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Palpation is a widely used examination technique in the assessment of muscle tone, which is also referred to as tension, tightness, or stiffness. Physiotherapists and clinicians use palpation to evaluate muscle tone by feeling the resistance of the tissue against their fingers. This technique is subjective and may vary depending on the patient's position and demeanour. To perform an accurate palpation, examiners should observe the patient's eyes and facial expressions for involuntary muscle movements that may indicate pain. Palpation is typically done in conjunction with other techniques such as inspection and manipulation to assess muscle tone and make informed clinical decisions.
| Characteristics | Values |
|---|---|
| Definition | Muscle tone is defined as "resistance to passive movements" |
| Palpation Technique | Physiotherapists commonly use digital palpation to assess muscle tone. |
| Purpose | To assess muscle tension, tightness, or subjective stiffness |
| Assessment | Muscle tone is assessed by feeling the resistance of the tissue against the palpating finger |
| Comparison | Therapists compare resistance with experience from previous practice or between muscles of one individual |
| Patient Position | Evaluate muscle tone in different positions (in recumbency and when standing) |
| Observation | Observe the patient's eyes while palpating the joints and surrounding structures |
| Inspection | Inspect the size, contour, and symmetry of muscles and joints |
| Muscle Strength | Muscle strength should be equal bilaterally |
| Range of Motion | Observe the patient's active range of motion and, if necessary, attempt passive range of motion |
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What You'll Learn
Palpate joints for warmth, swelling, or tenderness
Palpation is a widely used technique to assess joint warmth, swelling, or tenderness. It is a standard practice for physiotherapists to use palpation to assess muscle tone and make clinical treatment decisions. During palpation, the examiner assesses the resistance of the tissue against their palpating finger. This technique is used to determine the exact location of a patient's pain and identify the specific anatomic parts involved.
When palpating for joint warmth, swelling, or tenderness, it is important to follow a systematic approach. For example, when examining the knee, the Joint Line Tenderness (JLT) test is commonly used. This involves palpating each side of the tibiofemoral joint line separately to evaluate maximal joint line sensitivity. The knee is flexed at a 90-degree angle, and the medial and lateral joint lines are palpated separately, moving from the anterior to the posterior aspect of the knee.
Similarly, when palpating the ankle joint, examiners use their thumbs to feel the anterior aspect of each ankle joint, noting any swelling or tenderness. They may also palpate along the Achilles tendon for nodules and tenderness. Palpation of the heel, especially the posterior and inferior calcaneus, as well as the plantar fascia, can provide valuable information about tenderness in the area.
In addition to the lower limbs, palpation can be used to assess muscle tone and joint health in the thoracic and pelvic limbs. For example, the biceps and triceps reflexes can be elicited in dogs by lightly tapping the tendon of insertion of the triceps or placing a finger on the distal ends of the biceps and brachialis muscles. This technique can help assess muscle tone and identify any indications of atrophy.
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Observe involuntary muscle movements around the eyes
To observe involuntary muscle movements around the eyes, one must first understand the different types of eye muscles and their functions. There are six extraocular muscles that work together to facilitate eye movement and enable clear vision. These muscles include:
- Superior Rectus Muscle: Responsible for upward eye movement.
- Inferior Rectus Muscle: Moves the eye downward.
- Medial Rectus Muscle: Pulls the eye inward, towards the nose.
- Lateral Rectus Muscle: Moves the eye outward, away from the nose.
- Superior Oblique Muscle: Responsible for depressing the eye and slight inward rotation.
- Inferior Oblique Muscle: Elevates the eye and rotates it slightly outward.
In addition to these six muscles, there are two other important muscles located within the iris: the Ciliary Muscle and the Iris Sphincter Muscle. The Ciliary Muscle is ring-shaped and located directly behind the iris, while the Iris Sphincter Muscle is found within the iris itself.
When observing involuntary muscle movements, it is crucial to be aware of any signs of eye movement disorders. One common disorder is strabismus, which occurs when the two eyes do not line up in the same direction, resulting in "crossed eyes" or "walleye." This condition can be detected through the Cover Test, where the patient focuses on a distant object while one eye is covered, and the uncovered eye is observed for any movement. Another disorder is nystagmus, characterized by involuntary, rapid, and repetitive eye movements that can be horizontal, vertical, or rotary. Nystagmus can cause problems with vision, depth perception, balance, and coordination, and may indicate an underlying neurological disorder.
To assess the function and coordination of the eye muscles, various tests can be performed, such as the Hirschberg Test, which involves shining a light into the patient's eyes and observing the reflection on the cornea to detect any asymmetry suggesting strabismus. The Prism Cover Test is another method used to measure the angle of deviation in strabismus by placing a prism in front of one eye and determining the extent of misalignment based on the amount of light refraction required for normal binocular vision.
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Assess muscle strength with resistance
To assess muscle strength with resistance, you can use the Medical Research Council Manual Muscle Testing Scale. This involves testing the patient's key muscles against gravity and the examiner's resistance, grading the patient's strength on a scale of 0 to 5.
