Lower Limb Anatomy, Palpation & Surface Markings, 1e

149 Pages·2008·11.29 MB·English

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© 2008, Elsevier Ltd
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ISBN: 978 0 7020 3018 5
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contained in this book. It is the responsibility of the treating practitioner, relying on
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Printed in China.
Foreword
The original Anatomy, Palpation and Surface Markings joints, muscles and the neurovascular anatomy each
by Derek Field and Jane Owen Hutchinson was first covered in separate chapters. The individual chapters
published in 1994 and has since become one of the most adopt a proximal to distal progression, starting with
successful and best loved practical anatomy texts. The the lower back and pelvis and ending with the feet.
main title is now in its fourth edition and its combin- Pages are generously adorned with large, full-colour,
ation of meaningful clinical anatomy, clear photo- labelled photographs that set out clearly the surface
graphs, helpful diagrams and self-assessment sections anatomy, highlighting anatomical landmarks and pro-
is tried and tested. viding a visual anchor for clinical interpretation. The
This new spin-off version focuses on the lower limb, lower limb title continues the established and success-
an often neglected area of anatomy study. Although ful format of previous editions, pairing the clinical
based on the parent text, it has been specifically photographs with similarly labelled line drawings on
reworked for students of lower limb structure and facing pages. This approach helps the reader to con-
function. textualize the deep anatomy relative to the surface
In departments such as my own, with its mix of findings and provides strong graphical reinforcement.
clinicians, researchers and trainees, there is always a The supporting text provides the necessary anatomical
need and an appetite for a better understanding of leg detail along with clear instructions to aidthe reader in
and foot anatomy. The aim of this version of Field’s is accurately palpating the relevant structures. Finally,
to provide for the reader with an interest in the lower each chapter finishes with a revision and self-assess-
limb, both an impetus to think about leg and foot ment section, cross-referenced to the relevant page in
anatomy from a clinical perspective and an anatomy the main text, which will help the motivated reader to
primer of real practical worth. consolidate their knowledge. Where specific answers
Lower Limb Anatomy, Palpation and Surface Markings may not be found in the text itself, the question is
will be of use to: lower limb specialists, such as podi- followed by a sign (fr), which indicates that further
atrists in training; other therapists and coaches with a reading from other texts is required.
contextual interest in the lower limb; junior doctors, This is a book that brings lower limb anatomy to
for whom the detail of lower limb anatomy may have life, and it is our hope that students of leg and foot
been lost in the milieu of whole body anatomy and anatomy will be encouraged to use it actively in a
biological sciences that often overwhelm the first clinical setting. The ideal use of this book would per-
years of study; and, of course, established clinicians in haps be to prop it open next to an examination couch
search of an anatomy refresher that has real practical while the reader translates the page into practice with
application in their day-to-day practice. a colleague (or willing patient).
From the outset, the approach in the Field’s texts For the already inspired reader, the book should
has been to help develop an appreciation of applied provide an ideal clinical counterpoint to the heavy-
anatomy through direct palpation and the develop- weight anatomical titles, while for more hesitant
ment of an understanding of the relationship between reader it is sincerely hoped that the clinical flavour
deep structures and the surface. In short, the ability to will help overcome any reticence they may have
visualize deep anatomical structures through the skin about developing a better understanding of basic leg
–a very valuable clinical skill. and foot anatomy.
This skill is introduced explicitly in the opening
chapter, which covers the characteristics of palpation Anthony Redmond
and introduces relevant techniques. The rest of the Unit of Musculoskeletal Disease
book is set out in a consistent structure, with bones, University of Leeds, UK
Chapter 1
Palpation:
principles
and practice
Contents
Definitions and concepts 2
Palpation: definitions 2
General characteristics of palpation 2
Touch 2
General characteristics 2
The physiology of touch 3
The social significance of touch 4
Touch and clinical practice 5
Effects of palpation on the patient 6
Patient and person 6
The consultation process 7
Techniques of palpation 8
Improving the art of palpation 9
Care of the hands 10
Palpation of different tissues 10
Summary 12
2 LOWER LIMB ANATOMY
DEFINITIONS AND CONCEPTS proprioception, of changes in position and ten-
sion within our own muscular system.
