Palpation

Before commencing to palpate, ask the patient to point out any site of discomfort. It may be appropriate to mark this site to direct attention in the examination and ensure consistency of the witness.

Altered sensation on either side of the midline can be demonstrated by simultaneous digital dragging or pinching the skin on each side. Palpation of the muscles on either side, particularly in the lumbar region, assesses the presence of spasm: lumbar spasm may also be accompanied by loss of the normal lumbar lordosis.

The vertebral spines can be felt in a thin subject from C6 down to the sacrum, and the tips of the index finger can be inserted between and over them to locate any tender spots. Palpate the cervical, thoracic and lumbar spines (figure 9a–c) and the sacroiliac joints (figure 9d). Palpate on either side, over the transverse processes, the intervertebral joints and paravertebral muscle, to assess tone, spasm and tenderness. Assess paravertebral tone in the cervical, thoracic and lumbar regions, and the buttock (figure 10a–d).

First apply digital pressure over a symptomatic, or suspected abnormal area. If no tenderness is elicited, increase the pressure by using both thumbs. Progress to percussion, at first with a single fist thump, and then a more pronounced double hand thumb over the spines, and on each side (figure 11a–d).

Posteriorly, pressure is applied over the iliac crests, sacroiliac joints, the sacrum and the ischial tuberosities, to identify pelvic pain (figure12a–c).

Anterioly, palpate the iliac crests, the anterior superior iliac spines and pubic tubercles of the pelvis (figure 13a,b). The integrity of the pelvis is examined by side to side compression of the iliac bones, pressure on the pubis in the sagittal plane and simultaneous backwards pressure on the two iliac crests (figure 14a,b).

Limitation of straight leg raising is determined by lifting the patient’s heel from the lying position; it indicates tension in the radicals of the sciatic nerve and may be indicative of a lumbar disc abnormalities. The sign may be accentuated by simultaneous raising the head and dorsiflexion of the ankle (figure 15a–c).

Tension can be applied to the femoral nerve by passively flexing each knee in turn in the prone position (femoral nerve stretch test – figure 16).