What are the recommended physical exam tests for suspected scoliosis?

Physical Examination Tests for Suspected Scoliosis

The most important physical examination tests for suspected scoliosis include the Adams forward bend test combined with scoliometer measurement, as these together provide the most reliable clinical assessment for detecting spinal curvature. 1

Primary Screening Tests

• Adams Forward Bend Test: Patient bends forward at the waist with arms hanging freely and knees straight. The examiner observes from behind for asymmetry of the trunk, rib hump, or prominence of one scapula. While widely used, this test alone has limitations with a sensitivity of 84.37% and specificity of 93.44%, resulting in unacceptable false-negative findings. 1, 2

• Scoliometer Measurement: Used during the forward bend test to quantify trunk rotation. A measurement of ≥8 degrees warrants further evaluation. This tool has a sensitivity of 90.62% and specificity of 79.76%. 1, 2

Additional Assessment Methods

• Moiré Topography: A specialized optical technique that creates contour lines on the back surface, highlighting asymmetry. Has excellent sensitivity (100%) but lower specificity (85.38%). 2

• Humpometer: Measures the height difference of the rib hump. Shows good sensitivity (93.75%) but lower specificity (78.11%). 2

Comprehensive Physical Examination Elements

• Standing Posture Assessment: Evaluate for:

  • Shoulder height asymmetry
  • Uneven waistline
  • Trunk shift (plumb line test)
  • Pelvic obliquity 3, 4

• Neurological Examination: Critical to rule out underlying neurological causes. Assess for:

  • Focal neurological deficits
  • Abnormal reflexes
  • Muscle weakness
  • Pes cavus (high-arched feet) 1

• Skin Examination: Check for cutaneous stigmata that might suggest underlying spinal dysraphism:

  • Hemangiomas
  • Hairy patches
  • Nevi
  • Dermal appendages
  • Sinus tracts 1

Risk Factors to Document During Examination

• Red Flags requiring urgent evaluation:
  • Left thoracic curve (atypical pattern)
  • Short segment curve
  • Absence of apical segment lordosis/kyphosis
  • Long thoracolumbar curve
  • Rapid curve progression (>1° per month)
  • Functionally disruptive pain
  • Focal neurological findings
  • Male sex 1

Clinical Pitfalls and Considerations

• Limitations of Forward Bend Test: When used alone, this test results in unacceptable false-negative findings. Always combine with other assessment methods. 2

• Optimal Referral Criteria: To reduce unnecessary radiographic exposure, consider referral when finding:

  • Asymmetry of two or more Moiré fringes
  • Humpogram deformity of (D+H) ≥ 10 mm
  • Scoliometer angle ≥ 8 degrees 2

• Differential Diagnosis: The physical exam should help distinguish between:

  • Idiopathic scoliosis (diagnosis of exclusion)
  • Congenital scoliosis (vertebral anomalies)
  • Neuromuscular scoliosis (associated with conditions like cerebral palsy)
  • Syndrome-related scoliosis (Marfan syndrome, Ehlers-Danlos syndrome)
  • Secondary scoliosis (from tumors like osteoid osteoma) 1, 5

• Referral Thresholds: A child should be referred to a specialist if:

  • Curve is >10° in a patient younger than 10 years
  • Curve is >20° in a patient 10 years or older
  • Atypical features are present
  • Back pain or neurological abnormalities are associated 5

Using a combination of these physical examination techniques provides the most reliable clinical assessment for scoliosis, reducing unnecessary radiographic exposure while ensuring appropriate identification of patients requiring further evaluation. 1, 3, 2