Perform a general postural observation and note any difference from the norm. It is important to observe the relationship of the overall posture to the plumb line (Kendall et al. 2005).
In case of a suspected scoliosis, look for:
Lateral curvature of the spine
Asymmetry of the shoulders and scapulae (one more prominent)
Asymmetry of the waistline and the distance of the arms from the trunk
Asymmetrical waist triangle
Balance of the head/slanted head posture
Deformation of rib cage
Over time, it is important to observe for progression of the curve, with the progression risk being greater in women than in men (Eurospine 2007).
Palpation: ASIS and PSIS to see if they are level
The history and physical examination are intended to exclude secondary causes for the spinal deformity, as the diagnosis for scoliosis is mainly one of exclusion (Reamy et Slakey 2001). Next to the usual red flags, refer a patient in case of the following findings:
Markedly painful scoliosis
Deviation to one side during the Adams test
Sudden rapid progression in a previously stable curve
Extensive curve progression in a patient after skeletal maturity
Abnormal neurologic findings
Range of Motion
Side flexion and rotation to convex side may be limited (Magee 2006). Differentiate between structural and non-structural (functional) scoliosis; the curve does not change in structural scoliosis, whereas forward bending can diminish the non-structural scoliosis curvature (Magee 2006, Kendall et al. 2005). In case of a structural scoliosis, bending forward will relieve a prominence on the convex side of the curve (Kendall et al. 2005).
There is no ideal screening test (Reamy et Slakey 2001), although the Adams test can help identifying scoliosis and is easy to perform (Aggouris et al. 2010; Reamy et Slakey 2001). The Adams test is very sensitive compared to Cobb angle, but sensitivity and specificity depend on the skills of the examiner, the location of the curve, and the magnitude of the curve (Aggouris et al. 2010). Lumbar scoliosis with a Cobb angle greater than 20 degree is reported to have a sensitivity of 73% and a specificity of 68% (Aggouris et al. 2010). Leg length discrepancy should be tested as it can cause a structural scoliosis (Magee 2006; Gilles 2009; Kendall et al. 2005).
In idiopathic scoliosis, muscle imbalance might be the underlying cause (Kendall et al. 2005), so it is important to test muscles. According to Kendall et al (2005) muscle length should be tested especially in hip flexors, hamstrings, tensor fasciae latae, iliotibial band and teres and latissimus dorsi. Strength should be tested in back extensors, abdominals, hip flexors, extensors, adductors and abductors, gluteus medius and trapezius (Kendall et al. 2005).
On concave side: Muscles are commonly short and strong (contracted), hip abductors are elongated and weak
On convex side: Muscles are commonly elongated and weak, hip adductors are strong and shortened
(Kendall et al. 2005)
For the evaluation, several questionnaires can be used. The Walter Reed Visual Assessment Scale (WRVAS) is a valid tool to assess the patients perception of their deformity (Bago et al. 2006). The WRVAS has excellent internal consistency, and there is a highly significant correlation between the results of the test and the magnitude of the deformity (Bago et al. 2006). The SRS-22 HRQL questionnaire successfully discriminated among persons with no scoliosis or moderate scoliosis and large scoliosis, but does not discriminate among patients with single, double, or triple curves (Asher et al. 2003). The SRS-22 is reliable with internal consistency and valid when compared to the SF-36 (Asher et al. 2003).
The accepted standard for measuring scoliosis on radiographs is the Cobb angle (Aggouris et al. 2010; Cassar-Pullicino et al. 2001). The Cobb angle is “the angle between lines drawn along the upper end plate of the most tilted vertebrae above the curve’s apex and the lower end plate of the most tilted vertebrae below the apex” (Aggouris et al. 2010).
Other available imaging techniques are non-invasive optical systems like the Moiré-fringe mapping, the Integrated Shape Imaging System (ISIS), the Quantec system, 3D body scanners and many more (Aggouris et al. 2010).
The diagnosis for scoliosis is mainly one of exclusion of all serious spinal pathologies (Reamy et Slakey 2001).