Specific Examination Maneuvers
and Signs
Murphy’s sign, the psoas test, Rovsing’s sign, and others. These aren’t exotic add-ons to the exam — they’re targeted questions you ask the abdomen once basic palpation has already pointed you in a direction.
The parts of this series so far have covered the basic steps — inspection, auscultation, percussion, palpation — a systematic sweep of the entire abdomen. Specific maneuvers work differently: you don’t use them on every patient, only when findings from the previous steps point you toward a specific working diagnosis and you need to either support or challenge it. This part covers the maneuvers with genuine field utility — including an honest account of their limits.
Why these maneuvers aren’t diagnostic tests
Before going through the individual signs, one essential note that applies to all of them: none has sufficient sensitivity or specificity to confirm or rule out a diagnosis on its own. They are supporting findings that shift probability in a given direction — not binary yes/no answers.
A positive finding increases suspicion for a given diagnosis; a negative finding does not rule it out. Use them as a supplement to the overall clinical picture — history, pain location, time course, vital signs — not as a standalone deciding factor. In the field, their main value is that they let you sharpen your documentation for the receiving facility.
Murphy’s sign — cholecystitis
Technique: Place your fingers under the right costal margin at the location of the gallbladder (the intersection of the costal margin and the lateral edge of the rectus abdominis). Ask the patient to take a deep breath. On inspiration, the diaphragm — and with it, the inflamed gallbladder — moves downward toward your fingers.
Positive finding: The patient suddenly halts inspiration due to sharp pain (“inspiratory arrest”) at the moment the inflamed gallbladder contacts your fingers. This isn’t simply pain on pressure — the key feature is the interruption of the breath itself.
Psoas sign — retrocecal appendicitis
Technique: Patient lies on the left side. Grasp the right lower extremity below the knee and passively extend it at the hip backward, while stabilizing the pelvis with your other hand. Alternative: patient supine, actively raises the straightened right leg against your resistance.
Positive finding: Pain in the right lower quadrant with hip extension or active hip flexion. The iliopsoas muscle lies retroperitoneally in close proximity to the appendix — if the appendix is retrocecal and adjacent to the muscle, stretching it irritates the inflamed surrounding tissue.
Obturator test — pelvic/retrocecal appendicitis
Technique: Patient supine, right leg flexed at both the hip and knee to 90°. Grasp the ankle and knee and perform passive internal rotation of the hip (rotating the lower leg outward, which rotates the hip inward).
Positive finding: Pain in the hypogastrium or right lower quadrant. The obturator internus muscle lines the pelvic wall — internal hip rotation stretches it and irritates adjacent inflamed tissue in a pelvically positioned appendix.
Rovsing’s sign — referred tenderness
Technique: Palpate (press) in the left lower quadrant — the opposite side from your suspicion.
Positive finding: Pressure in the left lower quadrant elicits pain in the right lower quadrant. Explanation: pressure on the colon pushes gas and bowel content retrograde toward the cecum and appendix, which stretches and irritates inflamed peritoneum in the RLQ, even though you’re pressing elsewhere.
CVA tenderness — percussion over the costovertebral angle
Technique: Patient sitting or standing. With an open palm or a loosely closed fist, deliver a light but firm percussive strike over the costovertebral angle — where the last rib meets the spine — bilaterally.
Positive finding: Sharp pain on the strike, typically unilateral. Don’t confuse this with ordinary muscular tenderness on pressure — CVA tenderness is specifically a reaction to the percussive impact.
Kehr’s sign — referred shoulder pain
Finding: Pain radiating to the left shoulder (classically), which worsens when supine or in the Trendelenburg position (head down). This isn’t a maneuver you actively perform — it’s a spontaneously reported or history-elicited symptom that you need to actively ask about.
Mechanism: Blood or another irritant in the peritoneal cavity irritates the diaphragm. The diaphragm shares sensory innervation (phrenic nerve, C3–C5) with the shoulder — the brain interprets diaphragmatic irritation as shoulder pain.
Left shoulder pain without a clear orthopedic cause in a patient after blunt abdominal trauma, or in a woman with a missed period and abdominal pain, is sufficient reason to suspect intra-abdominal hemorrhage. This sign is easy to overlook because the patient spontaneously reports shoulder pain, not abdominal pain — so actively ask about the abdomen.
