Soft tissues, palpation

M. Tavakoli, R. R Patel, and M. Moallem, "Bilateral control of a teleoperator for soft tissue palpation Design and experiments," IEEE Inti. Conf. Robotics Automation, United States, pp. 3280-3285, 2006. 

On examination, the swelling of the joints may be visible or may be apparent only by palpation. The swelling feels soft and spongy be-causeitis caused by proliferation of soft tissues or fluid accumulation within the joint capsule. The swollen joint may appear erythematous and feel warmer than nearby skin surfaces, especially early in the course of the disease. In contrast, the swelling associated with osteoarthritis usually is bony (caused by osteophytes) and infrequently is associated with signs of inflammation. 

The cardinal clinical sign of fracture is bony tenderness and careful palpation of the injured ankle will often differentiate between a fracture and a soft tissue injury. Clinical prediction rules have been shown to be useful in determining which children with ankle injuries require X-ray investigation (Dayan et al. 2004 Myers et al. 2005). Adherence to such rules may miss the diagnosis of a small proportion of fractures but these will generally be those of little clinical significance. 

This lesion can occur when the erect penis is forcibly displaced towards the feet (Pryor and Hill 1979). Diagnosis of rupture of the suspensory ligament is made by history and by palpation of a gap between the base of the shaft of the penis and the symphysis pubis. An abnormal angle is noted during erection. Ultrasonography is able to document the gap between the pubis and the penile shaft and associated hematomas of the soft tissues (Fig. 12.5), but usually does not provide additional useful information (Bertolotto and Pozzi Mucelli 2004). 

Tenderness is the subjective sensation of pain or soreness that is reported by the patient in response to palpation of tissues by the physician. Tenderness is the most likely subjective finding. This sensation is almost always present in tissues surrounding a somatic dysfunction when the physician exerts no more than normal pressure. Pressing too firmly on soft tissues will almost always cause pain or tenderness. Pressure that should not normally cause pain will do so in tissues around a dysfunctional joint. 

Posteriorly, Chapman s reflexes are located in the soft tissues between the spinous process of a vertebra above and the transverse process of a vertebra below. For example, the posterior Chapman s point for the heart is located between the spinous and transverse process of the second and third thoracic vertebrae. The posterior points have the feel of a classic viscerosomatic reflex the operator will palpate what feels like a rubbery nodule. If the physician attempts to articulate a vertebral somatic dysfunction and the spine "bounces" away from the force, the possibility of a viscerosomatic reflex should be considered. 

The soft tissues of the thoracic area should be palpated for texture changes skin, fascia, subcutaneous tissues, and muscle. Large muscle hypertonicity or small localized areas of muscle tension should be noted. Areas of tenderness or specific Jones tender points or trigger points should be noted. 

Once the soft tissues have been palpated, the bony structures should be evaluated. The spinous processes and transverse processes are palpated and their symmetry compared. The tops of the iliac crests are in a line with the L4-L5 interspace. From this site it is possible to identify the other lumbar vertebrae. Another method for identifying the vertebrae is to find the twelfth rib and follow it to its attachment to T12. The first vertebra below T12 is LI, and the spinous processes can be counted down from there. The transverse processes lie at the same level as the vertebral body and are usually quite long in the lumbar region. They may be palpated deep to the erector spinae muscles. 

Physical examination revealed a slightly obese woman in obvious discomfort. She preferred to stand rather than sit on the examination table. The sacrum was freely movable and no somatic dysfunctions of the lumbar spine were noted. The coccyx was markedly lender to palpation and ihe soft tissues around il were tense and lender. There was a high flare-out tender point on the posterior surface of ihe sacrum. Rectal examination confirmed tenderness of the coccyx, but it was not severe enough to indicate a fracture and the coccyx was not dislocated. 

The soft tissues and bony structures are then palpated to evaluate the integrity of the bones and the presence of any tenderness, masses, asymmetries, or crepitus. Any temperature changes should be noted, especially over the bursa and around the joints. Bony landmarks should be identified and compared between elbows. Swelling, especially over the olecranon bursa, should be noted. The olecranon bursa should not be palpable unless it is filled with fluid or thickened. 

Infection of the skin or other soft tissues of the upper extremities will be apparent as an acute inflammatory event with the usual signs and symptoms of pain, heat, swelling, redness, and tenderness to palpation. Infections may be localized or may be more diffuse as in cellulitis. 

The foot and ankle may be palpated with the patient seated or supine. Soft tissues are palpated for tenderness and swelling. Tissue texture changes should be noted. Bony landmarks are palpated for any asymmetry or arthritic changes. 

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