THE SCIENCE OF PALPATION. PART IV
DEEP PALPATION OF THE SOFT TISSUES
By Dr. Ross Turchaninov
This is Part IV of our article on the Science of Palpation. Part I was published in Issue #4, 2015, Part II was published in Issue #1, 2016 and Part III was published in Issue #2, 2016. Also this article finishes the series of our articles on the Science of Evaluation of patients with somatic dysfunctions.
In Issue #1, 2012 we published the article, “Science of Clinical Interview” and in Issue #2, 2015 we published the article, “Science of Visual Observation.”
We see all this information as critically important for every therapist who practices clinical aspects of massage therapy since it summarizes all steps of soft tissue evaluation necessary for the formulation of successful treatment strategies.
THE THEORY OF DEEP PALPATION
Deep palpation means the palpation of the soft tissues located in the middle or deep layers. However, without a clear understanding of this process and application, the therapist gets zero useful clinical information about tissue he or she tries to examine.
Here are two videos which illustrate deep palpation of the piriformis muscle. The first video presents the incorrect way of deep palpation while the second video illustrates its correct and informed application.
Despite that on first look there are no significant differences between both videos, in reality the first video is completely uninformative. To understand why, we need to discuss how our peripheral and central nervous system forms and processes sensory information we obtain during palpation.
Every time we touch any object our touch, pressure, temperature receptors fire to the brain, which forms the actual sensation of what we are examining. The sense of structure, density, elasticity, temperature, firmness etc. of the object formed by our brain is based on the degree of deformation of peripheral receptors at the moment our skin comes in contact with the object.
The sensory information from the activated peripheral receptors is delivered to the brain through peripheral and later spinal nerves to the spinal cord first and from there it ascends to the part of the brain where information is analyzed and the actual sensation is formed.
The motor pathways located within the same nerve pathways will later deliver the motor commands from the motor cortex to the hand to execute and control hand and finger movements. Now we suggest the reader to do a little physiological experiment. Slowly and superficially slide your thumb along your friend’s palm trying to detect its contour, i.e., folds and bumps normally present on the palm. Now significantly increase pressure by the thumb and while compressing soft tissues on the palm repeat examination of the same area.
You will immediately notice that in the second case your examination will produce much less information about the palm’s contour and tissue structure. The palm is the same and your thumb and its receptors didn’t change either. The only difference in both cases is the degree of applied pressure and this simple factor interferes with your palpation skills or to be more precise, with the work of the sensory part of the brain responsible for touch discrimination.
Why has that happened? The answer is very simple. The activation of the motor cortex and motor commands which are sent to your thumb to increase pressure during palpation will always overpower activation of sensory receptors which are trying to gather sensory information and send it to the brain. This fact will greatly affect your ability to palpate and detect any possible pathological changes in the deeply located soft tissues.
To correctly palpate deeply located soft tissues the therapist’s motor impact (i.e., degree of applied pressure) must be diminished maximally. However, pressure is an essential factor to get to the deeply located tissues and palpate them. There is a clear controversy here.
Let’s look again at the videos presented at the beginning of the article. In the first video when incorrectly conducted deep palpation of the piriformis muscle was presented, the therapist applied deeper pressure by the thumb while at the same time he tried to palpate the piriformis muscle through the fibers of the gluteus maximus. In this case motor commands from the brain to the thumb to compress the skin and gluteus maximus to get to the piriformis muscle overpowered the thumb’s sensory receptors and the overall informativeness of the piriformis’ palpation diminished greatly.
The second video illustrated the correct application of deep palpation. To diminish the intensity of motor commands to the thumb and decrease their interference into activation of sensory receptors, the pressure applied during palpation must come from the body weight which the therapist brings in as an integrative part of the palpation. As you can see in the video, the therapist locks all joints of the upper extremity and slowly leans on the thumb with upper body weight while concentrating on the sensation he obtains from the sensory receptors there.
