1.1 Why Do Clinicians Need Surface Anatomy?
The need to locate anatomical features on living subjects for the purpose of assessment and treatment has existed since the beginning of professional training for massage therapists, physical therapists, and physicians.
In medical and health care training programs, information on the position, appearance, and function of musculoskeletal structures is mostly communicated verbally, with the support of two-dimensional illustrations.
Due to the enormous flood of information, students of anatomy quickly find study material dry and abstract. Didactic-style training programs demonstrate the functional importance of a specific structure within a kinematic complex or a complicated motion sequence. Using a large number of illustrations, they also convey only an approximate three-dimensional idea of that structure, which quickly exhausts the amount of time and materials available to students.
In addition, students are often unable to recognize anatomical features on specimens, for example, when they visit a pathological institute during basic professional training or continuing education courses. It is likewise rare that theoretical knowledge is successfully transferred onto living bodies. Surface anatomy (anatomy on living subjects) becomes a part of professional training that is mentioned in passing; a coincidence during the assessment and treatment of patients; the object of troublesome self-learning; and the content of expensive continuing education courses.
The anatomical images used for training and further education are often drawings demonstrating an idealistic norm. These drawings breach a basic principle of anatomy: variation (Aland and Kippers, 2005). The concept of the anatomical norm cannot be standardized. Rather, it has to include inter-individual (between two people) and intra-individual (left-right) variations in position and shape. Old anatomy books teach us about possible variations in certain topographical and morphological properties, something that modern anatomy books often lack. For example, the classic anatomy book by von Lanz and Wachsmuth Praktische Anatomie (2004a), describes the percentage of the population who have differently shaped or nonexisting structures; for example in 5 to 20% of the population the lumbar spine does not possess a fifth lumbar vertebra (depending on which anatomical study is cited). Töndury (1968, in von Lanz and Wachsmuth 2004a) wrote about the abundance of variation in all spinal section boundaries: “Only approximately 40% of all people have their boundaries [of the sections of the spine] in the normal location.”
What should we do when we lose our confidence in topographic orientation—the knowledge gained from our training—when coming across a variation? First of all, it is important to keep an open mind and be prepared to accept anatomical anomalies when palpating. Experience in palpating and faith in anatomical facts found in every individual take on an even greater significance. Certain structures remain constant in position and shape and can be identified without a large degree of variation; for example, the iliac crests, the scapula, the sternum, and the 1st to 10th ribs. Recognizing variants takes experience.
The palpation procedure starts with the therapist assuming the topographic standard and transferring this knowledge to the situation in the living body. The first step involves therapists attempting to locate a certain structure. They then imagine the structure’s approximate position and shape and start palpating with these details in mind. With the right technique and proper expectation of what you should feel, along with sufficient experience, you will soon become successful.
The less confident you are using concrete structural details for orientation, the more helpful technical tricks, guiding structures, or drawings become in confirming that the correct structure has been palpated.
It is highly likely, therefore, that in the treatment setting, important anatomical features cannot be located, and the error rate in local treatment becomes inevitably high. This is something that neither physicians nor therapists can really afford.
1.2 What Is Understood by Surface Anatomy in this Book?
This book deals with both clinically relevant structures in the musculoskeletal system and accessible conductive pathways (blood vessels and peripheral nerves). It uses precise palpation to systematically transfer topographical anatomical knowledge onto living bodies. Therapists should be provided with a logical system to locate relevant structures quickly and reliably. This toolbox of techniques not only includes the actual palpation, it also gives therapists indications of what to expect when searching for a structure and the difficulties they may encounter.
This book is not about reinventing palpatory techniques, but about the clarification of procedures and the detailed documentation of techniques in words and pictures. The substantial number of illustrations allows therapists to monitor their execution of the techniques. The descriptions allow even visually impaired clinicians to reliably locate each structure after hearing the text.
Some authors who have also dealt with surface anatomy (e.g., Winkel, 2004) incorporate the following in their books:
Surface topography (dividing the body into different regions).
Anthropometric methods (e.g., measurements of length and circumference).
