Palpation Techniques-Surface Anatomy for Physical Therapists - Bernhard Reichert

Palpation Techniques 261 Step 3: The LS spinous process is found approximately one finger-width (patient's index finger) superior to 5 1 . Its loweredge is reached by sliding the finger pads superiorly over the slanting sacrum until the tips ofthe fingers come across an explicitly hard object ( Fig. 1 0.45). The inferior edge of LS is mostly felt to be a step superior to the LS­ S 1 interspinous space. Tip: This palpatory step is im perative and must be confirmed through further information and using pal patory aids. Comments on Pathology Fig. 1 0.46 Posteroanterior pressure on 5 1 . In cases of severe spondylolisthesis in LS-5 1 , a local in­ crease in the lordosis with the formation of a step can be palpated between LS and 5 1 on slim patients (ski jump phenomena; Wittenberg et aI., 1 998). This palpatory re­ sult can be reached in the prone or standing 5P. Caution: these conclusions may not be reversed ! Not every pal­ pated step has to indicate the presence ofa spondylolisth­ esis. Confirming the Palpation Using the Shape and Fig. 1 0.47 Assessment of end feel at L5-phase 1 . Size of Structures Based on the anatomy described, it is normally expected that the LS spinous process has a smaller and rounded shape that juts out posteriorly. The Ll -L4 spinous pro- cesses are very long (superior-inferior dimensions). Oe- spite this anatomical knowledge, it may be confusing and difficult to locate LS, especially when the 51 spinous process has a distinct form. In this case, its shape and size are similar to LS. Confirmation Using the Assessment ofEnd Feel Fig. 1 0.48 Assessment of end feel at L5-phase 2 . Using anteriorly directed pressure to differentiate be­ Tip: Naturally, this differentiation technique should n o t be tween LS and 51 is diagnostically conclusive. The medial side ofthe hand is placed on the point where the therapist performed if the therapist suspects it will provoke pain. assumes Sl to be.The other hand is placed on top of it ( Fig. 1 0.46). The therapist then pushes their hand in an ante­ Confirmation Using Movement rior direction using slow oscillations. If pain is not pro­ voked by this, the therapist pushes down firmly one Another option is to feel the way LS moves when postero­ more time to clearly assess the posteroanterior end feel. anterior pressure is applied. The therapist starts by searching for the assumed position of the LS/51 interspi­ The same maneuver is performed over the point where nous space with their finger tip. Both of the neighboring the therapist assumes LS to be. The thumb is first placed spinous processes should be felt. The thumb or the hy­ over the point to emphasize the pointed spinous process pothenar eminence is then used to apply pressure to the ( Fig. 1 0.47). The thumb is then reinforced using the med­ ial side of the other hand or the thenar eminence ( Fig. 1 0.48). Rhythmical posteroanterior pressure is then reap­ plied and finishes with the end feel being assessed by firm pressure. The results of both of the posteroanterior pushes are now compared. It is expected that 51 will only minimally yield to pressure and that its end feel will be almost hard. LS usually yields significantly more to pressure and has a firm-elastic end feel.

