Costovertebral angle (CVA) tenderness is pain that results from touching the region inside of the

costovertebral angle The costovertebral angle () is the acute angle formed on either side of the human back between the twelfth rib and the vertebral column. The kidney lies directly below this area, so is the place where, with percussion (), pain is elicited when th ...

.Bickley, Lynn S., Peter G. Szilagyi, and Richard M. Hoffman. Bates' guide to physical examination and history taking. Philadelphia: Wolters Kluwer, 2017. Print. The CVA is formed by the 12th rib and the spine. Assessing for CVA tenderness is part of the

abdominal exam The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

, and CVA tenderness often indicates kidney

pathology Pathology is the study of disease. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatme ...

Anatomy

The CVA is an anatomic concept of the relationship of the 12th rib to the

transverse processes Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spina ...

of the

lumbar vertebrae The lumbar vertebrae are located between the thoracic vertebrae and pelvis. They form the lower part of the back in humans, and the tail end of the back in quadrupeds. In humans, there are five lumbar vertebrae. The term is used to describe t ...

. There is one CVA on each side of the

spine Spine or spinal may refer to: Science Biology * Spinal column, also known as the backbone * Dendritic spine, a small membranous protrusion from a neuron's dendrite * Thorns, spines, and prickles, needle-like structures in plants * Spine (zoology), ...

.Moore, Keith L., A. M. R. Agur, and Arthur F. Dalley. Clinically oriented anatomy. Philadelphia: Wolters Kluwer, 2018. Print. The

lateral Lateral is a geometric term of location which may also refer to: Biology and healthcare * Lateral (anatomy), a term of location meaning "towards the side" * Lateral cricoarytenoid muscle, an intrinsic muscle of the larynx * Lateral release ( ...

part of the CVA is formed by the lower border of the 12th rib, and the

medial Medial may refer to: Mathematics * Medial magma, a mathematical identity in algebra Geometry * Medial axis, in geometry the set of all points having more than one closest point on an object's boundary * Medial graph, another graph that repr ...

part of the CVA is formed by the transverse processes of the lumbar vertebrae. The CVA is distinct from the

costovertebral joints The costovertebral joints are the joints that connect the ribs to the vertebral column. * The articulation of the head of rib connects the head of the rib and the bodies of vertebrae. * The costotransverse joint connects the rib with the trans ...

. The lower poles of the

kidney In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organ (anatomy), organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and rig ...

s are within the CVAs. A small amount of

pleura The pleurae (: pleura) are the two flattened closed sacs filled with pleural fluid, each ensheathing each lung and lining their surrounding tissues, locally appearing as two opposing layers of serous membrane separating the lungs from the med ...

extends below the ribs in the CVAs.

Physical exam

To test for CVA tenderness, the examiner first applies gentle pressure to the region inside of the CVA with their finger.LeBlond, Richard F., et al. DeGowin's diagnostic examination. New York: McGraw-Hill Education, 2020. Print. If gentle pressure does not elicit tenderness, the examiner places one hand over the region inside the CVA and taps that hand gently with the closed fist of the other hand.

Differential diagnosis

CVA tenderness often indicates kidney pathology, but it may result from other medical problems.Stone, C K., and Roger L. Humphries. Current diagnosis & treatment. New York: McGraw-Hill Education, 2017. Print. CVA tenderness is often present in acute

pyelonephritis Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness. Other symptoms may include nausea, burning with urination, and frequent urination. Complications ...

.Rakel, Robert E., and David Rakel. Textbook of family medicine. Philadelphia: Elsevier/Saunders, 2011. Print. CVA tenderness may be present in patients who have a

kidney stone Kidney stone disease (known as nephrolithiasis, renal calculus disease, or urolithiasis) is a crystallopathy and occurs when there are too many minerals in the urine and not enough liquid or hydration. This imbalance causes tiny pieces of cr ...

,Doherty, Gerard M. Current diagnosis & treatment : surgery. New York: McGraw-Hill Education, 2020. Print. a stone in the

ureter The ureters are tubes composed of smooth muscle that transport urine from the kidneys to the urinary bladder. In an adult human, the ureters typically measure 20 to 30 centimeters in length and about 3 to 4 millimeters in diameter. They are lin ...

, a ureteropelvic junction obstruction, a kidney

abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...

, a

urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...

, and

vesicoureteral reflux Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the urinary bladder, bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally trave ...

. CVA tenderness is also present in patients who have retrocecal

appendicitis Appendicitis is inflammation of the Appendix (anatomy), appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, fever and anorexia (symptom), decreased appetite. However, approximately 40% of people do not have these t ...

and

retroperitoneal The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on thei ...

abscesses. In patients with

sickle cell disease Sickle cell disease (SCD), also simply called sickle cell, is a group of inherited Hemoglobinopathy, haemoglobin-related blood disorders. The most common type is known as sickle cell anemia. Sickle cell anemia results in an abnormality in the ...

, blockage of blood flow to the kidney may cause CVA tenderness. A lack of CVA tenderness in patients with low back pain supports a diagnosis other than kidney pathology.

History

This medical test was first described by the American surgeon

John Benjamin Murphy John Benjamin Murphy, born John Murphy (December 21, 1857 – August 11, 1916) was an American physician and abdominal surgeon noted for advocating early surgical intervention in appendicitis appendectomy, and several eponyms: Murphy’s button, ...

in 1884. In the

Post-Soviet states The post-Soviet states, also referred to as the former Soviet Union or the former Soviet republics, are the independent sovereign states that emerged/re-emerged from the dissolution of the Soviet Union in 1991. Prior to their independence, they ...

and

Eastern Europe Eastern Europe is a subregion of the Europe, European continent. As a largely ambiguous term, it has a wide range of geopolitical, geographical, ethnic, cultural and socio-economic connotations. Its eastern boundary is marked by the Ural Mountain ...

it is often called Pasternacki's sign after Belarusian internist Fiodor Ignatjevich Pasternacki, who described it during his rounds in a regional hospital in

Minsk Minsk (, ; , ) is the capital and largest city of Belarus, located on the Svislach (Berezina), Svislach and the now subterranean Nyamiha, Niamiha rivers. As the capital, Minsk has a special administrative status in Belarus and is the administra ...

in 1888. In Italian the manouvre is referred to as "Giordano's sign", after the Italian physician

Davide Giordano Davide Giordano (22 March 1864 Courmayeur – 1 February 1954 Venice) was an Italian surgeon historian of medicine and politician. He came from a Waldensian family originally from Torre Pellice, the son of Giacomo and Susetta Hugon. He was pr ...

. In Poland, it is often called Goldflam's sign after Polish neurologist

Samuel Goldflam Samuel Wulfowicz Goldflam (15 February 1852 – 26 August 1932) was a Polish-Jewish Isaac Lewin & Nathan Michael Gelber, ''A History of Polish Jewry during the revival of Poland'', Shengold Publishers (1990), p. 86 neurologist best known for his ...

, who described it in 1900.

References

{{Urinary system symptoms and signs Nephrology Abdominal pain