Where is tenderness typically located in a patient with suspected acute appendicitis?

Tenderness Location in Acute Appendicitis

Tenderness in acute appendicitis is typically located in the right lower quadrant (RLQ) of the abdomen, specifically at McBurney's point, which is the most characteristic finding for this condition. 1, 2

Classic Presentation

The typical pain pattern in appendicitis follows a characteristic migration:

• Initial periumbilical pain that subsequently migrates to the right lower quadrant is one of the strongest clinical discriminators for appendicitis 1, 3
• Right lower quadrant tenderness is the most common and reliable physical finding, present in the majority of patients with acute appendicitis 1, 4
• Rebound tenderness in the RLQ indicates peritoneal irritation and is a key sign of appendicitis 1

Additional Physical Examination Findings

Beyond simple RLQ tenderness, several specific examination maneuvers help confirm the diagnosis:

• Rovsing sign (pain in RLQ when palpating the left lower quadrant) is highly reliable for ruling in acute appendicitis, particularly in children 4
• Psoas sign (pain with right hip extension) suggests retrocecal appendix location 4
• Obturator sign (pain with internal rotation of flexed right hip) indicates pelvic appendix location 4
• Abdominal rigidity and guarding in the RLQ are among the best signs for ruling in acute appendicitis in adults 4

Important Clinical Caveats

The classic presentation occurs in only approximately 50% of appendicitis cases, making imaging essential even when clinical findings seem typical 5. This is a critical pitfall to avoid—do not rely solely on clinical examination.

Special Considerations in Elderly Patients

The presentation differs significantly in elderly populations:

• Tenderness in the right lower quadrant remains common but may be accompanied by more diffuse findings 1
• Signs of peritonitis (abdominal distension, generalized tenderness and guarding, rebound tenderness, palpable abdominal mass) are significantly more common in older patients due to delayed presentation and higher perforation rates 1
• The typical triad of migrating RLQ pain, fever, and leukocytosis is infrequently observed in elderly patients 1

Diagnostic Approach

Clinical examination alone is insufficient for diagnosis, with negative appendectomy rates as high as 25% when relying on physical findings without imaging 1, 5. The recommended diagnostic algorithm is:

1. Clinical assessment focusing on RLQ tenderness, migration of pain, and peritoneal signs 1, 4
2. Point-of-care ultrasound as first-line imaging when available 6
3. CT abdomen and pelvis with IV contrast if ultrasound is inconclusive or unavailable, achieving 85.7-100% sensitivity and 94.8-100% specificity 1, 6, 5

Even with classic RLQ tenderness and rebound, imaging is essential because CT identifies alternative diagnoses in 23-45% of patients presenting with RLQ pain and classic symptoms 5.