Palpation should be performed after the inspection, the active and passive movement examination and the muscle tests. This sequence causes less inconvenience to the patient (pain provocation comes at a later stage of the examination).
In the event of an abnormal finding, compare left and right. Palpation can be used to obtain specific additional information.
The conditions for reaching the correct findings are the same as those stated for the inspection. An additional aspect is that the examiner must have clean and warm hands with fingernails cut short. Both the examiner and the patient should adopt a comfortable position for the examination. Usually an effort is made to ensure maximum muscle relaxation in the patient, although sometimes it is useful to palpate both tensed and relaxed muscles (e.g. to differentiate between a muscle hernia and a lipoma). In many cases, the pain experienced makes it impossible for the patient to relax completely.
The following qualities can be investigated by means of palpation:
- Skin temperature (preferably using the back of the hand).
- Humidity of the skin.
- Structure and elasticity of the skin.
- The characteristics of any swelling/tumour (perimeters, shape, surface, size, mobility). Sometimes it is useful, especially if it is not clear whether there is a lipoma or a (muscle) hernia, to have the patient tense the group of muscles. A lipoma will remain fairly mobile, whereas a hernia will harden. Also, tensing the muscles often makes the location of tendons and intramuscular/intermuscular septa clearer.
- Location of tissues (muscle tissue, tendon tissue, nerve tissue, bone tissue, cartilage tissue, ligaments, blood vessels) and the nature of these tissues (tone of a muscle). Bone tissue feels hard and cannot be impressed. How a muscle feels varies with the degree of stretch and contraction and is dependent on the stiffness of the fascia. Muscle tension is palpated by placing the fingertips transversely over the course of the fibres. Herniations (consequence of fascia defects) and dimples/pits (consequence of a muscle rupture) can be detected by placing the tips of the palpating fingers along the longitudinal axis of the muscle.
- Location of pain. In the case of (suspected) inflammatory processes and acute traumas, the point where the pain is most intensely experienced precisely indicates the location of the process. However, the examiner should be aware that in the case of diffuse pain patterns or more chronic problems; palpation sometimes yields misleading information (referred pain).
- Pain upon axial compression. If a fracture is suspected, it is important to ascertain whether pushing along the long axis of the structure concerned (performed by the examiner) elicits pain at the location where the fracture is suspected. If so, a fracture is likely. In practice, if there is a clear suspicion of a fracture based on the history-taking, pain upon axial pressure is often determined before the basic function examination to avoid performing any further aggravating examinations.