Fig. 7.1 The structural–functional musculoskeletal examination sequence for the integrated manual medicine approach.

Observation occurs at two general levels, in form of a: (1) generalized or gross observation; and (2) the regional and localized (e. g. segmental, facet-level) observation. The generalized observation, which may already have been done during the initial neurologic or orthopedic examination, checks for gross postural abnormalities such as scoliosis, uneven shoulder or pelvis levels, head-forward carriage and obvious signs of trauma, prior surgery or applications of orthoses or prosthetics.

The regional or segmental observation takes into account observable regional or segmentally related skin changes, swelling, signs of trauma, or other visible changes that deviate from the “normal.”

The palpatory assessment of the various joint and osseous structures, including the overlying skin and associated fasciae, muscles, tendons, and ligaments, plays a central role in the integrated structural and functional NMSK assessment routine. Numerous palpatory approaches have been described in the field of manual medicine. The aim is to obtain additional information not immediately recognizable by the naked eye or by particular laboratory or other diagnostic studies.

Definitions; Required Skills; Applications

According to De Gowin and De Gowin (1981), the usual definition of palpation is the act of feeling by the sense of touch. The same authors elaborate on the art of palpation by stating that:

“As in inspection, all normal persons possess these senses—tactile, temperature and kinesthetic positional and vibrational senses—but practice and special intellectual background in medicine enable the physician to extract meaning that escape the layperson. If the reader doubts the influence of practice on palpation, let him observe a blind person reading a book printed in Braille, then close his eyes and attempt to distinguish between two Braille letters by touching them.”

Isaacs and Bookhout (2002) emphasize the need to develop adequate palpatory skills through repeated practice:

“One of the difficulties people have in understanding and applying techniques of manual medicine is that both diagnosis and treatment require a degree of palpatory skill that is different from, and in some ways greater than, that used in other branches of medicine.”

According to Greenman (1996), palpatory skill affects the following five key components of palpation in the assessment of the musculoskeletal system:

1. The ability to detect tissue texture abnormality.

2. The ability to detect asymmetry of position, both visual and tactile.

3. The ability to detect differences of movement in total range, quality of movement during the range, and quality of sensation at the end of range of movement.

4. The ability to sense position in space of both the patient and examiner.

5. The ability to detect change in palpatory findings, both improvement and worsening over time.

To be able to accurately assess and interpret the relevant palpatory finding, Greenman (1996) finds it essential that the physician fully concentrate on the act of palpation, the tissues that are being palpated, and the response of the palpating fingers and hands. Probably the most common mistake in palpation is the lack of concentration by the examiner.

Usually, palpation is started in the general area that is indicated by the patient as the most painful. However, if the area is exquisitely tender, the examiner may start in an adjacent area or the corresponding area on the other side of the body so as to obtain an initial impression of the tissues.

Comparison of symmetrical skeletal parts may be helpful but can also be misleading at times: disturbances may actually occur symmetrically, limiting the value of such a comparison. Thus, it is recommended to compare similar tissues or structures on the same side as that of the functional abnormality, or, if appropriate, to compare with locations with a similar anatomic arrangement on the unaffected side.

When changes are present in neighboring or analogous structures, the palpatory assessment is an important part of the examination in differentiating the offending source (s) from those structures that are secondarily affected.

NMSK Structures Examined by Palpation

While general palpation can be applied to every part of the body accessible to the examining fingers or hand, including solid abdominal viscera and solid contents of hollow viscera (De Gowin and De Gowin, 1981), the musculoskeletal palpatory assessment discerns information about the skin and hair, bones, joints, fascial and tendon sheaths, ligaments, superficial arteries and veins, as well as superficial nerves, accumulation of body fluids, joint swelling, tenderness, and heat, and also assists in localizing particularly painful or tender structures.

The following are assessed through the practice of layer palpation (Greenman, 1996):

1. Skin (thickness, moisture, temperature, smoothness).

2. Subcutaneous tissues (thickness, ease of displacement and compressibility).

(a) Note, this layer may reflect best or directly the tissue texture abnormalities associated with somatic dysfunction (abnormal segmental motion with tissue changes).

(b) Within the subcutaneous fascial layer are found the vessels, arteries, and veins.

3. Deep fascia (smoothness, firmness, continuity of fascial sheaths).

(a) In particular the muscle septa separating the various muscle bundles of one group from another can be palpated.

(b) Palpatory assessment can distinguish between the various muscle groups; moving “between” the various muscles, one can then advance to the deeper structures.

4. Evaluation of muscle, muscle tone, and muscle fiber direction.

(a) Determination whether there is “normal” muscle tone versus increased muscle tone from muscle “spasms” (physiologically “normal”) tospasticity; assessment of hypotonic muscles (denervation, atrophy, etc.).