Quick reference table
| Sign | Target area | Primary diagnosis | How it’s elicited |
|---|---|---|---|
| Murphy’s | RUQ | Cholecystitis | Inspiratory arrest on palpation under the costal margin |
| Psoas | RLQ | Retrocecal appendicitis | Pain on hip extension/flexion |
| Obturator | RLQ / pelvis | Pelvic appendicitis | Pain on internal hip rotation |
| Rovsing’s | LLQ → RLQ | Appendicitis | Referred RLQ pain on LLQ pressure |
| CVA tenderness | Costovertebral angle | Pyelonephritis, renal colic | Pain on percussive strike over the angle |
| Kehr’s | Shoulder (referred) | Hemoperitoneum | Spontaneous or history-elicited shoulder pain |
Which maneuvers to actually use in the field
Always worth doing: Murphy’s sign (fast, simple, high information value for RUQ pain), CVA tenderness (fast, important with fever + flank pain), actively asking about referred shoulder pain (Kehr’s sign — requires no maneuver, just a targeted question).
Consider if time allows and suspicion persists: Rovsing’s sign (fast, gentle way to confirm RLQ peritonism), the psoas test (useful for atypical RLQ pain).
Low priority in the field: The obturator test — technically more demanding, rarely changes immediate management; if time doesn’t allow it, that’s not a loss.
How to document these findings
“Hurts on the upper right side, maybe the gallbladder.”
“Positive Murphy’s sign — inspiratory arrest on palpation of the RUQ beneath the costal margin. History of pain after fatty food. Suspected acute cholecystitis.”
“Abdomen hurts on the lower right, probably appendicitis.”
“Tenderness on palpation with involuntary guarding in the RLQ. Positive Rovsing’s sign (LLQ pressure elicits RLQ pain). Psoas test positive. Suspected acute appendicitis, transport to a surgical facility.”
“Complaining about the shoulder, probably from the fall.”
“Patient reports left shoulder pain with no local traumatic finding on the shoulder itself. History of a fall onto the left side 2 hours ago. Abdomen actively assessed — tenderness on palpation in the LUQ. Suspected Kehr’s sign in possible splenic rupture. Priority transport, 2x IV access.”
Field case
The paramedic recalls Kehr’s sign and actively asks about the abdomen — the patient admits to mild left-sided pain she “didn’t think was important” compared to the shoulder pain. On palpation: tenderness in the LUQ with mild guarding. BP 108/70, HR 96/min.
Patient care record entry: “Patient after a fall with impact to the left side, primarily reports left shoulder pain with no local orthopedic finding — suspected Kehr’s sign. On directed questioning, tenderness on palpation in the LUQ with guarding. Suspected splenic rupture. HR borderline (96/min), monitor trend. Priority transport to a trauma center, 2x IV access, prepare for possible fluid resuscitation.”
Without knowledge of Kehr’s sign, the shoulder pain could have been cleared as an isolated musculoskeletal complaint, and suspected splenic rupture would have gone undetected until hemodynamic deterioration.
Summary
1. None of them is independently diagnostic — they’re supporting findings that shift probability, not confirm/rule out a diagnosis
2. Murphy’s sign and CVA tenderness have the highest priority in the field — fast, simple, high information value
3. Kehr’s sign requires no maneuver — it requires that you actively ask about the abdomen with unexplained shoulder pain
4. Rovsing’s and the psoas sign are useful additions for atypical RLQ pain, if time allows
5. Documentation should include a precise description of the maneuver and finding, not just a “positive/negative” conclusion
The next part of the series covers how the abdominal exam differs in trauma versus medical pain — and when the entire systematic exam takes a back seat to primary ABC management.
- Abdominal Inspection: what you see before you ever touch the patient
- Auscultation of the Abdomen: more than “sounds present/absent”
- Percussion of the Abdomen: why most crews skip it, and when it’s worth it
- Palpation Step by Step: light and deep technique
- Specific Examination Maneuvers and Signs (this article)
- Abdominal exam in trauma vs. medical pain
- Abdominal exam in the complicated patient
- Vital signs as part of the abdominal exam
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- Ashdown HF, et al. Pain Over the Costovertebral Angle in Renal Colic. BMJ. 2012;345:e8107.
- Trowbridge RL, Rutkowski NK, Shojania KG. Does This Patient Have Acute Cholecystitis? JAMA. 2003;289(1):80–86.
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- Meltzer AC, et al. Kehr’s Sign: A Case of Delayed Diagnosis of Splenic Rupture. J Emerg Med. 2012.