Alders sign

With the patient supine, the examiner identifies the site of maximal abdominal tenderness and maintains constant pressure at the same abdominal wall location while the patient turns onto the opposite side.

• Shifting tenderness: Pain diminishes or disappears as the uterus moves away from the examining fingers, suggesting a uterine source.
• Fixed tenderness: Pain persists despite repositioning, favouring an extrauterine source such as appendicitis.

Alders proposed the sign as an aid to evaluating abdominal pain in pregnancy, rather than as a specific test for appendicitis. Its diagnostic accuracy remains inadequately established.

Clinical significance and diagnostic accuracy

Alders’ original 1951 publication presented seven illustrative cases without formal assessment of diagnostic accuracy. Subsequent evidence remains limited. Tamir et al. (1990) recorded the sign in only two patients, while Chen et al. (1999) reported it in five of 14 patients with appendicitis without adequately defining a positive response.

The manoeuvre requires a sufficiently enlarged, mobile uterus. Adhesions and adnexal pathology may alter the expected response. There are insufficient data to establish sensitivity, specificity or likelihood ratios, and the sign cannot independently confirm or exclude appendicitis.

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History

1933 – William B. Marbury published Appendicitis in Pregnancy, describing the diagnostic difficulties caused by displacement of the abdominal viscera and reduced abdominal wall rigidity in advanced pregnancy. He observed that the gravid uterus changed position when the patient moved or turned, however this observation involved the spread of intra-abdominal infection rather than a diagnostic examination manoeuvre.

1944 – Ernest Chalmers Fahmy (1892-1982) discussed Abdominal Pain in Pregnancy in his Honyman Gillespie Lecture. He described examining pregnant patients in the left lateral position to displace the uterus and facilitate palpation of the appendiceal region. He outlined the positional principle underlying Alders sign but did not describe comparison of tenderness at a fixed abdominal wall location.

1951 – Nicholas Alders (1904–1995) published Sign for Differentiating Uterine from Extrauterine Complications of Pregnancy and Puerperium in the British Medical Journal. He described the sign of fixed or shifting tenderness, maintaining pressure over the site of maximal tenderness while turning the patient onto the opposite side.

Alders reported using the manoeuvre for approximately ten years and presented seven illustrative cases, including two patients with perforated appendicitis. He acknowledged that adhesions and adnexal inflammation could produce misleading findings.

The paper reports seven cases:

Case	Clinical condition	Tenderness
1	Perforated gangrenous appendicitis	Fixed
2	Perforated gangrenous appendicitis	Fixed
3	Concealed accidental haemorrhage	Shifting
4	Degenerating uterine fibromyoma, subsequently adherent to the abdominal wall	Initially shifting, later fixed
5	Acute salpingitis	Shifting
6	Puerperal endometritis	Shifting
7	Caecal volvulus	Fixed

The seven cases illustrated both the proposed value and limitations of the manoeuvre. Two patients with perforated appendicitis exhibited fixed tenderness, while a patient with a degenerating uterine fibromyoma developed fixed tenderness after the lesion became adherent to the abdominal wall. Acute salpingitis produced shifting tenderness, demonstrating that the response could not reliably distinguish all uterine from extrauterine pathology.

1954 – Alders revisited the manoeuvre in The diagnosis of the acute abdomen in pregnancy, published in Medical Illustrated. He reproduced the examination technique and reiterated its value in distinguishing uterine from extrauterine causes of abdominal pain.

He retained the name “sign of fixed or shifting tenderness” and reproduced the examination technique, including the need to maintain pressure while the patient turns.

With the patient lying straight on her back, the examining fingers find the area of maximum tenderness to pressure on the abdominal wall. While the fingers remain in contact with that area without altering the intensity of pressure they are exerting to elicit pain, the patient is made to turn over on the opposite side so that the plane of the anterior abdominal wall is approximately vertical. The pain produced by the pressure of the fingers will be less or will have entirely disappeared if the lesion is uterine and has fallen away from the examining fingers “shifting tenderness”

…this sign can be of use only if the uterus is large enough to be palpable abdominally, and that it may be misleading in the rare case in which a uterine lesion has become fixed by adhesions to the anterior abdominal wall. In acute salpingitis, which does occur in pregnancy, the result of the test will depend on the presence or absence of perisalpingitic adhesions

Alders 1954

1990 – Tamir, Bongard and Klein published Acute appendicitis in the pregnant patient. They reviewed 84 pregnant patients undergoing laparotomy for suspected appendicitis. Alders sign was assessed in only two patients, preventing meaningful evaluation of its diagnostic value.

1999 – Chen and colleagues published Acute appendicitis during pregnancy. They reported “Adler’s sign” in five of 14 patients (36%) with confirmed appendicitis during pregnancy. The examination technique and definition of a positive response were insufficiently specified to establish diagnostic sensitivity.

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Eponymythology

Alders originally described the manoeuvre as the sign of fixed or shifting tenderness, rather than using an eponym. The underlying principle of displacing the gravid uterus during abdominal examination was already recognised, notably in Marbury’s observations of uterine mobility (1933) and Fahmy’s discussion of lateral positioning (1944).

Alders’ contribution was to formalise a comparative tenderness test, maintaining constant pressure over the same abdominal wall location while the patient changed position. Although he reported using the technique for approximately ten years before publication, no earlier description of the complete manoeuvre has been identified in the sources reviewed.

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Associated Persons

• Nicholas Alders (1904–1995)

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Alternative names

• Sign of fixed or shifting tenderness in pregnancy

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References

Historical references

• Marbury WB. Appendicitis in pregnancy. American Journal of Surgery. 1933;19(3):437–441.
• Fahmy EC. Abdominal Pain in Pregnancy. Edinb Med J. 1944 May;51(5):229–46.
• Lennon G. The Rarer Causes of Abdominal Pain in Pregnancy. Proc R Soc Med. 1950 Feb;43(2):105-8.
• Alders N. Sign for Differentiating Uterine from Extrauterine Complications of Pregnancy and Puerperium. Br Med J. 1951; 2(4741): 1194-5.
• Alders N. The diagnosis of the acute abdomen in pregnancy. Medicine Illustrated. 1954; 8(8): 505-9.

Eponymous term review

• Horowitz MD et al. Acute appendicitis during pregnancy. Diagnosis and management. Arch Surg. 1985; 120(12): 1362-7.
• Tamir IL, Bongard FS, Klein SR. Acute appendicitis in the pregnant patient. Am J Surg. 1990; 160(6): 571-5; discussion 575-6.
• Chen CF, Tan KH, Shin FC, Chen HI. Acute appendicitis during pregnancy. J Med Sci. 1999; 19(9): 256-262
• DeSantis RA, Lockrow EG. Appendectomy during Pregnancy: A Survey of Two Army Medical Activities. Military Medicine 1999; 164(10): 671-674.
• Rastogi V et al. Abdominal Physical Signs and Medical Eponyms: Movements and Compression. Clin Med Res. 2018; 16(3-4): 76-82.