The profession of massage therapy has grown tremendously in recent years as the value of therapeutic touch has become increasingly recognized. Therapeutic touch can bring general emotional, psychological and physical relaxation to clients, as well as improve local fl uid circulation. In this regard, massage is always “clinical” in nature. However, the term “clinical massage” is often applied only when massage is done with intent toward healing a specific condition. Clinical massage can generally be divided into medical massage—primarily geared toward treating visceral/ metabolic problems in hospital settings—and orthopedic massage, primarily oriented toward the treatment of musculoskeletal conditions.
When working clinically, the massage therapist requires a greater “set of tools” than when working with the general application of touch. Certainly,knowledge of anatomy, physiology, kinesiology and pathology is always appropriate and helpful for all massage therapy.
However, with clinical orthopedic massage, it’s essential. A foundational understanding of science arms the therapist not only with a base of knowledge,but also with the critical reasoning skills necessary to be able to accurately assess and treat a client who presents with a specific musculoskeletal condition. It is largely the expansion of massage therapy into clinical orthopedic work that has solidified the role of massage therapy in the world of complementary alternative medicine, also known as integrative health.
Necessity of Assessment
In the world of medicine, there is an adage that states that treatment should never be administered without a diagnosis. Similarly, clinical orthopedic massage should never be done unless an accurate assessment has first been made. An assessment informs the therapist about the physical integrity of the tissues of the client’s body that are to be treated, and points the therapist toward the appropriate treatment tools to facilitate the healing of the condition.
Of all assessment tools available to the massage therapist, palpation, especially palpation of the musculature, is the most important. Indeed,muscle palpation is so integral to the field of massage therapy that it’s likely that the massage therapy profession leads all other health fields in muscle palpation skills.
The term palpation comes from the Latin term “palpare,” which literally means to touch. However, in the context of muscular assessment,palpation involves much more than simply touching the muscle. Muscular palpation has two major objectives. The first is to locate the target muscle that is being palpated. Once it has been located, the second objective is to assess its health by feeling for its tone and texture: Is it tight or loose? Are there trigger points located within it? Is it inflamed or tender to touch? Are fascial adhesions present?
Assessing the health of the muscle is the most important aspect of palpation because the integrity of the tissues is what informs our decisions regarding treatment. However,if we do not first locate and discern the muscles of the region, we will not even know what musculature we are assessing. Further, effective massage therapy often involves working the entirety of the muscle, from attachment to attachment,which can only be done if we know the exact borders of the muscle.
For these reasons, accurate location of target musculature is supremely important, and is the basis for clinical orthopedic massage. For each target muscle, there is a palpation protocol that can be carried out to identify and locate it (at times there may be a number of possible protocols that work equally well for a muscle).
Unfortunately, muscle palpation is often not well learned by students and therapists alike because of the manner in which it’s presented in textbooks and the classroom. Muscle palpation is often presented as protocols to be memorized with little understanding of why each step is done. As with most things that are memorized, they are often forgotten or in time become fuzzy, leaving us with weak palpation skills.
Further, the protocols are often passed along without being critically examined, setting the stage for massage therapists to learn less-than-ideal technique. Instead of memorizing a protocol for each and every muscle, it’s better to learn how to palpate. In other words, we need to learn an approach to muscle palpation that allows us to figure out how to palpate the muscles of the body. Further, it’s important to be sure that each protocol is ideal for not only locating the target muscle, but also clearly discerning it from adjacent musculature and other soft tissues. This can be accomplished with a set of guidelines that addresses the science and art of palpation.
To thoroughly cover this topic, a fairly long list could be given; however, this list can be pared down to the most important guidelines that, when followed, allow us to accurately and easily figure out how to palpate most every muscle of the body.
These guidelines are presented in a straightforward and commonsense manner that facilitates critical reasoning. Critical reasoning skills not only inform and improve our ability to palpate; they also inform and improve our hands-on clinical treatment technique, making us more effective clinical therapists. Together, these guidelines comprise the science and art of muscle palpation.
The Science of Palpation
Guideline No. 1: Know the Attachments of the Target Muscle
The first guideline is to know the attachments of the target muscle that is being palpated. Knowing the attachments is the first necessary step because it gives us the general location of where to place out palpating fingers.
Simply put, we palpate between the muscle’s attachments.For example, if the target muscle is the deltoid, knowing that it attaches from the lateral clavicle, acromion process, and spine of the scapula to the deltoid tuberosity of the humerus, tells us to place our palpating fingers between the scapular/clavicular attachment and the deltoid tuberosity (Figure 1, left).
More specifically, if we want to palpate the anterior deltoid, we place our palpating fingers just distal to the lateral clavicle. If we want to palpate the middle deltoid, we place our fingers just distal to the acromion process.
And if we want to palpate the posterior deltoid, we place our fingers just inferior to the spine of the scapula. Hence, knowing the attachments of the target muscle is the first necessary step for successful palpation. Each muscle palpation protocol should begin here. The protocol should not end here, however. Unfortunately, this is often the case.
