REIDER PART 1 22
10 Chapter 1 Terms and Techniąues
Figurę 1-7. Use of the goniometer to measure elbow motion.
contribute to the joint motion. These factors include morphology of the bones involved and tightness of the muscle-tendon units that cross the joint. Nevertheless, the term ligamentous laxity enjoys broad usage.
Four specific tests are widely used to evaluate gen-eralized ligamentous laxity (Fig. 1-8): (1) ability to hyperextcnd the elbows, (2) ability to passivcly touch the thumb to the adjacent forearm, (3) ability to pas-sively hyperextend the index finger metacarpopha-langeal joint morę than 90°, and (4) ability to hyperextend the knees. A person who can perform three or four of these tests is usually considered ligamentously lax. Screening for generalized ligamentous laxity may be an important adjunct to a specific joint examination. In multidirectional instability of the shoulder, for example, the presence of generalized ligamentous laxity is thought by many surgeons to influence the success ratę of surgery.
■ PALPATION
Palpation is the process of examining a body part by pressing on it, usually with the fmgertips. Palpation has many purposes. First, it can be used for orientation. Careful palpation can help the examiner identify the loca-tion of specific anatomie structures. This, in turn, can aid in the interpretation of symptoms or facilitate the performance of other portions of the physical examination. By determining the location of specific easily recogniza-ble structures, or landmarks, the examincr can estimate the location of other structures that are not otherwise identifiable. Often, the distinction between inspection of surface anatomy and palpation is somewhat arbitrary because many structures can be seen only in leaner patients and must be palpated in others. In this way, the processes of inspection and palpation intermingle in a continuous give and take.
The second purpose of palpation is to elicit tender-ness. Tenderness is a semi-objcctive finding. It requires the patient to inform the examiner verbally or physically that palpation of a given structure is painful. Tenderness must therefore always be interpreted with the knowledge that conscious deception or unconscious overreaction may be playing a role in the patients response. Never-theless, the identification of point tenderness is one of the most powerful tools in the clinicians armamentarium. Point tenderness can confirm or strongly corroborate such diagnoses as stress fracture, tendinitis, ligament sprain, or abscess. Palpation can pinpoint the specific structure involvcd in an injury. For example, careful palpation can refine a diagnosis of sprained ankle to one of sprained anterior talofibular ligament.
The third purpose of palpation is to verify the conti-nuity of anatomie structures. Careful palpation of an injured Achilles tendon, for example, will often allow the examiner to identify the discontinuity that confirms the diagnosis of Achilles’ tendon rupture. In the same way, palpation can help assess the severity of an injury. For example, palpating an identifiable divot in a strained quadriceps m uscle documents the presence of a severe muscle injury.
During palpation, the temperaturę of the area being examined can be assessed. In this manner, the warmth associated with infection or posttraumatic inflammation can be detected. Conversely, the coldness caused by vas-cular compromise or the transient vasocon$triction of reflex sympathetic dystrophy can be detected. Changes in temperaturę can often be quite subtle, so the examiner should always palpate the opposite limb simultaneously when a temperaturę change is suspected.
Palpation has special uses in the cxamination of neu-rovascular structures. By palpating pulses, the continuity of major arteries can be verified. Pressure on peripheral nerves can elicit or amplify pain or paresthesias, thus con-firming the diagnosis of a nerve injury or entrapment. Percussion of the peripheral nerves can yield similar infor-mation and is also described in the Palpation sections.
The question is often asked, “How much pressure should be applied during palpation?” In generał, palpation should be initiated with minimal pressure, especially if tenderness is anticipated. The amount of pressure can then be progressively inereased when the examiner is cer-tain that light pressure does not cause excessive discom-fort. In generał, the deeper the structure, the greater the pressure necessary to palpate it.
The contents of the Palpation section of cach chapter are not exhaustive. In truth, the number of structures that can be palpated is legion. Any anatomie structure that is identifiable by touch or that may become tender may be palpated. The structures described in each Palpation section should serve as a basie framework for the clinician. As a clinicians knowledge of anatomy grows, the useful-ness of palpation expands as well. For reasons of visual
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