Palpation: definitions (Chaitow 2003)
The Oxford Dictionary of English defines the verb ‘to As Frymann emphasizes, the hand is particularly well
palpate’ as: ‘to examine (a part of the body) by touch, equipped to play the key role in this activity. With
especially for medical purposes’. Its derivative noun reference to palpation of the human body, Chaitow
is ‘palpation’ (from the Latin verb palpare: to ‘feel or reminds us that different parts of the hand possess the
touch gently’.) According to The Chambers Dictionary, ability to discriminate between variations in tissue
the term ‘palp’ means ‘to feel, examine or explore by features: ‘...relative tension, texture, degree of moist-
touch’; palpare is defined as ‘to touch softly, stroke, ure, temperature and so on.’ He then makes the
caress or flatter’. Churchill’s Medical Dictionarydefines important point that ‘This highlights the fact that an
palpation as ‘to stroke, caress; to explore or examine individual’s overall palpatory sensitivity depends on
by touching and probing with the hands and fingers’. a combination of different perceptive (and proprio-
Whilst ‘stroking’, ‘caressing’ or (tactile) ‘flattering’ ceptive) qualities and abilities’ (Chaitow 2003).
represent practices (through ‘gentle touch’) that are
essentially designed to give physiological and psycho-
TOUCH
logical ‘healing’ to the recipient, palpation, for the pur-
poses of this text, is primarily a purposeful activity
General characteristics
requiring considerable skill. It is associated with meth-
odical exploration and detailed manual examination,
Palpation involves the use of one of the primary
the aim of which is to acquire objective information
senses, that of touch, in order to investigate and
that will eventually lead to a reasoned medical diag-
obtain information or to supplement that already
nosis upon which a subsequent treatment regimen
gained by other means, such as by visual and audit-
can be based. Gould’s Medical Dictionary makes the
ory input. As Poon (1995) points out:
direct link between the activity of palpation and diag-
nosis by gentle touch which involves the detection of The act of touching and the feeling of being
the ‘characteristics and condition of local tissues of touched are very powerful experiences ... (and
the underlying organs or tumors’. touch) is the earliest and most primitive form of
In The Oxford Dictionary of English, ‘to examine’ is communication.
defined as ‘to test; to inquire into; to question; to look (Poon 1995)
closely at or into; to inspect’. According to The Chamb-
Montague (1978) reminds us that:
ers Dictionary, ‘to examine’ is to ‘inspect (someone or
something) thoroughly in order to determine the nat- Touch is the first of the senses to develop in the
ure of a condition’. The activity involves critical, reflect- embryo and it plays a very important role in the
ive thinking: the systematic weighing up of evidence birth process itself and in the early life of the
in an attempt to arrive at a balanced conclusion. individual.
(Montague 1978)
Not only is it the earliest system to become functional
General characteristics of palpation in the human being but touch is also thought to be
the last of the senses to be lost immediately prior to
Palpation is a highly complex and sophisticated manual
death.
skill. Citing Frymann, Chaitow (2003) draws attention
Touch plays a very significant part in our everyday
to the potential which palpation offers members of
experience:
the healing professions:
When the other senses are not wholly effective,
The human hand is equipped with instruments
we return to the sense of touch to rediscover
to perceive changes in texture, surface texture,
reality. Clothing is felt to determine its quality,
surface humidity, to penetrate and detect suc-
fruit is squeezed to determine its ripeness and
cessively deeper tissue textures, turgescence,
paint is touched to test for dryness.
