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Palpation Of Tissue Texture Changes

In massage therapy training, most learn about the “4 Ts” of palpation: Tone, Texture, Temperature, and Tenderness. This is an extremely useful list that aids the therapist in remembering and organizing; what is being felt, what that might tell us about the state or acuity of the tissues and what to do about it.


September 28, 2009
By David Zulak


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In massage therapy training, most learn about the “4 Ts” of palpation: Tone, Texture, Temperature, and Tenderness. This is an extremely useful list that aids the therapist in remembering and organizing; what is being felt, what that might tell us about the state or acuity of the tissues and what to do about it.

shoulder-massage-ink.jpg The “4 T’s” of palpation are the focus of this article as we explore tissue texture changes.

Changes in tissue texture, noted during examination through palpation, are key indicators in locating lesions. It may tell us whether the lesion (causing dysfunction) lies:

  • directly beneath the noted tissue, (e.g. an underlying strain or strain of tissue below the skin); or
  • possibly from a lesion (causing dysfunction) located at another area in the body. It can be found a distance away from the noted tissue, and be referring or relaying information to the site, causing  palpable change – (e.g. visceral referral, autonomic changes expressing themselves at the referral site of a trigger point (TrP). (Note: The actual site of the TrP will also show tissue texture changes).

Palpation of soft tissue brings with it a multitude of sensorial information for the massage therapist. From this information we need to focus on and sort out what those sensations are telling us. This requires that we, not only, list what we feel, but more importantly, note what should feel “normal” for the soft tissue we are palpating. What feels altered, or changed from the norm.

This changed area may be just millimetres away from where we were palpating what seemed to be “normal” tissue – having good tone, temperature, and the expectant texture of healthy tissue, with the colouring associated with health.

In turn, the patient may speak to us about tenderness being present. Tissue changes can present in several ways: 

  • hotter/cooler than the surrounding areas, higher or lower tone, (the skin feels stretched and tight, or boggy or slack);a change in the texture, the “grain” of the tissue, (the surface gives resistance, a sense of drag, or even a slipperiness);the skin is dryer/wetter;
  • it is observed to be darker or lighter or having the presence of acne or other small skin lesions.

The image on the opposite page is an outstanding summary of palpatory changes. As illustrated by the image, an extensive list of palpatory findings are shown that speak to conditions present on site. Also shown are; local changes in blood flow and drainage, protective muscle spasming, changes to connective tissue, (from the skin to the deep fascia around the muscle and perimysium fascicles within the muscles); acute inflammatory states, or the adhesions involved in some chronic conditions.

Tissues findings tell us what we need to do – e.g. to cool down and inhibit inflammatory states; or break down adhesions and provide the conditions for normal blood flow and drainage.

Sometimes, motion palpation is indicated. Here an area is palpated while either the patient moves or we passively move the patient.

Again, we are feeling for restriction of motion that may be accompanied by some of the tissue texture changes mentioned above. Here we are not just palpating, but are sensing the stimulation we are putting through the body and how the body is responding. There are a number of areas of the body where tissue texture changes are present at one site, yet are due to referral from a distant site. These could be, as stated above, from visceral or TrP referral.

Why we need to understand visceral referral: When treatment does not seem to change tissue texture
Referral from Visceral, or other tissues, can refer to other sites on the skin or superficial tissue (“cutaneous referral”) by sending such a barrage of afferent or sensory signals via the nerve root to the spinal cord that they cause a ‘spill over’ effect at the spinal level. This spillover causes adjacent sensory nerves/neurons, (in a “pool of neurons”) that are receiving signals from other sensory fibres from the body, arriving at that nerve root level, to fire. They now also send signals up the spinal cord as well. The higher centres in the brain are receiving multiple signals from seemingly multiple sources. This spillover is referred to in physiology/neurology as “cross talk”. An example is the classic referral pattern into the neck, jaw and/or left arm and hand due to a heart in distress.

Why we need to remember our Dermatome, Myotome And Sclerotomes
One rule that governs how the spine and brain work with respect to sensory information is that when it receives information from a lower sensory area (such as organs we are not conscious of), the brain does not recognize them per se, but will recognize the more highly innervated tissue that is also served by the same nerve root level as the source of the signal (Head’s Law) – of which the skin is one of the most sensitive tissues in the body. Next in line, from the same nerve root level, is the richly innervated muscle or joint capsules of the body. (The skin is prioritized to such an extent it can often over-ride even muscle and joints; remember “pain gate theory”).

