Table Of Content�a Palpation Techniques
li rll
Complementary
Surface Anatomy for Physical Therapists
Medicine
Bernhard Reichert
With the collaboration of
Wolfgang Stelzenmueller
�Thieme
This lavishly illustrated guide to palpation techniques provides readers with a solid
understanding oftopographic anatomy using clear, step-by-step descriptions that
teach how to first identify, then distinguish between, the various body structures.
Full-color photographs feature models with detailed drawings of muscles, bones,
and tendons on their skin, indicating exactly where and how to palpate. Comple
mentary color drawings show the functional significance of each anatomic region.
Features:
In- pth coverage of the entire body-upper extremities, lower extremities,
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and the head and trunk-all in one comprehensive volume
Over 850 full-color photographs and illustrations enhance the text, making it
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especially useful for the visual learner
Easy-to-reference text boxes contain tips and tricks, including advice on finger
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placement, pressure application levels, and more
Study questions at the end of each chapter aid readers in self-assessment and
•
review of the material
Palpation Techniques: Surface Anatomy for Physical Therapists will enable
students and practitioners of physical therapy or osteopathy to develop their
anatomic knowledge and optimize patient care.
Bernhard Reichert, M, PT, MT, BSC PT, is Massage Therapist and Physical Therapist,
VPT Academy, Fellbach, Germany.
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ISBN 978-3-13-146341-8
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9 783131 463418 www.thieme.com
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PalpatTieocnh niques
Surface Anatomy for
Physical Therapists
Bernhard Reichert, M,P T,M I,B Se PI
Massage Therapist. Physical Therapist
VPT Academy
Fellbach. Germany
With the collaboration of
Wolfgang Stelzenmueller
Dreieich. Germany
861 illustrations
Thieme
Stuttgart . New York
Library oj Congress Cataloging-in-Publication Data Important note: Medicine is an ever-changing science
Reichert, Bernhard, 1959- undergoing continual development. Research and clinical
[Anatomie in vivo. English] experience are continually expanding our knowledge, in
Palpation techniques: surface anatomy for physical particular our knowledge of proper treatment and drug
therapists / Bernhard Reichert, with contributions by therapy. Insofar as this book mentions any dosage or
Wolfgang Stelzenmueller. application, readers may rest assured that the authors,
p.; cm. editors, and publishers have made every effort to ensure
ISBN 978-3-13-146341-8 (alk. paper) that such references are in accordance with the state of
1. Palpation 2. Anatomy, Surgical and topographical. knowledge at the time of production of the book.
.I Stelzenmueller, Wolfgang. II. Title. Nevertheless, this does not involve, imply, or express any
[DNLM: 1. Palpation. 2. Body Regions-anatomy & guarantee or responsibility on the part of the publishers in
histology. 3. Physical Therapy Modalities. WB 275] respect to any dosage instructions and forms of applica
RC76.5.R4513 2010 tions stated in the book. Every user is requested to exam
611. '9-dc22 ine carefully the manufacturers' leaflets accompanying
2010033219 each drug and to check. if necessary in consultation with
a physician or specialist, whether the dosage schedules
This book is an authorized and revised, merged transla mentioned therein or the contra indications stated by
tion of Volume 1 (2nd ed) and Volume 2 of the German the manufacturers differ from the statements made in
edition published and copyrighted 2005 and 2007 by the present book.S uch examination is particularly impor
Georg Thieme Verlag, Stuttgart, Germany. Title of the tant with drugs that are either rarely used or have been
German edition: Anatomie in vivo (Vol 1: palpieren und newly released on the market. Every dosage schedule or
verstehen im Bereich der Extremitaten; Vol 2: palpieren every form of application used is entirely at the user's
und verstehen im Bereich Rumpf und Kopf). own risk and responsibility. The authors and publishers
request every user to report to the publishers any dis
Translator: Michelle Hertrich, Nettetal, Germany crepancies or inaccuracies noticed. If errors in this work
Illustrator: Martin Hoffmann, Thalfingen, Germany are found after publication, errata will be posted at
Photos: Oskar Vogl; Benjamin Stollenberg; authors www.thieme.com on the product description page.
We wish to thank the leading manufacturer of anatomical
teaching aids, 3B Scientific, for their kind support.
