"Rubbish," I said to myself. But then over the last year I began to ask my fellow chiropractors questions concerning cervical spine anatomy. I realize that we need not be anatomists, however if we expect to be recognized as the best at what we do then we should at least know the names, general origins and insertions and agonist/antagonist actions. You may want to try this for yourself: Draw a simple cervical vertebra and then put an X where the muscles attach and/or pass by en route to their final attachments. You should be able to get at least 16 or so in all three areas of the spine: now add the ribs and put in the muscles that attach to the ribs that impact, for example, on the motion of the C2 vertebra.
The point I'm attempting to make here is that if you are not aware of the normals, then how is it possible for you to determine the abnormals and formulate a diagnosis? In other words, "Hey, Doc, what are you palpating?"
This applies to muscles, osseous, and neurological anomalies as well. B.J. Palmer once stated that chiropractors, one day, should be paid similar to surgeons; would you go to a surgeon who did not know anatomy? I think not! I wonder then why should we expect other professionals and the public to refer patients to us if we do not know what lies beneath our fingers. There is no question that our colleges provide us with the information to get into practice, but this information is just the tip of the iceberg and is really a license to begin the educational process of learning and studying new and improved methods, just as our founders did: constantly changing and the seeking out of better, more efficient ways to get sick people better.
Palpation is a learned process. It takes time and knowledge of anatomical structures, and a consistency that is hard to master. There is no better way to learn (or re-learn) the anatomy of the body and peripheral nervous system than by palpating. Palpation has been described by some as seeing with your fingers, as it opens an awareness and appreciation for the consistencies and the anomalies that co-exist in our bodies. Palpation is one of the things that separates us from other health care givers. We touch and feel the tissues and bones of our patients while replaying anatomy texts in our heads and looking to the cause of the patients distress. We adjust with our hands taking up slack and utilizing tissue sense to deliver the thrust at the right moment and in the right direction.
Palpation creates an awareness and appreciation of the huge variables that exist in our patients. Sacral nutation in static upright weightbearing posture, for example, is not the same as when the patient is either prone or supine and has an enormous impact on leg length. A trochanteric shift, the result of an inversion ankle sprain or poorly fitting orthotics, can evoke a force closure of the iliosacral joint and counter rotation of the ilia, also resulting in leg length inequalities. Iliosacral obliquity can be created in the supine or prone position to create an illusion of leg length discrepancy. Palpation can and does tell us a lot, but you must be aware of your normal anatomy.
Nerves can be palpated. Nerves are not symmetrical nor are they homogeneous structures.
- Palpation of the ulnar nerve at the elbow or upper arm creates a paresthesia.
- Palpation of the radial nerve as it bifurcates at the elbow creates a local pain and may over time cause a paresthesia.
- In the lumbar spine a posterior to anterior pressure applied to the area supplied by the posterior primary rami (you should know this without looking it up) should result in a pain from deformation, a form of mechanical traction or paresthesia.
- When palpating or producing an anterior to posterior shear of the talocrural joint with either internal rotation or external rotation of the tibia and the thumb overlying the talus, the peroneal nerves are palpated.
- The sciatic nerve can be palpated between the ischial tuberosity and the greater trochanter; it can also be followed down the leg, a very useful palpatory test.
- The tibial nerve can be palpated in the popliteal fossa where it lies lateral to the popliteal artery and vein, a great peripheral pulse to be taken when dealing with leg pains. The tibial nerve is also palpable posterior to the medial malleolus, where it is often confused with the tendons, as it is very thick and round at this location. The tibial nerve can often be followed distally and palpated as it bifurcates to form the medial and lateral plantar nerves.
- The common peroneal nerve can be palpated medial to the tendon of the long head of the biceps and can be traced around the head of the fibula. The nerve can be sensitized by inversion ankle sprains through lateral compartment involvement which (with inflammation, adhesions, and time) could result in an inability of the tibialis anterior to function in harmony with the peroneus longus during the normal gait cycle; the longitudinal-muscle-tendon-fascia sling.
On the dorsum of the foot the superficial peroneal nerve is quite accessible to palpation when the foot is plantar flexed and inverted; in some it can be followed proximal for a short distance. The deep peroneal nerve lies between the first and second metatarsals. It is often confused by inexperienced examiners as the soft tendon of the extensor hallucis longus, but the nerve is hard and round.
- The sural nerve can be palpated on the lateral aspect of the foot and can be traced proximal posterior to the lateral malleolus and parallel to the Achilles' tendon. Dorsiflexion and inversion make this much easier to palpate. The femoral nerve lies lateral to the femoral artery, inferior to the inguinal ligament and can be palpated with some difficulty.
- The saphenous nerve, from the femoral nerve, can be palpated between the tendons of the sartorius and gracilis at the level of the medial joint line of the knee. Lying on the proximal aspect of the tibia is the infrapatellar branch of the saphenous nerve which, like the ulnar nerve is susceptible to motion.
- The lateral femoral cutaneous nerve is often accessible to palpation at a location approximately 1cm medial to the ASIS.
- The brachial plexus and the posterior cords are somewhat palpable, as is the suprascapular nerve at the lateral aspect of the base of the neck, shoulder depression will be an aid to the locating of these structures.
- In the axilla the median, ulnar, and radial nerves are readily palpable.
- In the forearm the superficial radial nerve can be felt and flicked with a finger nail at the lateral and volar aspect of the radius. The nerve will feel hard and the tendon of the brachioradialis will feel soft. The nerve can be followed into the anatomical snuff box where it is easily located.
- The ulnar nerve can also be palpated just medial to the hook of the hamate.
- The greater occipital nerve can be located and felt as it exits through the fascia at the base of the skull.
From this it should be obvious that a concise and accurate understanding of human anatomy is a huge asset in your formulation of a diagnosis and subsequent treatment plan. Better still, when a sensitive spot is elicited, think of all the possible structures, conditions, and/or causes that could result in this response and use symptom analysis and structural differentiation to find just what the cause for this sensitivity is.
Keith Innes, DC
Ontario, Canada