elasticity and irritability. The human hand,
(Mason 1985)
furthermore, is designed to detect minute mot-
ion, motion which can only be detected by the Experience suggests, however, that there are instances
most sensitive electronic pick-up devices avail- when touch is often subjugated in favour of reliance
able. This carries the art of palpation beyond upon other sensory modalities. Only when an aware-
the various modalities of touch into the realm of ness of an alteration in incoming stimuli occurs do we
CHAPTER 1 PALPATION: PRINCIPLES AND PRACTICE 3
become conscious of the sense of touch. An example Sensitivity to spatial discrimination is poor in the lum-
of this phenomenon might be when picking up a bar region, the legs and the back of the hands. In the
garment, we recognize its unfamiliarity through its back of the hands, for example, two points can only be
texture or ‘feel’; another example might be an aware- perceived separately if they are more than 50–100mm
ness of the material of trousers touching the legs apart. The lips, tongue and fingertips, however, rate
immediately after a long period of wearing shorts. high (1–3mm). Thus individuals with normal sensat-
Touch may be divided into two distinct categories: ion in the fingertips should be able to distinguish
instrumental and expressive. Touch is described as between two points even when they are less than
instrumental when it is associated with a deliberate 6mm apart. This is referred to as the ‘Two Point
action: locating an anatomical structure for the Discrimination Test’ (see Chaitow 2003, Evans 2000,
purposes of examination during a clinical assessment, Magee 1997). The significance of this is that only
for example. Touch is identified as expressive when it relatively large objects can be recognized by the recept-
is associated with spontaneous, affective actions: orsin the lumbar region whereas fine point discrimin-
touching a distressed person’s arm in order to convey ation can be achieved when employing the fingertips.
sympathy and offer comfort (MacWhannell 1992, Chaitow makes the further point that:
Poon 1995).
Not only is there a difference of perception
Touch can be experienced as safe or unsafe; physi-
relating to spatial accuracy, but also one relating
cally comfortable or uncomfortable. It can be used to
to intensity. An indentation of 6 micrometers is
establish rapport: hand-shaking as a formal greeting
capable of being registered on the finger pads,
at the beginning of a clinical interview or as a means
while 24 micrometers is needed before the sens-
of ending a treatment session. Communication by
ors in the palm of the hand reach their threshold
touch is specifically permitted within particular inter-
and perceive the stimulus.
personal relationships (see later). In certain contexts,
(Chaitow 2003)
however, permission to touch may be required, for
example, at the commencement, and during the vari- Additionally, Evans (2000) contends that:
ous stages of a clinical examination and treatment
Under normal conditions, touch is an explora-
session. Touch is associated with psychological react-
tory sense rather than purely receptive, and it is
ions: it is difficult to touch or be touched by those who
becoming increasingly evident that tactile acuity
elicit negative responses. The anticipation of touching
is enhanced in active exploration when compared
or being touched can increase stress levels and these
with passive reception.
reactions may be influenced by personality, cultural
(Evans 2000)
and social factors: some female patients may deliber-
ately avoid consulting a male therapist; some patients Citing Meyers, Etherington and Ashcroft (1958) Evans
may be reluctant to remove clothing. It is important to suggests that:
remember that professional personnel are placed in
An early indication of the phenomenon may be
an extremely powerful and privileged position in
seen in an examination of the parameters of
relation to others: they are given a license to touch and
perception required to read Braille. The dots are
this power and privilege should never be abused.
separated by 2.3mm, which is close to the
threshold value for two-point discrimination at
the pad of the index finger. Reduction of the
The physiology of touch
inter-dot space to 1.9mm only moderately
All areas of the skin supplied with appropriate recept- reduces the legibility of the Braille text.
ors are normally able to perceive a variety of sensat- (Evans 2000)
ions (pain, degrees of pressure, temperature changes,
While sighted Braille transcribers, relying solely on
etc.) to a greater or lesser degree. Some areas, however,
visual input, have been known to become proficient at
are more sensitive to stimuli than others because:
reading Braille by the end of only three weeks, experi-
The degree of tactile sensitivity in any area is in ence confirms that individuals attempting to conquer
direct proportion to the number of sensory the system by touch are estimated to take an average
units present and active in that area, as well as of 1½–2years to reach a speed suitable for serious
to the degree of overlap of their receptive fields, study, even with regular practice. This is not due to
which vary in size. Small receptive fields with lack of knowledge of the system; rather it is because
many sensory units therefore have the highest the palpation and recognition of the signs using tactile
degree of discriminatory sensitivity. input requires a considerable amount of dedicated
(Chaitow 2003) time and practice in which to develop. As with all
4 LOWER LIMB ANATOMY
skills, the speed and quality of reading depends upon burning, scorching, boiling, extremely hot, very hot,
the frequency and amount of use. The ability to palpate fairly hot, hot, quite hot, very warm, blood heat,
with any finger or fingers can usually be developed, the warm, fairly warm, slightly warm, cool, cold, quite
use of the index finger being the most popular. Read- cold, very cold, bitterly cold, freezing and icy cold. A
ing speed is further enhanced by using the fingers of temperature of 42°C read from a thermometer has
both hands. In some cases, this skill never develops if little practical meaning as to whether something is too
the individual has not learnt to employ touch from an hot or too cold to touch.
