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Last Updated: Oct 30, 2026
The belly press test for shoulder assessment tells you whether the subscapularis can still hold the arm in internal rotation. The patient presses a flat palm into the stomach and keeps the elbow in front of the trunk. A wrist that folds forward, or an elbow that slides back behind the trunk, is a positive result.
That points to a torn or badly weakened subscapularis. Getting the call right matters, because a missed tear changes the repair and the rehabilitation that follows it.
You will find the technique, the interpretation, what the published accuracy supports, and when to switch to the lift-off or bear hug.
Key takeaways
The belly press test loads the upper portion of the subscapularis, so it cannot rule out a lower-portion tear on its own.
A positive result is wrist flexion, or the elbow drifting behind the trunk, during the palm press.
Reported sensitivity runs from roughly 28% to 88%, while specificity holds between 68% and 99%.
The test is the practical choice when a patient cannot reach behind the back for a lift-off test.
Record the test name, the side, the result, and the sign you saw, or the note will not support the referral.
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What the belly press test checks, and why it works
The belly press test is an orthopedic special test that looks for tears or marked weakness in the subscapularis muscle and tendon.
It needs no equipment, works standing or seated, and takes seconds. The Napoleon test is a related, graded variant, named for portraits of Napoleon Bonaparte with a hand tucked inside his coat.
The mechanism is simple. Pressing the palm into the stomach with the elbow forward asks the subscapularis to hold the shoulder in internal rotation against resistance.
If the tendon is torn, the patient cannot generate that force from the shoulder. So they borrow it, either by flexing the wrist or by pulling the elbow backwards to recruit the shoulder extensors.
That borrowed movement is the whole finding. Watch the wrist and the elbow, not the hand.
- Related variant: Napoleon test, a graded version scored by wrist flexion
- Structure tested: Subscapularis muscle and tendon, mainly the upper portion
- Test type: Isometric provocation, an orthopedic special test
- Setting: Standing or seated, no equipment needed
- Positive sign: Wrist flexion, or the elbow drifting behind the trunk
Why the subscapularis is the hardest cuff muscle to test
The subscapularis is the largest and strongest of the four rotator cuff muscles. It runs from the subscapular fossa, on the front surface of the scapula, to the lesser tubercle of the humerus. It rotates the arm inward, adducts the glenohumeral joint, and holds the humeral head forward in the socket.
So a tear costs the patient strength and front-of-joint stability at once. Most tears start at the upper border of the tendon, often alongside biceps pathology. Overhead athletes, patients recovering from an anterior dislocation, and older adults with degenerative cuff disease make up most of the caseload.
It also sits deep and anterior, tucked between the scapula and the ribs. You cannot palpate it the way you can the supraspinatus. The only way to judge it is to load the muscle and watch what the patient does instead.
The tendon has an upper and a lower component, and that split drives the whole testing strategy. Electromyography work by Tokish and by Chao found that the belly press preferentially loads the upper portion.
The lift-off is the test that stresses the lower portion. Running only one of them leaves part of the tendon unexamined.
When to reach for the belly press test
Use the belly press whenever the history or the screening exam points at the subscapularis. Anterior shoulder pain with weak internal rotation is the classic trigger, and so is restricted passive external rotation.
It belongs early in the shoulder battery, not as an afterthought once imaging has already been ordered.
- Suspected subscapularis tear, partial or full thickness
- Anterior shoulder pain with weak internal rotation on manual muscle testing
- A history of anterior shoulder dislocation or subluxation
- Follow-up after subscapularis repair, anterior stabilization, or shoulder replacement, once the surgeon has cleared resisted internal rotation
- Limited passive external rotation, which can suggest subscapularis contracture or tear
- Suspected anterosuperior impingement, because subscapularis tears often travel with rotator interval and biceps pulley lesions
- Return-to-sport screening, where internal rotation strength has to be cleared before an athlete progresses
- Patients who cannot get into the lift-off position because internal rotation is restricted
That last one is the reason this test earns its place. The Gerber lift-off needs the patient to put a hand behind the lower back and rotate the shoulder inward. Plenty of painful or stiff shoulders simply will not go there.
The belly press asks for a much easier position, so you still get a subscapularis reading on the patients who need it most.
Because so much of this hangs on available movement, measure and record the range first. A printable shoulder range of motion chart gives you the baseline to compare against at the next visit.
How to run the test in under a minute
Technique decides the result here more than in most special tests. Small changes in elbow position, starting wrist posture, or how you phrase the instruction will flip a finding. The sequence below follows the method described in peer-reviewed clinical skills resources.
