Palpation Techniques E-Book

Bernhard Reichert

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 940

Veröffentlichungsjahr: 2021

Beschreibung

<p>This completely updated third edition of the award-winning <cite>Palpation Techniques</cite> is a beautifully illustrated guide with clear step-by-step descriptions that teach readers how to identify and distinguish between a multitude of underlying body structures, based mainly on palpation alone. A unique graphic technique using detailed drawings of muscles, bones, and tendons directly on the skin, which come alive in almost 900 full-color photographs along with complementary color illustrations, provides a solid understanding of the functional significance of each anatomic region. The previous edition introduced palpation techniques for the shoulder and included new photos and illustrations for the hand, hip, and foot. This third edition is upgraded with a chapter on the abdominal area and additional subchapters on further starting positions and palpation techniques of the shoulder, elbow, and hip/groin. Many new illustrations accompany these new sections.</p><p><strong>Readers will learn how to use:</strong><ul><li>Palpation during physical examination to localize painful, injured structures (provocative palpation)</li><li>Joints as critical landmarks in carrying out tests and guiding manual therapy techniques</li><li>Palpation of peripheral nerves to localize and assess sources of dysfunction and pain</li><li>Deep soft-tissue palpation to relieve musculoskeletal pain</li></ul></p><p>This outstanding book will enable physical therapy and osteopathy practitioners and students to refine their knowledge of practical anatomy further and thus optimize patient care.</p><p>This book includes complimentary access to a digital copy on <a href="https://medone.thieme.com">https://medone.thieme.com</a>.</p>

Leseprobe

Palpation Techniques

Surface Anatomy for Physical Therapists

Third Edition

Bernhard Reichert, MScPT, MTPracticing Massage Therapist, Physical Therapist, and Manual TherapistFellbach, Germany

With the collaboration ofWolfgang Stelzenmüller and Omer Matthijs

877 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is a new updated edition based on the authorized translation of both volumes of the German editions of ‘Anatomie in vivo’, published and copyrighted 2012 and 2007 by Georg Thieme Verlag, Stuttgart, Germany, and merged with the authorized translation of parts from the German edition of ‘Palpations-Techniken’, published and copyrighted 2018 by Georg Thieme Verlag, Stuttgart, Germany.

Original translation by: Gertrud G. Champe, Surry, Maine, USA; Michelle Hertrich, Nettetal, GermanyNew parts translated by: Karen Leube, PhDLeube Translation and Language ServicesAachen, Germany

Photos: Oskar Vogl, Affalterbach, Germany; Benjamin Stollenberg, Ludwigsburg, Germany; Kirsten Oborny, Thieme Group

Illustrations: Martin Hoffmann, Neu-Ulm, Germany;Markus Voll, München, Germany

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KGRüdigerstraße 14, 70469 Stuttgart, Germanywww.thieme.de+49 [0]711 8931 421, [email protected]