The site an organ may be referring to, is related to the same spinal nerve roots involved in the sensory input from the organ:

  1. dermatome, the area of skin innervated by that specific nerve root;
  2. a myotome, the primary nerve root governing the action of a muscle or group of muscles (within the peripheral nerve innervating them);
  3. the sclerotome, the periosteum, and joint connective tissue primarily innervated by that nerve root.

Tissues being erroneously perceived as injured, or under stress, will feel painful, and be sent efferent/motor signals to respond to the ‘phantom’ information they are believed to be sending to the central nervous system. This could, for example, cause an increase or decrease in muscular tone, that down the line, may lead to other tissue changes on site.

There may also be ‘erroneous’ signals sent via the Autonomic Nervous System in response to such “cross talk” signals to tissues with phantom symptoms, and such signals will then begin to cause changes to local capillary blood flow, etc. Again, that site will now start to have perceivable palpatory changes. Remember that even changes to the blood flow alone, are going to impact the health of the skin and cause changes, in muscle (via even mild ischemia)
and connective tissue matrix, at that site of referral.

If we treat these referral areas, we often find that we get little change to tissue texture, or, any changes are short lived and the tissue texture changes re-appear.

Therefore, when confronted with this situation we need to think: “What nerve roots innervate this area? What dermatome, myotome, or sclerotome (nerve root) level is here?” We can then begin to check other tissues innervated by the appropriate nerve root levels, and see if they could be the source of the referral.

zulak-pic-winter06-clean.jpg

• From Foundations for Osteopathic Medicine: 2nd Ed., Robert C. Ward, D.O. executive editor, 2003, Lippincott Williams & Wilkins, p.647


Why we need a basic understanding of neural facilitation
There is another name for this spillover from “cross talk.” It’s “facilitation.” This term is used when referring to the effect at the nerve root level when being bombarded by sensory information.

The effect is an increase in local muscle tone. (the “4th layer muscles of the spine”; multifidus, rotatores, interspinales and intertransversarii). This results in the motions between two spinal vertebrae, (“the motion segment”) to be adversely affected. Tissue texture changes can be felt through the skin and restriction of range of motion is noted.

If sustained, this (chronic) hypertonicity can result in physiological changes in these deep structures: shorting of the facial component of muscle and of the joints affected due to lack of movement – “adhesions” and “restrictions.” And, the patient may report tenderness at the site of the hypersensitive (‘facilitated’) facet joints or of the muscle tissues when palpated or when motion is attempted through that site. In turn, the chronicity will result in tissue changes in the overlying skin, which of course will also become palpable and even observable.

We need not be surprised that such dysfunction at a spinal level will, in turn, be sending information back through its afferent nerves, signals, contributing to the cross talk happening. The spine can become a literal tower of babble. The therapist really needs to know/refresh their anatomy and physiology along with the “4 Ts” of palpation. We need to keep in mind that the presence of these tissue texture changes at a specific site may also be speaking to us of
‘distant’ problems or dysfunctions. And, this in turn may explain why we cannot get the results we always want. The original lesion site might be somewhere else entirely.

A dysfunctional bladder ‘in pain’ may refer to the skin of the abdominal area right over it; but it may also cause a cascade of neural signals at S2-3-4 that spills over to; SI joint dysfunction, peroneals/fibularis, gastroc’s and hamstrings weakness (myotomes), cutaneous pain down the back of the leg (dermatomes), and may even cause edema at the ankles, (via the now dysfunctional muscle pump, and adhesions that may have developed). Remember, visceral referral and Somatic referral are reciprocal.

Conclusion

When we have recurrent problems, have tissues that resist change or will not sustain change, following treatment, we must start to look farther afield.
Tissue changes noted during palpation, prompt us to think of what lies at that site, what nerves innervate that site, and what other structures throughout the body share the same nerve root(s).

By knowing what dermatome, myotome or sclerotome are related to the nerve root that feeds the site of tissue texture changes, we then have some clues as to what other areas of soft tissues to investigate.

 Without question, a continual study of anatomy, needs to coincide with our increasing palpatory sensitivity and skills, if we wish to uncover a patient’s complaints and provide relief. It is equally important to be able to identify possible red flags of organ dysfunction.

Such understanding and palpatory skills, improves our assessment and treatment skills, and further secures the safety and wellness of those who trust us to help them with their health concerns.


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