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Palpation is an important procedure for manual therapists and is integral to musculoskeletal assessment. It involves feeling or touching a part of the body to gain information. When palpating the neck, it is important to expose the entire neck and upper shoulders. The patient should be informed when you palpate the neck, and it is usually done with the patient in a sitting position. The therapist should use the tips of their index and middle fingers to check for tenderness, muscle spasm, or a subtle underlying bony deformity. The patient may also be asked to perform certain actions, such as flexing the head forward or extending it. The palpation of neck muscles can help reveal tissue inflammation, the buildup of fibrous adhesions within soft tissues, and possible strain or injury.
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What You'll Learn
Palpating the neck for swelling and temperature changes
Understanding the Neck Anatomy:
Before beginning the palpation, it is essential to have a basic understanding of the neck anatomy, including the locations of the muscles, bones, and other soft tissues. Know the attachments and actions of the target muscles to determine the correct placement of your hands during palpation.
Patient Positioning:
The patient's position will depend on the specific muscle or area being examined. For example, the trapezius muscle is usually palpated with the patient seated, allowing for easy comparison between the two sides of the neck.
Palpating for Swelling:
Begin by palpating the small, deep carotid tubercles, located about 1 inch lateral to the carotid ring and anterior to the transverse process of C6. Move your fingers gently, quickly, and unilaterally to avoid stimulating the carotid reflex. Then, palpate the carotid pulse with your index and middle fingers, noting the pulse strength and comparing it between both sides.
Next, palpate the supraclavicular fossa, starting at the sternum and moving laterally. Here, you are checking for abnormal swellings (e.g., traumatic edema), masses (e.g., tumors, swollen lymph nodes), or unusual depth of the fossa (e.g., clavicular fracture).
Additionally, palpate the areas around the sternocleidomastoid and trapezius muscles, paying attention to any abnormal size, shape, tension, tenderness, or masses. Lymph nodes in these areas are usually not palpable unless inflamed or calcified.
Palpating for Temperature Changes:
While direct temperature palpation is not possible, you can assess for temperature-related muscle tension in the neck. Temperature changes can influence muscle tension, with cold temperatures causing muscle stiffness and involuntary contractions, and warmer temperatures leading to muscle relaxation due to increased blood flow.
Feel for temperature differences and muscle tension by placing your hands on either side of the neck and comparing them. Note any areas of increased warmth, which may indicate inflammation, or coolness, which could be a sign of reduced blood flow.
Additional Considerations:
It is important to perform a health history and range of motion (ROM) examination before palpation to identify areas of focus. Additionally, critical thinking is essential during palpation; understand the principles of muscle palpation rather than memorizing a protocol for each muscle.
Remember that imaging tests, such as X-rays or MRIs, may be necessary if there is a suspected serious injury, severe pain, or if palpation findings require further investigation.
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Palpating the neck for tissue inflammation
To begin the examination, the patient should remove clothing to expose the entire neck and upper shoulders. The patient should be asked to turn their head to the side to palpate the sternomastoid muscle on the opposite side. The trapezius muscle should also be palpated, evaluating for tenderness or palpable muscle spasms. The patient should then be asked to flex their head forward as far as possible, ideally touching the chest. Next, the patient should be asked to extend their head as far as possible, which should be done without pain and the patient should be able to look at the ceiling. The patient should then be asked to look as far laterally as possible in both directions. Lastly, the patient should laterally flex their neck, trying to touch their ear to their shoulder.
The therapist should then palpate the neck from behind, starting from the base of the skull and moving down to the upper back. The neck should have near perfect symmetry, and the head should be positioned in the midline. Tilting to one side may suggest a muscle spasm. The form and bulk of the paraspinous muscles that surround the midline spinous processes should be observed. There may be asymmetry due to a spasm related to trauma or overuse injury. The neck should then be inspected from the lateral side, observing the smooth lordotic (reverse C-shape) curve. A loss of this curve may indicate a non-specific reaction to cervical injury or pain.
The palpation should be done using the tips of the index and middle fingers to check for tenderness, muscle spasm, or underlying bony deformity. The spinous processes, posterior facet joints, and paraspinous muscles should be palpated. The C2 vertebra should be felt first, moving downwards and inspecting each process until the C7 vertebra is reached. The C7 vertebra is the most prominent of all the spinous processes. The posterior facet joints should be palpated by moving the fingers a few centimeters to the left or right of each spinous process. Tenderness may suggest a contusion or underlying fracture, while a step off may indicate a fracture or ligament disruption.
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Palpating the neck for muscle spasms
To begin the palpation, the patient should remove clothing to expose the entire neck and upper shoulders. The therapist should stand behind the patient, who is usually seated, and inform them that the palpation is about to begin. The therapist should then use their fingertips, specifically the index and middle fingers, to check for tenderness, muscle spasm, or a subtle underlying bony deformity.
Starting at the base of the skull in the midline of the neck, the therapist should palpate downwards, inspecting each process until they reach the C7 vertebra, the most prominent of the spinous processes. The therapist should check for tenderness or an abrupt step-off from one process to the next, as these may indicate a contusion, fracture, or ligament disruption.
The therapist should then palpate the cervical facets, located about one inch lateral to the spinous processes, and the paraspinous muscles, which surround the midline spinous processes. Here, asymmetry may be observed due to spasm related to trauma or overuse injury. The trapezius muscle, in particular, should be evaluated for tenderness or palpable muscle spasms.