Cover design: Thieme Publishing GroupTypesetting by DiTech, India

Printed in Germany by Aprinta Druck GmbH

ISBN 978-3-13-242987-1

Also available as e-book:eISBN 978-3-13-242988-8

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Contents

Foreword to the First English Edition

Preface

Acknowledgments

1 Basic Principles

1.1 Why Do Clinicians Need Surface Anatomy?

1.2 What Is Understood by Surface Anatomy in this Book?

1.3 When Can Surface Anatomy Be Used?

1.3.1 Physical Therapy Assessment

1.3.2 Basic Principles of Regional or Local Treatment

1.4 Workflow for Palpation

1.4.1 Objective and Location

1.4.2 The Reliable Result

1.4.3 Central Aspects of the Procedure

1.4.4 Pressure Applied during Palpation

1.5 Palpatory Techniques

1.5.1 Palpating the Skin

1.5.2 Palpating Bony Edges

1.5.3 Palpating Bony Prominences

1.5.4 Palpating Muscle Bellies

1.5.5 Palpating the Edge of Muscles

1.5.6 Palpating Tendons

1.5.7 Palpating Ligaments

1.5.8 Palpating Capsules

1.5.9 Palpating Bursae

1.5.10 Palpating Peripheral Nerves

1.5.11 Palpating Blood Vessels (Arteries)

1.6 Palpation Aids

1.6.1 Guiding Structures

1.6.2 Connecting Lines

1.6.3 Supporting Measures for Confirming a Palpation

1.6.4 Marking Structures

1.6.5 Starting Positions for Practice (Practice SPs)

2 Shoulder Complex

2.1 Introduction

2.1.1 Significance and Function of the Shoulder Region

2.1.2 Common Applications for Treatment in this Region

2.1.3 Required Basic Anatomical and Biomechanical Knowledge

2.2 General Orientation — Posterior

2.2.1 Summary of the Palpatory Process

2.2.2 Topographical Position of the Scapula

2.3 Local Palpation — Posterior

2.3.1 Overview of the Structures to be Palpated

2.3.2 Summary of the Palpatory Process

2.3.3 Palpation of Individual Structures

2.4 Local Palpation — Lateral

2.4.1 Overview of the Structures to be Palpated

2.4.2 Summary of the Palpatory Process

2.4.3 Palpation of Individual Structures

2.5 General Orientation — Anterior

2.5.1 Starting Position

2.5.2 Supraclavicular and Infraclavicular Fossae

2.6 Local Palpation — Anteromedial

2.6.1 Overview of the Structures to be Palpated

2.6.2 Summary of the Palpatory Process

2.6.3 Palpation of Individual Structures

2.6.4 Tips for Assessment and Treatment

2.7 Local Palpation—Anterolateral

2.7.1 Overview of the Structures to be Palpated

2.7.2 Summary of the Palpatory Process

2.7.3 Palpation of Individual Structures

3 Elbow Complex

3.1 Introduction

3.1.1 Significance and Function of the Elbow Complex

3.1.2 Common Applications for Treatment in this Region

3.1.3 Required Basic Anatomical and Biomechanical Knowledge

3.2 General Orientation — Anterior

3.2.1 Boundaries of the Cubital Fossa

3.3 Local Palpation — Anterior

3.3.1 Overview of the Structures to be Palpated

3.3.2 Summary of the Palpatory Process

3.3.3 Palpation of Individual Structures

3.3.4 Neurovascular Bundle

3.3.5 Proximal Radioulnar Joint (PRUJ)

3.3.6 Tips for Assessment and Treatment

3.4 Local Palpation — Medial

3.4.1 Overview of the Structures to be Palpated

3.4.2 Summary of the Palpatory Process

3.4.3 Palpation of Individual Structures

3.4.4 Differentiation in the Presence of Epicondylitis

3.4.5 Tips for Assessment and Treatment

3.5 Local Palpation — Lateral

3.5.1 Summary of the Palpatory Process

3.5.2 Locating the Most Important Osseous Structures

3.5.3 Locating the Muscles and their Insertions

3.5.4 Locating the Lateral Insertion Tendinopathies

3.5.5 Tips for Assessment and Treatment

3.5.6 Palpation in the Radial Tunnel

3.6 General Orientation — Posterior Humerus

3.6.1 Summary of the Palpatory Process

3.6.2 Palpating Warmth and Swelling

4 Hand

4.1 Significance and Function of the Hand

4.1.1 Causes of the Diversity of Functions in the Hand

4.1.2 Common Applications for Treatment in this Region

4.1.3 Required Basic Anatomical and Biomechanical Knowledge

4.1.4 Axial Divisions of the Skeleton of the Hand into Columns and Their Clinical Significance

4.1.5 The Carpus

4.1.6 Kinematic and Kinetic Model of the Hand

4.1.7 Triangular Fibrocartilage Complex (TFC)

4.1.8 Construction of the Carpal Tunnel

4.1.9 Extensor Tendons and their Compartments

4.2 General Orientation — Dorsal

4.2.1 Summary of the Palpatory Process

4.2.2 Palpation of Individual Structures

4.2.3 Tips for Assessment and Treatment

4.3 Local Palpation of the Dorsal Soft Tissues

4.3.1 Summary of the Palpatory Process

4.3.2 Palpation of Individual Structures

4.3.3 Radial Nerve, Cephalic Vein, and Radial Artery

4.3.4 Tips for Assessment and Treatment

4.4 Local Palpation of the Dorsal Aspect of the Carpal Bones

4.4.1 Summary of the Palpatory Process

4.4.2 Carpal Bones in the Radial Column

4.4.3 Carpal Bones in the Central Column

4.4.4 Tips for Assessment and Treatment

4.4.5 Carpal Bones in the Ulnar Column

4.4.6 Tips for Assessment and Treatment

4.5 General Orientation — Palmar

4.5.1 Summary of the Palpatory Process

4.5.2 Edge of the Radius

4.6 Local Palpation of the Palmar Soft Tissues

4.6.1 Summary of the Palpatory Process

4.6.2 Palpation of Individual Structures

4.6.3 Summary of all Radial Structures

4.6.4 Summary of all Ulnar Structures

4.6.5 Tips for Assessment and Treatment

4.7 Local Palpation of the Palmar Aspect of the Carpal Bones

4.7.1 Summary of the Palpatory Process

4.7.2 Palpation of Individual Structures

4.7.3 Tips for Assessment and Treatment

5 Hip and Groin Region

5.1 Introduction

5.1.1 Lumbar-Pelvic-Hip Region

5.1.2 Functional Significance of the Pelvis and Hip Joint

5.1.3 Pathology and Common Applications for Treatment in this Region

5.1.4 Required Basic Anatomical and Biomechanical Knowledge

5.2 Local Palpation — Lateral

5.2.1 Overview of the Structures to be Palpated

5.2.2 Summary of the Palpatory Process

5.2.3 Palpation of Individual Structures

5.3 Local Palpation — Dorsal

5.3.1 Overview of the Structures to be Palpated

5.3.2 Summary of the Palpatory Process

5.3.3 Palpation of Individual Structures

5.4 Local Palpation — Anterior

5.4.1 Overview of the Structures to be Palpated

5.4.2 Summary of the Palpatory Process

5.4.3 Palpation of Individual Structures

6 Knee Joint

6.1 Introduction

6.2 Significance and Function of the Knee Joint

6.3 Pathological Conditions and Common Applications for Treatment

6.3.1 A Selection of Possible Pathologies

6.3.2 Common Assessment and Treatment Techniques

6.4 Required Basic Anatomical and Biomechanical Knowledge

6.4.1 Construction of the Femorotibial Joint

6.4.2 Construction of the Patellofemoral Joint

6.4.3 Proximal Tibiofibular Joint

6.4.4 Muscles of the Knee Joint

6.4.5 Neural Structures

6.5 Palpation for Warmth and Swelling

6.5.1 Palpating an Increase in Temperature

6.5.2 Palpating Edema

6.6 Local Palpation — Anterior

6.6.1 Summary of the Palpatory Process

6.6.2 Palpation of Individual Structures

6.6.3 Tips for Assessment and Treatment

6.7 Local Palpation — Medial

6.7.1 Summary of the Palpatory Process

6.7.2 Boundaries of the Joint Space

6.7.3 Medial Epicondyle of the Femur

6.7.4 Medial Gastrocnemius Tubercle

6.7.5 Anteromedial and Medial Soft Tissues

6.7.6 Tips for Treatment

6.8 Local Palpation — Lateral

6.8.1 Summary of the Palpatory Process

6.8.2 Palpation of Individual Structures

6.8.3 Tips for Assessment and Treatment

6.9 Local Palpation — Posterior

6.9.1 Summary of the Palpatory Process

6.9.2 Palpation of Individual Structures

6.9.3 Tips for Assessment and Treatment

7 Foot

7.1 Introduction

7.1.1 Significance and Function of the Foot

7.1.2 Special Characteristics of the Bony Construction

7.1.3 Features of the Nomenclature

7.1.4 Special Biomechanical Characteristics

7.1.5 Common Symptoms in the Foot

7.1.6 Required Basic Anatomical and Biomechanical Knowledge

7.2 Local Palpation of the Medial Border of the Foot

7.2.1 Summary of the Palpatory Process

7.2.2 Overview of the Structures to be Palpated

7.2.3 Position of the Medial Ligaments

7.2.4 Tips for Treatment

7.3 Palpation of the Lateral Border of the Foot

7.3.1 Summary of the Palpatory Process

7.3.2 Overview of the Structures to be Palpated

7.3.3 Tips for Assessment and Treatment

7.4 Local Palpation of the Dorsum of the Foot

7.4.1 Summary of the Palpatory Process

7.4.2 Overview of the Structures to be Palpated

7.4.3 Tips for Assessment and Treatment

7.5 Local Palpation of the Distal Posterior Leg

7.5.1 Summary of the Palpatory Process

7.5.2 Overview of the Structures to be Palpated

7.5.3 Borders of the Achilles Tendon

7.5.4 Insertion of the Triceps Surae

7.5.5 Palpation of the Tendon

8 Soft Tissues

8.1 Significance and Function of Soft Tissues

8.2 Common Applications for Treatment in this Region

8.3 Required Basic Anatomical and Biomechanical Knowledge