These aspects have been deliberately left out of this book, and readers should understand the term “surface anatomy” as a system used for palpation only.
1.3 When Can Surface Anatomy Be Used?
The precise palpation of structures is used in physical therapy assessment and treatment.
1.3.1 Physical Therapy Assessment
A physical therapy assessment comprises the following:
Defining the areas to be treated.
Confirming the presumed location.
Examining the consistency of skin and muscles.
Extremities: The provocation of ligaments, tendons, insertions, joint capsules, etc.
Spinal column: The provocation of local segmental parts and assessment of segmental mobility.
One of the aims of assessment is to identify the affected structure by applying a specific test to provoke the patient’s current symptoms. The accuracy of tests and the interpretation of their findings are quite refined nowadays; nevertheless, it is not always possible to differentiate a painful tendon from a group of synergistic muscles, for example.
Often, the possible causes of pain in a structure are spread over only a few centimeters. For example, in one muscle the cause could be located at the site of insertion, the tendon, or the junction between the muscle and the tendon. Only provocative precise palpation is of help in these instances.
1.3.2 Basic Principles of Regional or Local Treatment
Treatment is based on the following methods:
Regional treatment: Swedish massage, functional massage, connective tissue massage, electrotherapy, hydrotherapy, heat therapy, balneotherapy, and manual therapy techniques.
Local treatment: segmental oscillations for pain relief, local segmental manual therapeutic mobilization techniques to maintain or improve mobility, cross-frictions according to Cyriax, and colon massage.
Disorders of the musculoskeletal soft tissue usually appear in very localized areas. Only large traumas or inflammation spread over larger areas. Physical therapy interventions for the treatment of soft-tissue conditions also include local, thermic, electrotherapeutic, and mechanical interventions. Local application of these treatments can only be effective if applied precisely to the affected structure.
Accurate location of an affected site is ensured only through the experienced and reliable use of palpatory techniques.
1.4 Workflow for Palpation
This simple phrase illustrates the necessity of a solid background in topographical and morphological anatomy for local palpation. It does not make sense to look for a specific transverse process if you are unable to visualize its shape, position, and spatial relationship to its surroundings.
It is always a difficult task to recall the exact anatomy of a clinically relevant structure. A lot of time and motivation are needed to deal with this considerable amount of information. For this reason, two short theoretical sections can be found at the start of each topic:
The significance and functional importance of each region and its individual parts. This acts as an introduction to the topic and refers to current knowledge about the fascinating interplay between individual parts.
Required basic anatomical and biomechanical knowledge. It is extremely useful to recall topographical relationships again before searching for specific structures. Important anatomical details required for palpation are therefore mentioned in the text and highlighted in the figures.
▶ Fig. 1.1 shows the procedure to be used for palpation.
1.4.1 Objective and Location
The objective of precise palpation of detailed structures is to obtain local orientation for assessment and treatment based on the reasons described above.
The therapist should start with the areas that they know best. The description of the palpatory process generally starts with the palpation of known and easy-to-reach bony structures (e.g., sacrum, occiput) and muscles (erector spinae, semispinalis).
1.4.2 The Reliable Result
Certain measures (tensing specific muscles, passive vertebral movement, etc.) can be applied to test whether the structure in question has actually been found. It is also helpful to draw the structure or its borders on the skin. This obliges the therapist to determine and then document that the structure is actually located where indicated by palpation and drawing. This is even more interesting when students are palpating in a small study group and comparing their results.
In his courses, Vleeming (personal communication), the founder of the Rotterdam Spine and Joint Centre and pioneer of targeted palpation, recommends drawing the palpated structure for each palpation session, including palpation carried out on patients.
Every author on precise palpation writes about the importance of practical experience. The author of this textbook believes that each structure should be deliberately and correctly palpated at least 10 times to achieve an approximate idea of the technique to be applied and the location and shape of the structure.
▶ Fig. 1.2 summarizes the prerequisites for surface anatomy in an empirical formula.
1.4.3 Central Aspects of the Procedure
Three essential features characterize the palpatory process:
As explained above, topographical and morphological knowledge and experience in precise palpation are crucial. Each structure requires a certain palpatory technique, and it is necessary to have an idea about what the structure should feel like. Before palpating, it is also important to know exactly what type of resistance the palpating finger will encounter when it exerts pressure or slides over the structure being sought.