Setting the patient up
Have the patient stand or sit upright with the arm relaxed. Ask them to lay the palm flat on the stomach, roughly at the level of the navel. The fingers point across the stomach toward the other side. The elbow bends to about 90 degrees and stays in front of the trunk, not out to the side.
That forward elbow position is the landmark the whole test hangs on. If the elbow drops behind the trunk during the press, that movement is itself part of the positive sign.
What you watch for
Stand facing the patient on the side you are testing. Check the wrist and the elbow first, because you need the starting posture to compare against. Then give the instruction and watch for the two compensations.
- Confirm the palm is flat and the wrist is neutral or slightly extended before you give the instruction
- Say: “Press your hand firmly into your stomach and hold it there”
- Watch the wrist. Does it fold forward so the palm angles into the stomach?
- Watch the elbow. Does it slide behind the plane of the trunk?
- Check that the patient can hold the press for three to five seconds without either compensation
Then repeat the whole sequence on the other shoulder. Test the uninvolved side first, so the patient learns the movement before you load the painful one.
Setup errors that skew the result
When a belly press goes wrong in practice, the setup is usually the reason. Check these four before you trust the result.
- Elbow already behind the trunk: if the elbow starts level with or behind the trunk, you cannot judge drift. Move it forward and hold it there for a second, then ask for the press.
- Watching from the side: stand in front of the patient, level with the forearm. A side view hides small amounts of wrist flexion.
- A soft instruction: patients rarely give maximal effort unless you ask for it. Cue it in plain words, such as “press as hard as you can without moving your elbow.”
- Reading pain as weakness: pain inhibits the contraction. If the patient winces as the wrist drops, record the result as equivocal and say why.
What a positive result tells you, and what it doesn’t
Two compensations count, and either one on its own makes the test positive. A negative test is a firm press held with the wrist neutral or extended and the elbow kept forward for the whole hold. That pattern says the subscapularis is doing its job.
Here is how that plays out. A 58-year-old arrives six weeks after a fall, with anterior shoulder pain and weak internal rotation. The lift-off position is out of reach.
The belly press shows a clear wrist drop on the right and none on the left. That side-to-side contrast is enough to justify imaging.
A positive result raises the suspicion of a tear. It does not confirm one. MRI or arthroscopy is what settles the diagnosis, and the test result belongs alongside the history, the imaging, and the rest of the battery.
Diagnostic accuracy: A positive result carries more weight than a negative one
Published accuracy for the belly press swings widely between studies. Three factors drive that spread. Studies differed in how they defined a positive sign, in whether MRI or arthroscopy was the reference standard, and in which patients they recruited.
The figures below come from a systematic review of 13 studies covering eight subscapularis tests. Seven reported belly-press results, and the ranges come from the six that scored partial and full-thickness tears together.
Read those two rows together and the clinical rule falls out. Specificity is high in most studies (pooled 94%), though one reported 68%. Sensitivity collapses in some of them. So a positive belly press moves you toward imaging, and a negative one moves you almost nowhere.
The per-study figures are set out in the systematic review of subscapularis special tests on PubMed Central. When you write to a referring clinician, quote the range rather than a single number, and say which reference standard the study used.
The single study most clinicians quote is Barth et al. (2006) in Arthroscopy. It examined 68 consecutive patients before shoulder arthroscopy and used the arthroscopic findings as the reference standard.
Barth’s team ran all four subscapularis tests in the same study, which makes their figures the cleanest side-by-side comparison. The bear hug was the most sensitive, and the lift-off the least.
Source: Barth et al. (2006), with arthroscopy as the reference standard.
The tests also turn positive at different tear sizes. Running all of them helps you estimate how much of the tendon is gone, as well as whether it is torn. A positive lift-off alongside a positive belly press points to a large tear.
Even with all four tests run, 40% of the tears in that study were not predicted before arthroscopy. A clean cluster lowers your suspicion, but it does not clear the tendon.
Barth’s belly-press figures work out to a positive likelihood ratio of about 19 and a negative one of about 0.6. A positive press moves the odds of a tear sharply upward, while a negative press barely shifts them.
Pre-test probability frames all of it. Take a patient with anterior pain, a history of dislocation, and measurable internal rotation weakness. A positive press in that patient makes a tear the leading explanation. The same result in a low-probability shoulder deserves more caution.
Pro Tip
Run all three subscapularis tests, not just the one you like. The belly press and the bear hug both load the upper tendon, so the lift-off is what covers the lower portion. Combining them lifts accuracy only marginally, so treat a cluster of negatives as support for your clinical judgment rather than proof.