8.4 Summary of the Palpatory Process

8.4.1 Extent of the Palpation

8.4.2 Criteria for Palpation

8.5 Method and Techniques of the Palpatory Process

8.6 Starting Position

8.6.1 Difficult and Alternative Starting Positions

8.7 Palpation Techniques

8.7.1 Palpating the Surface of the Skin

8.7.2 Palpating the Quality of the Skin (Turgor)

8.7.3 Palpating the Consistency of Muscle (Assessment of Muscle Tension)

8.8 Tips for Assessment and Treatment

8.8.1 Differentiating between Tissues

8.8.2 Interpreting the Findings of Skin Surface Palpation

8.8.3 Interpreting the Skin Consistency (Turgor) Palpation Findings

8.8.4 Interpreting the Muscle Consistency (Tension) Palpation Findings

8.9 Examples of Treatment

8.9.1 Lumbar Functional Massage in Side-lying

8.9.2 Functional Massage of the Trapezius in Side-lying

9 Posterior Pelvis

9.1 Significance and Function of the Pelvic Region

9.2 Common Applications for Treatment in this Region

9.3 Required Basic Anatomical and Biomechanical Knowledge

9.3.1 Gender-based Differences

9.3.2 Coxal Bone

9.3.3 Sacrum

9.3.4 The Pelvic Ligaments

9.3.5 The Sacroiliac Joint

9.3.6 Sacroiliac Joint Biomechanics

9.3.7 Ligament Dynamization in the Sacroiliac Joint

9.4 Summary of the Palpatory Process

9.5 Palpatory Techniques for Quick Orientation on the Bones

9.5.1 Starting Position

9.6 Palpatory Procedures for Quick Orientation on the Muscles

9.6.1 Starting Position

9.7 Local Palpation Techniques

9.7.1 Summary of the Palpatory Procedure

9.7.2 Ilium—Iliac Crest

9.7.3 Ilium—Posterior Superior Iliac Spine (PSIS)

9.7.4 Sacrum—S2 Spinous Process

9.7.5 Sacrum—Median Sacral Crest

9.7.6 Sacrum—Insertion of the Multifidus

9.7.7 Sacrum—Sacral Hiatus

9.7.8 Sacrum—Sacrococcygeal Transition

9.7.9 Sacrum—Inferolateral Angles of the Sacrum

9.7.10 Sacrotuberous Ligament

9.7.11 Long Posterior Sacroiliac Ligament

9.8 Orienting Projections

9.8.1 Posterior Inferior Iliac Spine (PIIS)

9.8.2 Sacroiliac Joint Projection

9.8.3 Piriformis

9.8.4 Sciatic Nerve and the Gluteals

9.9 Tips for Treatment

10 Lumbar Spine

10.1 Significance and Function of the Lumbar Spine

10.1.1 Supporting the Weight of the Body

10.1.2 Spatial Alignment of the Upper Body

10.1.3 The Importance of Stability for Standing and Lifting

10.1.4 Movement in the Trunk

10.1.5 Development of Energy Needed for Locomotion

10.1.6 Junction between the Rigid and Mobile Vertebral Column

10.2 Common Applications for Treatment in this Region

10.3 Required Basic Anatomical and Biomechanical Knowledge

10.3.1 Anatomical Definitions

10.3.2 Shape of the Inferior Lumbar Vertebrae and Intervertebral Disks

10.3.3 Detailed Anatomy of Bony Structures

10.3.4 Detailed Anatomy of the Ligaments

10.3.5 Detailed Anatomy of the Muscles

10.3.6 Basic Biomechanical Principles

10.4 Overview of the Structures to be Palpated

10.5 Summary of the Palpatory Process

10.6 Starting Position

10.6.1 Positioning in the Frontal Plane

10.6.2 Positioning in the Transverse Plane

10.6.3 Difficult and Alternative Starting Positions

10.7 Palpation Techniques

10.7.1 Orienting Projections

10.7.2 Local Bony Palpation

10.8 Tips for Treatment

10.8.1 Research Findings on Reliable Lumbar Palpation

10.8.2 Test for Rotation (Transverse Vertebral Pressure)

10.8.3 Posteroanterior Segmental Joint Play

10.8.4 Palpation during Flexion and Extension Movements

10.8.5 Anteroposterior Segmental Joint Play

10.8.6 Local Segmental Mobility Using Coupled Movements

10.8.7 Training the Multifidus

11 Abdominal Region

11.1 Significance of the Region

11.2 Common Applications for Treatment in this Region

11.3 Required Knowledge (Topographic and Morphologic)

11.3.1 Boundaries of the Abdominal Wall

11.3.2 Regions of the Abdominal Wall

11.3.3 Deep and Superficial Abdominal Muscles

11.3.4 Organs of the Abdominopelvic Cavity

11.3.5 Anatomy of the Groin

11.4 Summary of the Palpatory Process

11.5 Overview of the Structures to be Palpated

11.5.1 Bony Structures

11.5.2 Orienting Projections

11.5.3 Muscles

11.5.4 Palpation of the Colon

11.5.5 Palpation of the Groin Region

11.6 Starting Position

11.6.1 Difficult and Supplementary SPs

11.7 Palpation of the Bony Structures

11.7.1 Preparation

11.7.2 Xiphoid Process

11.7.3 Costal Arch

11.7.4 Anterior Superior Iliac Spine (ASIS) and Inguinal Ligament

11.7.5 Pubic Symphysis

11.8 Orienting Projections

11.8.1 Epigastric Region

11.8.2 Lower Abdomen

11.8.3 Anterior Median Line

11.9 Muscles

11.9.1 Rectus Abdominis

11.9.2 Linea Semilunaris

11.9.3 Regional Subdivision of the Central Abdomen

11.10 Palpation of the Colon

11.10.1 Locating the Cecal Point

11.10.2 Locating the Ascending Point

11.10.3 Locating the Linear Point

11.10.4 Locating the Descending Point

11.10.5 Locating the Sigmoid Point

11.11 Palpation of the Groin Region

11.11.1 Technique and Expectations

11.11.2 Palpation of Inguinal Hernias

12 Thoracic Spine and Thoracic Cage

12.1 Significance and Function of the Thoracic Region

12.1.1 Protective Function

12.1.2 Supportive Function

12.1.3 Junction between the Cervical and Lumbar Spines

12.1.4 Respiration

12.1.5 How Does this Affect Palpation?

12.2 Common Applications for Treatment in this Region

12.3 Required Basic Anatomical and Biomechanical Knowledge

12.3.1 Functional Divisions in the Thoracic Spine

12.3.2 Anatomical Characteristics of the Thoracic Spine

12.3.3 Thorax

12.3.4 Thoracic Back Muscles

12.4 Overview of the Structures to be Palpated

12.5 Summary of the Palpatory Process

12.6 Starting Position

12.6.1 Difficult and Alternative Starting Positions

12.7 Posterior Palpation Techniques

12.7.1 Cervicothoracic Junction in the Sitting Starting Position

12.7.2 Cervicothoracic Junction in the Prone Starting Position

12.7.3 Tips for Assessment and Treatment

12.8 Anterior Palpation Techniques

12.8.1 Anterior Palpation in the Sitting Starting Position

12.8.2 Anterior Palpation in the Supine Starting Position

12.8.3 Thoracic Palpation in the Side-lying Starting Position

12.8.4 Tips for Assessment and Treatment

13 Cervical Spine

13.1 Significance and Function of the Cervical Spine

13.2 Common Applications for Treatment in this Region

13.3 Required Basic Anatomical and Biomechanical Knowledge

13.3.1 Sections of the Cervical Spine

13.3.2 Anatomy of the Lower Cervical Spine

13.3.3 Lower Cervical Spine Biomechanics

13.3.4 Anatomy of the Occiput and the Upper Cervical Spine

13.3.5 Ligaments of the Cervical Spine

13.3.6 Biomechanics of the Upper Cervical Spine

13.3.7 Posterior Muscles

13.3.8 Anterior and Lateral Muscles

13.3.9 Nerves and Blood Vessels

13.4 Overview of the Structures to be Palpated

13.5 Summary of the Palpatory Process

13.6 Starting Position

13.6.1 Difficult and Alternative Starting Positions

13.7 Posterior Palpation Techniques

13.7.1 Occiput

13.7.2 Suboccipital Fossa and Ligamentum Nuchae

13.7.3 C2 Spinous Process

13.7.4 Spinous Processes of the Lower Cervical Spine

13.7.5 Facet Joints

13.7.6 Muscles, Suboccipital Nerves, and Blood Vessels

13.8 Tips for Assessment and Treatment

13.8.1 Functional Massage of the Trapezius in Supine Position

13.8.2 Test for the Alar Ligaments

13.8.3 Identifying the Level of Chronically Irritated Intervertebral Disks

13.8.4 Functional Massage

13.9 Lateral Palpation Techniques

13.9.1 Angle of the Mandible

13.9.2 C1 Transverse Process

13.9.3 C2 and C3 Transverse Processes

13.9.4 Boundaries of the Posterior Triangle of the Neck

13.9.5 Occipital Triangle of the Neck

13.9.6 Supraclavicular Triangle of the Neck

13.10 Anterior Palpation Techniques

13.10.1 Anatomy

14 Head and Jaw

Wolfgang Stelzenmüller

14.1 Introduction

14.1.1 Significance and Function of the Temporomandibular Joint

14.1.2 Common Applications for Treatment in this Region

14.1.3 Required Basic Anatomical and Biomechanical Knowledge

14.2 Anatomy of the Bony Skull

14.2.1 Dividing the Head into Regions

14.2.2 Overview of the Frontal Aspect of the Viscerocranium

14.3 Palpation of the Bony Skull

14.3.1 Frontal Aspect of the Viscerocranium

14.3.2 Lateral Aspect of the Skull

14.4 The Jaw—Temporomandibular Joints

14.4.1 Required Basic Knowledge of Topography and Morphology

14.4.2 Biomechanics of the Temporomandibular Joint

14.4.3 Assessing Deviations from the Mid-line during Mouth Opening

14.5 Palpating the Temporomandibular Joints

14.5.1 Overview of the Structures to be Palpated

14.5.2 Summary of the Palpatory Process

14.5.3 Assessment of the Clicking Phenomenon during Active Mouth Opening

14.6 Palpatory Examination of the Jaw Muscles

14.6.1 Overview of the Structures to be Palpated

14.6.2 Summary of the Palpatory Process

14.6.3 Masseter

14.6.4 Tips for Assessment and Treatment