For example, the exact location of a bony edge is found by palpating at a right angle to the edge being sought. The structure is expected to have a hard consistency. The position and shape of a structure can be correctly found among the surrounding tissue when the therapist is able to differentiate between the different types of consistencies found in the different tissues.
Soft, elastic tissue is examined slowly to perceive the elasticity.
Hard tissue is examined with a quick movement to feel the hardness.
These principles are also recommended when assessing the end-feel using angular tests (passive functional tests) and translation tests (joint play tests).
1.4.4 Pressure Applied during Palpation
The palpation pressure is usually selected by applying a given technique in a downward direction.
In general, the amount of pressure applied should be as much as necessary and as little as possible.
It is definitely incorrect to insist that palpation is always conducted with minimal pressure. The amount of pressure applied depends on the following:
The expected consistency of the targeted structure. For example, if you are searching for a bony edge or prominence, it is correct to assume that it will feel hard when direct pressure is applied to it. In this case, the palpation tends to be performed with more intensity so that the hard tissue response can be felt. Soft tissue is detected using less pressure. It is impossible to perceive its resilience if too much pressure is applied.
The firmness and thickness of the more superficial tissue. Deeply located bony landmarks covered by a strong muscular layer or a layer of fat cannot be reached by palpating lightly.
A dexterous therapist can easily locate the structure sought and the expected consistency by using the appropriate technique and the suitable palpation pressure.
1.5 Palpatory Techniques
1.5.1 Palpating the Skin
Skin quality: the palm of the hand strokes the skin.
Skin temperature: the back of the hand strokes the skin.
Skin consistency: displacement test, skin lifting test, skin rolling.
Skin quality: smooth, pliable skin. Light hair growth is sometimes present.
Skin temperature: uniform body temperature.
Skin consistency: soft and very elastic. The skin becomes firmer when more tension is placed on it.
▶ Commentary. The skin qualities described above represent the ideal situation for young patients. Needless to say, age-related changes to the skin should not be immediately classified as pathological.
The skin’s consistency is determined by the balance of fluid in the skin. Elasticity tests are used to assess the consistency of skin and include the displacement test, lifting test (▶ Fig. 1.3), and skin rolling. All three tests should provide identical results. The same amount of elasticity, sensitivity, and changes in these parameters should be found. If this is not the case, techniques should be reassessed or patients questioned again. These tests place different tensile stresses on the skin. The displacement test can be used to find a sensitive or significantly inflamed region; small changes in consistency can be detected especially well using skin rolling with a large amount of stretch.
Experienced therapists need only use one of these tests when working with patients. The choice of test depends on the sensitivity of tissues. In principle, skin rolling provides therapists with the largest amount of information.
1.5.2 Palpating Bony Edges
▶ Examples. Spine of the scapula (▶ Fig. 1.4), edge of the acromion, joint line of the wrist, a variety of joint spaces, iliac crest, rib shaft, spinous process, mastoid process, mandibular arch.
▶ Technique. The fingertip palpates perpendicular to the edge of the bone.
▶ Expectations. Hard consistency and a clearly defined border.
▶ Commentary. This technique enables the therapist to accurately locate the outer boundaries of a bone. The palpating finger must always be positioned perpendicular to the edge of the structure. All other techniques are less reliable. This is particularly important when looking for the component bones of small joints and for delineation of the intra-articular space.
To feel the hard consistency and palpate the bony edge distinctly, the therapist should palpate the soft tissue first and then gradually move toward the presumed location of the bony edge.
It becomes increasingly difficult to locate bony contours when superficial tissue is tense. Muscles tense up when patients are seated in an unsupported position. Tension increases in all soft tissue when the SP alters the normal curvature of the spine, and tissue is stretched, for example, when padding is placed under the abdomen in the prone position or when sitting patients place their arms in front of them on a treatment table.
Arthritic swelling and bone deformations change the expected consistency and contour of the target structure at the affected joint.
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