Please also see page 398-399 or
www.3bscientific.com.
Some of the product names, patents, and registered
© 2011 Georg Thieme Verlag, designs referred to in this book are in fact registered
Rlidigerstrasse 14, 70469 Stuttgart, Germany trademarks or proprietary names even though specific re
http://www.thieme.de ference to this fact is not always made in the text. There
Thieme New York, 333 Seventh Avenue, fore, the appearance of a name without designation as
New York, NY 10001, USA proprietary is not to be construed as a representation by
http://www.thieme.com the publisher that it is in the public domain.
This book, including all parts thereof, is legally protected
Cover design: Thieme Publishing Group by copyright. Any use, exploitation, or commercialization
Typesetting by Hagedorn Kommunikation, Viernheim, outside the narrow limits set by copyright legislation,
Germany without the publisher's consent, is illegal and liable to
Printed in Germany by Offizin Andersen Nexb, Zwenkau prosecution. This applies in particular to photostat repro
duction, copying, mimeographing, preparation of micro
ISBN 978-3-13-146341-8 123456 films, and electronic data processing and storage.
v
Foreword to the English Edition
The clinical practice community has been left wanting for suspicion of that structure's involvement in the patient's
a textbook dedicated to the precise execution of in-vivo condition.
anatomical examination, and this excellent text emerges Surface anatomy is essentially manual in nature. Thus,
in a timely fashion. Healthcare professionals have wit this text can serve as a segue for accurate localization of
nessed an escalation in the need for relevant clinical ex structures involved in a manual therapeutic intervention.
aminations and the use of manual therapeutic interven Moreover, because a patient's response to manual thera
tions, both of which rely on a thorough understanding peutic interventions could be influenced by a clinician's
and execution of precision in-vivo surface anatomy skills. confidence in technique execution, the clinician's thor
Because surgical exposure may not be readily available, ough knowledge of structural architecture that is ac
the clinician must rely on nonsurgical measures for iden companied by accurate tactile localization could serve to
tifying relevant anatomical structures. Thus, surface ana enhance the patient's response to treatment.
tomy skillsets become indispensible for localizing struc The knowledge and skills gained from this text can pro
tures and landmarks. This text can serve as a roadm ap vide a foundation for increased clinical confidence, as it
for locating relevant structures with exactitude. The clear can reduce the clinician's guesswork when navigating to
means by which this text instructs the clinician in tactile a particular structure. The authors offer practical gui
localization will compliment essential knowledge in dance for enhancing the clinician's success with an in
structural and functional anatomy. vivo surface anatomy experience. So not only are clini
The authors have organized the approach to identify cians instructed on what skills to utilize, they are addi
ing structures by both layer and region. This process of tionally guided on how to best implement them. This
organization can guide the clinician to visualizing a parti text can join the top ranks of a clinician's library and
cular structure's relative depth and relationship to sur serve as a bridge between foundational science, clinical
rounding structures. Moreover, the text is complete, offer knowledge, and practical skills. With these features in
ing a thorough and methodical approach to all major mind, the text can support an individual's development
musculoskeletal areas of the human body. This will assist and progress as a master manual clinician.
the clinician in developing a musculoskeletal surface anat
omy approach to the entire human, allowing for identifi Phillip S. Sizer Jr., PT, PhD, OCS, FAAOMPT
cation of patterns, similarities, and differences between Professor and Program Director,
structures in the different regions. Finally, the clinician ScD Program in Physical Therapy
is cued on how the information can be directly applied Director, Clinical Musculoskeletal Research Laboratory,
to clinical examination, which bridges the gap between Center for Rehabilitation Research
knowledge and implementation. When used in accompa School of Allied Health Sciences, Texas Tech University
niment to a thorough, systematic clinical examination, Health Sciences Center
precise structural localization can help to confirm a Lubbock, IX, USA
VI
Foreword to the German Edition
Our understanding of the anatomy and biomechanics of Expert knowledge of in vivo anatomy plays a central
the musculoskeletal system has increased manifold in re role when we want to differentiate between structures
cent decades. The enormous expansion of new scientific and identify at which level and in which layer the pain
knowledge certainly represents the general trend in med is the strongest. It is only then that we can address the sec
icine. Perhaps this is also the main reason why today's ond question: why is the patient suffering?