14.6.5 Medial Pterygoid Muscle

14.6.6 Lateral Pterygoid Muscle

14.6.7 Temporalis

14.6.8 Anterior and Posterior Bellies of the Digastric

Index

Foreword to the First English Edition

The clinical practice community has been left wanting for a textbook dedicated to the precise execution of in-vivo anatomical examination, and this excellent text emerges in a timely fashion. Healthcare professionals have witnessed an escalation in the need for relevant clinical examinations and the use of manual therapeutic interventions, both of which rely on a thorough understanding and execution of precise in-vivo surface anatomy skills. Because surgical exposure may not be readily available, the clinician must rely on nonsurgical measures for identifying relevant anatomical structures. Thus, surface anatomy skillsets become indispensable for localizing structures and landmarks. This text can serve as a roadmap for locating relevant structures with exactitude. The clear means with which this text instructs the clinician in tactile localization will complement essential knowledge in structural and functional anatomy.

The authors have organized the approach to identifying structures by both layer and region. This process of organization can guide the clinician to visualizing a particular structure’s relative depth and relationship to surrounding structures. Moreover, the text is complete, offering a thorough and methodical approach to all major musculoskeletal areas of the human body. This will assist the clinician in developing a musculoskeletal surface anatomy approach to the entire human body, allowing for the identification of patterns, similarities, and differences between structures in the different regions. Finally, the clinician is cued on how the information can be directly applied to clinical examination, which bridges the gap between knowledge and implementation. When used in accompaniment to a thorough, systematic clinical examination, precise structural localization can help to confirm a suspicion of that structure’s involvement in the patient’s condition.

Surface anatomy is essentially manual in nature. Thus, this text can serve as a segue for accurate localization of structures involved in manual therapeutic intervention. Moreover, because a patient’s response to manual therapeutic interventions could be influenced by a clinician’s confidence in technique execution, the clinician’s thorough knowledge of structural architecture that is accompanied by accurate tactile localization could serve to enhance the patient’s response to treatment.

The knowledge and skills gained from this text can provide a foundation for increased clinical confidence, as it can reduce the clinician’s guesswork when navigating to a particular structure. The authors offer practical guidance for enhancing the clinician’s success with an in-vivo surface anatomy experience. So not only are clinicians instructed on what skills to utilize, they are additionally guided on how to best implement them. This text can join the top ranks of a clinician’s library and serve as a bridge between foundational science, clinical knowledge, and practical skills. With these features in mind, the text can support an individual’s development and progress as a master manual clinician.

Phillip S. Sizer Jr., PT, PhD, OCS, FAAOMPTProfessor and Program DirectorScD Program in Physical Therapy;Director, Clinical Musculoskeletal Research LaboratoryCenter for Rehabilitation ResearchSchool of Allied Health Sciences, Texas Tech UniversityHealth Sciences CenterLubbock, Texas, USA

Preface

This book is the result of years of teaching anatomy and practical experience with diagnostics and therapy. Proficiency in targeted palpation is the key to a number of local applications, ranging from physical therapy to local injection.

My realization that practitioners do not really learn anatomy until they have translated theoretical knowledge into tactile familiarity led me to reassess the importance of surface anatomy.

I also realized that experienced therapists and even physicians themselves may still find it challenging to locate certain anatomical structures, even after years of working in the medical profession. My work in training future medical and health professionals has shown me that they must have orientation toward local anatomy to gain the confidence required to apply specific manual techniques.

In this vein, teaching surface anatomy is very satisfying. Identifying the structures being sought, feeling the different types of tissue resistance, and recognizing details is genuinely exciting for students and course participants. Suddenly, the anatomical interconnections become clear, and the learner starts viewing the musculoskeletal system three-dimensionally.

What’s New?

Some of the tests and approaches based on palpation have been substituted with those based on scientific evaluation and practical relevance. For learners to be able to rely on palpation results, emphasis on both reliability and validity is indispensable. Keeping in view the trend for a stronger focus on scientific publications, this edition features a separate list of references for each chapter.

One may think that when it comes to topographic and morphological anatomy, there is nothing new to learn. Nothing is further from the truth. New, high-quality anatomical studies are helping us in locating clinically relevant structures more efficiently. One example of this is the discussion about the origin and course of the medial collateral ligament of the knee joint in the revised chapter “Knee Joint.” Findings from studies conducted at the Institute of Anatomical Sciences, Texas Tech University Health Sciences Center, Texas, USA, are presented in various chapters of this book.

A new chapter “Abdominal Region” focuses on palpation of the abdomen and groin. This anatomical region is less familiar to therapists and is thus characterized by a high degree of uncertainty. This chapter offers simple and practical access to this region.

In addition to the content changes and updates, the book design has been refreshed, which enhances its look and feel and makes it easier to understand.

What Has Remained the Same?

This book targets individuals working towards the diagnosis and treatment of musculoskeletal disorders and diseases.

It intends to enable experienced students in training for careers in physical therapy. Participants in various continuing professional education courses, medical students and physicians, as well as experienced therapists can orient themselves with the musculoskeletal system using this book.

The only way to learn palpation is through practice. This book encourages its readers to simulate the palpation activities presented.

The book aims to present instructions for beginners presented in clear, easy-to-understand language. Research findings and anatomical studies help therapists and instructors become more secure in dealing with the results of specific palpation.

Choice of Structures

Surface anatomy discussed in this book focuses on the key parts of the musculoskeletal system that lead to complaints in the extremities, in many cases, irritated joints and tendons, and their insertions and tendon sheaths. Muscle bellies, bursae, and ligaments are also the target of specific palpations.

The structures selected for this book are the most important sites on which examination and treatment techniques are applied in daily practice.

The instructions are oriented toward “normal” structures of the musculoskeletal system or, in other words, those that are not pathologically altered. To be able to identify pathological changes, the examiner must be well versed in the palpation of normal structures.

Applicability of Surface Anatomy

Surface anatomy is undeniably important for diagnosis and treatment. Several examples illustrate its significance:

• During the examination, the practitioner attempts to precisely locate a diseased structure or perform pain testing by applying pressure or transverse friction (provocative palpation).

• In most cases, the joint space is the crucial factor. Thus, in many cases, local identification of certain bony points and palpation of the course of the joint space is dependent on correct execution of tests and treatment techniques as part of manual therapy.

• The palpation of peripheral nerves is also a key element of surface anatomy. However, only a few examiners are familiar with them in terms of palpation, despite the fact that several peripheral nerves of the arm and leg are quite thick structures and are very easy to find in some places.

• Deep frictions of soft tissue structures constitute another mode of therapy; they are primarily used for pain relief.

