Fascial palpation

Leon Chaitow, Patrick Coughlin, Thomas W Findley and Thomas Myers

Touch can be considered to be one of the special senses, along with sight, hearing and taste. Neuroanatomists commonly use the terms “somatic sensation” or “somatosensory” to describe this sensory or “afferent” function. Palpation implies touching with some form of therapeutic inquiry, if not necessarily overt diagnostic intent. Because touching another person is a deeply individual experience, the intent of the practitioner becomes a significant factor in the outcome (the gathering of information). Thus information can be gathered actively (“going and getting it”). At the same time, information can also be gathered by using a more passive approach, i.e., allowing the information to come into the practitioner’s somatosensory system. In either case, a thorough and accurate visual picture of the underlying anatomy will always be a major asset to the therapist.

In recent years, manual therapeutics has recognized the fascial system as a prime target and has turned its attention there. In fact, several major schools of manual therapy, such as Structural Integration, or Rolfing^®, have built their treatment philosophy and rationale around the fascial system.

The fascial system has been described as an ‘endless web,’ that is, far more organized than was previously imagined (Schultz & Feitis 1996). Fascia surrounds the entire body just under the skin as the superficial fascia, and enwraps all the other tissues and organs of the body as the deep fascia. It is, as observed by Ida P. Rolf, PhD, the “organ of form” (Rolf 1977). But in addition to its anatomical and physical properties, the fascial system is increasingly recognized for its physiologic properties (Langevin et al. 2004, 2006).

Active versus passive assessment

Palpating a moving structure can produce a great amount of clinical information. This can be done actively where the client performs an action, or passively, where the practitioner moves the structure for the client. Motion quality, range, and end-feel can all be assessed using this method. In addition, motion against resistance can inform the practitioner as to the relative strength and/or sensitivity of a movement. Some of these approaches are to be found in the exercises later in the chapter.

When are you palpating?

Any time a therapist makes manual contact, a palpatory experience occurs, and palpation is routinely used to assess the condition of the client prior to any therapeutic intervention (whether or not a diagnosis is made). Palpation may be employed during a therapeutic intervention, and may be used to assess the results of such intervention(s).

Palpation tools

While the hand is probably the primary palpatory tool, manual therapists will occasionally use more than just the palms of the hands and fingers for this purpose, with knuckles, fists, forearms, elbows, and sometimes even involving tools (See Chapter 7.14) being employed.

The amount of pressure applied by the therapist will vary, depending on the depth of the structure that is being assessed. The direction of the applied pressure may vary, depending on whether the practitioner is performing a ‘direct’ or ‘indirect’ technique, i.e., pushing toward or away from a motion barrier, respectively. To an extent, such choices will depend on the relative acuteness or chronicity of the involved tissues. Additionally, the direction of palpation may be across a muscle, tendon, or ligament, depending on the information being gathered. Usually, the speed that a practitioner’s contact moves through the tissues will be dependent on the rate of “release” that is noted, with slower movements indicated in more tender areas, or those areas that are palpably different; for example, more dense, in texture.

What is being palpated?

The different forms of manual therapy will have varying anatomical targets. However, regardless of the target, the ability to accurately visualize the structures beneath the hands is of utmost importance, whether the practitioner’s hands are moving broadly or deeply. Such knowledge allows the practitioner to predict where the hands are headed and what they can expect to encounter. It will also contribute to the development of a treatment strategy, i.e., where to go next, or in some cases, where not to go next.

Two examples come to mind.

• First, the organization of the thoracolumbar fascia, where the superficial posterior layer has a significantly different directionality than the deeper layer. In turn, the middle layer has a significantly different thickness and organization than the first two. Obviously, this speaks to their different functional roles, and knowledge of the anatomy can influence the treatment plan.

• The second example involves the muscles of the posterior neck. This extraordinarily complex group has the all-important function of aligning the head such that the eyes are parallel to the horizon. At least a dozen muscles or muscle groups are present on each side of the midline. As the hands and fingers palpate from superficial to deep, different fiber directions will be encountered as well as different levels of muscle tone.

The need for a relaxed therapist

To maximize the information gathered from palpation, it is helpful to minimize the amount of noise in the system. As the therapist is bombarded with sensory information in their own body, coming not only from the skin, but also from the joints, muscles, and fascia, a conscious effort to reduce these signals is fundamental to palpation. In other words, the therapist should make an effort to improve the signal-to-noise ratio in his/her own system. This is achieved by ensuring that the body is well supported, from the ground up, that posture is correct, and that the upper limbs are as relaxed as possible. This is especially true of the muscles of the shoulder girdle, neck, temporomandibular joint, and face. In addition, during palpation, the breath should be slow, deep, and as unrestricted as possible.