This is a correct and much more informative way of deep palpation because the number of motor commands to the thumb decreased greatly, since pressure is a result of the body weight the therapist uses. It gives to sensory receptors in the thumb a chance to examine the piriformis muscle in detail.
Another critical aspect of deep palpation, especially for the novice therapist who would like to improve palpation skills, is to close eyes during examination of the deeply located tissues. Our visual analyzer constantly overwhelms the brain with sensory data and its closure allows the brain to process sensory information from peripheral receptors more thoroughly.
APPLICATION OF DEEP PALPATION OF THE CONNECTIVE TISSUE ZONES IN THE THIRD LEVEL
In Part II of the Science of Palpation article published in Issue # 1, 2016 we presented techniques of palpation of CTZs in the first level (dermis of the skin) and in Part II published in Issue #2, 2016 readers will find the techniques used for palpation of the CTZs in the second level (superficial fascia).
Now we are going to discuss the Opposite Shift Technique (OST) used to examine CTZs located in the third level in the deep fascia. The goal of OST is to examine the deep fascia which separates superficial and deep skeletal muscles and maintains fluidity of their contractions. The same way skin is held by fibrotic bridges against superficial fascia, the similar fibrotic bridges hold superficially located skeletal muscles against deep skeletal muscles. The reader may see fibrotic bridges separated palmaris longus muscle from flexor digitorum superficialis on the inner forearm in Fig. 5 in the article “Concept of Biotensegrity” by John Sharkey published in Issue #4, 2015.
Any tension formed in the deep fascia will restrict mobility and elasticity of the superficially located muscles against the deep muscle layer and it can be tested by OST. In such case the therapist detects the presence of tension in the deep fascia based on restrictions to the lateral shift applied to the superficial muscles.
The video below illustrates the application of OST in the left lower back. With this evaluation technique the therapist tests the elasticity of deep fascia which in this area separates superficially located lumbar erectors from the deeply located quadratus lumborum muscle.
Here is step by step description of OST, presented in the video above, to detect tension developed in the deep fascia which separates lumbar erectors from QL muscle:
- With index fingers the therapist detects the lateral edge of lumbar erectors.
- Place both thumbs on top of the lumbar erectors.
- Create the extra skin behind the palpating thumbs and placing them into starting position for OST application. To do so the therapist slides both thumbs with the skin medially into the groove which separates the medial edge of the lumbar erectors and the line of the lumbar vertebrae. While doing that he or she pushes the skin back into the groove, always keeping extra skin behind the thumbs.
- Using the weight of the body the therapist leans forward to push erectors away from the vertebral column and back to detect the elasticity of the deep fascia on the unaffected side.
The goal is to see how much the groove can be widened by application of OST and how elastic deep fascia is.
The need for issue of extra skin behind palpating thumbs needs to be discussed separately. The video below shows the incorrect application of OST without the fold of skin Please compare it with previous video.
If readers compare both videos it is obvious that in the second case the absence of the fold of skin, behind the thumbs, restricts the lateral shift of erectors since the tight skin becomes the obstacle. This can be completely avoided if as it is shown in the first part of the video the extra skin is present behind palpating thumbs.
Finally the video below puts together application of OST on the normal (left) and affected (right) sides of the lower back. It is obvious that on the right side the lateral shift of lumbar erectors is greatly restricted. This is unquestionable proof that tension developed in the deep fascia now glues the lumbar erectors against the underlying quadratus lumborum muscle.
PALPATION OF DEEP MUSCLES
Examination of deeply located muscles to detect their structure or trigger point location is the most frequent application of deep palpation. There are three variants of this examination:
- Examination of the deep muscle after mobilization of the superficial muscle
- Examination of the deep muscle by positioning
- Examination of the deep muscle through the fibers of the superficially located muscle
Examination Of The Deep Muscle After Mobilization Of The Superficial Muscle
It is very difficult to examine fibers of deep muscle through the fibers of the muscle located on top of it. Thus, if the anatomy of the area allows, the superficial muscle must be mobilized first to open direct access to the deep muscle without it being an obstacle. There is another equally important aspect of such mobilization. Exactly the same access is used for actual work on the deep muscle when it undergoes the therapy.