Additionally, the therapist may palpate the lymph nodes of the head and neck, starting at the midline and moving inferiorly to pass over the thyroid cartilage. They may also palpate the carotid pulse by placing their fingers deeply and unilaterally between the cricoid ring and the lateral cervical muscles.
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Palpating the neck for bone deformities
Step 1: Patient Positioning and Clothing
Ensure the patient is comfortably seated, with their head facing forward. Ask them to remove any clothing that may obstruct your access to the neck and upper shoulder areas. This is important to ensure you have a clear view and can properly palpate the necessary areas.
Step 2: Visual Inspection
Before beginning palpation, visually inspect the patient's neck from behind. Observe the neck's symmetry and the position of the head. Any tilting to one side could suggest a muscle spasm or a condition like torticollis. Pay attention to the form and bulk of the paraspinous muscles surrounding the midline spinous processes, as asymmetry may indicate a spasm related to trauma or overuse injury. Also, inspect the neck from the lateral side and observe the lordotic curve (reverse C-shape). A loss of this curve could indicate a non-specific reaction to cervical injury or pain, while a straightening of the cervical spine may suggest ankylosing spondylitis.
Step 3: Palpation Technique
Using the tips of your index and middle fingers, start palpating at the base of the skull in the midline of the neck. You should first feel the process of the C2 vertebra. Gradually move downwards, inspecting each process until you reach the C7 vertebra, which is the most prominent spinous process. As you palpate, check for tenderness or an abrupt step-off from one process to the next, as these could indicate a contusion, fracture, or ligament disruption.
Step 4: Palpating Specific Areas
Focus on palpating specific areas of the neck, including the spinous processes, posterior facet joints, and paraspinous muscles. When palpating the posterior facet joints, move your fingers a few centimeters to the left or right of each spinous process. For the paraspinous muscles, palpate along either side of the spinous processes, feeling for tenderness or spasm, which could indicate a muscle injury or reaction to pain from the underlying cervical spine. Additionally, pay attention to the superior nuchial ligament, which extends from the base of the skull to the cervical spinous processes. While it is not usually palpable, tenderness may indicate a ligament defect or stretch injury.
Step 5: Checking for Swelling and Lymph Nodes
Palpate the neck for any swelling, especially around the lymph nodes. Palpable lymph nodes are usually indicative of inflammation, infection, or calcification. Check the size, shape, location, and consistency of any lumps or swellings you find. The supraclavicular fossa, for example, may exhibit abnormal swellings, masses, or unusual depth, which could indicate issues like traumatic edema or a clavicular fracture.
Step 6: Neck Range of Motion
Assess the patient's neck range of motion by asking them to perform various movements. This includes forward flexion (moving the chin to the chest), extension (lifting the chin upwards), twisting (placing the chin on each shoulder), and side bending (placing the ear on each shoulder). Compare the range of motion on both sides. Additionally, ask the patient to laterally flex their neck, trying to touch their ear to their shoulder. Note that age-related degeneration may limit the neck's range of motion.
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Palpating the neck for lymph nodes
Patient Positioning:
Position the patient sitting upright on an exam table, and stand behind them to begin palpating the neck. Ask the patient to tilt their chin slightly downwards to relax the neck muscles and facilitate palpation. You may also ask them to relax their hands in their lap.
Initial Inspection:
Before palpation, inform the patient to let you know if they experience any pain or tenderness during the procedure. Begin by visually inspecting the lymph node areas on the head and neck for any signs of swelling, asymmetry, or erythema (skin discolouration). Normally, lymphatic areas are symmetrical on both sides, with no discolouration, swelling, or visible nodes.
Palpation Technique:
Use the pads of your second, third, and fourth fingers to gently press and roll the lymph nodes over the surrounding tissue. Start in the submental area (under the chin) and work your way posteriorly, palpating the submandibular, preauricular, and posterior auricular lymph nodes. Then, follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, and palpate behind the posterior border (posterior cervical chain) up to the mastoid process.
Bilateral Palpation:
Remember to palpate bilaterally, comparing the right and left sides simultaneously. For the preauricular nodes, assess the left and right sides at the same time. For the submental lymph nodes, use the fingers of your dominant hand just under the chin behind the bony prominence. When assessing the deep cervical chain, you may need to work on one side at a time, asking the patient to tip their head towards the side being examined.
Characteristics to Assess:
When palpating the lymph nodes, note their size, shape, location, consistency, fluctuance, trans-illumination, pulsatility, temperature, mobility, and any overlying skin changes. Benign lymph nodes are typically small (less than 1 cm), smooth, rounded, non-tender, and mobile. Reactive lymph nodes associated with infections are often tender, mobile, and accompanied by symptoms like fever. Hard, firm, and irregular lymph nodes are often indicative of malignancy.
This guide provides a structured approach to palpating the neck for lymph nodes, aiding in the detection of potential abnormalities and facilitating timely medical intervention.
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Frequently asked questions
Palpation is the process of feeling a part of the body, in this case, the neck, to gain information. In the case of neck palpation, it can be used to check for tenderness, muscle spasm, or a subtle underlying bony deformity.
There are two types of palpation: muscle palpation and soft tissue palpation.
To palpate neck muscles, it is important to have the patient expose their neck and upper shoulders. The palpation should be done using the tips of the index and middle fingers. Start at the base of the skull in the midline of the neck and palpate downwards, inspecting each process until you reach the C7 vertebra.
Important areas to palpate in the neck include the spinous processes, the posterior facet joints, and the paraspinous muscles. The neck range of motion (ROM) should also be assessed, with the patient seated.
