Rebound Tenderness Test

Br. J. Surg. 1991, Vol. 78, July.
795-796 Rebound tenderness test

M. I. Liddington and
W. H. F. Thomson The usefulness of the rebound tenderness test in indicating peritonitis
Department of Surgery,
was prospectively assessed in 142 unselected patients admitted as
Gloucestershire Royal Hospital, emergencies with abdominal pain and tenderness. It was found to he of
Great Western Road, Gloucester no predictive value.
GL 1 3NN, UK
Correspondence to:
W. H. F. Thomson
The rebound tenderness test (RTT) is authoritatively Results

advocated',' and, from personal observation, generally and Eight of the 150 patients had no abdominal tenderness at all
credulously practised in the diagnosis of acute abdominal pain. and were excluded from further study (two hepatic metastases
It is performed by gradually increasing the pressure of the and one each of abdominal aortic aneurysm, gastroenteritis,
palpating hand over the tender spot, and then suddenly pneumonia, myocardial infarction, disseminated prostatic
removing it. A start of pain makes the test positive, and this is carcinoma and gastric carcinoma). Of the remaining 142, 88
generally held to indicate the strong likelihood of peritonitis. had a positive and 54 a negative RTT (19 patients with
However, it may be argued that, as tenderness is simply the equivocal tests were counted as negative). Table I shows how
sensory perception of irritated nerve endings stimulated by a the diagnoses of the 142 patients were related to the RTT and
change in tissue tension through distortion, a rapid alteration to peritonitis.
will be more unpleasant than a slow one. If this is so, rebound The results shown in Table2 suggest that while the RTT
tenderness may signify nothing more than simple tenderness; had a reasonably good sensitivity (43 out of 53 cases of
and tenderness to abdominal palpation has other causes besides peritonitis were correctly anticipated, sensitivity 0.81 ) it had a
peritonitis. low specificity (the test was also positive in 45 of 89 patients in
The test, theoretically at least, is therefore of doubtful value, whom there was no evidence of peritonitis, showing specificity
and Prout3 has already shown its limitations. Although of only 0.50). The test had a positive predictive value of only
rebound tenderness is still widely sought, if meaningless, it must 49 per cent.
inflict much fruitless discomfort; it may also be diagnostically The study group included 14 children whose ages ranged
misleading. from 7 to 16 years. The findings were similar to those of adults:
the sign was positive in two with peritonitis but also in six
Methods without peritonitis; it was negative in two with peritonitis and
negative in four without.
One hundred and fifty unselected, though not consecutive, patients,
comprising 63 males and 87 females (age range 7-84 years; mean 37,
median 46) admitted over 20 weeks during the duty hours of one Discussion
surgical firm were examined by one of us (ML).The initial RTT result
was recorded in each case. Equivocal results were regarded as negative Abdominal tenderness can be found in conditions as diverse as
in order to err, if anything, in favour of specificity. When clinically ureteric colic and diverticulitis, perforated ulcer and pelvic
indicated physical signs were reassessed at intervals, but this was not inflammatory disease: by itself it does not indicate peritonitis.
part of the study. The final diagnosis was recorded when it became The question is: does the RTT help in discriminating tenderness
available. from peritonitis from tenderness from non-peritonitic causes?
Table 1 Diiignosis unii RTT results in 142 putients with ubdominul tenderness
Peritonitis Number No peritonitis Number

- - -
RTT positive Appendicitis 21 Non-specific abdominal pain 16
Cholecystitis 4 Ureteric colic 6
Diverticulitis 5 Gastroenteritis 6
Haemoperitoneum 1 Pelvic inflammatory disease 4
Perforated viscus 12 Biliary colic 2
Small bowel obstruction 1
Dyspepsia 1
Cystitis 1
Inflammatory bowel disease 8
Total 43 Total 45
RTT negative Appendicitis 6 Nonspecific abdominal pain 7
Cholecystitis 2 Gastroenteritis 9
Perforated viscus 2 Ureteric colic 6
Biliary colic 5
Dyspepsia 2
Cystitis 3
Pelvic inflammatory disease 2
Trauma 3
Small bowel obstruction 3
I
Gastrointestinal bleed 2
Constipation 3
Total 10 Total 44
0007-1323/91/070795-02 (01991 Butterworth-Heinemann Ltd 795

Rebound tenderness test: M. I. Liddington and W. H. F. Thornson
Table 2 Sensitivity and specijicity of the RTT In 1964 Rex Lawrie said that the test was ‘an unkind way of
emphasising what is already o b v i o ~ s ’ ~
perhaps,
; 26 years after
Peritonitis positive Peritonitis negative his condemnation and 20 years after Prout’s, it is time the test
RTT positive 43 45 was abandoned.
RTT negative 10 44 M. I. Liddington is now at Odstock Hospital, Salisbury, U K
References
1. Clain A (ed.). Hamilton Bailey’s Demonstration of Physical Signs
This study provides no support for the teaching and practise in C&nicalSurgery. 17th ed. London: John Wright, 1986: 295.
of the RTT. Indeed the test was found markedly positive in the 2. Sabiston DC (ed.) Textbook of Surgery. 13th ed. Sabiston DC:
majority of patients who were finally considered to have WB Saunders Company, 1986.
non-surgical abdominal pain, patients in whom Carnett’s 3. Prout WG. The significance of rebound tenderness in the acute
test4-’ was usually positive, indicating that the source of the abdomen. Br J Surg 1970; 57: 508-10.
4. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and
pain was in the anterior abdominal wall. tenderness. Surg Gynaecol Obstet 1926; 42: 625-32.
We d o not consider these findings to be in conflict with the 5. Thomson H, Francis DMA. Abdominal wall tenderness: A useful
pioneering work of De Dombal and colleagues in computer- sign in the acute abdomen. Lancet 1977; ii: 10534.
aided diagnosis of the acute abdomen’, although they list 6. Gray DWR, Seabrook G, Dixon JM, Collin J. Is abdominal wall
rebound tenderness as ‘vital’ information. However if the RTT tenderness a useful test in the diagnosis of non-specific abdominal
is simply a more dramatic way of demonstrating tenderness pain? Ann R CONSurg Eng 1988; 70: 2334.
and guarding, also listed as ‘vital’, and so is simply another 7. Gallegos MC, Hobsley M. Recognition and treatment of
aspect of what is already being recorded, it is possible that abdominal wall pain. J R Soc Med 1989; 82: 3 4 3 4 .
omission of the test from their data collection chart would not 8. McAdam WAF, Brock BM, Armitage T, Davenport P, Chan M,
De Dombal FT. Twelve years’ experience of computer aided
change their results. diagnosis in a district general hospital. Ann R Coll Surg Eng 1990;
In conclusion, we agree with Prout3 that the demonstration 7 2 : 140-6.
of rebound tenderness suffers the twin disadvantages of being
unpleasant for the patient and of being diagnostically useless. Paper accepted 8 February 1991
796 Br. J. Surg., Vol. 78, No. 7,July 1991

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Br. J. Surg. 1991, Vol. 78, July.

795-796 Rebound tenderness test

The rebound tenderness test (RTT) is authoritatively Results

Peritonitis Number No peritonitis Number

0007-1323/91/070795-02 (01991 Butterworth-Heinemann Ltd 795

796 Br. J. Surg., Vol. 78, No. 7,July 1991

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