Bernhard Reichert, MScPT, MT

Acknowledgments

Revising, refining, and compiling existing material requires the same care and prudence as writing a new text and only works in a team. I am very grateful to Angelika-Marie Findgott, who has proven to be a highly experienced, competent, and composed project manager in the publishing house. She guided the team through this project in a finely coordinated and reliable manner. She and Deborah Cecere executed the editorial fine-tuning of the new and revised text with utmost precision and style. Dr. Karen Leube also deserves thanks for translating the new parts of the text and integrating them into the existing second edition with a great deal of finesse. My gratitude goes to illustrator Markus Voll for his outstanding work with adapting and recreating various graphics. Dennis Wagner, the model for my massage therapy book, also kindly posed for some new photographs that were expertly photographed by Kirsten Oborny.

Dr. Brigitte Klett, a general practitioner specializing in internal and psychosomatic medicine and an expert in Traditional Chinese Medicine (ida-therapiezentrum.de), advised me on developing the chapter on palpation of the abdomen and groin.

I would especially like to thank Dr. Omer Matthijs, ScD PT, for his collaboration on the subject matter of the book. As a research director at the International Academy of Orthopedic Medicine (IAOM.eu), collaborator in research projects at Texas Tech University, Lubbock, Texas, USA, and through his work as a practitioner of physical therapy, he promotes the continuity of the development of specialized practical knowledge, which greatly benefits therapists in practice. Dr. Matthijs contributed to this project by sharing specialized skills and knowledge he developed and gathered and has been a true asset for assuring the high quality of the book’s content.

Bernhard Reichert, MScPT, MT

Chapter 1

Basic Principles

1.1 Why Do Clinicians Need Surface Anatomy?

1.2 What Is Understood by Surface Anatomy in this Book?

1.3 When Can Surface Anatomy Be Used?

1.4 Workflow for Palpation

1.5 Palpatory Techniques

1.6 Palpation Aids

“You must be relaxed to have a good tactile sense”

(A. Vleeming, Berlin, 2003)

1.1 Why Do Clinicians Need Surface Anatomy?

The need to locate anatomical features on living subjects for the purpose of assessment and treatment has existed since the beginning of professional training for massage therapists, physical therapists, and physicians.

In medical and health care training programs, information on the position, appearance, and function of musculoskeletal structures is mostly communicated verbally, with the support of two-dimensional illustrations.

Due to the enormous flood of information, students of anatomy quickly find study material dry and abstract. Didactic-style training programs demonstrate the functional importance of a specific structure within a kinematic complex or a complicated motion sequence. Using a large number of illustrations, they also convey only an approximate three-dimensional idea of that structure, which quickly exhausts the amount of time and materials available to students.

In addition, students are often unable to recognize anatomical features on specimens, for example, when they visit a pathological institute during basic professional training or continuing education courses. It is likewise rare that theoretical knowledge is successfully transferred onto living bodies. Surface anatomy (anatomy on living subjects) becomes a part of professional training that is mentioned in passing; a coincidence during the assessment and treatment of patients; the object of troublesome self-learning; and the content of expensive continuing education courses.

The anatomical images used for training and further education are often drawings demonstrating an idealistic norm. These drawings breach a basic principle of anatomy: variation (Aland and Kippers, 2005). The concept of the anatomical norm cannot be standardized. Rather, it has to include inter-individual (between two people) and intra-individual (left-right) variations in position and shape. Old anatomy books teach us about possible variations in certain topographical and morphological properties, something that modern anatomy books often lack. For example, the classic anatomy book by von Lanz and Wachsmuth Praktische Anatomie (2004a), describes the percentage of the population who have differently shaped or nonexisting structures; for example in 5 to 20% of the population the lumbar spine does not possess a fifth lumbar vertebra (depending on which anatomical study is cited). Töndury (1968, in von Lanz and Wachsmuth 2004a) wrote about the abundance of variation in all spinal section boundaries: “Only approximately 40% of all people have their boundaries [of the sections of the spine] in the normal location.”

What should we do when we lose our confidence in topographic orientation—the knowledge gained from our training—when coming across a variation? First of all, it is important to keep an open mind and be prepared to accept anatomical anomalies when palpating. Experience in palpating and faith in anatomical facts found in every individual take on an even greater significance. Certain structures remain constant in position and shape and can be identified without a large degree of variation; for example, the iliac crests, the scapula, the sternum, and the 1st to 10th ribs. Recognizing variants takes experience.

The palpation procedure starts with the therapist assuming the topographic standard and transferring this knowledge to the situation in the living body. The first step involves therapists attempting to locate a certain structure. They then imagine the structure’s approximate position and shape and start palpating with these details in mind. With the right technique and proper expectation of what you should feel, along with sufficient experience, you will soon become successful.

Memorize

The less confident you are using concrete structural details for orientation, the more helpful technical tricks, guiding structures, or drawings become in confirming that the correct structure has been palpated.

It is highly likely, therefore, that in the treatment setting, important anatomical features cannot be located, and the error rate in local treatment becomes inevitably high. This is something that neither physicians nor therapists can really afford.

1.2 What Is Understood by Surface Anatomy in this Book?

This book deals with both clinically relevant structures in the musculoskeletal system and accessible conductive pathways (blood vessels and peripheral nerves). It uses precise palpation to systematically transfer topographical anatomical knowledge onto living bodies. Therapists should be provided with a logical system to locate relevant structures quickly and reliably. This toolbox of techniques not only includes the actual palpation, it also gives therapists indications of what to expect when searching for a structure and the difficulties they may encounter.

This book is not about reinventing palpatory techniques, but about the clarification of procedures and the detailed documentation of techniques in words and pictures. The substantial number of illustrations allows therapists to monitor their execution of the techniques. The descriptions allow even visually impaired clinicians to reliably locate each structure after hearing the text.

Some authors who have also dealt with surface anatomy (e.g., Winkel, 2004) incorporate the following in their books:

• Surface topography (dividing the body into different regions).

• Anthropometric methods (e.g., measurements of length and circumference).

• General and local observation of regions of the body.

These aspects have been deliberately left out of this book, and readers should understand the term “surface anatomy” as a system used for palpation only.

1.3 When Can Surface Anatomy Be Used?

The precise palpation of structures is used in physical therapy assessment and treatment.

1.3.1 Physical Therapy Assessment

A physical therapy assessment comprises the following:

• Defining the areas to be treated.

• Confirming the presumed location.

• Examining the consistency of skin and muscles.

• Extremities: The provocation of ligaments, tendons, insertions, joint capsules, etc.

• Spinal column: The provocation of local segmental parts and assessment of segmental mobility.

• Examining the craniomandibular joint.

One of the aims of assessment is to identify the affected structure by applying a specific test to provoke the patient’s current symptoms. The accuracy of tests and the interpretation of their findings are quite refined nowadays; nevertheless, it is not always possible to differentiate a painful tendon from a group of synergistic muscles, for example.

Often, the possible causes of pain in a structure are spread over only a few centimeters. For example, in one muscle the cause could be located at the site of insertion, the tendon, or the junction between the muscle and the tendon. Only provocative precise palpation is of help in these instances.

1.3.2 Basic Principles of Regional or Local Treatment

Treatment is based on the following methods:

•Regional treatment: Swedish massage, functional massage, connective tissue massage, electrotherapy, hydrotherapy, heat therapy, balneotherapy, and manual therapy techniques.

•Local treatment: segmental oscillations for pain relief, local segmental manual therapeutic mobilization techniques to maintain or improve mobility, cross-frictions according to Cyriax, and colon massage.

Disorders of the musculoskeletal soft tissue usually appear in very localized areas. Only large traumas or inflammation spread over larger areas. Physical therapy interventions for the treatment of soft-tissue conditions also include local, thermic, electrotherapeutic, and mechanical interventions. Local application of these treatments can only be effective if applied precisely to the affected structure.

