How to assess for rebound abdominal tenderness in a 22-year-old male with severe abdominal pain and recent vodka consumption?

How to Assess for Rebound Tenderness

Apply gentle, steady pressure to the abdomen with your hand, hold for a few seconds, then quickly release—a positive test occurs when the patient experiences sharp pain upon release, indicating peritoneal irritation. 1

Proper Technique

• Position the patient supine with knees slightly flexed to relax the abdominal wall muscles 2
• Begin palpation away from the area of maximum pain to avoid immediate guarding and patient anxiety 1
• Apply gradual, firm pressure (approximately 4-5 cm deep) with your hand flat against the abdomen, holding for 2-3 seconds 1
• Release pressure suddenly by quickly withdrawing your hand from the abdominal wall 1
• Observe the patient's face during release—grimacing, wincing, or verbal expression of sharp pain indicates a positive test 2
• Document the specific location where rebound tenderness is elicited, as this guides differential diagnosis (e.g., right lower quadrant suggests appendicitis) 3

Alternative Technique: The "Pinch-an-Inch" Test

• Grasp a fold of abdominal skin over the area of concern (such as McBurney's point) and elevate it away from the peritoneum 4
• Allow the skin to recoil briskly back against the peritoneum 4
• This alternative causes less discomfort than traditional rebound testing while still detecting peritoneal irritation 4
• A positive test occurs when pain increases as the skin fold strikes the peritoneum 4

Critical Interpretation and Limitations

Rebound tenderness has high sensitivity (78-95%) but poor specificity (48-60%) for conditions like appendicitis, meaning many false positives occur. 1, 5 The test's greatest value is its negative predictive value of 81.3%—absence of rebound tenderness makes significant peritoneal pathology less likely. 1

Important Caveats:

• Rebound tenderness should never be used in isolation to make surgical decisions, as approximately 5% of patients with intestinal perforation remain asymptomatic despite serious pathology 1
• The test has little additional diagnostic value when local tenderness or rigidity is already present 5
• In elderly or unconscious patients, physical examination findings may be minimal or absent despite severe intra-abdominal disease 1
• Up to one-third of patients with spontaneous bacterial peritonitis may be entirely asymptomatic, making physical examination unreliable 1
• Alcohol intoxication (relevant to your 22-year-old patient with vodka consumption) can mask peritoneal signs and reduce the reliability of abdominal examination 2

Integration with Other Clinical Findings

Combine rebound tenderness assessment with:

• Involuntary guarding—rigid, board-like abdomen suggests peritonitis and is more specific than rebound alone 2
• Fever, tachycardia, and hypotension—suggest systemic inflammatory response or sepsis 2
• Absence of bowel sounds—indicates ileus or peritonitis 2
• Migratory pain pattern—pain starting periumbilically then localizing to right lower quadrant increases appendicitis likelihood 1
• Psoas sign and obturator sign—additional tests for appendicitis when rebound is equivocal 1

When to Proceed Beyond Physical Examination

For intermediate clinical suspicion in adults with positive rebound tenderness, obtain CT abdomen/pelvis with IV contrast rather than proceeding to surgery based on examination alone. 1 In your 22-year-old male with severe pain, the combination of rebound tenderness, recent alcohol consumption (which may mask symptoms), and young age warrants imaging to avoid missing serious pathology like bowel perforation, mesenteric ischemia, or appendicitis. 2

Serial examinations every 4-6 hours increase diagnostic accuracy when initial findings are equivocal, as peritoneal signs from bowel injury may take several hours to develop. 2