A 12-year-old female came to clinic for her health supervision visit in June. She was doing well but her mother was concerned about her back as her aunt had noticed a “lump” on her back when she bent over at the swimming pool. The mother said that it just looks like her shoulder is a little higher on the right side. The girl denied any pain, discomfort or problems with mobility. The patient had not started her periods but had started to “develop” per her mother and was getting taller. The family history was negative for any back problems including scoliosis, but the mother said that her maternal great grandmother had lost height and became more “hunchback” when she was older. The review of systems was negative.
The pertinent physical exam showed a cooperative female with normal vital signs and growth parameters. Her height was 75% which was slightly increased from the 50-75% she had been tracking. Her weight was 50%. Her musculoskeletal examination was negative. On Adams forward bend test she had an elevation of the right rib/scapula that improved but did not go away with proper re-positioning of the patient. Her hips and shoulder levels appeared to be normal. She was Tanner 3 for breast and Tanner 2 for pubic hair. The rest of her examination was normal including skin examination.
The diagnosis of probable idiopathic scoliosis with a positive forward bend screening test was made in a skeletally immature female. The radiologic evaluation of a spine radiograph showed a right thoracic curve of 11°. The patient’s clinical course showed that after discussing the results with the family, they wanted a referral to an orthopaedist because she was undergoing her growth spurt. Repeat radiographs one year later showed an increase in the Cobb angle to 13° and another year later it was 15°. At this time she was postmenarchal and repeat examination 6 months and 1 year later showed no additional progression. She was clinically well over this entire followup time period.
Scoliosis is a lateral and rotational curvature of the spine from a plumb line hanging from C7 to the floor.
Idiopathic scoliosis is the most common form. A review of scoliosis and its differential diagnosis can be found here.
Depending on the age, 2-4% of adolescents have a positive Adams Forward Bend Test when assessed and ~2% may have idiopathic scoliosis of > 10 degrees. Curve progression relates to the magnitude of the curve and the patient’s age. Thus increased risk of progression occurs in patients with higher curvature magnitude at diagnosis, females (earlier start of puberty and therefore possibly not identified or have great curvature to start with), younger children (same reason), being skeletally immature, symptomatic (pain or other neurological problems), underlying disease (e.g. congenital, neuromuscular, connective tissue disease, or foot deformities), and patients with excessive lordosis or kyphosis.
Routine clinical screening is controversial but several professional organizations including the American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics recommend screening. It is recommended to screen females in US in 5th and 7th grades (10-11 years and 12-13 years), and males in 8th grade (13-14 years).
In general, idiopathic scoliosis that has a Cobb angle 50 degrees often progress at a rate of 0.75-1.00 degree/year. Those between ~30-40 degrees may or may not progress but are at risk especially if skeletally immature.
The most common curve variation is a righted-sided thoracic curve with a compensatory left-sided lumbar curve. Some people remember this as RIGHT in the thoRax and LEFT in the Lumbar spine. If a different pattern is seen then alternative causes to idiopathic scoliosis should be considered. Treatment options depend on the magnitude of the curve and risk of progression.
Mr. William Adams (1820-1900) along with Dr. Thomas Hodgkin (1798-1866) described scoliosis in a post mortem examination of a contemporary physician in 1854. Mr. Adams later described his “Forward Bend Test” in lecture 10 in his series of Lectures on the Pathology and Treatment of Lateral and Other Forms of Curvature of the Spine.
The primary evaluation for scoliosis is inspection looking for asymmetric laterality and the Adams Forward Bend Test.
- The patient is inspected standing upright with feet together and knees extended/straight with arms held at the side. The head should be in an upright neutral position. The patient is inspected from the front noticing differences in shoulder or waist alignment from side-to-side or prominence of the chest.
- The patient is again inspected from the back noticing any differences in the shoulder or waist alignment or prominence of the scapula or ribs. The location and laterality of any potential abnormalities should be noted.
- The patient is then instructed to put both of their palms together, head down and bend forward, similar to diving. The palms should be together but arms should hang freely.
The examiner’s eyes should be level with the spine from behind and noticing if there are any differences in the scapula, rib cage or paraspinous muscles.
- If a scoliometer (inclinometer) is used and there is a difference in laterality, 5-7 degrees is considered the cut-off point for positive screening.
Other areas to note on examination include dermatological examination for sign of neurofibromatosis (e.g. axillary freckling, cafe-au-lait spots, subcutaneous fibromas), joint examination for signs of connective tissue disease (e.g. joint laxity, arachnodactly), and midline spinal abnormalities such as dimpling. Leg length discrepancy may also cause a false positive Adams test.
While inspection and the Adams Forward Bend Test seems to be a simple painless test, patients will often not understand the instructions or fail to move their body into the correct position and therefore need additional instructions. The patient may need to be reminded to stand erect during the upright part of the test with weight balanced between their feet. This should correct any positional changes that are solely caused by posture or positioning. If abnormalities do not correct then there is possible scoliosis or a leg length discrepancy. Placing the examiner’s fingers on the top of the scapula (acromium) and thumb on the inferior angle of the scapula can also help the examiner to determine if there is mild shoulder height differences or scapular prominences. The examiner’s own spatial perception of where his/her hands are in space may be more sensitive than visual inspection alone. Similarly, placement of the examiner’s hands on the iliac crests bilaterally may again also allow better visual inspection for height differences between sides, especially in obese patients. The examiner’s spatial perception may also detect small alignment differences.
During the bending part of the test, patients will often try to keep their head up, place their hands on their knees or bend their knees. Again reminding the patient to move into the proper position and maintain it while the examination is carried out is important. Some patients will try to touch their feet and will not have enough flexibility to do this, thus they move during the examination. Reminding the patient they do not have to stretch, just bend forward often helps. Running the examiner’s hand over the entire spine from C7-L5 during the forward bend part of the examination may also help to assess alignment or rotation, especially in obese individuals.
Indications for further evaluation include if abnormalities are noticed on physical examination, a scoliometer reading of > 5-7 degrees, abnormal curve pattern or other abnormal physical examination findings particularly in young or skeletally immature patients.
Questions for Further Discussion
1. What other caveats do you have for performing the Adams Forward Bend Test?
2. How successful are non-surgical and surgical treatment for scoliosis?
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Hodgkin T, Adams W. Case of Distortion of the Spine, with observations on Rotation of the Vertebrae as a complication of Lateral Curvature. Med Chir Trans. 1854;37:167-180.5.
Adams W. Lectures on the Pathology and Treatment of Lateral and Other Forms of Curvature of the Spine, 2nd ed. London; J & A Churchill, 1882.
Fairbank J. Historical perspective: William Adams, the forward bending test, and the spine of Gideon Algernon Mantell. Spine (Phila Pa 1976). 2004 Sep 1;29(17):1953-5.
Rosenberg JJ. Scoliosis. Pediatr Rev. 2011 Sep;32(9):397-8; discussion 398.
Horne JP, Flannery R, Usman S. Adolescent idiopathic scoliosis: diagnosis and management. Am Fam Physician. 2014 Feb 1;89(3):193-8.
Hresko MT. Clinical practice. Idiopathic scoliosis in adolescents. N Engl J Med. 2013 Feb 28;368(9):834-41.
Hresko MT, Talwalkar V, Schwend R; AAOS, SRS, and POSNA. Early Detection of Idiopathic Scoliosis in Adolescents. J Bone Joint Surg Am. 2016 Aug 17;98(16):e67.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
December 4, 2017