Often, the student is told the attachments of the target muscle and instructed to simply palpate from attachment to attachment. The problem is that although this approach may work well when palpating the center of a superficial muscle, once we continue to palpate that muscle toward its borders, how do we know if we have strayed off it and onto an adjacent muscle?
The problem is that this guideline does not help us discern the borders of the target muscle from the adjacent muscles and other soft tissues. For deeper muscles, approaching palpation just by palpating from attachment to attachment is even more problematic because we can never be sure whether we are feeling our target muscle or a more superficial muscle that overlies it. So, as important as using guideline No. 1 is,it’s not sufficient for effective palpation.
Guideline No. 2: Know the Actions fo the Target Muscle
When the target muscle contracts, it hardens and becomes palpably clearer. Continuing with the deltoid as our example, if we know the muscle’s actions, we know what to ask the client to do to make it contract: We ask the client to abduct their arm at the glenohumeral joint. The deltoid contracts and becomes palpably harder, allowing us to palpate its entirety and more easily discern it from the adjacent musculature (Figure 2, left).
Guideline No. 3: Choose the Best Action of the Target Muscle to Engage It
Adding contraction of the target muscle to knowing where to place our palpating fingers (guidelines No. 1 and No. 2) often creates an effective palpation protocol. However, there are many times when simply choosing any action of the target muscle will not be sufficient for a successful palpation.
This is another place where some palpation protocols are less than ideal. The purpose of guideline No. 2 is to engage the target muscle so that it hardens and stands out from the adjacent soft tissues. However, if the chosen action also causes other muscles to engage and contract, then discerning the target muscle from these other muscles will be difficult, and our palpation will not be clear. Always keep in mind that our goal is not just to feel the target muscle, but to be able to know when we are on it and when we are not. In other words, we must clearly discern the target muscle from all other tissues.
This means that we need to find an action that engages the target muscle but does not engage the adjacent muscles. In effect, we want an isolated contraction of the target muscle. Although this is not always perfectly possible, most of the time it can be achieved quite well. Here, guideline No. 3 becomes important: Choose the best action to engage the target muscle.
In a sense, this guideline is a refinement of guideline No. 2. However, it’s a critically important refinement. Choosing the best action to create an isolated contraction of the target muscle requires knowledge of not just the actions of the target muscle, but also the actions of all the adjacent muscles. This is where our foundation of science knowledge and critical thinking skills truly become important. What we need to do is think through all of the actions of the target muscle to find the action that is most different from the actions of the adjacent muscles.
For example, continuing with the deltoid as our example, glenohumeral abduction will engage anterior, middle and posterior fibers of the deltoid. However, if we want to palpate and discern only the anterior deltoid, flexion of the arm at the glenohumeral joint is a better joint action because it engages the anterior deltoid without also engaging the middle deltoid.
In fact, an even better action for palpation of the anterior deltoid is horizontal flexion of the arm at the glenohumeral joint because it creates a more powerful contraction, and engages fewer adjacent muscles (Figure 3a, top left).
Similarly, if we want to palpate the posterior deltoid, glenohumeral joint extension is better than abduction because it engages the posterior deltoid without engaging the middle deltoid. And horizontal extension of the arm at the glenohumeral joint is the very best joint action to have the client perform because it creates the most powerful and isolated contraction of the posterior deltoid (Figure 3b, bottom left).
Another example is palpation of the fl exor carpi radialis (FCR) of the wrist flexor group. If we ask the client to flex the hand at the wrist joint, the FCR engages, but so will many other muscles of the anterior forearm, including the adjacent palmaris longus (PL) (Figure 4a, right). This might not matter if we are palpating only the distal tendon of the FCR because it’s far from the PL’s distal tendon. But as we palpate more proximally onto the FCR’s belly, the belly of the PL lies directly adjacent, so you might have difficulty discerning the FCR from the PL.
In this case, a better action is to have the client radially deviate (abduct) the hand at the wrist joint (Figure 4b, right). This action still engages the FCR, but the PL remains relaxed and soft. So, when palpating the FCR, guideline No. 2 only asks us to find an action that engages it. Flexion of the hand accomplishes this goal, but is also a common action of other adjacent muscles. Guideline No. 3 asks us to find an action unique to the FCR amongst its adjacent musculature. In this instance, the best action is radial deviation of the hand at the wrist joint.
Sometimes it’s not possible to find an action that is unique to the target muscle because every one of its actions is common to at least one adjacent muscle. In these cases, choosing the best action depends upon which aspect of the target muscle we are palpating. An excellent example is the fibularis longus (FL) (please note, the FL was formerly called the peroneus longus) of the leg (Figure 5, left). The FL everts and plantarflexes the foot. What action would be the best one to use? The answer depends upon whether we are palpating the anterior or posterior aspect of the muscle.