Accurate location of an affected site is ensured only through the experienced and reliable use of palpatory techniques.

1.4 Workflow for Palpation

“You cannot feel what you do not know.”

This simple phrase illustrates the necessity of a solid background in topographical and morphological anatomy for local palpation. It does not make sense to look for a specific transverse process if you are unable to visualize its shape, position, and spatial relationship to its surroundings.

It is always a difficult task to recall the exact anatomy of a clinically relevant structure. A lot of time and motivation are needed to deal with this considerable amount of information. For this reason, two short theoretical sections can be found at the start of each topic:

• The significance and functional importance of each region and its individual parts. This acts as an introduction to the topic and refers to current knowledge about the fascinating interplay between individual parts.

• Required basic anatomical and biomechanical knowledge. It is extremely useful to recall topographical relationships again before searching for specific structures. Important anatomical details required for palpation are therefore mentioned in the text and highlighted in the figures.

▶Fig. 1.1 shows the procedure to be used for palpation.

Fig. 1.1 General workflow in palpation.

1.4.1 Objective and Location

The objective of precise palpation of detailed structures is to obtain local orientation for assessment and treatment based on the reasons described above.

The therapist should start with the areas that they know best. The description of the palpatory process generally starts with the palpation of known and easy-to-reach bony structures (e.g., sacrum, occiput) and muscles (erector spinae, semispinalis).

Memorize

Precise palpation always requires the appropriate technique. There is a specific technique especially suited to each structure.

1.4.2 The Reliable Result

Certain measures (tensing specific muscles, passive vertebral movement, etc.) can be applied to test whether the structure in question has actually been found. It is also helpful to draw the structure or its borders on the skin. This obliges the therapist to determine and then document that the structure is actually located where indicated by palpation and drawing. This is even more interesting when students are palpating in a small study group and comparing their results.

In his courses, Vleeming (personal communication), the founder of the Rotterdam Spine and Joint Centre and pioneer of targeted palpation, recommends drawing the palpated structure for each palpation session, including palpation carried out on patients.

Every author on precise palpation writes about the importance of practical experience. The author of this textbook believes that each structure should be deliberately and correctly palpated at least 10 times to achieve an approximate idea of the technique to be applied and the location and shape of the structure.

Fig. 1.2 The formula for successful palpation.

▶Fig. 1.2 summarizes the prerequisites for surface anatomy in an empirical formula.

Memorize

Experience is ultimately the deciding factor in obtaining the necessary confidence.

1.4.3 Central Aspects of the Procedure

Three essential features characterize the palpatory process:

• The application of the appropriate palpatory technique.

• The expected consistency of tissue.

• Differentiating the resistance felt in palpated structures.

As explained above, topographical and morphological knowledge and experience in precise palpation are crucial. Each structure requires a certain palpatory technique, and it is necessary to have an idea about what the structure should feel like. Before palpating, it is also important to know exactly what type of resistance the palpating finger will encounter when it exerts pressure or slides over the structure being sought.

For example, the exact location of a bony edge is found by palpating at a right angle to the edge being sought. The structure is expected to have a hard consistency. The position and shape of a structure can be correctly found among the surrounding tissue when the therapist is able to differentiate between the different types of consistencies found in the different tissues.

Memorize

Soft, elastic tissue is examined slowly to perceive the elasticity.

Hard tissue is examined with a quick movement to feel the hardness.

These principles are also recommended when assessing the end-feel using angular tests (passive functional tests) and translation tests (joint play tests).

1.4.4 Pressure Applied during Palpation

The palpation pressure is usually selected by applying a given technique in a downward direction.

Memorize

In general, the amount of pressure applied should be as much as necessary and as little as possible.

It is definitely incorrect to insist that palpation is always conducted with minimal pressure. The amount of pressure applied depends on the following:

• The expected consistency of the targeted structure. For example, if you are searching for a bony edge or prominence, it is correct to assume that it will feel hard when direct pressure is applied to it. In this case, the palpation tends to be performed with more intensity so that the hard tissue response can be felt. Soft tissue is detected using less pressure. It is impossible to perceive its resilience if too much pressure is applied.

• The firmness and thickness of the more superficial tissue. Deeply located bony landmarks covered by a strong muscular layer or a layer of fat cannot be reached by palpating lightly.

A dexterous therapist can easily locate the structure sought and the expected consistency by using the appropriate technique and the suitable palpation pressure.

1.5 Palpatory Techniques

1.5.1 Palpating the Skin

▶ Example. Posterior trunk.

▶ Technique

• Skin quality: the palm of the hand strokes the skin.

• Skin temperature: the back of the hand strokes the skin.

• Skin consistency: displacement test, skin lifting test, skin rolling.

▶ Expectations

• Skin quality: smooth, pliable skin. Light hair growth is sometimes present.

• Skin temperature: uniform body temperature.

• Skin consistency: soft and very elastic. The skin becomes firmer when more tension is placed on it.

▶ Commentary. The skin qualities described above represent the ideal situation for young patients. Needless to say, age-related changes to the skin should not be immediately classified as pathological.

Fig. 1.3 Using the lifting test to check skin consistency.

The skin’s consistency is determined by the balance of fluid in the skin. Elasticity tests are used to assess the consistency of skin and include the displacement test, lifting test (▶Fig. 1.3), and skin rolling. All three tests should provide identical results. The same amount of elasticity, sensitivity, and changes in these parameters should be found. If this is not the case, techniques should be reassessed or patients questioned again. These tests place different tensile stresses on the skin. The displacement test can be used to find a sensitive or significantly inflamed region; small changes in consistency can be detected especially well using skin rolling with a large amount of stretch.

Tip

Experienced therapists need only use one of these tests when working with patients. The choice of test depends on the sensitivity of tissues. In principle, skin rolling provides therapists with the largest amount of information.

Memorize

The examination of skin consistency does not provide therapists with information on changes in muscle tension.

1.5.2 Palpating Bony Edges

▶ Examples. Spine of the scapula (▶Fig. 1.4), edge of the acromion, joint line of the wrist, a variety of joint spaces, iliac crest, rib shaft, spinous process, mastoid process, mandibular arch.

▶ Technique. The fingertip palpates perpendicular to the edge of the bone.

Fig. 1.4 Palpating the edge of bone, demonstrated here on the scapular spine.

▶ Expectations. Hard consistency and a clearly defined border.

▶ Commentary. This technique enables the therapist to accurately locate the outer boundaries of a bone. The palpating finger must always be positioned perpendicular to the edge of the structure. All other techniques are less reliable. This is particularly important when looking for the component bones of small joints and for delineation of the intra-articular space.

Tip

To feel the hard consistency and palpate the bony edge distinctly, the therapist should palpate the soft tissue first and then gradually move toward the presumed location of the bony edge.

It becomes increasingly difficult to locate bony contours when superficial tissue is tense. Muscles tense up when patients are seated in an unsupported position. Tension increases in all soft tissue when the SP alters the normal curvature of the spine, and tissue is stretched, for example, when padding is placed under the abdomen in the prone position or when sitting patients place their arms in front of them on a treatment table.

Arthritic swelling and bone deformations change the expected consistency and contour of the target structure at the affected joint.

1.5.3 Palpating Bony Prominences

▶ Examples. Medial epicondyle of the femur, Lister tubercle, anterior superior iliac spine, tibial tuberosity, Gerdy tubercle.

▶ Technique. Circular palpation using the finger pads and a minimal amount of pressure.

▶ Expectations. The bony prominence protrudes from the surrounding bone. The structure itself feels hard when direct pressure is applied to it.

