Scoliosis physical examination

Patients with scoliosis usually appear normal. Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.

Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.^[1][2][3]

• Patients with scoliosis usually appear well.
• Tanner staging done to predict magnitude of curve progression.

Patients with scoliosis and other complications may have:

• High blood pressure due to pulmonary hypertension and cor pulmonale

• Skin for café au lait spots indicative of neurofibromatosis
• Spina bifida as evidenced by a dimple, hairy patch, lipoma, or hemangioma

• HEENT examination of patients with scoliosis is usually normal.

• Neck examination of patients with scoliosis is usually normal. But, patients may have lateral bending of their neck due primary or secondary curve.
• when scoliosis is complicated with pulmonary hypertension, it’s physical findings may include:
  • Prominent ‘a’ wave: due to forced atrial contraction
  • Prominent ‘v’ wave: later if tricuspid regurgitation develops with right ventricular failure
  • Elevated JVP: can be present if right ventricular failure develops
  • Postive Kussmaul’s sign: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure

Patients with scoliosis and other complications may have:

• Chest wall or breast asymmetry is seen
• Decreased breast sounds upon auscultation of the lung

Patients with scoliosis and it’s late complications such as pulmonary hypertension and cor pulmonale include physical findings:^[4][5][6]

• Left parasternal heave
  • Due to hyperdynamic right ventricle
• Palpable P2
  • Correlates with severity of the disease
• Ausculation
  • First and second heart sound (S1,S2)
    • Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration.
  • Splitting of S2
    • Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.
    • Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.
  • Extra Heart Sounds
    • S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
    • S3: if right ventricular failure develops. Increased with inspiration.
  • Additional Sounds
    • Systolic pulmonary ejection click: increased with inspiration
  • Murmurs
    • Ejection midsystolic murmur: increased with inspiration
    • Diastolic murmur (Graham-Steele murmur): indicates pulmonary regurgitation
    • Pansystolic murmur: indicates tricuspid regurgitation and developing right ventricular failure

• Abdominal examination of patients with scoliosis is usually normal
• Flank fullness may be seen

• Genitourinary examination of patients with scoliosis is usually normal. But, in neuromuscular scoliosis, patient may present with bowel and bladder incontinence.

• Patient is usually oriented to persons, place, and time

• Patients usually walk with bipedal unassisted gait.
• Some patients with neuromuscular scoliosis walk with a spastic gait.

• No local rise in temperature
• Tenderness is usually not present.
• Head may be centered or tilted away from pelvis
• Shoulders asymmetry
• Scapular asymmetry with one scapula being farther away from the the mid-line
• Spinous process are deviated away from mid-line
• Lateral curvature of the spine, with curve described in terms of convexity directed to right or left
• Paraspinal muscle spasm may be present
• Rib razor hump is usually present
• Posterior Superior Iliac spine (PSIS) asymmetry seen
• Anterior Superior Iliac spine (ASIS) asymmetry seen
• List and step are usually not present
• Sagittal balance (Head in line with sacrum) may be disturbed
• Sinuses and tuft of hair may be present
• Flank fullness may be seen

• Flexion and extension are usually affected
• Lateral flexion and rotation helps to identify rigidity of the curve

• Lateral bending test are usually affected
• Traction test are usually abnormal
• Prone position test are usually abnormal

• Motor
  • Motor weakness may be seen
  • Spasticity and rigidity may be seen depending on level of involvement
  • Sensory
    • Fine touch and crude touch may be lost
    • Hypoesthesia may be seen
    • Postion sense and vibration may be disturbed
    • Two point discrimination may be lost
  • Reflexes
    • Hypo or Hyper reflexia may be seen depending on level of involvement
    • Clonus may be seen
  • Coordination
    • Coordination may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation

• Adam’s forward bending test makes the hump prominent

• Hump height
• Chest expansion is usually decreased
• Limb length discrepancy may be present
• Truncal height is measured in standing and sitting position, which is usually abnormal
• Scoliometer is used to measure the curve

• Straight leg raising (SLR) test may be positive
  • Test:
    • Patient in supine position with knee and hip in extension
    • Elevate the patient’s leg in air, so the hip gets gradually flexed with knees in extension
    • Presence of radiating pain in the leg between 30-70 degrees of hip flexion indicates a positive test

• Cross SLR is usually absent
  • Test:
    • Patient in supine position with knee and hip in extension
    • Elevate the patient’s contralateral leg in air, so the hip gets gradually flexed with knees in extension
    • Presence of radiating pain in the ipsilateral leg indicates a positive test

• Lassegue test may be positive
  • Test:
    • Patient in supine position with knee and hip in extension
    • Elevate the patient’s leg in air, so the hip gets gradually flexed with knees in extension
    • If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly lower down the angle of flexion at the hip and dorsiflex the ankle
    • Presence of radiating pain in the leg again indicates a positive test

• Bowstring test may be positive
  • Test:
    • Patient in supine position with knee and hip in extension
    • Elevate the patient’s leg in air, so the hip gets gradually flexed with knees in extension
    • If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly bend the kneewhich will relieve the symptoms
    • Apply digital pressure in popliteal fossa over the posterior aspect of sciatic nerve
    • Reproduction of radiating pain indicates nerve compression

• Femoral stretch test may be positive
  • Test:
    • Patient in prone position with knee bend to 90 degrees and hip in extension
    • Grasp the lower end of the femur and extend the hip
    • Presence of pain on the anterior aspect suggests compression of the femoral nerve

• Feet may show cavovarus deformity

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