Diagnosis and evaluation

Diagnosis and evaluation

As already mentioned, scoliosis is a three-dimensional condition which must be evaluated and treated accordingly. It is not only about the sideways curve and degrees that we measure in an X-Ray but there are many other factors which we must check and evaluate prior to the therapeutic intervention. Thus, for the evaluation, it is important to consider both the clinical check and X-ray.

X-Ray and clinical evaluation factors:

The Cobb Angle is the commonest way of measuring the sideways curve of the spine and it determines the grade of scoliosis in degrees. According to the scientific communities, SRS and SOSORT, degrees which are smaller than 10ο are not considered as scoliosis.

The measurement of the Cobb angle is made always by the specialized doctor and physiotherapist based on the X-Ray and it is very important both for the diagnosis of scoliosis and the evaluation of its development.

Angle Trunk Rotation (ATR)

Another important factor of measurement is the angle trunk rotation of the vertebrae. With regard to scoliosis, we are not interested only in the sideways curve of the spine but also the rotation of the vertebrae separately. This measurement is a crucial prognostic factor for the development of scoliosis and important input for the decisions which must be taken; whether the child needs systematic special physiotherapy exercises for the treatment of scoliosis, whether bracing is required, or a simple monitoring of the progress suffices etc.

The rotation angle can be measured both clinically and with X-Rays. The latter can be done with the Raimondi, Nash Moe and Perdiolle methods. The most reliable and common way is to do it clinically with the use of the scoliometer. Measuring with the scoliometer is more practical and can be done at regular intervals, contrary to the measurement with X-rays which requires the child to be exposed to X-rays frequently which is not feasible.

Measuring the rotation angle with the use of the scoliometer during the Adam’s forward bend test.

Risser Sign (child’s development stage)

This measurement determines the stage of bone development of the child and how much bone development remains. This measurement is made with X-rays and the percentage of ossification of the apophysis of the iliac crest in the pelvis can be observed.

The Risser grade is a decisive factor for the selection of the use of a brace or not. The guidelines issued by the scientific communities of scoliosis of SRS and SOSORT are that at a Risser grade 0-3 when much of the child’s development still remains and in cases of scoliosis over 25 degrees, the use of a brace and systematic Physiotherapy Scoliosis-Specific Exercises are mandatory. On the contrary, in Risser grade 4 and 5, when the bone development has been almost completed, the brace does not seem to offer any benefit and the treatment must be made only with Physiotherapy Scoliosis-Specific Exercises.

The grades of measurement range from 0 to 5, with 0 indicating that the bone development of the child has not started at all, and 5 indicating that it has been fully completed.

Risser 0: Bone development has not started at all and this is why there are no signs of iliac apophysis ossification.

Risser 1: Bone development has started and iliac apophysis ossification by 25% is observed. Usually, in little girls, this is the time the first period appears.

Risser 2: Iliac apophysis ossification by 50% is observed.

Risser 3: Iliac apophysis ossification by 75% is observed. At this stage, the pace of development of the child starts to decrease but development is still ongoing.

Risser 4: Iliac apophysis ossification by 100% is observed, but it has not been connected with the iliac crest yet. At this stage the child’s development slows down significantly.

Risser 5: The iliac apophysis has been fully coossified with the iliac crest. The child’s development finishes at this stage.

Pelvis parameters

As it is widely known scoliosis does not induce changes only to the spine and the trunk, but to the whole body, thus the pelvis too. The position of the pelvis plays a significant role in determining the type of scoliosis.

In simple words, there are some factors in the pelvis (SVA, Pl, PT, SS, T1-Tilt) that we have to measure in the X-Ray so as to check the following:

  • the position of the pelvis in relation to the sagittal plane,
  • the position of the femoral heads,
  • the anteroposterior tilt of the pelvis in relation to the lower spine,
  • the alignment of the spine and
  • in general, the relation between the spine and the pelvis.

Pelvic incident (Pl): 40ο-65ο
Pelvic tilt (PT): 10ο-25ο
Sacral slope (SS): 30ο-50ο

TRACE Scale (Evaluation of the asymmetries based on the patient’s clinical image)

The doctor and the physiotherapist evaluate clinically the patient, observe and mark down any possible asymmetries in the body. Asymmetries can be observed in the shoulders, the scapulae, the chest/ribs and the waist.

Shoulder asymmetries

(Score 0-3)

One shoulder may be higher than the other.

0: Full Symmetry
1: Slight Asymmetry
2: Moderate Asymmetry
3: Important Asymmetry

Scapulae Asymmetries

(Score 0-2)

0: Full Symmetry
1: Slight Asymmetry
2: Moderate Asymmetry

Waist Asymmetries

(Score 0-4)

0: Full Symmetry in the waist

1: Slight Asymmetry in the waist with very slight displacement of the pelvis to the right or left

2: Mild Asymmetry and displacement of the pelvis

3: Moderate Asymmetry of the waist with important displacement of the pelvis to the right or left

4: Important Asymmetry of the waist with full displacement of the pelvis to the right or left


Another type of evaluation is made with questionnaires that the patient is requested to fill in by evaluating himself. There are various types of questionnaires, such as the SRS-22 questionnaire, the TAPS (Trunk Appearance Perception Scale), the Brace questionnaire. Through the questionnaires, the patient reports various asymmetries observed on his/her body.