▶ Commentary. The iliac spines are usually distinctly elevated from the surrounding structures and can be clearly discerned (▶Fig. 1.5). The borders are not always so easy to detect as in ▶Fig. 1.5. This technique can also be used to palpate smaller elevations in the extremities referred to as tubercles or tuberosities. Moving the palpating finger over the area makes it possible to discern the shape, but too much pressure makes palpation difficult because the differences in the shape and position can no longer be clearly felt. Direct pressure on the structure is used only to confirm that the structure is a bone.

Tip

Therapists can gain an idea about the shape of the raised bony structure from their knowledge of morphological anatomy. However, variations are common; see, for example, the external occipital protuberance, which may be distinctly elevated or very flat.

1.5.4 Palpating Muscle Bellies

▶ Examples. Infraspinatus, deltoid, and gluteal muscles (▶Fig. 1.6).

▶ Technique. Slow palpation over the area with the finger pads positioned perpendicular to the muscle fibers little pressure.

▶ Expectations. Soft consistency. Tissue yields slightly to pressure. Deeper structures can frequently be palpated.

▶ Commentary. The muscles are palpated using one or several finger pads. Pressure should target the muscle directly. The tissue’s soft, elastic consistency can only be felt by proceeding slowly.

Fig. 1.5 Locating the superior posterior iliac spine.

Tip

Tissue consistency is directly dependent on the strength or tension in the fascia enveloping the muscle or the section of the trunk or extremities.

Thickness of the Fasciae

Fasciae can be very soft on the anterior and lateral sides of the trunk, in the neck, along the throat, in the medial forearm, the calf, or the medial aspect of the thigh, for example. Muscles yield easily to the pressure of precise palpation here and have an especially soft, elastic consistency. In contrast, extremely hard fasciae feel significantly firmer during palpation, even when the active muscle tension is normal. Typical examples of this are the thoracolumbar fascia superficial to the lumbar erector spinae and the rectus sheath. Therapists may easily conclude that muscles are tense when increased resistance is felt in the tissues. Once they are aware of the qualities fasciae possess, however, they will have correct expectations regarding the consistency of muscle tissue.

Fig. 1.6 Palpating muscle bellies, demonstrated here on the small gluteal muscles.

Tension in the Fasciae

Memorize

The consistency of muscle and skin is also influenced largely by the length of tissues. An approximated muscle (where the ends of the muscle are found close to each other) generally feels softer than the resting tension felt in a stretched muscle.

Approximation or lengthening occurs in the limbs due to the angular position of joints. It is very difficult to palpate local quadriceps induration when the knee is bent at 90°.

Positioning can influence muscle length in the trunk considerably. The changes to palpation become obvious when the lumbar and thoracic trunk extensors in the sitting SP are palpated and this is compared with palpation in the prone position. Even when resting the upper body on a treatment table and other supportive surfaces, muscles are stretched by the flexion/kyphosis of the lumbar spine in a sitting position and by the forward bend of the body. Tissue feels significantly firmer when pressure is applied. Therapists may interpret this as a pathological increase in muscle tension. The amount of tension in the back muscles is also altered when the therapist places padding underneath the abdomen in the prone position, lowers the head end of the treatment table, and elevates the arms. It is not always possible to avoid approximating or stretching muscles during the positioning or skillful examination of patients while keeping symptoms to a minimum. It is important that the therapist takes this into account when looking at the expected consistency of the muscles to be palpated and does not reach the wrong conclusion when interpreting results.

The following exercises should clarify how differences in fascial tension can affect the interpretation of palpatory results on the posterior aspect of the body:

•Exercise 1: The gluteal region is palpated, starting at the sacrum and moving systematically in a lateral direction. A hardened area is frequently palpated between the greater trochanter and the iliac crests. The iliotibial tract is located here (thickening of the fascia in the buttocks and the thigh), running from the iliac crest toward the greater trochanter and the lateral thigh. The therapist changes the hip joint’s SP by moving it into more abduction or adduction and attempts to feel how the tract changes under direct palpation (different consistencies due to the muscle being stretched or approximated).

•Exercise 2: Firm fascia already restricts direct pressure from being applied to the lumbar trunk extensors. The patient’s pelvis is moved toward or away from the therapist. This causes lumbar lateral flexion. The therapist palpates the trunk extensors and attempts to find out how their consistency changes (→ different consistencies due to the muscle being stretched or approximated). Lumbar tension is also increased when patients raise their arms over their heads.

1.5.5 Palpating the Edge of Muscles

▶ Examples. Sartorius, adductor longus (▶Fig. 1.7), hand extensors, semispinalis capitis, erector spinae, sternocleidomastoid.

▶ Technique. A muscle edge is usually palpated with the muscle slightly tensed. The palpating fingers can be positioned using all possible variations (fingertips, finger pads, sides of the fingers) and should be placed against the edge of the muscle as best as possible. Once the edge of the muscle has been located, it is steadily followed so that the course and the length of the muscle can be perceived.

Fig. 1.7 Palpating the edges of muscles, demonstrated here on the adductor longus muscle.

▶ Expectations. When tensed, the edge of the muscle has a firm consistency and a uniform, smooth contour. Large and small gaps differentiate the edges of the muscle from neighboring muscles.

▶ Commentary. Many neighboring muscles and borders cannot be differentiated from one another or identified without selective activation of the muscle. Well-trained muscles with low fat content as well as muscles with pathologically increased tension are exceptions and project themselves from their surroundings.

Tip

A muscle and its edges can be quickly identified in difficult situations by alternating muscular tension. The patient is instructed how to quickly alternate between tensing and relaxing the muscle. Reciprocal inhibition is sometimes an option to help switch off neighboring muscles. Often the muscle edges can be followed along their further course, as tendons, as far as their insertion onto a bone.

1.5.6 Palpating Tendons

▶ Examples. Tendons in the extensor compartments of the wrist, flexors of the wrist and fingers (▶Fig. 1.8), biceps brachii tendon, ankle plantar flexors and toe flexors, and hamstring tendons. The trunk muscles rarely attach onto the bone via a tendon. A fleshy insertion is more common. Limb muscles near the trunk are more likely to have insertions that feel like tendons when palpated, for example, the common head of the hamstrings.

Fig. 1.8 Palpating tendons, demonstrated here on the wrist and finger flexors.

▶ Technique. The choice of technique depends on how difficult it is to find the target tissue and the aim of palpation:

• Tendon that is difficult to locate: place the finger pads flatly and directly onto the point where you suspect the tendon to be, then alternately tense and relax the muscle.

• Tendon that is easy to locate: place the tip of the finger alongside the edge of the tendon. Tense the muscle when necessary.

• For pain provocation: administer transverse friction massage using the finger pads, applying firm pressure on the presumably affected site.

▶ Expectations. Firm consistency and, when the muscle is tensed, very firm consistency. A tendon remains somewhat elastic when direct pressure is applied to it, even when under a large amount of tension. In most cases, the tendon is a rounded structure with a clearly defined contour.

▶ Commentary. Tendons and their insertions belong to the soft-tissue structures in the musculoskeletal system that most frequently present with local lesions. It is therefore imperative to familiarize oneself with the different techniques used for this taut connective tissue.

Tip

The treating finger should not slip off the tendon while Cyriax transverse friction is being applied to the tendon for treatment or pain provocation. The tendon is kept stable by positioning the muscle in a stretched position, thus placing the tendon under tension.

1.5.7 Palpating Ligaments

▶ Examples. Medial collateral ligament or the patellar ligament at the knee joint (▶Fig. 1.9), talofibular ligament at the ankle. With very few exceptions the precise palpation of spinal ligaments is rarely possible. The pelvic ligamental structures, e.g., the sacrotuberous ligament (▶Fig. 1.9, as well as the supraspinosus and the nuchal ligaments, are the only ligaments on the trunk that can be palpated well.

