4Osteopathic Layer-by-Layer PalpationExamination Sequence

1. Observat ion2. Temperature3. Skin topography and texture4. Fascia5. Muscle6. Tendon7. Ligament8. Erythema fr ic t ion rub

ObservationPr ior to touching the pat ient , the phys ic ian shoud v isual ize the area to be examined for

ev idence of t rauma, in fect ion, anomal ies, gross asymmetr ies, skin lesions, and/or anatomic

var iat ions. The pat ient should be pos i t ioned comfortab ly so that the most complete

examinat ion can be per formed. At th is point , the pr imary interest is in changes associated

wi th somat ic dysfunct ion and any autonomic re la ted ef fects . The physic ian should v isual ly

inspect the area for c lues that somat ic dysfunct ion may be present (e .g. , hyperemia,

abnormal ha ir pat terns, nevi , fo l l icu lar erupt ions) ( Fig. 4 .1 ) .

TemperatureTemperature is evaluated by us ing the volar aspect o f the wr is t or the dorsal hypothenar

eminence of the hand. The physic ian does this by p lacing the wr is ts or hands a few inches

above the area to be tested and using both hands to evaluate the paravertebra l areas

bi la teral ly and s imul taneously ( Fig 4.2 ). Changes in heat distribution may be palpated

paraspinally as secondary effects of metabolic processes, trauma, and so on (acute versus chronic

fibrotic inflammation). Heat radiation may also be palpated in other areas of the body (e.g.,

extremities, abdomen). If unable to determine the thermal status of the region in question, the

physician may at this point make slight physical contact with the appropriate area of the palpating

hand.

Figure 4.1. Visual observation of patient.

Figure 4.2. A and B. Evaluation for thermal asymmetry.

Skin Topography and TextureA very l ight touch wi l l be used. Gent le palpat ion with the palmar sur face of the t ips of the

f ingers wi l l prov ide the necessary pressure. The pressure wi l l permi t the f inger pads to

gl ide gent ly over the sk in wi thout drag ( f r ic t ion). There should be no change in the co lor of

the physic ian 's na i lbeds. When the phys ic ian is touching the pat ient , i t is important to

expla in the nature of the examinat ion and receive the pat ient 's acceptance before

cont inu ing. Therefore, i t is impor tant to be prepared menta l ly to apply the hand as

conf ident ly and professional ly as possible.

Sk in topography and texture are evaluated for increased or decreased humid i ty, o i l iness,

th ickening, roughness, and so on.

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FasciaThe physic ian adds enough pressure to move the skin wi th the hand to evaluate the fascia.

Th is pressure wi l l cause sl ight reddening of the nai lbed. The physic ian moves the hand very

gent ly in cephalad, caudad, lef t , r ight , c lockwise, and counterclockwise di rect ions to e l ic i t

mot ion and tens ion qual i ty barr iers of ease and bind ( Fig. 4 .3 ) . Min imal changes in pressure

to evaluate the d i f ferent leve ls o f fascia are he lpful .

MuscleMuscle is deeper t issue; therefore, the next degree of palpatory pressure is appl ied. The

phys ic ian adds sl ight ly more pressure to evaluate the muscle 's consis tency and determines

whether there is rop iness, res is tance to pressure, st r inginess, and so on. This pressure wi l l

cause b lanching of the physic ian's na i lbeds ( Fig. 4 .4 ).

Figure 4.3. Fascial evaluation for ease– bind asymmetry.

Figure 4.4. Blanching of the nail bed with muscle depth palpation.

TendonsTendons should be traced to the ir bony at tachments as wel l as to thei r cont inu i ty wi th

muscle. Any f ibrous thickening, change in e last ic i ty, and so on should be noted.

LigamentsLigaments must be considered when restr ic t ion of jo int mot ion, hypermobi l i ty ( jo in t laxi ty) ,

pa in, and so on are present . Obviously, l igaments vary in type and are more or less

palpable depending on the ir anatomic p lacement.

Erythema Friction Rub

The f inal s tep is to per form the ery thema f r ict ion rub, in which the pads of the physic ian 's

second and th ird d ig i ts are placed just paraspinal ly and then in two to three quick st rokes

drawn down the sp ine cephalad to

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caudad. Pal lor or reddening is evaluated per spina l segment for vasomotor changes that

may be secondary to dysfunct ion. This is not typica l ly done on the extremit ies, as the

purpose of th is test is to ident i fy cent ra l spina l areas of autonomic change re lated to

segmental dysfunct ion (Fig. 4 .5 ).

Figure 4.5. A to C . Erythema friction rub.

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Thoracic Region Cross-Section

Lumbar Region Cross-Section