Where the belly press test lets you down
Most limitations below push the test toward a false negative. Biceps pathology can do the opposite. Knowing them stops you treating a negative result as an all-clear.
- Pain inhibition: anterior shoulder pain stops some patients pressing hard enough to expose the weakness, so no compensation appears
- Biceps pathology: a painful long head of biceps can pull the wrist into flexion and mimic a positive subscapularis sign
- Upper against lower tears: the belly press loads the upper tendon, so an isolated lower-portion tear can pass it and fail the lift-off
- Restricted wrist movement: wrist pathology changes the resting posture and muddies the reading
- Partial tears: small partial-thickness tears often leave enough strength that no compensation shows at all
- Examiner experience: subtle posterior elbow drift takes practice to see, and newer examiners both miss it and overcall it
So a negative belly press on its own never rules out subscapularis pathology. A cluster of negatives lowers suspicion further, but Barth’s team still missed 40% of tears with all four tests run.
Belly press, lift-off, or bear hug: Which test to reach for
Three tests share this job: the belly press, the lift-off, and the bear hug. They differ in which part of the tendon they load and in what they ask the patient’s shoulder to do. The second difference is usually what decides which test you can run on the day.
The lift-off test covers the lower portion
The Gerber lift-off test loads the lower subscapularis through active internal rotation. The patient puts a hand behind the lower back, palm facing away, then lifts it off against gravity or your resistance. Failing to lift off, or failing to hold the lifted position, is positive.
Its weakness is the starting position. Patients with restricted internal rotation, acute pain, or a stiff shoulder cannot get the hand behind the back at all. That is the moment to switch to the belly press.
When the hand does reach the back, the internal rotation lag sign removes the active lift. You raise the forearm for the patient, release the wrist while supporting the elbow, then watch for drift.
The bear hug test overlaps on the upper portion
For the bear hug, the patient places a hand on the opposite shoulder with the elbow raised. You try to lift the hand away while they resist. A positive sign is losing the hand position, or a force deficit greater than 20% against the other side.
Because it also stresses the upper tendon, it does not substitute for the lift-off. Think of the bear hug as a second look at the upper portion, useful when the belly press is equivocal or pain limits the press.
Slotting the test into a full shoulder exam
The belly press answers one question about one muscle. Knowing where it sits in the sequence stops you repeating tests that load the same tendon. It also stops you missing the supraspinatus, infraspinatus, or teres minor altogether.
- Suspected supraspinatus tear: start with the empty can or full can test, not the belly press
- Suspected subscapularis tear: belly press first, then the lift-off if range allows, then the bear hug
- Suspected subacromial impingement: Neer sign and Hawkins-Kennedy, because the belly press does not assess impingement
- Suspected posterior cuff involvement: add the infraspinatus test to check external rotation strength
- Suspected massive cuff tear: drop arm test to screen, then belly press if anterior pain or weak internal rotation is present
- After an anterior dislocation: always run the belly press, because subscapularis avulsion is a known complication
A workable order for anterior shoulder pain with suspected cuff pathology runs like this. Neer sign, Hawkins-Kennedy, empty can, drop arm, belly press, bear hug, then Speed’s test for the biceps tendon. That sweeps the whole cuff and clears the common confounders before anyone orders an MRI.
Documenting the result so the note holds up
An entry reading “shoulder pain, query rotator cuff” will not support a referral, justify imaging, or defend you later. The test is quick, and so is recording it properly. What trips teams up is inconsistency. Two clinicians in the same practice describe the same finding in different words.
A shoulder assessment template inside your physical therapy EMR fixes that, because the fields do the remembering instead of the clinician. Run through this list before you close the note.
- The test name, written in full, and the side tested
- The result, recorded as positive or negative rather than described loosely
- Which sign you saw, wrist flexion or posterior elbow drift, since they are not interchangeable
- The comparison finding from the uninvolved shoulder
- Whether pain limited the effort, which is what makes a negative unreliable
- The other subscapularis tests you ran, and their results
SOAP format maps cleanly onto a shoulder exam. The press result goes under Objective, and your working diagnosis goes under Assessment. If the note turns into a referral, also state what you want back, whether that is imaging, a surgical opinion, or both.
Coding follows the diagnosis, not the test. In ICD-10-CM, subscapularis pathology sits in the M75 shoulder lesions category. M75.1 covers rotator cuff tear or rupture, not specified as traumatic. It splits further into M75.11 for an incomplete tear and M75.12 for a complete one.
