By Ross Turchaninov, MD
Science of Palpation articles are the final part of our evaluation series. The Science of the Clinical Interview was published in issue #1, 2012 of JMS and the Science of Visual Evaluation was published in issue #2, 2015 of JMS. The first part of this article on the Science of Palpation we published in #4, 2015 issue of JMS.
Palpation is the only evaluation tool which is legally available to therapists and the inability to use it or incorrect interpretation of its results makes the therapist’s efforts useless when he or she works on patients, especially in complex cases.
Palpation isn’t for the therapist to establish a diagnosis, but it is a priceless tool in the formulation of the correct treatment strategy. For example, a patient was in a car accident and went to his primary care physician with cervical pain and headache. The doctor did all necessary tests and established a diagnosis of Whiplash. This is a commonly used medical diagnosis which according to ICD-10 has S.13.4 code and the physician is reimbursed according to it. This patient then was referred to a Medical Massage clinic for treatment. Did the diagnosis of Whiplash give the therapist any useful information he or she can use to develop a correct treatment strategy? No it didn’t, since this diagnosis didn’t clarify if the trapezius was affected or the levator scapulae was in spasm or to what degree the fascia was injured or the occipital nerves were compromised, etc. All of these answers and much more the therapist will find when he or she masters the science of palpation.
If readers want to succeed in the massage therapy profession we highly recommend they carefully study this and following articles on the subject of clinical palpation. You won’t find this information in your school, textbooks or at continuing education seminars. Read it and immediately apply it on your patients/clients to witness firsthand the professional importance of the information we’re sharing with you. The subject of clinical palpation is a vast topic. Thus we will review this information in several articles since we don’t want to overwhelm our readers. Overall, palpation techniques should be split into three groups: superficial palpation, deep palpation and abdominal palpation.
Under superficial palpation we understand examination of the skin, superficial fascia, superficial skeletal muscles and parts of the periosteum covered by the skin only.
1. Examination of the local temperature.
Usually this evaluation is done during initial contact with the patient. Examination of the skin temperature allows you to detect a decrease of arterial supply (cooler skin or hypothermia) or insufficient venous and lymphatic drainage (warmer skin or hyperthermia).
There are two critical issues to get a correct reading of local skin temperature:
a. The examination is always conducted by the dorsal surface of the hands since the skin there has a larger number of temperature receptors.
b. The local skin temperature must be compared to the opposite (unaffected) side or if the symptoms are bi-lateral to the upper segments on the same side.
To do the evaluation correctly the therapist should register two things: the difference in the skin temperature at first contact and possible difference in local temperature while the therapist’s hands are still in contact with the patient’s skin for approximately 10 seconds. Why is there the need for a two-step approach to the examination of skin temperature?
In a majority of cases the initial contact gives needed information. However, if the patient is in a lot of pain, especially for some period of time, his or her body may see even simple touch as a potential threat. This is explained by the so called phenomenon of hyperirritability when all peripheral receptors including the touch receptors drop the threshold of their activation and over react to any additional sensory stimulation. In such cases the initial contact may trigger immediate local vasoconstriction, which the therapist will feel as the skin is slightly cooler.
To avoid being misled, keep your hands in the same position for 10 seconds and concentrate on the sensations of a possible difference in temperature between the affected and unaffected sides.
1. Close your eyes. Shutting down your visual analyzer allows your brain to better concentrate on the interpretation of information from your temperature receptors.
2. Place the dorsal surfaces of both hands exactly in the same areas on opposite sides of the body (anterior legs in the video).
3. Moving up along the segment, analyze the first input of sensory information delivered to your brain. Is the temperature in both areas equal?
4. Now come back to the affected areas and keep your hands in contact for 10 seconds while continuing to analyze sensations and try to detect a temperature difference if it is present (see Video 2).
If the patient has bi-lateral pathology compare the skin temperature in the affected area with segment located above the examined area on the same side.
You will find decrease of local temperature or hypothermia if the patient suffers from transient vascular spasm due to anxiety or any over activity of the sympathetic nervous system (Tansey, 2014), Raynauld’s Phenomenon, in cases of peripheral neuralgia (e.g. Sciatica), diabetic or autoimmune neuropathy. Always match areas of hypothermia with the map of dermatomes since this is frequently the first sign of chronic irritation of the nerve which supplies the soft tissues in the affected area and its irritation triggers local vasoconstriction.
In the areas of hypothermia, the goal of Medical Massage is to decrease the sympathetic tone and trigger local vasodilation. One of the very helpful Medical Massage techniques is superficial friction (except in cases of severe neuropathy).
You will find an increase of local temperature or hyperthermia if there is a decrease of the lymphatic and/or venous drainage or local inflammation, e.g in the joint (Ménard and Paquette 1980). The therapist will find this increase even in the case of initial stages of edema in so called cases of “hidden edema.”
The goal of Medical Massage is to use the principles of Lymph Drainage Massage to stimulate the drainage.
2. Examination of the Superficial Epithelium
Reflex zones in the skin or cutaneous reflex zones are formed if the peripheral nerve is chronically irritated along its pathway by disk or soft tissue structures or examined part of the skin shares the common innervation with pathologically affected inner organ. One of the signs of cutaneous reflex zones is the formation of patches of rough skin. These areas are called coarse superficial epithelium. The dermatological disorders must be ruled out by the physician. The Video 3 illustrates the application of the test.