early age. In rare instances, people who have been
unable to use their fingers have developed the same
ability to read Braille by using their toes or even their The social significance of touch
lips! (see above). This means that, regardless of the
The concept of the novice engaged in learning to
method by which this skill is acquired, the ability to
interpret incoming stimuli received through touch
increase the information received through sensory
extends, of course, into the realm of social interaction.
input can be improved,given time and serious dedi-
As suggested above, touch can represent a powerful
cation to regular practice. This can be of great benefit
means of expressive communication (Nathan 1999).
to the clinical practitioner who wishes to ‘read’ inform-
The way in which this communication is interpreted
ation that lies deep to the skin. The controlled use of
will be contingent upon such variables as personality,
pressure and movement, coupled with feedback and
upbringing, culture and social situation and, in these
experience, unlocks a vast quantity of information
contexts, it seems unhelpful to separate touch into
that is often unavailable to the eye.
mechanical and psychosocial categories. Referring to
Obtaining information through touch is a skill, the
a medical intervention, Nathan contends that:
practical significance of which is often not fully apprec-
iated or valued until it is needed, perhaps to com- Touching a person’s body in a non therapeutic
pensate for the impairment or loss of one of the other context is not normally considered an act of
senses: sight or hearing, for example. Because of this, merely mechanical significance. Nor is it a pro-
considerable practice is often required before the skill cedure of a technique–rather it is an act of self-
of palpation becomes developed to the point where it expression, or occasionally self-assertion, or
is of practical use to the individual concerned (see preservation.
above). Initially, new techniques have to be devised (Nathan 1999)
and then undertaken slowly and carefully, with regular
The degree to which people will engage in touching
practice and evaluation, often involving feedback from
will be dictated by the nature of the interpersonal
other observers with consequent modification of
relationship in which they are involved at the time.
behaviour. Efforts to recognize and accurately interpret
Nathan continues:
tactile sensory input demand high levels of concen-
tration which necessarily cause anxiety and additional In the main, frequent touching is reserved for
stress to an individual who is unaccustomed to placing parent–child relationships, lovers and close
such reliance on this variety of incoming stimuli. These friends. In these contexts it both signifies emot-
reactions are likely to be experienced by the novice ional intimacy and is emotionally significant.
clinical practitioner as well as by the recently disabled (Nathan 1999)
person and should be regarded as normal responses to
Touch can be employed to communicate a variety of
the process of acquiring a new range of sophisticated
emotions. For example, affection may be conveyed by
psychomotor skills and personal strategies (Owen
a gentle squeeze of the hand whereas a loose hand-
Hutchinson, Atkinson and Orpwood 1998).
shake may imply indifference or even dislike. Touch-
In other non-medical contexts, touch-related skills
ing and being touched can be extremely therapeutic.
are used to acquire general information about the
Montague summarizes the observations of many
environment such as establishing the temperature of
researchers who conclude that:
water. Athermometer could be employed for this pur-
pose, but it is often easier (and quicker) to test water Cutaneous stimulation in the various forms in
temperature by utilizing the input from the sensory which the newborn and young receive it is of
endings in the skin. While the results of this method prime importance for their healthy physical and
of temperature testing are likely to be far less accurate behavioural development ... It appears probable
than if a thermometer were to be used, they provide a that for human beings, tactile stimulation is of
range of potentially significant information upon fundamental significance for development of
which subsequent action could be based. The water healthy, emotional and affectional relationships.
