pooled sensitivity was approximately 55%, while specificity exceeded 90% across the clinical tests analyzed. This supports its role as a useful examination maneuver but also demonstrates that a negative result cannot reliably exclude a subscapularis tear. <Cite refs={[“turn458635search1″,”turn458635search5”]}/>

When clinical suspicion remains high, the examiner may consider additional tests and imaging, such as magnetic resonance imaging (MRI) or ultrasound, depending on the clinical situation.

Frequently Asked Questions (FAQ)

1. What does the Bear Hug Test assess?

The Bear Hug Test assesses subscapularis tendon function and is primarily used to identify possible subscapularis tears, particularly those involving the upper portion of the tendon.

2. How do you perform the Bear Hug Test?

The patient places the palm of the affected hand on the opposite shoulder, with the fingers extended and the elbow pointing forward. The examiner applies external rotational resistance at the wrist while the patient attempts to keep the hand against the shoulder.

3. What is a positive Bear Hug Test?

A positive result occurs when the patient cannot maintain the hand against the opposite shoulder or demonstrates noticeable weakness compared with the unaffected side. Reproduction of anterior shoulder pain may also suggest subscapularis dysfunction.

4. What are the sensitivity and specificity of the Bear Hug Test?

In the original study by Barth and colleagues, sensitivity was 60% and specificity was approximately 92%. These values vary between studies, and pooled evidence suggests that sensitivity is generally limited. <Cite refs={[“turn458635search0″,”turn458635search1”]}/>

5. Can a negative Bear Hug Test rule out a subscapularis tear?

No. Some patients with confirmed subscapularis tears have a negative test. If symptoms, weakness, or the injury mechanism suggest a tear, further clinical assessment may be necessary.

6. Which tests can be combined with the Bear Hug Test?

The Belly-Press Test, Lift-Off Test, and Internal Rotation Lag Sign are commonly used to assess subscapularis function. Combining the Bear Hug Test with the Belly-Press Test may improve diagnostic performance compared with relying on a single maneuver. <Cite refs={[“turn458635search6″,”turn458635search2”]}/>

7. Does a positive Bear Hug Test confirm a rotator cuff tear?

No. It raises suspicion for subscapularis tendon pathology but does not independently confirm a tear. Diagnosis requires clinical correlation and, when indicated, imaging or other investigations.

References

1. Barth JRH, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22(10):1076–1084. Read on PubMed.
2. Lädermann A, et al. Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis. Read on PubMed.
3. Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review. Read on PubMed.
4. Clinical Diagnosis of Subscapularis Tendon Tear Using the Bear Hug Semiology Maneuver. Read on PubMed.