Close your eyes and slowly glide the dorsal surface of your hand along the examined area trying to detect the presence of patches of rough skin. Mark the borders of these areas and match their location with the map of dermatomes. By knowing which spinal/peripheral nerve innervates skin where patches of coarse superficial epithelium are formed, it is easy to examine its pathway.
The areas of coarse superficial epithelium will slowly disappear if the innervation of the affected part of the skin is completely restored. Local therapy in the form of superficial friction, skin kneading or gentle movable cupping is helpful, but the innervation must be restored first.
3. Sensory Test (ST)
ST is a priceless diagnostic tool. It doesn’t matter what and where the patient feels pain or any other uncomfortable sensations, if ST is positive the therapist can’t treat the abnormality as a local pathology only. In these cases the mild irritation of the nerve which supplies the affected soft tissues including the skin is the real cause. Such irritation may trigger a variety of secondary symptoms which frequently mislead therapists and sends them on the completely wrong track (Frost et al., 2015).
For example, mild irritation of the sciatic nerve by the piriformis muscle will initially show itself as a clinical picture of Plantar Fasciitis and since the patient never complained to anyone about any symptoms in the gluteal area, everyone was treating pain on the bottom of the foot as Plantar Fasciitis, while the real trigger was in a completely different area. Also ST will be positive in patients with diabetic or autoimmune neuropathy (Sharma et al, 2014).
Mild irritation of the spinal or peripheral nerve never shows itself as symptomatic at the place of irritation. The first symptoms appear where the nerve ends. In the discussed case it is the bottom of the foot. The Video 4 illustrates the application of the ST on the palm separately for each nerve which supplies the hand (radial, median, ulnar).
To conduct the ST correctly ask the patient to close his or her eyes (to better concentrate on the Test). Strike the skin with the fingernails of your index fingers in the same areas on opposite sides of the body (palms in the video) or on the affected and unaffected areas on the same side if the symptoms are bi-lateral.
If the ST is positive the patient feels the skin stimulation as less intense on the affected side. In these cases the therapist doesn’t have the professional right to treat the affected area as a local pathology. At this point it doesn’t matter what you’ve practiced, what you’ve learned or what you believe. The only correct approach is to find the trigger of nerve irritation and remove it using matching Medical Massage protocol or other clinical modality. Only after the appropriate treatment strategy has removed the nerve irritation and the ST is now negative can the therapist then address postural changes, kinetic chains etc.
Local therapy in the form of superficial friction alternated with ice-cube massage, skin kneading or gentle movable cupping must be used on the skin where ST is positive but later after the affected nerve is freed from irritation.
4. First level of connective tissue zones (CTZ)
The first level of CTZs is located in the skin itself and more precisely in its dermis layer where collagen fibers form a very strong network which gives the skin its combination of durability and elasticity. Clinically, the tension is the first level of CTZs and it is seen as a thickening of the skin fold.
The palpation technique designed to examine the first level of CTZs is called the First Part of Kibler’s Technique. It was developed by the German physician, Dr. M. Kibler (1958). As you can see in the video below the technique consists of a formation fold of skin on both sides of the body in symmetrical areas and evaluation of the fold’s thickness comparing the affected side to the unaffected side (see Video 5).
As you can see in the video, the fold of skin is thicker on the right side. To correctly read Kibler’s Technique the practitioner must form an absolutely identical fold of skin on both sides.
Why is the fold of skin thicker if tension is built up in the first level of CTZs? We can compare the skin and subcutaneous tissues with a sponge. In healthy tissues the circulation isn’t affected and the therapist works with a “dry sponge,” using therapeutic massage to maintain elasticity of the skin and subcutaneous tissues as well as its drainage.
The situation changes dramatically as a result of trauma, chronic overload, irritation of peripheral nerves, etc. The normal drainage from the skin and especially subcutaneous tissues suffers. In this scenario the therapist works with a “wet sponge,” if we continue to use same analogy, and it can be clinically seen as thicker skin fold.
In these cases the basic massage techniques have very limited clinical potential and tension in the first level of CTZs must be eliminated using Medical Massage methods and techniques. In areas where thicker fold of skin is detected the therapist should use Lymph Drainage Massage or effleurage with unequally distributed pressure (if areas of “wet sponge” are located in the upper or lower extremities).
In the next article we will discuss the palpatory examination of the fascia or more precisely Connective Tissue Zones in the second and third levels as well as perisoteum.
Frost LR, Bijman M, Strzalkowski ND, Bent LR, Brown SH. Deficits in foot skin sensation are related to alterations in balance control in chronic low back patients experiencing clinical signs of lumbar nerve root impingement. Gait Posture. 2015 May;41(4):923-8.
Kibler M. Das Strorugsfeld bei Gelenkerkrankungen und inneren krankheiten. ‘Hippokrates’, Stuttgart, 1958
Ménard HA, Paquette D. Skin temperature of the knee: an unrecognized physical sign of inflammatory disease of the knee.
Can Med Assoc J. 1980 Feb 23; 122(4): 439–440.
Sharma S, Kerry C, Atkins H, Rayman G. The Ipswich Touch Test: a simple and novel method to screen patients with diabetes at home for increased risk of foot ulceration. Diabet Med. 2014 Sep; 31(9):1100-3
Tansey EA, Roe SM, Johnson CJ. The sympathetic release test: a test used to assess thermoregulation and autonomic control of blood flow. Adv Physiol Educ. 2014 Mar; 38(1):87-92.
Category: Medical Massage
Tags: Issue #1 2016