Having completed this lesson, you will be able to:

• Outline a specific step-by-step approach to the palpation of a region (e.g., the school or instructor should determine the approach students are expected to take when palpating structures in a region; in a general example one approach might be to (a) review the anatomical structures present in a specific region and make a list of structures to palpate, (b) look at the surface area of the region to palpate and visualize the structures using a textbook, (c) use a full palmar surface to palpate, (d) work from superficial layers to deeper layers, (e) palpate “normal” first, (f) palpate muscle tissue in at least two different directions, (g) utilize isometric muscle contractions to make the target muscle easier to identify, (h) ask the client to give feedback on the sensations noticed while the tissue is palpated).

Structure your palpation practices carefully to develop good skills and make efficient use of time. The more systematic you are now in assessing the client’s tissue and gathering data, the easier it will be for you to shift into assessment for health care massage in upcoming chapters. A systematic approach to palpation also ensures that you will be more thorough and not overlook important findings. Box 12-2 (Palpation Exploration) provides a structure for students to use as they explore the layers and rhythms of the body. <box12-2>

Layers and Structures that are Palpable

When palpating a client’s tissue therapists most often work from the superficial layers of tissue into the deeper layers of tissue. This is for two reasons. First, the sensitivity of light-touch receptors in the hands is diminished for a brief period of time after the hands have been used to apply deeper pressure. You may be more responsive and aware of variations in superficial tissue if you access it first. Second, the client may feel discomfort if you immediately drop into deeper tissue and so may brace or guard, decreasing your ability to experience the tissue in it’s normal state.  The layers that can be palpated include just above the body, the skin, the superficial fascia, skeletal muscle layers, and bones. Tendons, ligaments, joint movement quality, lymph nodes, organs in the abdominal cavity, blood vessels, and body rhythms.

Above the Body Palpation

When the hands are held just above the body the therapist can palpate differences in temperature (Fig. 12-3). Some therapists believe they can perceive a delicate resistance that hovers over the client, as if the hands meet a transparent barrier, or that the client’s body seems to pull the therapist’s hands downward as if the hands and body are magnetized. A region directly over a particular body area can feel like dense air, or empty, thin air. In some Eastern and energetic bodywork traditions these variations in temperature and sensation are believed to indicate a general over-activity or under-activity in the body area or in the subtle energy fields of the body. Interestingly, some therapists believe that they can correspond conditions of hyperactivity, inflammation, trigger points, pathologies, and soft-tissue injury sites to areas above the body that feel over-active. Cool areas that feel empty or fragile may correspond to conditions of under-activity including decreased circulation or nerve innervation, stagnate lymphatic conditions, or flaccid muscle tissue. It should be pointed out that these types of palpation findings are controversial because they are subjective in nature, and there are therapists who don’t believe that anything besides temperature can be palpated from above the body. You are advised to explore this issue with practice clients, teachers, and classmates to draw your own conclusions.

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Palpation of the Skin’s Surface

When palpating the skin’s surface the therapist might notice if the skin feels dry and crackly (dehydrated) or moist and plump (hydrated) (Fig. 12-4). Bumps, roughness, decreased elasticity, and superficial lines are hints at the client’s overall health and vitality. These variations can also signify the degree of hydration experienced by the client and provide some indication of what you are likely to find in deeper tissue. Skin color and skin temperature are also noted as the palms make contact with different areas. The client might report that a particular area feels numb or deadened as the therapist passes the hands across the skin’s surface. This can be an indication of poor circulation and hypertonic muscles causing decreased nerve activity. Areas where the skin is hot and red suggest inflammation and need further investigation to rule out contraindications. Also notice if bruising or scar tissue is present.

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Palpation of the Superficial Fascia

As you probably remember, the superficial fascia connects the skin to the underlying muscle tissue (Fig. 12-5). Palpation of the superficial fascia will also include the skin as these two connected structures are lifted away from the fascial sheath surrounding the muscle below during techniques like skin rolling. Blood and lymph tissue is palpable in this layer and therapists may feel a pulse or small pea-shaped nodules, especially in areas where lymph nodes are concentrated.

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The superficial fascia should glide and lift away from the muscular layer easily and evenly. Differences in the amount of lift of the tissue or places where the tissue is “glued down” are noticed. The fingertips can compress the superficial fascia and glide it over the underlying structures in every direction. If the tissue glides more easily in one direction than another this difference is noted. Patterns of tension may start to emerge as the therapist continues to work with the tissue. For example, you might find that the superficial fascia moves easily in a horizontal plane but is restricted when it is moved longitudinally.

Palpation of Skeletal Muscles

Directly under the superficial fascia you will encounter the first layer of skeletal muscle. Muscles are layered, and so deeper muscles are palpated by dropping through the first layers, and in some cases down to the bone (Fig. 12-6). For example, when palpating skeletal muscle on the back the first muscle you will encounter on the upper back is the trapezius. As you drop through the trapezius you can feel the rhomboids. If you keep going you may be able to distinguish the erector spinae group. Obviously, pressure must be slow and allow the tissue to melt and relax before dropping to the next layer, otherwise the client will experience discomfort and tense the muscles to guard the area. One muscle layer should glide easily and freely over the muscle below it. If one muscle sticks to another, note this as an area of adhered tissue.

