Assessing suspected appendicitis relies on a systematic approach to the physical exam, where specific appendicitis exam maneuvers help localize inflammation and guide clinical decision-making. While no single sign is definitive, the combination of findings provides a powerful tool for narrowing the differential diagnosis and determining the urgency of surgical consultation. The goal of each maneuver is to reproduce pain in a pattern consistent with irritation of the parietal peritoneum overlying the inflamed appendix.
Foundational Principles of the Examination
Before diving into specific maneuvers, the examination begins with a focused history and a gentle inspection of the abdomen for visible distension or guarding. Palpation typically starts away from the area of maximum pain to avoid causing guarding that could obscure findings, often moving toward the right lower quadrant. The physician must maintain a high index of suspicion, as anatomical variations and atypical presentations are common, especially in pediatric, geriatric, and pregnant patients.
McBurney's Point and Deep Tenderness
Locating McBurney's point, which is one-third of the distance from the anterior superior iliac spine to the umbilicus, is a standard landmark for identifying deep tenderness. Direct pressure over this area elicits pain when the appendix is inflamed and positioned retrocecally or within the pelvis. This maneuver is often the initial step, and rebound tenderness is assessed immediately afterward to evaluate for peritoneal irritation, a sign that the inflammation has progressed to involve the lining of the abdominal cavity.
Rovsing's Sign and Referred Pain
Rovsing's sign is elicited by applying firm pressure to the left lower quadrant, which increases discomfort in the right lower quadrant through the transmission of force across the peritoneal cavity. This phenomenon suggests that the inflamed appendix is fixed in place, causing pain when adjacent structures are moved. A positive Rovsing's sign reinforces the clinical diagnosis but must be interpreted alongside other findings to avoid false positives seen in patients with pelvic inflammatory disease or diverticulitis.
Psoas and Obturator Signs for Retrocecal and Pelvic Appendices
The psoas sign is tested by extending the right hip while the patient lies on their left side, creating tension on the psoas muscle that lies behind the appendix. Pain during this maneuver indicates that an inflamed retrocecal appendix is irritating the muscle or nearby nerves. Conversely, the obturator sign involves flexing the right hip and knee and internally rotating the hip, which stretches the obturator internus muscle. A positive result here suggests irritation of an appendix located in the pelvis, close to the obturator nerve.