medical students receive less and less information in To give an example: in cases of lumbo-pelvic pain, it is
more and more specialties. The medical study period is important to find out whether pain is coming from (from
simply too short to keep up with the "explosion" of new where) the gluteus maxim us (large muscle of the but
medical information and too short to be able to properly tocks), the multifidus muscle (multiply divided muscle
and thoroughly absorb all this information during the ba in the back), the gluteus medius (middle muscle of the
sic medical training. This unfortunately results in medical buttocks), or the long posterior ligament of the sacroiliac
universities worldwide paying too little attention to the joint. These structures are located close to each other
study of the complicated musculoskeletal system. In the when the area around the posterior superior iliac spine
past, students studied the anatomy of the musculoskeletal is being palpated. It is only after structures have been dif
system over a period ofthree year,s. In many faculties, the ferentiated in detail and the most painful structures have
same material is now being covered in just three weeks! It been identified that we can begin to search for the source
is no exaggeration to say that the study of anatomy plays of this specific pain.
an increasingly smaller role in medical studies. As author of one of the first detailed books on in vivo
In order to examine and treat our patients' musculo anatomy in the musculoskeletal system, I am glad to see
skeletal problems effectively, we must be able to answer that a real evolution has been set into motion in this field
at least two fundamental questions: where does the pain of knowledge. This book not only represents a large step in
come from (i.e., which part of the body is diseased or in the right direction compared with the first edition: most
jured?) and what has triggered the pain? We have to pos importantly, it also presents in great detail the alterna
sess detailed knowledge in topographical anatomy to an tives available to expand our knowledge of the "anatomy
swer the first question when diagnosing. However, this on the living body" to the benefit of our patients.
alone is not enough. It is also necessary to be able to apply It is my sincere hope that this book will be accepted as
this knowledge to the benefit of our patients. This requires an important tool for answering the questions of from
deep insight into in vivo anatomy (anatomy on living sub where and why and contribute to the better care of our pa
jects). Do we pay enough attention to our patients as liv tients for not only students and clinicians in the fields of
ing beings capable of feeling when we apply our structural physical therapy, osteopathy, and manual therapy, but
anatomical knowledge? Are we able to combine receptive also for medical students and physicians. This book is ex
touch with our knowledge of anatomy to such an extent ceptionally well-suited for deepening our understanding
that we can answer our patient's specific questions and of human anatomy. Knowledge of in vitro anatomy (anat
provide clarity about the circumstances surrounding their omy outside the living organism) can only be applied if we
pain? combine it effectively with hands-on in vivo touch. This re
It is of great importance that the clinician recognizes quires extensive practice, intuition, and "listening touch."
and understands what the patient reports about their An improvement in skills on living subjects will undoubt
pain so that the patient feels their complaints are being ac edly bring about improvements in diagnosis and clinical
knowledged in a discerning manner.A lthough this is often practice and hence contribute to better patient care.
not always possible, the application of in vivo anatomy can
assist us in making the right decisions, even in cases of
generalized and sensitized pain.
Perhaps the first rule of medicine should be "to recog Prof Dr. Andry Vleeming, PhD, PT
nize the patient as an individual": the clinician must inter Chairman, World Congress on Low Back and Pelvic Pain
pret the patient's physiological symptoms and complaints Founder oj the Spine and joint Centre
as being unique and persona.l Rotterdam, The Netherlands
VII
Preface
The aim of this book is to make the introduction to in vivo subject matter. The experienced therapist or physician
anatomy (anatomy on living subjects) easier and to help has a reference book to selectively search for specific
standardize palpatory techniques. structures. Teachers involved in therapist training can ex
I am very pleased with how well this English edition tract several aspects to round off classes in assessment or
has turned out. The original German version of the book anatomy.