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Muscle areas are easy to differentiate by the way they feel. The belly of the muscle is likely to feel plump and fleshy, and in many cases the fingers can grasp around the whole muscle belly and lift it (i.e., sternocleidomastoid, triceps). As the muscle transitions into the tendon at the muscle’s attachment sites the tissue becomes noticeably smoother and denser. The edges of muscles can be felt, especially where one muscle crosses over another. It is not difficult to feel the edges of muscles in the neck and upper back because changes in fiber direction help the therapist differentiate between the trapezius, splenius capitis, splenius cervicis, and levator scapulae.

Notice all the different textures of muscle tissue. Healthy muscle feels plump, springy, full, and pliable, while hypertonic muscle feels dense, hard, uneven, bound, and unyielding. Hypotonic muscle may feel flaccid, limp, and cool. It may feel empty and unresponsive. An area under constant stress or the site of a past soft-tissue injury might feel taut, ropey, stringy and cord-like. Bands of tissue might form tough, sinewy strands that can literally be plucked like guitar strings.  Sometimes metabolic wastes build up in the tissue because of poor circulation causing the muscle to feel grainy, crunchy, and crumbly. Tender nodules within tight bands of muscle tissue called trigger points may cause pain that refers beyond the site where the point is palpated.

Palpation of Tendon and Ligament

Tendons and ligaments feel denser than muscle tissue because they are made up of higher concentrations of collagen fibers. Muscle fibers run together in a particular direction. This can be felt as a series of small parallel groves; tendons feel smoother.  Some tendons are easy to palpate and can help you get a feel for the differences between tendon and muscle. The gastrocnemius attaches to the calcaneus via the calcaneal tendon (also called the Achilles tendon).  The transition from muscle to tendon occurs approximately halfway down the posterior leg. Palpate this region and see if you can feel the changeover from muscle fibers to tendon fibers. If you change the position of the leg by lifting the foot and bending the knee this may help you feel these structures especially when the client plantar flexes and dorsiflexes the foot.

Ligaments have a more uneven fiber configuration than tendons and will always be taut, regardless of the position of the joint. A tendon is connected to muscle and so will be taut or relaxed depending on if it is shortened or lengthened.

Palpation of Bone

Bones feel solid and hard. They have irregular shapes with knobs, grooves, holes, spines, depressions, and angles. Boney prominences help therapists find their way around the body and so are called boney landmarks. For example, the therapist can identify the spine of the scapula as the oblique ridge located just below the top of the shoulder on the posterior body. When palpating the spine of the scapula you know the muscle just above the spine is the supraspinatus, while the muscle just below the spine is the infraspinatus. This boney landmark is key in locating these two muscles of the rotator cuff. Bones also help the therapist determine if the two sides of the body are symmetrical during some types of assessment. For example, in a posture assessment the therapist palpates the position of the anterior superior iliac spine (ASIS) for the anterior assessment and the posterior superior iliac spine (PSIS) for the posterior assessment. If the ASIS or PSIS on one side is elevated it may indicate that there is a tilt in the pelvis.

Palpation of Joints

Joints are most often palpated during range of motion techniques where the joint is moved actively or passively. This type of assessment allows the therapist to feel the quality of the movement. Is it smooth, free, fluid, and full, or is it irregular, restricted, stiff, and shortened? Resisted joint movements assess the muscles around the joint for weakness or uneven firing patterns. Different structures including muscles, tendons, ligaments, and the bones and cartilage that make up the joint itself can become unbalanced or inflamed and cause painful movement, restricted movement, or too much movement (hyper-mobility). Small fluid-filled sacs called bursa reduce friction between joint structures and can sometimes be felt as balloon-like gel-caps but most often they are difficult to palpate. You will learn specific techniques for joint palpation during range of motion in Chapter 19.

Palpation of Abdominal Viscera

The liver and large intestine can be palpated in the abdominal cavity by therapists who know the location of organs and approach these structures cautiously. Palpating through the abdominal muscles and intestines accesses the psoas muscle, which is an important muscle to massage when clients report low back pain. You will learn how to access and massage this muscle in later chapters (Fig. 12-7).

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Palpation of Body Rhythms

In Chapter 4 the concept of entrainment was discussed. To review, entrainment is defined in physics as the process whereby two oscillating systems, which have different rhythms when they function independently, assume the same rhythm. In the body, entrainment could be thought of as the harmonizing and synchronization of different rhythms so that the body finds equilibrium. Biological rhythms such as heart rate, respiratory rate, waking and sleeping cycles, digestive cycles, the urinary excretion of potassium, the menstrual cycle, body temperature changes, and the secretion of some hormones have a natural tempo. When the body is in balance these tempos become entrained. You will notice that you can feel when the body’s rhythms are in harmony. Some of these rhythms are easy to palpate such as the even rise and fall of the abdominal area and chest as the client breathes. The heart rate is detectable at the client’s pulse points. Therapists trained in craniosacral therapy learn to palpate the expansion and retraction of the cranial bones and sacrum known as the craniosacral rhythm.