temperature, for example, might be experienced as (Montague 1978)
CHAPTER 1 PALPATION: PRINCIPLES AND PRACTICE 5
Montague quotes examples of cases that were studied Touch and clinical practice
by Lorna Marshall, a researcher who spent much time
Palpation, then, would seem to be a practice which
between 1950 and 1961 living among the Bushmen of
involves a combination of many other skilled activi-
the Kalahari Desert in Botswana, South West Africa. He
ties: the appropriate use of touch, the application of
observed that, within this society, the development of
methodical investigatory techniques, accurate inter-
the newborn, infant, adolescent and adult appeared
pretation of sensory feedback (based upon sound
to be influenced by the way in which the child was
general knowledge), the ability to draw on previous
handled in early life. Montague also refers to accounts
experience, to reflect, critically, upon findings and
by Margaret Mead, who studied the Arapesh and Mun-
arrive at a reasoned conclusion.
dugumor societies in New Guinea during the 1930s and
documented the characteristics of their respective social Palpation is the art of feeling tissues with your
practices. In the former tribe, the child was in contact hands in such a manner that changes in tension
with the mother for most of the day. The adults of this and position within these tissues can be readily
tribe were observed to be kind, happy and peace-loving noticed, diagnosed and treated.
people. In the latter tribe, the child had little human (Mitchell, Moran and Pruzzo (1979)
contact, being kept in a rough plaited basket which was cited in Chaitow 2003)
usually suspended from the mother’s forehead. The
A skill is attained and retained by its continual use,
adults of this tribe were observed to become unattract-
evaluation and modification of practice (Phillips 2004).
ive, aggressive and cannibalistic. The study and practice of manual contact techniques
The tendency to avoid close physical contact can be over a long period of time enables the practitioner to
demonstrated in adults from certain cultures and become highly skilled in the art of palpation. The dev-
within some social backgrounds of particular nation- elopment of this skill provides valuable supplement-
alities. Montague comments that ‘There exists not only ary information to that which can be obtained through
cultural and national differences in tactile behaviour observation and verbal questioning and is crucial to
but also class differences.’ He cites the English upper arriving at a meaningful clinical diagnosis. After many
class as a an example of a social group that is char- years experience of practising palpation skills, the
acterized by non-tactile social behaviour when com- moving, stretching and compression of tissues will be
pared with social groups of other nationalities: French undertaken with precise control. This will enable the
and Italian people display more demonstrative behav- therapist to receive and interpret vital information
iour when greeting one another and are observed to from the patient and to apply and modify techniques
engage in more physical interpersonal contact. as appropriate. Small changes in tension, temperature,
When considering the practice of palpation skills, dampness, movement and swelling will be identified
the significance of Montague’s observations cannot be by the sense of touch; these will then be noted and the
underestimated. Not only is it crucial for us to appropriate course of action taken. Grieve states:
recognize the relevance of culture, nationality and
Of the entire objective examination of the verte-
social class on the degree to which people commun-
bral column, the palpation examination of access-
icate by touch, but also the impact of living in a
ible tissues is probably the most informative and
multicultural society in which we are likely to
therefore the most valuable.
encounter unfamiliar and potentially disconcerting
(Grieve 1986)
practices. Additionally the effect of globalization on
our patterns of non-verbal communication has been As has been noted above, however, learning to palpate
considerable. is also associated with acquiring the skills to ‘read’,
In contrast to the somewhat reserved behaviour of accurately, the patient’s problem. Citing Ford (1989),
English people in the 19th and early 20th centuries, Chaitow reminds us that:
we now regularly witness overt instances of emotion In days gone by, when a physician had to diag-
(love and friendship, happiness and sadness) through nose by touch a good practitioner did not feel a
physical contact. Behaviour such as mutual embrac- tumour at his fingertips but he projected his
ing, hand-holding and kissing is frequently to be vibratory and pressure sensations into the pat-
observed in public places. Sports-people will leap in ient. So we regularly project our sense of touch
the air and hug each other following a winning beyond our physical being and...merely make
achievement such as the scoring of a goal in football; the ordinarily unconscious process available to
equally, it is not uncommon for athletes to display our conscious mind. In so doing, we cross the
tears of misery and frustration and to engage in delicate boundary between self and other, to
mutually sympathetic embraces after a failure to explore, to learn, and ultimately to help.