Layers (see Figure 6.2.1)

Palpation by definition begins with skin-to-skin contact. Here, observations can be made regarding the skin: is it smooth, rough, oily, dry, sweaty, are its characteristics limited to a specific area, etc.? Palpation of the skin can be performed by simply moving the hands lightly along the surface without actually moving the skin.

Fig. 6.2.1 • Typical fascial layering, seen here as in the thigh. Other areas contain more or fewer layers between skin and bone. From Chaitow, 2010, with permission.

The layer just deep to the skin is the superficial fascia. This layer is of varying depth around the body, and can be encountered by applying just enough pressure, such that the skin will move with the hands of the therapist. It is considered a loose, areolar type of connective tissue.

The superficial fascia is specialized in various areas to perform specific functions, such as cushioning the soles of the feet, and supporting the lower abdominal wall (Scarpa’s fascia). Occasionally, the superficial fascia virtually disappears, leaving the deep fascia very close to the surface, e.g., the dimples at the posterior superior iliac spines.

Just deep to the superficial fascia is the deep fascia, which forms the “endless web” described by Schultz and Feitis (1996). It surrounds and supports muscles, nerves, blood vessels, and organs.

From a developmental point of view, the fascia is derived from the embryonic mesoderm and forms the template in which all other mesenchymal derivatives arise. For example, bones and muscles develop within sheaths of mesodermal tissue, the periosteum and epimysium, respectively. As a result, very rarely do muscles attach directly to bone. Usually there is some form of intervening connective tissue. In fact, each individual muscle cell is encased in the connective tissue endomysium, while groups of myofibers, the muscle fascicles, are wrapped in perimysium. Joint capsules, tendons, and ligaments are all specializations of mesodermal connective tissue and are considered fascial elements by many practitioners.

Accessing the deepest layers of fascia presents a challenge to the therapist. To address these deep layers, it is paradoxically best not only to go slower, but also to lighten the pressure applied. There seems to be an inverse relationship between pressure and depth.

Moving through the deep fascia is possible without causing discomfort to the client/patient. A phenomenon exists where the tissue seems to “melt” under the hands of the therapist. Moving slowly into the movement endpoint of the tissue usually will result in a release, and further movement potential.

This releasing phenomenon may relate to a property of the extracellular matrix known as thixotropy. However, at this time, the reported palpation experiences of manual therapists remain unexplained.

Communicating with the client

A problem with palpation is that although receptor and neuronal activity can be objectively measured, its interpretation is, by definition, subjective.

Such interpretation is expressed in language that can vary considerably. In any therapeutic relationship, effective communication is a key element. The therapist and client are in a partnership that will only function maximally if free lines of communication and trust exist. This entails making sure the client is in control of the situation, where he/she is able to understand the language of the therapist and that the client is aware of what’s going to happen next.

It is important to remember that many of the mechanoreceptors in the fascia also double as pain receptors (nociceptors). As such, there will be an intensity threshold for every individual where pressure becomes painful. Since each person’s experience of the phenomenon is different, it is important to monitor that experience periodically by asking the client about their experience, especially when addressing areas of potential tenderness (e.g., close to bones).

Palpating for information

It is axiomatic that practitioners who use their hands to manipulate soft or bony structures should be able, accurately and relatively swiftly, to feel, assess, and judge the state of a wide range of physiologic and pathologic conditions and parameters, relating not only to the tissues with which they are in touch but others associated with these, perhaps lying at greater depth.

The information a practitioner needs to gather will vary according to the therapeutic approach, possibly including:

• the range of motion

• the feel of joint play

• the relative weakness or tightness in muscles

• the amount of induration, edema or fibrosis in soft tissues

• the feel, densitiy and mobility of palpable fascial structures

• identification of regions in which reflex activity is operating

• possible differences in the quality of perceived tissue vitality (flaccid, toned, etc)

• variations in regions of the body

• and many other pieces of acquired information.

In other words, the individual practitioner needs to fit the acquired information into his or her own belief system, to use in accordance with whatever therapeutic methods are seen to be appropriate. The aim is therefore to help to identify what is under our hands when they are in contact with the patient, and, in the context of this book, what information we can gather regarding fascial structures and behavior in particular.

Palpation objectives

Philip Greenman (1989), in his book Principles of Manual Medicine, summarizes the five objectives of palpation. He suggests that the practitioner/therapist should be able to:

1. detect abnormal tissue texture

2. evaluate symmetry in the position of structures, both physically and visually

3. detect and assess variations in range and quality of movement during the range, as well as the quality of the end of the range of any movement

4. sense the position in space of yourself and the person being palpated

5. detect and evaluate change in the palpated findings, whether these are improving or worsening as time passes.

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