262 10 Lumbar Spine superiorly located spinous process. It is expected that the superiorly lying spinous process moves anteriorly and the inferior spinous process stays still. This attempt at differ­ entiation between the assumed localization of 5 1 and 52 results in no movement. This technique is also used to dif­ ferentiate between the other lumbar spinous processes and is also illustrated below. Tip: Both of the last tests for confirmation are based on the Fig. 1 0.49 Palpating L4/L5 presumption that L5 moves a nteriorly when a posteroanterior pressure is applied and that Sl remains immobile. Regardless of how helpful and i nformative both of these tests may be, some inaccuracy remains. These tests are not useful when variations in the anatomy are present in terms of hemisacra­ lization or restriction in segmental movement at L5/S 1 . In this case, the position of L5 can only be confirmed by comparing its size to L4 and L3. These spinous processes are usually sig­ nificantly longer than L5. Summary 1. Locate the PSIS and the 52 spinous process. 2. Palpate in a superior direction from 52 onto 51. 3. Palpate the inferior edge of the L5 spinous process. 4. Confirm its position using a posteroanterior pressure with the assessment of end feel. 5. Confirm its position using posteroanterior pressure with movement. 6. When necessary, confirm its position by locating the first long spinous process (L4). Fig. 1 0.50 Palpating L3/ L4 Locating Additional lumbar Spinous Processes good measure, the finger should be kept on the inferior edge of L5 for the moment. If the therapist is unable to The other lumbar spinous processes can be sought after find the inferior edge of L4, they can always start the pro­ the L5 spinous process has been located as correctly as cedure again from L5. The suspected location of the infer­ possible. The therapist can be sure that they have located ior edge of L4 is marked. the respective spinous process correctly by: Step 2: The same technique is used to locate the L3 spinous • Examining its shape and size. process: the finger remains over L4/L5 and the next super­ • Using movement to confirm the position. iorly lying interspinous space is sought (Fig. 1 0.50). All further spinous processes can be found using this method. As has already been mentioned, the Ll -L4 spinous pro­ cesses are rather broad and have an extremely irregular Tip: Therapists should not let the length of the L4-L1 spinous shape with indentations along their posterior aspect, giv­ ing them an undulating appearance. The waves formed by processes u nsettle them. They should trust their instincts. the spinous processes are found on the sides and poster­ iorly and imitate the presence of an interspinous space. Step 3-Confirmation with movement: To-confirm the cor­ To precisely locate the interspinous space, the therapist rect localization of an interspinous space, the therapist palpates along the side of the spinous process until a moves the segment. The movement can be felt by the pal­ gap becomes apparent. It is less reliable to palpate poster­ pating finger. An interspinous space has been correctly lo­ iorly as the supraspinous ligament is solid, fibrotic, and cated when the superiorly lying spinous process moves may be tensed, preventing the therapist from gaining ac­ and the inferior spinous process remains immobile. This cess to the expected gap. is achieved by placing a finger pad posteriorly over the in­ terspinous space. The confirmation of the L3/L4 interspi­ Step 1 : The inferior edge of L5 is marked using a short line. nous space is demonstrated in Fig. 1 0.51. The thumb The therapist palpates to the side of this in a superior di­ pad applies oscillating posteroanterior pressure to the rection. The space between the L4 and L5 spinous pro­ L4 spinous process superior to the position where the cesses is felt after a few millimeters ( Fig. 1 0.49). For therapist assumes the interspinous space to be. The pal-

Palpation Techniques 263 Fig. 1 0.51 Confirmation with movement. Fig. 1 0.52 Iliac crest and the 1 2th rib. pating finger pad can feel the superior spinous process moving up and down in the interspinous space. Tips: The posteroanterior push does not have to be particu, Fig. 1 0.53 Confirming the position of the iliac crest. larly strong. It is the returning movement. not the downward movement. that can be felt best. The posteroanterior push should therefore be released very quickly to ensure that the tip of the palpating finger can gain clearer information. When the anatomy of a patient makes localization difficult. this technique may have to be repeated several times to confirm the correct palpation of the interspinous space. It is helpful to mark the superior and inferior edges of the spinous process so that the therapist can always proceed from a confirmed point. All spinous processes in the functional sec­ tion of the lumbar spine can principally be found and marked on the skin using this method. The thoracolumbar junction is reached when the size of the spinous processes changes abruptly. The spinous processes are more pOinted again superior to T1 2. Palpating from a Superior Position via the T1 l Spinous Process Locating the T1 1 spinous process via the 1 2th rib is ideal for quick orientation in the thoracolumbar region. The tips of the 1 2th rib hang freely in the posterolateral trunk wall. Step 1 : To find the 1 2th rib. the therapist first orients Fig. 1 0.54 Locating the 1 2th rib. themselves on the lumbar back extensors and then moves laterally in the space between the iliac crest and the infer­ Tip: It is important that the therapist palpates rather medially. ior costal arch. This space usually measures only two fin­ near the back extensors. The therapist will palpate the 1 1 th ger-widths ( Fig. 1 0.52). rib if they palpate too laterally. On pressure. the 1 2th rib does Step 2: A perpendicular technique is used next to confirm not have the typical hard osseous consistency. As already the position of the iliac crest ( Fig. 1 0.53). The therapist mentioned. this rib is relatively mobile and hangs freely in the then turns their palpating fingers in a superior direction. trunk wall. making it more mobile than the ribs with direct or attempts to locate the inferior edge of the 12th rib ( Fig. indirect contact to the sternum (1 st-1 Oth ribs). The 1 2th rib 1 0.54). and encounters a very firm structure relatively must be able to move out of the way of the iliac crest when quickly. extensive lateral flexion is being performed.