Excursus: Using Friction to Treat Tendinopathy

The techniques of transverse friction of soft tissue structures developed by James Cyriax can also be used as provocative palpation in settings other than examinations. They can also be used to treat inflammation in the junctions between muscles and tendons, tendons, insertions, tendon sheaths, and joint capsules, as well as for painful degenerative tendinopathy. This excursus will present methods for implementing the techniques to be used for the examples discussed in subsequent chapters. For more detailed information, see Reichert (2015).

Transverse/Longitudinal Friction in Tendons with Inflammation

Pain relief from the treatment can be expected in a matter of minutes. Once this has set in, the intensity can either be applied again, at a higher level, or an adjacent—now more painful—area may be sought. Since the assessment of the pain-relieving effect is dependent on what the patient reports, at the outset of treatment the patient should deliberately register the intensity with which the transverse frictions are executed.

• Direction: Transverse or longitudinal to the course of the fibers of the affected structure.

• Submaximal intensity: Transverse frictions may be distinctly perceived by the patient, but should not be excessively painful. The patient should not perceive pain higher than level 2 to 3 out of 10 on the visual analog scale (VAS) for pain.

• Pressure emphasis is in only one direction.

• Duration is around 5 to 10 minutes.

• Additional treatment methods: Ointment dressings with anti-inflammatory agents, relaxation of the affected muscle bellies, functional tape dressings, and thermal and electrotherapeutic physiotherapy methods.

Transverse Friction for Treating Chronic Painful Tendinopathy

For strenuous eccentric exercise, an established method for treating tendonitis, it takes several weeks for pain relief to set in. Before the model for influencing neovascularization of tendinosis through the successful application of transverse frictions, many therapists followed the notion of Prentice (1994) that the effect was a result from conversion of a chronic inflammation to an acute inflammation which would then heal. The latter model to explain tendonitis is now obsolete, since during the healing of tendonitis no signs of inflammation are observed (Alfredson and Lorentzon, 2002).

• Direction: Transverse or longitudinal to the course of the fibers of the affected structure.

• High intensity: For this method to be indicated, the patient must report pain of at least 5 out of 10 on the VAS in order to influence neovascularization.

• Pressure emphasis is in both directions.

• Duration is around 10 to 20 minutes.

• Pain relief during treatment cannot be expected.

• Additional training methods: Eccentric exercise and night splints.

Fig. 1.9 Palpating ligaments, demonstrated here on the patellar ligament.

▶ Technique

• Ligament that is easy to locate: The tip of the finger is positioned on the edge of the ligament, for example, sacrotuberous ligament.

• Ligament that is difficult to locate: Initially place the ligament under tension and use direct pressure to palpate the firm, elastic consistency, for example, nuchal ligament.

• For pain provocation: Administer transverse friction using the finger pads, applying firm, direct pressure onto the ligament, for example, supraspinous ligament.

▶ Expectations. Firm consistency. Very firm consistency when stretched. A ligament remains somewhat elastic, even when placed under a large amount of tension. Clearly defined contours are seldom found for the rest of the capsule.

▶ Commentary. Capsular ligaments consisting of dense connective tissue act as mechanical reinforcements. In contrast to tendons, most ligaments are not easily distinguishable from the unreinforced capsule or other tissues. As components of the fibrous membrane of the articular capsule, they very rarely exhibit distinct edges. Two exceptions are the patellar ligament and the medial collateral ligament of the knee joint. For other ligaments, one must know the characteristic course and the associated bony landmarks in order to visualize their location.

Tip

Passive prestressing and muscular stretching to reveal the contour and confirm the location are not usually helpful. If the therapist wishes to administer provocative or therapeutic transverse frictions to a ligament, the corresponding structure must be stable and should not be allowed to slide away from underneath the finger. The joint is therefore positioned so that the ligament is taut.

When patients have only recently overstretched or partially ruptured ligaments, prepositioning is done with the necessary amount of care, that is, slowly and without aggravating pain. Muscle contraction usually does not help to make the ligament stable enough for palpation.

1.5.8 Palpating Capsules

▶ Examples

• Test for large effusions in the knee joint, effusions at the elbow joint.

• Pain provocation: Cervical facet joints (▶Fig. 1.10).

▶ Technique

• The palpation is performed at a slow pace with the entire surface of the finger pads palpating directly over the capsule. The finger pads move repeatedly over the capsule, applying minimal pressure.

• Pain provocation: The palpation is performed at a slow pace with the entire surface of the finger pads palpating directly over the capsule. The finger pads move repeatedly over the capsule, applying minimal pressure.

▶ Expectations

• Test for swelling: A very soft consistency and fluctuation of synovial fluid inside the swollen capsule is to be expected.

• Pain provocation: During the objective of pain provocation in arthritis, the consistency of the capsule may feel softer than an unaffected capsule.

▶ Commentary. The palpatory findings, that is, the identification of swelling, must match the results of observation at a local level. Palpation for an increase in temperature is also usually positive.

The sacroiliac joints, the lumbar and thoracic facet joints, and the atlanto-occipital joints cannot be directly reached using palpation. It is not customary to palpate for warmth or swelling as there is too much soft tissue overlying these joints. The focus is the provocation of pain using palpation to locate the level of the cervical facet joints. The result of this palpation, that is, the discovery of sensitivity to pressure and possible associated swelling, must be accompanied by a functional assessment (end-of-range combined movement).

Fig. 1.10 Palpating the capsules of the cervical facet joints.

Tip

In addition to searching for lesions on an injured capsule-reinforcing ligament of the joint of an extremity, confirming capsular swelling constitutes another important reason for palpating the joint capsule when arthritis is expected.

1.5.9 Palpating Bursae

▶ Examples. Olecranon bursa (▶Fig. 1.11), trochanteric bursa.

▶ Technique. The palpation is performed at a slow pace with the entire surface of the finger pads palpating directly over the bursa. The palpatory movements are repeated several times, applying minimal pressure.

Fig. 1.11 Palpating bursae, demonstrated here with the olecranon bursa.

▶ Expectations. The normal expectation: no exceptional palpation result. When a bursitis is present, it is expected that the bursa will have a soft consistency and that the fluid in the inflamed bursa will fluctuate with repeated palpation.

▶ Commentary. One reason for wanting to feel the fluctuation in a bursa is local pain. This pain arises in tests of the basic joint examination, which cause compression of the bursa. Another reason is the presence of clearly visible local swelling. With bursitis of the trochanter, activity against resistance in the direction of abduction and passive adduction of the hip joint is painful.

Tip

Local swelling can be clearly seen in a superficially located bursa. The fluctuation of fluid can be felt well when two finger pads are used for the palpation and pressure is alternately applied using one finger and then the other. Muscular or tendinous structures located superficial to the affected bursa (iliotibial tract over the trochanteric bursa) should not be tensed or stretched during the palpation. The consistency naturally changes when palpating through these tissues. They may lose the softness, and fluctuations can no longer be palpated. In this case, the technique serves only to provoke pain in cases of suspected bursitis.

1.5.10 Palpating Peripheral Nerves

▶ Examples. Median nerve, ulnar nerve, tibial nerve, common peroneal nerve, and superficial peroneal nerve (▶Fig. 1.12).

Fig. 1.12 Palpating peripheral nerves, demonstrated here on the superficial peroneal nerve.

▶ Technique. The fingertips palpate at a right angle to the path of the neural structure sought. It is possible to slide over the nerve if the nerve is placed under tension beforehand. This is similar to plucking a tightened guitar string. Do not use too little pressure and do not proceed too slowly.

▶ Expectations.