Scoliosis is a medical condition defined by an irregular, three-dimensional curvature of the spine, which includes a lateral bend and a rotational component. The physical examination serves to screen for this spinal deformity, determine the extent of any visible asymmetry, and establish a baseline for monitoring potential progression. This systematic assessment process is important for deciding if a patient requires further diagnostic imaging or specialized treatment.
Initial Inspection and Posture Assessment
The physical exam begins with a static visual assessment of the patient standing with their back exposed. The examiner observes the patient from behind to check for asymmetry in the trunk and shoulders. Attention is paid to shoulder height and the level of the pelvis and waistline.
Scapular symmetry is evaluated, noting if one shoulder blade protrudes more prominently than the other. Gait observation is an initial step, looking for abnormal sway or limp that might indicate a functional curve or leg length discrepancy. Documenting any truncal shift, where the head and shoulders are not centered over the pelvis, provides evidence of coronal imbalance.
The skin overlying the spine must be inspected for cutaneous stigmata, which can suggest an underlying spinal cord abnormality. These findings, often referred to as “red flags,” include a patch of hair, skin dimples, or café-au-lait spots. The presence of such findings, especially with an atypical curve pattern, warrants a more aggressive workup.
The Adam’s Forward Bend Test
The Adam’s Forward Bend Test is the most specific maneuver for highlighting the rotational element of a scoliotic curve. The patient bends forward at the waist, keeping their feet together and knees straight, with arms hanging freely. The examiner observes the contour of the back from both the front and the rear.
As the patient bends forward, structural spinal rotation becomes fixed and magnified, making it clearly visible. This rotation manifests as a unilateral prominence, known as a rib hump (thoracic spine) or a lumbar prominence (lower back). The prominence occurs because the vertebrae and attached ribs rotate toward the side of the curve’s convexity.
This maneuver effectively differentiates a structural curve, which remains visible during the bend, from a non-structural or postural curve, which will typically disappear. Documenting a positive Adam’s test confirms the presence of a rotational deformity requiring subsequent measurement. The inability to perform the test due to pain or hamstring tightness should also be recorded, as this may indicate other underlying pathologies.
Quantifying Curve Location and Rotation
Documentation transitions from qualitative observation to quantitative measurement by recording the curve’s characteristics. The curve is identified by its location (thoracic, lumbar, or thoracolumbar) and its direction of convexity, labeled as right (dextro) or left (levo).
The rotational deformity is measured using a scoliometer (inclinometer) placed over the most prominent part of the trunk during the Adam’s test. This reading quantifies the Angle of Trunk Rotation (ATR) in degrees. A measurement of 7 degrees or more is used as a threshold to suggest the need for further evaluation with spinal X-rays.
The scoliometer measures rotation, a clinical finding, not the angle of the curve itself. The definitive measurement of curve severity, the Cobb angle, can only be determined from a standing radiograph. Documentation should also include basic growth metrics (height and weight) and an assessment of skeletal maturity, such as Tanner staging or notation of menarche, as this influences the risk of curve progression.
Documenting Associated Neurological and Musculoskeletal Findings
The physical exam must extend beyond the spine to identify any underlying pathology or secondary effects of the spinal deformity. Documentation includes a focused neurological assessment to rule out conditions like intraspinal tumors or syringomyelia. This involves testing deep tendon reflexes and assessing muscle strength in key muscle groups.
The presence and symmetry of superficial reflexes, such as the abdominal reflex, are also documented, as an absent reflex may suggest a neurological issue. Musculoskeletal findings peripheral to the spine must be recorded, including leg length discrepancy or pelvic obliquity. These findings can contribute to a functional curve or be a consequence of a structural one.
The documentation should note any systemic signs that might suggest a syndromic form of scoliosis. Specific features of connective tissue disorders (e.g., hypermobility in Marfan syndrome) or signs of neurofibromatosis (skin tumors and pigmentation) should be recorded. These associated findings help classify the scoliosis and guide the appropriate diagnostic pathway.