Palpation

Procedure

• Palpate the patient first in the standing position, possibly in the sitting position or bending over (if the patient is in these positions you stand behind them) and subsequently, in prone position.
• Palpate, unless indicated differently, preferably with the fingertips.
• Ask the patient to indicate exactly where and when it is painful. In the case of an abnormal finding, compare left and right if possible.
• Also pay attention to:
  • swelling and its characteristics
  • the muscle tone (with the palpating fingers placed transverse to the course of the fibres)
  • abnormal agility
  • abnormal structures
  • discontinuity
• The following bones and soft tissues are accessible for palpation with the patient seated:

Cervical [Figures 32, 33, 34]:

• external occipital protuberance and cervical spinous processes (of C2 and the vertebrae in the caudal direction) (during which the forehead rests against the examiner’s hand); alternative: lying on the side
• skin
• paravertebral cervical musculature and trapezius muscle (descending part) (hypertonia)

Figure 32

Figure 33

Figure 34

• muscle attachments of the occipital bone (from the external occipital protuberance to the mastoid process bilaterally) (tendoperiostitis or disorder of the major or minor occipital muscle) [Figure 35]

Figure 35

Thoracic and lumbar [Figure 36]:

• spinous processes; alternative: lying on the side
• skin
• erector muscle of spine (thoracic) (hypertonia)
• erector muscle of spine (higher lumbar) and multifidus muscle(lower lumbar) (hypertonia) (see also muscle tests)

Figure 36

• test the spinous processes, in an upright position, from C7 caudally, for impact pain (during this, tap with the ulnar side of the fist) [Figure 37]
  (spondylitis, spondylolisthesis, spinal metastases)

Figure 37

• test the complete spine for axial pressure pain (during this, apply axial compression using both hands, from the head and/or shoulders in the caudal direction) (disc degeneration, spondylolisthesis) [Figure 38]

Figure 38

• coccyx (the most caudal bone structure of the spine, which can be palpated from the natal cleft) (only when indicated, e.g. following a fall on the ‘tailbone’: in such instances always combine it with a rectal examination) (fracture)

The following bones are accessible in a prone position; the patient is lying completely flat with both arms adjacent to the torso:

• spinous processes (in a caudal direction from C7) [Figure 39]; test, if pain was indicated during the examination, the bordering spinal column area for compression pain (technique: press ventrally on to the separate spinous processes with the tip of the thumb) (fracture, spondylitis, spondylolisthesis, spinal metastases)

Figure 39

Alternative: lying on the side; the cervical spinous processes can only be examined with the patient lying on the side [Figure 40]
(alternative: in the supine position; see “Special examination techniques”)

Figure 40

• superior posterior iliac spine (SI joint disorders, tendinopathy of the erector muscle of spine) [Figure 41]

Figure 41

• sacro-iliac joint (indirect palpation) (just caudally from the superior posterior iliac spine on both sides) [Figure 42]

Figure 42

• ischial tuberosity (teninopathy of the hamstrings or ischiocrural muscles, ischiogluteal bursitis) [Figure 43]

Figure 43

The following soft tissues are accessible in a prone position; the patient is lying completely flat with both arms adjacent to the torso [Figure 44]:

• skin (paravertebral lipomas)
• muscles: paravertebral musculature (from C7) (hypertonia)

Figure 44

• nerves: three pressure points of Valleix bilaterally [Figure 45] (paravertebral L5, in the middle of the gluteus maximus muscle (at the position of the greater sciatic foramen) and in the middle of the natal cleft (laterally from the ischial tuberosity) (ischialgiform symptoms)

Figure 45