If we are palpating toward its anterior border next to the extensor digitorum longus (EDL), then it’s best to ask the client to plantarfl ex the foot because this action engages the FL but not the EDL (the EDL dorsifl exes and everts the foot). If we had chosen eversion, both the FL and EDL would engage, making discerning the border between them difficult.
On the other hand, if we are palpating toward the FL’s posterior border, next to the soleus, the best action is eversion of the foot. Eversion engages the FL, but not the soleus (the soleus plantarfl exes and inverts the foot). If we had asked the client to plantarfl ex in this case, both the FL and the soleus would have contracted, making it difficult to discern the border between them.
As you can see, the foundation of muscle palpation rests on knowing the attachments and actions of the musculature, precisely the information that we learned in our anatomy/physiology/myology/kinesiology classes! This manifests how science knowledge, far from being simply a burden that had to be learned to pass exams at school and for licensure/certification, is actually very important to the hands-on skill set of massage therapy. Science informs the practice of massage therapy, raising the competence of the therapist and allowing the therapist to do more effective orthopedic assessment and treatment. The most competent clinical therapist is the one who marries the science of knowledge with the art of hands-on skills.
Guideline No. 4: When Necessary, Add Resistance to the Client's Contraction
The next step is to pay attention to how hard the client contracts the target muscle. The reason that we ask clients to actively contract the target muscle is to make it palpably harder so it stands out among the adjacent soft tissues. This action often causes the muscle to pop out under your palpating fingers when it first contracts.
However, simply asking the client to perform the joint action does not always cause a strong enough contraction to make the target muscle easily palpable. This is especially true when the body part being moved is either not being moved upward against gravity and/or is not very heavy so that its weight does not offer enough resistance to create a strong enough contraction.Here, guideline No. 4 becomes important.
By adding resistance, the client’s target muscle must contract with greater force and will palpably become even harder—and easier to palpate. So, if the client contracts the target muscle and you still cannot feel it contract, add resistance. If necessary, continue to add more resistance until you feel the muscle contract. Of course, more contraction strength is not always better. The ideal degree of target muscle contraction can vary from muscle to muscle within the same client, and from client to client for the same muscle. If more resistance does not work, try less. Be prepared to be creative with the resistance that you add.
Adding resistance to the contraction of the target muscle is where palpation protocol errors are most often made. These errors involve placement of the therapist’s hand to contact the client when adding resistance. For this reason, the following addendum to guideline No. 4 is helpful: when adding resistance to a client’s contraction, never cross a joint that does not need to be crossed. In short, if we are resisting the client’s target muscle from moving the arm at the glenohumeral joint (such as the deltoid), we need to contact the client’s distal arm, not cross the elbow joint to contact the forearm. Similarly, if the target muscle contracts to move the forearm at the elbow joint, then we should contact the client’s distal forearm and not cross the wrist joint to contact the client’s hand.
The problem with contacting the client across a joint that does need to be crossed is that it causes the client to recruit and contract additional muscles. Remember, out goal is to create an isolated contraction of the target muscles so that it is the only hard tissue among a sea of soft tissue.
A good example of this is the FCR, whose palpation was shown in Figure 4. Note that the therapist added resistance to the FCR’s contraction by contacting the client on the palm of the hand. The therapist did not cross the metacarpophalangeal and/or interphalangeal joints to contact the fingers. Had the fingers been contacted, finger flexor muscles (flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus) would have been recruited to contract. Because these muscles lie adjacent and deep to the FCR, their contraction would confuse the therapist, making it difficult to discern the FCR from these other muscles.
Another good example is palpation of the brachioradialis. The brachioradialis flexes the forearm at the elbow joint, and is especially active if the forearm is in a position that is halfway between full pronation and full supination. If we want to add resistance to its contraction, then we should contact the distal forearm, and not cross the wrist joint to contact the client’s hand, which is so often shown in palpation protocols (Figure 6, left). If we instead contact the hand, then muscles that radially deviate the hand at the wrist joint, such as the adjacent extensor carpi radialis longus, will contract, making it difficult to palpate and discern the brachioradialis.
An example from the lower extremity is palpation of the tensor fasciae latae (TFL). The TFL flexes, abducts and medially rotates the thigh at the hip joint. Therefore, when adding resistance to its contraction, contact should be on the distal thigh (Figure 7, right). Massage therapists should not cross the knee joint to contact the leg. If the leg is contacted, the vastus lateralis of the quadriceps femoris group will also contract, making it difficult to discern the TFL.
Assessment lies at the heart of clinical orthopedic massage, and no assessment technique is more valuable to the world of massage therapy than muscular palpation.
The science of muscle palpation involves understanding and applying a set of guidelines that allows us to critically reason how to approach the muscles of the body instead of memorizing rote palpation protocols. The art of muscle palpation involves the quality of our touch and how we seamlessly weave together these guidelines as we work with our clients. The guidelines presented in this article form the foundation of palpatory literacy. Working with these guidelines can improve not only our assessment skills, but also help us to become more effective clinical orthopedic therapists.