Blumberg sign – Rebound tenderness

Blumberg sign (or Rebound tenderness positive sign) is elicited by palpating slowly and deeply over a viscus and then suddenly releasing the palpating hand. If rebound tenderness is positive then the patient experiences pain. The sign is explained by the fact that gradual stretching of the abdominal wall by deep palpation followed by sudden release of this pressure stimulates the parietal peritoneum which, if inflamed, produces pain. Rebound tenderness is not always a reliable sign and should be interpreted with caution, particularly in those patients with a low pain threshold.

Rebound tenderness is commonly done as part of physical examination of a patient of appendicitis. Rebound tenderness is also named positive Blumberg’s sign.

Note that it refers to the pain due to the removal of the pressure, rather than the pain due to pressure (tenderness).

What does Blumberg’s sign indicate?

Blumberg’s sign is performed during the physical examination of a patient, usually arriving at the clinic or emergency department with the complain of abdominal pain.

The positive blumberg’s sign indicates peritonitis.

Blumberg’s sign and Appendicitis

As a positive rebound tenderness or blumberg’s sign is indicative of peritonitis, this method is helpful in diagnosing appendicitis during emergency management. It’s also part of MANTRELS scoring system for appendicitis.

During the physical examination of a patient with appendicitis, the examiner asks the patient to lie down flat and comfortably. If they’re unable to lie straight due to the guarding and tenderness in the abdominal wall, they can keep something below the head to bend the neck slightly and also bend their knees (hence bending the hip joint), further releasing the pressure on the abdominal muscles, reducing the tenderness and guarding.

Once the patient is lying straight, pressure is applied gradually on the right iliac fossa and it’s pressed as much as possible. Then, the doctor keeps the hand in that position for a while until the patient is comfortable with the pressure and then the pressure is suddenly released.

If the patient shows sign of impulse of pain on releasing the pressure from the right iliac fossa, it’s positive rebound tenderness, if not then negative.

Note that ask your patient to naturally talk to him to keep the eyes open and keep talking to you randomly while you elicit the blumbergs sign, because that way the impulse from rebound tenderness will be more obvious as compared to closed eyes and a silent patient.

Note that the positive blumbergs sign on right iliac fossa is not always an indicative of appendicitis and should be correlated with other symptoms and overall presentation of the patient.

Why is Rebound tenderness called Blumberg’s sign?

The examination for rebound tenderness is called Blumberg’s sign in the memory of the German surgeon Jacob Mortiz Blumberg (1873–1955).

He was a surgeon as well as a gynecologist. He invented the technique for rebound tenderness and thus it’s named after him as blumberg’s sign.

Blumberg Sign incorrect on Wikipedia

While reading about appendicitis on wikipedia.com i found out that the definition of Blumberg’s sign is given wrong over there. According to wikipedia (on 7th May, 2010) Blumberg’s sign due to inflamed vermiform appendix is:

Palpation of the left iliac fossa, followed by sudden release causes contralateral (right iliac fossa) rebound tenderness.

Which is obviously not so. It is even technically incorrect as rebound phenomenon occurs on the ipsilateral side and not the contralateral. I have submitted the correction in the wikipedia article regarding Blumberg’s sign mistake. Hopefully they will approve it.

Image demonstrating blumberg sign / rebound tenderness

Note that the doctor is examining the right iliac fossa of the patient. This way to press is not appropriate however, first try using the palm resting on the right iliac fossa and then pressing in to elicit blumberg sign / rebound tenderness . Also always approach the patient from the right side.

What is a positive rebound tenderness sign?

As said above, Blumberg’s sign is same as rebound tenderness sign. A positive rebound tenderness sign means that rebound tenderness was successfully elicited.

How is rebound tenderness checked? The patient is asked to lie down flat with a pillow if possible and knees bent a bit to relax the muscles of the abdomen. Once in this position, the doctor examining the patient pushes the right iliac fossa inside using the fingers (or altering the method, depending on their expertise). While pressing the hand into the fossa gently, the patient is distracted like by asking his personal profile, name, symptoms etc, and then the hand is held in the pressed position for a few seconds, so that the patient forgets about the pain. Remember patient has to be distracted. And while he is talking, he is asked to keep his eyes open and then suddenly the hand is removed, releasing the compressed right iliac fossa. If this release elicits a sign of pain in the patient this is called positive rebound tenderness sign or blumbergs sign.

Blumberg’s sign significance

The positive blumberg’s sign or rebound tenderness is indicative of peritonitis (inflammation of peritoneum). Which means that blumberg sign can be positive for any disease condition inside the abdominal cavity which leads to peritonitis such as appendicitis (inflammation of appendix). In appendicitis the blumber’s sign or rebound tenderness will be positive in right iliac fossa of the patient (and on the left in case of citus inversus).

False positive rebound tenderness

There can be conditions where patient might give an impression of false positive rebound tenderness. Blumberg’s sign can be false positive if the patient is in extreme pain and guarding the abdomen due to tenderness.

Although if done carefully, it can be confirmed if it’s really positive or not.

Also note, that there are conditions which may show rebound tenderness but are not associated with appendicitis, e.g. in some cases of UTI (urinary tract infection) there is often rebound tenderness seen too.

Therefore correlate withe all the symptoms and overall presentation of the patient before concluding which disease condition is the patient suffering from.

Blumberg sign vs Rovsing sign

As noticed in comments, there is some confusion among people regarding Blumberg sign and Rovsing sign.

Rovsing sign is very much different from Blumberg sign. The blumberg sign is the direct rebound tenderness test. However, Rovsing’s sign is when you press the left iliac fossa and as a result the pain aggravates in the right iliac fossa. This happens due to the overall increase in pressure on the appendix for example, due to the push and shift of the viscera towards the opposite side.

Eliciting and comprehending surgical signs is a skill and takes time to master. Always confirm from your seniors and supervisors whenever in doubt. As it might be a routine for us, doctors, but not for the patient and one wrong diagnosis can result in disaster for him or her.

Hopefully now it’s clear what blumberg sign and rebound tenderness is and how it’s different from rovsing’s sign.