attain high standards of performance. (Chaitow 2003)
6 LOWER LIMB ANATOMY
Personal experience confirms that patients can easily social model of disability which ‘is a way of concept-
distinguish between a novice and an expert practit- ualizing the multifactorial and complex system that
ioner. During the initial examination, both the shapes a person’s experiences of pain and disability’
practitioner and the person being palpated progress (Christensen, Jones and Edwards 2004.) Citing var-
through a learning process in which each is engaged ious sources, Christensen, Jones and Edwards explain
in assessing the other by the giving and receiving of the biopsychosocial theory:
information. Relatively little significant information
...the degree of disability a person develops
can be obtained if one of the participants in this relat-
will be based upon the reactions of that person
ionship is reluctant to communicate. This learning
to the pain experienced far more than on the
process takes time and it is often the case that an accur-
physical experience of the pain itself. The bio-
ate picture of the underlying issues does not appear
psychosocial model places a complaint of pain
until much later in the treatment session. The reason
into a more holistic context, and views the pain as
for this is partly due to the need for each participant to
important not in isolation, but in relation to any
become comfortable with the other, so permitting mut-
disability the person with pain is experiencing
ual reduction in anxiety and the relaxation of tension.
as a result of that pain.
It is also due to the need for both parties to become
(Christensen, Jones and Edwards 2004)
familiar with the learning process itself, so that each
can benefit from the knowledge gained as a result of (See also Ramsden 1999, Stevenson, Grieves and
their participation in this two-way event. The skill of Stein-Parbury 2004).
palpation, therefore, should not be regarded merely as
The last decade has also witnessed a growth in the
an arbitrary form of physical intervention; rather it
popularity of complementary medicine, whose under-
must be respected as a highly skilled investigative
lying holistic principles stand in direct contrast to
process which elicits specialized information to both
those of orthodox medical practice. This trend would
participants. In our experience, the skill of palpation
suggest that patients prefer to be treated as whole
is estimated to be only 10% innate: the other 90% is
persons rather than as bodies requiring cures. When
acquired through dedicated practice.
they seek consultation with a therapist, patients are
asking for help with more than just a painful neck or
back: they want far more than to be the passive
EFFECTS OF PALPATION ON
recipient of skilfully performed physical techniques.
THE PATIENT
Indeed, patients regard a satisfactory healing experi-
ence as one that acknowledges the inextricable links
Patient and person
between mind and body and which therefore treats
It is far beyond the scope of this book to enter into the the whole person who is more than just the sum of a
complexities of the mind–body debate, but its signifi- collection of constituent parts. Recognizing this, the
cance in relation to clinical diagnosis and manage- therapist must adopt an empathic and sensitive
ment cannot be ignored. Traditionally, medical pract- approach to all input from the patient, both in terms
ice has been characterized by the biomedical model of of verbal and non-verbal communication. Social and
health. This model is underpinned by the philosoph- cultural factors must also be taken into account.
ical principles of dualism: the mind and body are The quality of all clinical interventions will improve
regarded as separate and distinct entities that do not dramatically if the person-centred approach to patient
interact and, essentially, the practitioner is engaged in management is adopted. The therapist, however,
treating one or the other. The manual therapist would, should not underestimate the degree to which pat-
in this context therefore, be regarded as being con- ients have learned the conventions associated with
cerned only with the treatment of the patient’s body. society in general and medicine in particular. During
Indeed, it is not uncommon to hear therapists refer to the session, patients will often choose to use language
a patient as ‘a neck’ or ‘a back’. The body is con- to conceal as well as to reveal emotional states: ‘That
sidered to resemble a sophisticated machine; if part of movement does not hurt any more’; ‘I feel much freer
that machine is malfunctioning, physical intervention now’. It must always be remembered that the patient
is required in order to rectify the fault (Chaitow in has this choice. It must also be borne in mind that
Nathan 1999, Christensen, Jones and Edwards 2004, some patients may not have recognized the link
Owen Hutchinson 2004). between physical and psychological states and may
The 1990s, however, have witnessed significant need to be encouraged to reflect upon their choice of
changes in the approach towards illness and disability language in order to gain insight into certain aspects
with the consequent development of the biopsycho- of their emotional lives.