Begin by asking the patient to sit and inspecting the size and contour of their muscles and joints, checking for symmetry. Observe the skin over the joints and muscles and note any tenderness, swelling, erythema, deformity, or asymmetry. Then, observe how the patient moves their extremities and note any pain or limitations in their active range of motion (the degree of movement the patient can voluntarily achieve in a joint without assistance).
Palpation is typically done simultaneously during this inspection. As you observe, palpate each joint for warmth, swelling, or tenderness. If you observe decreased active range of motion, gently attempt passive range of motion by stabilizing the joint with one hand while using the other hand to gently move the joint to its limit of movement.
To assess upper extremity strength, begin by assessing bilateral hand grip strength. Extend your index and second fingers on each hand toward the patient and ask them to squeeze them as tightly as possible. Then, ask the patient to extend their arms with their palms facing up.
It is important to evaluate muscle tone in different positions, such as in recumbency and while standing. A patient's muscle tone can vary depending on their position and demeanor. For example, in an anxious or scared patient, muscle tone can be increased because the patient may not be able to relax. Therefore, it is crucial to consider the patient's position and emotional state during the assessment.
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Inspect the size and contour of muscles and joints
To inspect the size and contour of muscles and joints, you should begin by dividing the musculoskeletal system into functional parts. For beginners, it is recommended to start distally with the upper extremity, working proximally through the shoulder. Then, beginning with the temporomandibular joint, move on to the cervical spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, for the lower extremity, again start distally with the foot and proceed proximally through the hip.
When inspecting the muscles and joints, look for discoloration (e.g. ecchymoses, redness), soft tissue swelling, bony enlargement, wasting, and deformity (abnormal angulation, subluxation). Observe the skin over the joints and muscles and note any tenderness, swelling, erythema, deformity, or asymmetry. The patient's eyes should also be observed during palpation, as involuntary muscle movements about the eyes can indicate pain.
For the knees, specifically, look for discoloration, swelling, and deformities, and note whether they are laterally angulated (genu varum) or medially angulated (genu valgum). Also, observe a backward bowing of the knee (genu recurvatum) and a lack of full extension of the knee (flexion contracture). These abnormalities are best noted with the patient standing and weight-bearing. For the remainder of the examination of the knees, the patient should be supine. Look for atrophy of the quadriceps muscles and observe the contour of the knees.
When assessing older adults, it is important to evaluate their mobility and their ability to perform activities of daily living. Ask the patient if they use any assistive devices such as a brace, cane, walker, or wheelchair, and if they have experienced any recent falls or near falls.
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Flex and extend limbs to assess muscle tone
To assess muscle tone, it is important to evaluate a patient's muscle tone in different positions, such as when standing or lying down. This is because a patient's muscle tone can vary depending on their position and demeanour. For instance, an anxious or scared patient may exhibit increased muscle tone due to their inability to relax, which should not be mistaken for UMN dysfunction. Similarly, a calm and relaxed patient may display reduced muscle tone, which is also not indicative of LMN dysfunction.
When flexing and extending limbs to assess muscle tone, it is crucial to follow certain steps. Firstly, ask the patient to sit and inspect the size, contour, and symmetry of the muscles and joints. Observe the skin over these areas and look for any signs of tenderness, swelling, erythema, deformity, or asymmetry. Pay attention to how the patient moves their extremities and note any signs of pain or limitations in their active range of motion (ROM). Active ROM refers to the degree of movement a patient can voluntarily achieve in a joint without assistance.
Next, gently attempt passive range of motion exercises by stabilising the joint with one hand and using the other hand to carefully move the joint to its limit. Palpate each joint for warmth, swelling, or tenderness. Observe the patient's eyes during palpation, as involuntary muscle movements about the eyes can indicate the most objective indicator of the magnitude of tenderness.
Additionally, assess muscle strength by testing key muscles against gravity and the examiner's resistance. A common method is the Medical Research Council Manual Muscle Testing Scale, which grades the patient's strength on a 0 to 5 scale. For the upper extremities, assess bilateral hand grip strength by asking the patient to squeeze the examiner's fingers as tightly as possible, and then extend their arms with palms facing up.
By following these steps and flexing and extending limbs, healthcare practitioners can effectively assess muscle tone and make informed clinical decisions.
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Frequently asked questions
Palpation is a technique used to assess muscle tone by feeling the resistance of the tissue against the palpating finger.
Palpation is a widely used but subjective examination method. Physiotherapists commonly use digital palpation to assess muscle tone, but little is known about the reproducibility of these measures between practitioners.
First, divide the musculoskeletal system into functional parts. For the upper extremity, start with the hand and work proximally through the shoulder. Then, assess the joints, muscles, and surrounding structures for discoloration, swelling, warmth, tenderness, or deformity. Finally, observe the patient's eyes and expression for signs of pain.
A patient's muscle tone can vary depending on their position and emotional state. For example, muscle tone may be increased in an anxious or scared patient, and reduced in a calm and relaxed patient.
Muscle strength should be equal on both sides of the body, and the patient should be able to fully resist an opposing force. A common method of evaluation is the Medical Research Council Manual Muscle Testing Scale, which grades the patient's strength on a 0 to 5 scale.
