Belly Press Test

The Belly Press Test is a clinical examination used to assess the function of the subscapularis muscle, a key component of the rotator cuff. Subscapularis is responsible for internal rotation and stabilization of the humeral head within the glenoid, particularly during pressing and holding movements in front of the body.

The test is especially useful in patients who cannot perform the Lift-off Test, for example due to pain, stiffness, or limited shoulder extension. It provides valuable insight into partial or complete subscapularis tears, particularly at the musculotendinous junction near the lesser tubercle.

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Advantages and Limitations

Advantages:

• Can be used when shoulder extension is restricted (e.g., frozen shoulder, pain)

• Detects weakness, rupture, or neuromuscular dysfunction of subscapularis

• Easy to perform, requires no equipment

• High specificity for lesions in the upper subscapularis

Limitations:

• May be influenced by pain inhibition in the acute phase

• Many patients compensate with wrist flexion or by moving the elbow backward

• Lower sensitivity – a negative test does not exclude subscapularis pathology

• Best at detecting larger, clinically significant tears

Test Procedure

Position:

• Patient seated or standing

• Elbow flexed to 90°, hand placed flat against the abdomen

Execution:

1. Patient presses palm against abdomen with active internal rotation.

2. Examiner instructs patient to keep the elbow forward, not drifting backward.

3. Observe for:

   • Wrist flexion compensation

   • Elbow moving posteriorly

   • Loss of controlled internal rotation

Positive test:

• Elbow drifts backward during pressure

• Wrist flexion compensation

• Inability to maintain palm flat against abdomen

Negative test:

• Palm pressed firmly against abdomen

• Elbow maintained in forward position

• No compensatory wrist or elbow movements

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Clinical Relevance and Differential Diagnosis

The Belly Press Test is particularly sensitive for upper subscapularis tears, but should always be combined with other tests:

• Lift-off Test

• Bear Hug Test

• Napoleon Sign

Used in cases of:

• Traumatic rotator cuff tears

• Chronic degenerative changes of the shoulder

• Early subscapularis insufficiency before full rupture

• Differentiation between muscular weakness and neurologic impairment

Further imaging (MRI, ultrasound) is indicated in case of positive test with significant pain, weakness, or loss of function.

Evidence and Validity

• Specificity: 0.90–0.96 → very high, excellent for confirming clinical suspicion¹

• Sensitivity: 0.34–0.60 → low to moderate, cannot exclude pathology if negative¹

• EMG validation: High activation of upper subscapularis during Belly Press vs. other cuff tests²

• Reliability: Good inter-examiner agreement when standardized instructions are provided³

Recommendation: Always use the Belly Press Test as part of a test battery for rotator cuff assessment.

Sources:

1. Dutton M, Magee D, Hengeveld E, Banks K, Atkinson K, Coutts F, Hassenkamp AM. Orthopaedic examination, evaluation, and intervention. McGraw-Hill Medical; 2004.

2. Tokish JM, Decker MJ, Ellis HB, Torry MR, Hawkins RJ. The belly-press test for the physical examination of the subscapularis muscle: electromyographic validation and comparison to the lift-off test. Journal of shoulder and elbow surgery. 2003 Sep 1;12(5):427-30.

3. The Physio Channel. Belly-press Rotator Cuff Subscapularis Test. Available from: https://www.youtube.com/watch?v=cI4GN8NqRdg [last accessed 9/1/2021]

4. Kappe T, Sgroi M, Reichel H, Daexle M. Diagnostic performance of clinical tests for subscapularis tendon tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2018 Jan 1;26(1):176-81.

5. Cadogan A, Laslett M, Hing W, McNair P, Williams M. Interexaminer reliability of orthopaedic special tests used in the assessment of shoulder pain. Manual therapy. 2011 Apr 1;16(2):131-5.