PALPATION TECHNIQUE

PALPATION TECHNIQUE

Palpation is the only test currently recommended for identifying PGMs and reliability depends on the experience and skill level of the physician. This finding has implications for clinicians and training programs, which should emphasize developing precise PGM palpation skills before educating students on specific treatment options. Palpation techniques include pincer grasp and flat palpation and form the basis of the physical examination technique. These techniques are also used as processing methods for PGMs. A thorough understanding of the anatomy, location and insertions of muscles, direction of muscle fibers and muscle layers greatly improves accuracy and the ability to properly palpate muscles. Muscles should be palpated with the patient in a relaxed position, with optimal passive tension on the muscle to expose the taut fascia. The degree of tension or loosening required depends on the individual patient. In patients with hypermobility, such as Ehlers-Danlos syndrome, the muscle often needs to be placed in a tense position, while in other less mobile patients, the muscle may need to be placed in a more relaxed position. The optimal position is where the doctor can obtain useful information.

This statement may be obvious, but attention to placement is important for clinical efficiency and effectiveness. The doctor palpates perpendicular to the direction of the muscle fiber to identify the taut fascia. During the examination, the muscle is palpated with sufficient compression to induce local pain. It is not always necessary to cause referred pain, but if desired, the PGM may need to be compressed for at least 15 seconds as it may take some time for referred pain to appear. Some muscles have problems with palpation, as these muscles may not be accessible. Consider, for example, the difference between flat palpation of the accessible infraspinatus muscle and limited palpation of the less accessible subscapularis muscle.


• Flat palpation: finger or thumb pressure is applied directly to the muscle in a direction perpendicular to the direction of the muscle fiber, while the muscle fibers are compressed against the underlying tissue or bone. An example is palpation of the infraspinatus and the small flat plate against the scapula.


• Palpation with forceps: a grip with forceps is used between the doctor's fingers and thumb, always essentially perpendicular to the direction of the muscle fiber. Muscle fibers are rolled into the socket to allow for tissue examination. For example, forceps palpation is used to palpate MTrPs in the superior trapezius muscle and axillary portions of the pectoral major and latissimus dorsi muscles.

PALPATION RELIABILITY

Currently, no gold standard diagnostic imaging or laboratory test exists for MTrPs, and clinicians must rely on the history and physical examination findings for the diagnosis of myofascial pain.  Because of the reliance on physical examination, adequate intrarater and interrater palpation reliability for the identification of MTrPs is important in construct validity. Nine published studies addressed MTrP palpation interrater and intrarater  reliability of various subjects and muscles. Palpation reliability studies were systematically reviewed by McEvoy and Huijbregts, who used the Data Extraction and Quality Scoring Form for Reliability Studies of Spinal Palpation. The review concluded that MTrPs can be reliably identified in certain muscles, but a caveat to these findings is that reliability depends on a high level of rater expertise, training, and consensus discussion on technique. Furthermore, location of MTrPs by palpation in the upper trapezius was found to be highly reliable when a threedimensional infrared camera was used for assessment.


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