Rovsing Sign
The sign demonstrated is Rovsing sign, which is elicited when deep palpation in the left lower quadrant causes pain in the right lower quadrant, indicating peritoneal irritation from appendicitis. 1
Definition and Technique
Rovsing sign is a clinical maneuver where the examiner applies deep pressure to the left lower quadrant of the abdomen, and upon quick withdrawal or during the compression itself, the patient experiences pain referred to the right lower quadrant. 1 This occurs due to retrograde pressure transmitted through the colon, causing movement of peritoneal contents and irritation of the inflamed appendix. 2
Important Caveat About Technique
- There is significant confusion in the medical literature about how to properly elicit Rovsing sign, with many sources describing it incorrectly. 2
- The original description by Niels Thorkild Rovsing in 1907 has been mistranslated in English medical texts, leading to widespread teaching errors. 2
- Despite this confusion, the sign remains clinically useful when properly performed as part of the appendicitis evaluation. 1, 3
Clinical Context in Appendicitis Diagnosis
- Rovsing sign should be evaluated alongside other clinical findings including right lower quadrant tenderness, rebound tenderness, guarding, and rigidity. 1, 3
- Rebound tenderness has been shown to have high sensitivity (94.7%) for appendicitis, though Rovsing sign remains a valuable complementary finding. 3
- Clinical scoring systems like the Alvarado Score incorporate multiple physical examination findings to stratify risk and guide the need for imaging. 4
Role in Diagnostic Algorithm
- When Rovsing sign is positive in the context of right lower quadrant pain, imaging confirmation is recommended. 1
- CT scan without oral contrast is the preferred imaging modality in adults, with sensitivity of 90-100% and specificity of 94.8-100%. 5, 4
- Ultrasound is recommended as first-line imaging in pediatric patients and women of childbearing age. 1, 4
- MRI demonstrates excellent diagnostic performance with 96% sensitivity and specificity, particularly useful in pregnant patients. 5, 1
Distinguishing From Other Signs
- Psoas sign: Pain with hip extension or flexion, indicating retrocecal appendix irritating the psoas muscle
- Obturator sign: Pain with internal rotation of the flexed hip, suggesting pelvic appendix
- Murphy sign: Inspiratory arrest during right upper quadrant palpation, specific for cholecystitis
- McBurney sign: Direct tenderness at McBurney's point (one-third the distance from anterior superior iliac spine to umbilicus)