CHAPTER 1 PALPATION: PRINCIPLES AND PRACTICE 7
As has been suggested above, the act of touching It is crucial that the practitioner should manage the
and the feeling of being touched are very powerful initial investigation with great care and sensitivity as
experiences and the degree to which people engage in this process is likely to have a significant influence on
touching is largely contingent upon personality, cult- both parties during the subsequent clinical examin-
ural and social factors. Both patient and therapist may ation. The practitioner should exercise the same degree
experience an increase in stress levels due to unfamil- of tact and diplomacy when conducting the subse-
iarity within particular therapeutic contexts. The pract- quent physical examination, which should be under-
itioner must demonstrate a respect for the patient as a taken with equal care, precision and gentleness. Physi-
person. Permission to touch should be obtained at the cal or verbal clumsiness at this stage of the pro-
commencement, and during the various stages of a ceedings could lead to a complete breakdown of the
clinical intervention. Abuse of power and the priv- interpersonal relationship between the therapist and
ilege of being licensed to touch must be avoided. patient, who may become reluctant to communicate
vital information. The therapist employs palpation
techniques during the first contact with the patient
and it is vital that efficient methods of obtaining
The consultation process
information are employed at this time. Experience
For a variety of physical and psychosocial reasons, suggests that most patients have an expectation that a
many patients remain reluctant to consult professional clinical examination involving the use of palpation
personnel on matters associated with their personal techniques will take place; indeed, they would
issues, especially those problems relating to their own consider it to be unprofessional practice if such a pro-
bodies. Barriers may be erected by one or both partici- cedure were not undertaken. Inevitably, each person
pants in the therapist–patient relationship, although will exhibit different reactions to being touched and it
both must contribute to the dismantling of these barr- is important that the practitioner should establish and
iers if effective communication and co-operation are to evaluate the patient’s unique reaction to such inter-
be achieved. Experience suggests that each patient ventions at the earliest opportunity. An initial indi-
usually presents with a combination of issues which cation of the patient’s reaction to physical contact can
are revealed by the identification of problems, the be obtained by the act of hand-shaking at the com-
giving of information and the posing of a number of mencement of the session. Additionally, information
questions during the consultation process. Typically, gained by the act of assisting the patient to and from
no particular order of priority emerges except perhaps a chair can provide the practitioner with valuable
that associated with the overriding presence of pain. feedback relating to the patient’s degree of willingness
Some of the information provided by the patient may or reluctance to accept help. Of course, such strategies
appear to be somewhat peripheral in relation to the represent only part of the range of techniques being
practitioner’s objective of establishing a clinical diag- employed during this initial session. The use of visual,
nosis, but it nevertheless represents a vital component auditory and olfactory input can also provide useful
of the overall clinical picture and must be thoroughly sources of relevant clinical information.
evaluated before it can be discounted. During the period of questioning, the practitioner
The practitioner must be sympathetically receptive is recommended to make sensitive and careful
to all forms of information offered by the patient. physical contact with the area of the patient’s pain.
Standards governing all areas of professional practice When these techniques are performed successfully,
demand that the clinician must objectively evaluate all this encourages both parties to focus attention on the
clinical evidence and attempt to produce a compre- patient’s motivation in seeking the consultation. All
hensive analysis of the presenting situation. On some movements should be tested carefully, palpation
occasions, a prescribed plan will be used to facilitate skills being employed simultaneously with continual
the compilation and evaluation of data; at other times, observation of the ongoing situation, the therapist
the practitioner will be expected to tailor the procedure monitoring any reluctance on the part of the patient to
according to the patient’s individual circumstances. perform movements due to tension, muscle spasm,
The use of such strategies will enable the practitioner joint anomalies and pain. Inadvertently eliciting
to arrive at a reasoned clinical diagnosis. Care must be symptoms of acute pain will inevitably destroy the
taken, however, that any prescribed plan does not patient’s confidence, resulting in an unwillingness to
preclude the practitioner from obtaining relevant offer potentially significant information.
