Gerber's test (Lift-Off Test)

The Gerber’s Test, also known as the Lift-Off Test (LOT) or Gerber’s Lift-Off Test, was first described by Gerber and Krushell in 1991¹. It was developed as a simple yet reliable clinical examination to diagnose or exclude clinically significant ruptures of the subscapularis tendon.

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The subscapularis is one of the four rotator cuff muscles, alongside the supraspinatus, infraspinatus, and teres minor. Each muscle has its own specific clinical test to assess integrity and function. In 1996, Gerber et al. introduced the Belly Press Test (BPT) as an alternative for patients unable to perform the Lift-Off Test due to pain or restricted range of motion.

Purpose

Gerber’s Lift-Off Test is used to:

• Evaluate the integrity of the subscapularis tendon

• Detect partial- or full-thickness tears of the subscapularis

• Differentiate subscapularis pathology from other shoulder disorders

Test Procedure

Patient position

• Standing, with the examiner positioned behind the patient.

Execution

1. The patient places the dorsum of the hand on the lower back.

2. The patient is asked to lift the hand away from the back (active internal rotation).

3. The examiner may apply gentle resistance to assess muscle strength.

Positive Test

• Inability to lift the hand away from the back.

• Compensatory movements, such as elbow extension or shoulder extension, instead of true internal rotation².

Limitations

• Requires adequate passive internal rotation to position the arm behind the back.

• Pain can limit performance and reduce diagnostic accuracy.

Evidence

Electromyographic (EMG) studies

• Greis et al. (1996): Subscapularis activated at ~70% of maximum voluntary contraction during the Lift-Off Test, significantly higher than other shoulder muscles (p < 0.05)⁴.

• Pennock et al. (2011): Confirmed that LOT isolates the subscapularis significantly more than other muscles, regardless of arm position⁵.

Clinical studies

• Barth et al. (2012): Lift-Off Test correlated with the severity of subscapularis tears (p < 0.05), but could not be performed in 18% of cases due to pain or restricted ROM².

• Kappe et al. (2018): Compared five subscapularis tests and found LOT had 35% sensitivity and 98% specificity for subscapularis ruptures (p < 0.001)⁶.

Clinical Significance

• High specificity (98%) → A positive test strongly indicates a subscapularis rupture.

• Low sensitivity (35%) → A negative test does not rule out subscapularis injury.

• Should be combined with other subscapularis-specific tests such as the Belly Press Test and Internal Rotation Lag Sign for better diagnostic accuracy.

Summary

Gerber’s Lift-Off Test is a specific but not sensitive clinical tool for diagnosing subscapularis tendon tears. While a positive result strongly suggests subscapularis pathology, a negative result should not exclude the condition. For optimal reliability, LOT should be part of a comprehensive shoulder assessment alongside other rotator cuff tests and imaging.

References

1. Gerber C and Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. The Journal of Bone and Joint Surgery. British volume 1991 73-B:3, 389-394

2. J. Barth, S. Audebert, B. Toussaint, C. Charousset, A. Godeneche, N. Graveleau, T. Joudet, Y. Lefebvre, L. Nove-Josserand, E. Petroff, N. Solignac, C. Scymanski, M. Pitermann, C.-E. Thelu. Diagnosis of subscapularis tendon tears: Are available diagnostic tests pertinent for a positive diagnosis?, Orthopaedics & Traumatology: Surgery & Research, 2012, Volume 98, Issue 8, Supplement, Pages S178-S185,

3. Examination of the Rotator Cuff - Lift-off Test - Clinical Examination. Available from: http://www.youtube.com/watch?v=t9dSDVRbjn0

4. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R. Validation of the Lift-Off Test and Analysis of Subscapularis Activity During Maximal Internal Rotation. The American Journal of Sports Medicine. 1996;24(5):589-593. doi:10.1177/036354659602400505

5. Pennock AT, Pennington WW, Torry MR, Decker MJ, Vaishnav SB, Provencher MT, Millett PJ, Hackett TR. The influence of arm and shoulder position on the bear-hug, belly-press, and lift-off tests: an electromyographic study. Am J Sports Med. 2011 Nov;39(11):2338-46. doi: 10.1177/0363546510392710. Epub 2011 Feb 7. PMID: 21300808.