Chapter 1

Basic Principles

1.1 Why Do Clinicians Need Surface Anatomy?

1.2 What Is Understood by Surface Anatomy in this Book?

1.3 When Can Surface Anatomy Be Used?

1.4 Workflow for Palpation

1.5 Palpatory Techniques

1.6 Palpation Aids

"You must be relaxed to have a good tactile sense"

(A. Vleeming, Berlin, 2003)

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.

Memorize

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).

General and local observation of regions of the body.

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.

Examining the craniomandibular joint.

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

"You cannot feel what you do not know."

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...