The video below illustrates the palpatory examination of the supraspinatus muscle after the mobilization of the superficially located trapezius muscle.
At the beginning of the video the therapist uses his index finger to show the location of the free edge of the horizontal portion of the right trapezius muscle. The first step of mobilization is flat placement of the thumb just above edge of the trapezius muscle. As we discussed above, for successful mobilization extra skin is needed, otherwise its absence will restrict the evaluation. The flatly placed thumb slightly descends while pushing only skin down until the finger gets under the free edge of the trapezius muscle.
Now use the entire edge of the thumb to lift up the horizontal portion of the trapezius muscle. In the video the therapist again uses his index finger to indicate free edge of the trapezius muscle which is now lifted to expose the supraspinatus muscle.
As soon as the thumb lifts the entire muscle mass of trapezius which you see as bulge of tissues and gets between two bones (spine of the scapula and clavicle) the therapist applies horizontal pressure which brings him or her in direct contact with the belly of the supraspinatus muscle. All this time the entire trapezius muscle remains lifted and its fibers don’t block palpation or therapy which is conducted later.
Examination Of Deep Muscle By Positioning
For some deep muscles examination by mobilization of superficial muscle is anatomically impossible, but examination by positioning can be successfully implemented. The video below illustrates examination of the upper part of the quadratus lumborum (QL) muscle under the last rib by positioning.
The QL muscle is the deepest layer of lower back muscles which forms the posterior abdominal wall and provides cushion for the kidney. Only the lateral edge of the muscle is available for direct palpation.
At the beginning the video the position of the last rib is indicated by the solid line. The next part is detection of the lateral edge of the lumbar erectors with application of a dashed line to indicate its position. The free edge of the QL muscle is always below this line.
The therapist positioned the thumb at a 45 degree angle to the body’s vertical axis below the dashed line and just under the last rib. At this moment the free edge of the QL muscle is directly against the palpating thumb. Slowly lean forward with the body’s weight and concentrate on the sensations to palpate the QL.
Examination Of The Deep Muscle Through The Fibers Of The Superficially Located Muscle
This is the most challenging type of deep palpation. Let’s one more time use palpation of the piriformis muscle through the fibers of the gluteus maximus as an example. There is no way the gluteus maximus muscle can be mobilized or positioned to help the therapist. This palpation of the piriformis can be done only through the fibers of the gluteus maximus muscle. The video below illustrates such palpation.
To palpate piriformis the therapist must slowly compress the gluteus maximus and use its fibers as a tool to examine tension build up in the piriformis muscle. In the area where piriformis is located under the gluteus maximus, the therapist places the thumb as it is shown in the video and starts to lean with the body weight slowly submerging into the gluteus maximus. Close your eyes and pay attention to the sensations built up under the thumb.
First the tissue will be soft but with further slow submergence soft tissues start to get firmer. Don’t miss the moment when you start to feel the first resistance of the tissue to the thumb’s submergence. This moment means that you have compressed the gluteus maximus and everything you will feel from now on comes from the piriformis muscle.
If this moment of change in tissue resistance is missed, the further examination of the piriformis will fail since there is no way the therapist can detect the difference between fibers of the gluteus maximus and fibers of the piriformis.
For those who have followed all our articles on the evaluation of the patient with somatic abnormalities we would like to emphasize the critical value of this information and we suggest to use it as a guide to get as much as possible valuable clinical data from the patient in a short time. After all needed information is gathered it becomes the foundation for the formulation of a treatment strategy unique for each patient. As soon as the therapist starts to individualize treatment protocol he or she becomes a massage clinician.
Category: Medical Massage
Tags: Issue #3 2016