invoked an interest for palpation in many of its European Cross-references are continually used to link the indi
readers. I hope the same holds true for readers of the Eng vidual sections and improve navigation between the
lish edition. chapters. In the end. the connection between theory and
Palpation is learnt by palpating. It cannot be learnt by practice should be successfu.l Quite a large section of
reading. It is for this reason that this book claims to be the book involves information on assessment and treat
an easy-to-understand guide to the independent study ment to clarify how important in vivo anatomy is. The
of in vivo anatomy. study questions at the end of each chapter should help
We achieve this by starting on the surface before mov readers to consciously reflect on certain topics. This
ing deeper. layer by layer. toward the more deeply situ book contains only a selection of the palpable structures
ated structures. The interest in neighboring structures in of interest for the clinical practice. I would be happy to
the musculoskeletal system understandably grows as we receive suggestions from readers to strengthen and also
become more specialized and improve our knowledge in broaden the repertoire of techniques. I also hope that
biomechanics and pathology. When this happens. I am this book will instigate a discussion on the standardiza
under the impression that we "forget" during palpation tion of anatomy in vivo. With this in mind. the palpatory
to view the skin as a signal organ and the muscles as sta techniques demonstrated in this book should only be
bilizers and mobilizers. Including the skin and muscles seen as an attempt to standardize both technical pro
was therefore of particular concern to me. cedures and the criteria used to evaluate palpatory re
The level of difficulty gradually increases in the book. sults.
The basic features of palpation are practiced at the start The language has been selected so that the facts are
and the specific tests and complicated maneuvers are presented as accurately as possible while still being easy
found at the end. This book is therefore suitable for differ to read.
ent target audiences. The beginner can start with the easy
material and gradually work through to the more difficult Bernhard Reichert
VIII
Acknowledgements
I have collected quite a lot of knowledge and skills from VPT's (Verband Physikalische Therapie-Physical Therapy
previous publications (Hoppenfeld, Winkel, and Vleem Association) manual therapy group, starting with Omer
ing) in this volume in addition to suggestions, tips, and Matthijs, Didi van Paridon-Edauw, and Sabine Reichel,
knowledge gained in my long involvement with anatomy are responsible for my continuing professional develop
and manual therapy. ment. Notes in the text regarding personal correspon
This book would never have come into being without a dence from the IAOM group (International Academy of
large number of people, whom I would like to thank. First Orthopedic Medicine) reflect the IAOM group's knowl
of all, I would like to thank the team atThieme responsible edge gained from years of literature studies and clinical
for the original German edition of this book. The profes experience.
sionalism of the publisher can also be judged by the qual A further great role model is Professor Andry Vleem
ity of the editor and the graphic artist. Martin Hoffmann's ing. I was permitted to observe his lectures and courses
graphics captivate with their preciseness and three over many years. Professor Vleeming and his study group
dimensional brilliance. He was able to find a good way at the Spine and Joint Centers in Rotterdam, the Nether
to demonstrate precise anatomical details while still high lands, are responsible for the enthusiasm associated
lighting particular relationships. with linking topographical, functional, pathologically
.
The Thieme Publishers team responsible for the com oriented, and palpatory anatomy.
pletion of this English edition was just as professional. A great deal of thanks goes to my model Andreas
This book has been able to reach the English-speaking Hofacker for the good teamwork and friendship. He un
public thanks to the initiative of Angelika-M. Findgott. derstood how to prepare his amazing body perfectly for
Anne Lamparter coordinated the team at all stages of the photo shoots. His cheerful nature and his excellent
the publishing process and helped and supported me in specialist knowledge have contributed to the successful
numerable times. photographs.
My next thanks go to the photographers Benjamin The biggest thanks go to my family. I tested their pa
Stollenberg and Oskar Vogl, whose enthusiasm and exper tience more than once with my many hours of writing
tise made the photo shoots pleasant and effective. spread over approximately three years. My wife, Ulrike,
I would also like to sincerely thank Mr. Wolfgang Stel and my children, Yvonne and Svenja, have followed the
zenm ueller for his chapter on the palpation of the skull development of this book with their patience and love.
and the jaw. His extensive specialist knowledge and amaz My wife is also my biggest and most important critic:
ing illustrations enhance this book tremendously. "You have to get to the point quickly and accurately."
Thank you to Sabine Reichel, who advised me in the I hope that I have done it well.
details of the anatomy of the skull, and Christiane Pauling,
who saw me through the correct procedure for the re
spiratory therapy techniques. All of the colleagues in the Bernhard Reichert
