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Test library › Shoulder & upper arm

Belly-off sign

For: Subscapularis tear

Website-only test: not part of the book.

A tear in the subscapularis, the rotator cuff tendon at the front of the shoulder that turns the arm inwards (internal rotation).

Treat with caution (see below)
Sensitivity87%
Specificity91%
LR+ (positive)10.1
LR− (negative)0.15

Likelihood ratios calculated from the counts implied by the study (13 of 15 tears positive; 3 of 35 patients without a tear positive); the rounded 87% and 91% shown would give an LR+ of about 9.7.

Caution: Single study of 50 patients (15 tears) by the group that described the sign; a later study (Kappe 2018) found sensitivity only 31%.

These figures have not been confirmed against the full paper (checked against the abstract or a secondary source only).

How it is done

The examiner passively brings the arm into flexion and internal rotation, with the elbow bent, and places the palm of the hand on the abdomen, then lets go and asks the patient to keep the palm there. Positive: the patient cannot keep the palm on the abdomen (the hand lifts off).

What the studies found

Subscapularis tear. Bartsch et al. 2010 examined 50 consecutive patients before arthroscopic shoulder surgery; 15 had a subscapularis tear. The belly-off sign had sensitivity 87% (95% CI 62–96%) and specificity 91% (95% CI 78–97%), the highest overall accuracy of the subscapularis tests in that study. The study comes from the same research group that first described the sign (Scheibel 2005), which also reported that the sign turns negative, and loses its value, when the external rotators are also deficient. A later study (Kappe 2018) found sensitivity only 31% with specificity 97%, so a negative belly-off sign may miss many tears. There were too few studies for the 2021 meta-analysis (Lädermann) to pool it, and a 2012 review (Hegedus) listed it among promising tests whose figures still needed confirming in more than one study.

What the numbers mean

  • Positive result: see the caution above before relying on this result.
  • Negative result: see the caution above before relying on this result.

The ladder: what a result does to your estimate

If you thoughtAfter a positiveAfter a negative
10%53%2%
30%81%6%
50%91%13%

Calculated from the likelihood ratios above. Read the caution above before relying on these. For any other starting estimate, use the probability calculator.

Work out what a result means for your patient: probability calculator

Other tests in the library for subscapularis tear

Compare all the tests for subscapularis tear side by side

Source

Bartsch M, Greiner S, Haas NP, Scheibel M. Diagnostic values of clinical tests for subscapularis lesions. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1712–1717. Journal article (DOI) · single study
Also cited: Scheibel M, Magosch P, Pritsch M, Lichtenberg S, Habermeyer P. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions. Arthroscopy. 2005;21(10):1229–1235. Journal article (DOI)
Also cited: Kappe T, Sgroi M, Reichel H, Daexle M. Diagnostic performance of clinical tests for subscapularis tendon tears. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):176–181. Journal article (DOI)
Also cited: Lädermann A, Collin P, Zbinden O, Meynard T, Saffarini M, Chiu JCH. Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2021;9(9):23259671211042011. Journal article (DOI)
Also cited: Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964–978. PubMed

Website-only test: added to the library on 9 October 2026 and not part of Rule It In, Rule It Out. Figures independently checked against the sources cited above; any note above says where only the abstract could be checked. If a newer or better study changes them, this page will be updated.

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