Pointing Sign in Appendicitis and other Physical Signs

Photo of Signs of Appendicitis: Psoas, Rovsing, Obturator, Aaron and Pointing signs on Examination

Signs of Appendicitis are easy to elicit during the physical examination of the patient, especially the pointing sign of appendicitis; these signs are useful in the assessment and calculation of the Alvarado score using the MANTREEL Mnemonic. The Alvarado score helps in the clinical diagnosis of Appendicitis or if you need to further investigate the patient with ultrasound or count of the white blood cells to rule out other differential diagnoses. These physical signs are listed and explained below.

Physical signs of Appendicitis

  1. Rovsing’s sign
  2. Psoas sign
  3. Obturator sign
  4. Aarons sign
  5. Straight leg raising sign
  6. Pointing sign
  7. Rebound tenderness
  8. Abdominal guarding
  9. Digital rectal examination
A sign of Appendicitis is tenderness at the McBurney point
A sign of Appendicitis is tenderness at the McBurney point

Rovsing’s signs

In this sign of appendicitis, deep palpation of the left iliac fossa causes pain in the right iliac fossa.

Psoas sign

Also known as the Ilio-psoas sign. Passive extension of the right hip may cause pain in the right iliac fossa. This shows the appendix is retrocecal (behind the cecum) or it is pelvic appendix; causing retroperitoneal inflammation.

Obturators sign or Cope’s sign

Named after Zachary Cope. In this, flexion and internal rotation of the right hip cause pain. Usually occurs in the pelvic appendix.

Aaron’s sign

This is done in males as it involves retraction of the testes whenever the right iliac fossa is palpated. This shows the appendix is not perforated.

Straight leg raising sign

Exerting a digital pressure over the area of tenderness in the right iliac fossa and raising the leg causes pain. This shows the appendix is behind the cecum.

Pointing sign of appendicitis

The patient is asked to point to where the pain started and where it has moved to which usually starts at the Periumbilical region and moves to the right lower abdomen.

Rebound tenderness

This occurs when the patient coughs or when pressure is applied at the site of tenderness; releasing the pressure causes pain.

Abdominal guarding

The patient is seen guarding the abdomen at McBurney’s point. The McBurney’s point is the point of maximum tenderness in appendicitis and it is usually the meet point, one-third lateral and two-third medial, the distance from the anterior superior iliac spine and the umbilicus

Digital rectal Examination

This reveals tenderness in the right side of the rectum and occurs in the pelvic appendix or when there is a pelvic abscess.

These physical signs of appendicitis are usually elicited during the examination and are used in the assessment of a patient with appendicitis in order to calculate the Alvarado score for diagnosis and preparation for possible surgery to prevent rupture of the appendix. They are the Extra signs in the Modified Alvarado score (MANTREEL SCORE).