information from the patient; adherence to such stand- In most cases, the patient will gradually gain confi-
ard proforma can sometimes adversely affect the dence and learn to trust the practitioner. Much of the
practitioner’s judgement and thus lead to an incorrect apprehension of meeting will have passed during the
clinical assessment of the patient’s current problem. initial contact. When the time comes for the therapist
8 LOWER LIMB ANATOMY
to undertake an objective physical examination of the tension, and bone structure can be evaluated and
patient’s movements, rapport should have been well recorded. The practitioner’s speed of movement can
established which overcomes that initial reluctance to be adjusted to facilitate the full interpretation of
seeking of medical advice. information. The importance of regularly modifying
Palpation continues throughout the examination the speed of movement can be demonstrated by the
and subsequent treatment. If it is carried out carefully following example. If the fingers are run over Braille
and sympathetically, it reveals valuable information script too quickly, dots can be felt but no information
concerning the patient’s physical and psychological is obtained; if the individual adapts the speed accord-
condition. Indeed, palpation has the potential to ingly, however, what initially appeared to be an
‘unlock’ psychological issues which had hitherto been incomprehensible mass of dots now becomes an
deliberately ignored or unrecognized by the patient as intelligible text.
having any relevance to the presenting physical prob- Sometimes palpation techniques need to be per-
lem. Many practitioners will have experience of formed slowly and at considerable depth; at other
patients who seek medical consultation for a relatively times they should be carried out quickly and at a
minor physical ailment which, during the examinat- superficial level. For example, palpation of the trans-
ion or treatment, will be found to be masking much verse processes of the spines of the lumbar region or
deeper and more complex issues. All practitioners the hook of the hamate needs careful application of
should be sensitive to this possibility and should note deep pressure, combined with slow movement and
any incongruous sentiments that the patient may sensitivity to the patient’s reactions. Palpation of the
express during the session. Experience suggests that it spines of the thoracic vertebrae–particularly when
is the physical contact with the patient which appears counting downwards–is much easier if the fingertips
to facilitate the unveiling of these underlying issues are gently moved up and down three or four
but the importance of recognizing this phenomenon centimetres at a time, marking each spine with the
is contingent upon the quality of the practitioner’s finger of the other hand and holding it until the
professional training. position of the next spine is confirmed. This type of
That the patient must have confidence in the pract- palpation works in a similar way to a scanner using a
itioner cannot be over-emphasized. This will promote beam to build up a clearer picture. The technique can
the offering of information through both verbal and be used to obtain a clearer picture of the rib cage,
non-verbal communication methods. Throughout the particularly from the posterior aspect.
consultation, the practitioner should be receptive to In our experience, using one or even two complete
the patient; as the session progresses, continual evalu- palms and fingertips conveys more information
ation of the patient’s verbal and non-verbal reactions regarding movement below the skin surface and about
to events should take place. Whether complex or the patient’s general reaction to physical contact than
simple, all treatment sessions should promote mutual if the fingertips alone were used. The application of
trust and understanding. Experience indicates that the the fingertips alone, for example, would be used for
degree to which a patient contributes to the treatment palpating a pulse. Generally, if the structures below
session is directly proportional to the practitioner’s the surface are stationary, the hands will have to be
input; this reciprocal relationship is, however, conting- used in a controlled movement, whereas if the struct-
ent on the practitioner’s willingness to impart inform- ures are mobile, the hands should remain stationary.
ation and the patient’s genuine interest in receiving it. The finer the movement below the surface, the more
delicate the palpation technique must be: this is clearly
demonstrated when searching for a faint pulse.
TECHNIQUES OF PALPATION If joints are being manipulated to examine the
quality of movement and to assess limiting factors,
It is not enough merely to place the hands on the the hands should be moved as little as possible so as
patient’s body and hope to receive the information to avoid any feedback from the palpator’s own tissues
required. Positive steps must be taken to search for the which would obscure information from those of the
data. As has been noted above, palpation is associated patient. In fact, with this kind of palpation, a mini-
with the seeking of information and all techniques mum of all other movements–with the exception of
must be approached in a rational and logical manner. the joint being examined–is required. This involves
The practitioner can gain very little by contacting a adopting a stance which will avoid movement of the
surface with the hands and remaining stationary. feet, applying a hold that will allow the full range of
Movement of the hands is required so that structures movement without change and also reducing all skin
can pass under the fingers in a controlled manner so sliding by firm contact. Finally, the palpator must be
that any alterations in skin temperature, surface absolutely sure that the patient’s position is stable and