The final digit carries laterality, so a confirmed complete, non-traumatic tear of the right shoulder codes to M75.121. A tear from a fall or other injury codes to S46.01- instead, with a sixth character for side and a seventh for the encounter.
Until imaging confirms the tear, document the weakness and the test findings rather than coding a tear.
M75.3 covers calcific tendinitis of the shoulder, which is a common alternative once imaging comes back. Codes change every October, so check the current ICD-10-CM files from CMS before you submit rather than trusting a cheat sheet.
On the procedure side, a shoulder examination normally falls under evaluation and management coding, and the level depends on the setting and the payer. Your billing team is the right check there, not a blog.
How Pabau keeps shoulder findings in one patient record
Most practices still record special tests in free text. The wording drifts between clinicians, the side gets left out, and six months later nobody can find the note that mattered. Rebuilding the picture then takes longer than the original appointment did.
Pabau, the EMR and practice platform we build, swaps that for a structured form you set up once. The shoulder assessment template carries fields for the test, the side, the result, and the sign observed. The same information reaches the record whoever is in the room.
Those findings then sit in patient record management alongside the appointment they came from. The next clinician opens the record and sees what changed since the last visit. You can track a subscapularis over six weeks instead of guessing.
Pabau Scribe, our AI scribe, can also draft the assessment note from your spoken summary. You review it before it saves.
Record every shoulder assessment the same way
Pabau gives physical therapy and sports medicine practices structured digital forms, AI-assisted clinical notes, and searchable patient records. Every special test result lands in the right place and stays findable at the next visit.
Conclusion
Treat the belly press as a rule-in test and it will serve you well. Specificity is high across the literature, so a clear wrist fold or a drifting elbow is worth escalating. Sensitivity is not, so a clean press proves very little on its own.
The bigger shift is remembering which part of the tendon you examined. The belly press and the bear hug both report on the upper subscapularis. Skip the lift-off and the lower portion goes unchecked, which is how isolated lower-pole tears reach the surgeon undiagnosed.
The trade-off worth holding onto is speed against certainty. The test takes seconds, and that is the point, as long as the note that follows carries the side, the sign, and the effort. Book a demo to see how Pabau turns a shoulder assessment into a structured record your whole team can read.
Continue your research
Need to check the lower portion of the tendon? Lift-off test walks through the position, the resistance, and what a positive result means.
Working through the rest of the rotator cuff? Infraspinatus test covers the external rotation side of the same assessment battery.
Need a printable range chart for the shoulder? Shoulder range of motion template gives you a baseline to measure against at the next visit.
Tightening up your clinical documentation? Physiotherapy compliance requirements sets out what your records need to show and why.
Setting up a new practice? Opening a physiotherapy clinic covers the operational and documentation groundwork before you see patients.
Frequently asked questions
Is the belly press test painful?
It should not be. The press is isometric and the arm stays in a comfortable position, so most patients tolerate it easily. Anterior shoulder discomfort is common with subscapularis pathology, though. Pain that stops the patient pressing firmly makes the result unreliable. Record the pain rather than the weakness, then repeat the test once symptoms settle.
How soon after a subscapularis repair can you use it?
Follow the surgeon’s protocol rather than a fixed timeline. Resisted internal rotation pulls directly on the repair, so protocols hold it back for several weeks after surgery. Once resisted internal rotation has been cleared, the belly press gives a quick side-to-side check on how the tendon is recovering.
Does a positive result mean surgery is needed?
No. The test points to subscapularis weakness, and plenty of causes of that respond to rehabilitation. Imaging decides the next step. Tendinopathy and small partial tears are usually managed conservatively, while a full-thickness tear in an active patient is more likely to be referred.
Should both shoulders be tested?
Yes, and start with the uninvolved side. It sets the patient’s normal and shows them the movement before you load the painful shoulder. Subscapularis weakness is far easier to spot as a difference between sides than as an absolute finding, so record both results.
Is the belly press test the same as the Napoleon test?
Many clinicians use the two names for the same maneuver, since the hand-on-stomach pose recalls portraits of Napoleon. Barth’s team treated the Napoleon test as a graded version, scoring how far the wrist flexes during the press.
When should you skip the belly press test?
Skip it in the acute phase after an anterior dislocation, until X-rays rule out a fracture and the patient can press firmly. After that, run it, because a subscapularis tear is a known complication of dislocation.
What else causes a positive belly press test?
Weakness has causes beyond a tear. Injury to the subscapular nerves and long-term disuse can produce the same wrist drop, and pain can fold the wrist when strength is intact. Read the result against the history and the rest of your exam.
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