Layer by Layer Palpation

by Tyler Cymet, DO, FACOFP

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    00:01 When you palpate, I usually palpate layer by layer starting with the skin making sure there’s glide, making sure I know if the tissue texture feels appropriate.

    00:10 You observe above the skin, you check out the skin, you look at the subcutaneous tissue by going a little bit deeper maybe half a pound to a pound, you feel whether or not where you can tell where the vessels are or if there’s any pulsations, and then you get a little bit deeper down to 1 to 2 pounds where you start feeling the deep fascia, and you start to feel the muscle with about 5 pounds of pressure.

    00:30 Then once you get to 9 pounds, you can typically feel a ligament or a bone.

    00:34 And that’s the general way that you’re going to get to feel what’s going on underneath the skin.

    00:40 The viscera are also palpated through different layers of skin and different levels of sensitivity just to be aware of.

    00:47 I usually do a skin drag test to make sure that’s there’s no restrictions and that the patient isn’t dehydrated, which will affect skin drag, or have other issues that would limit their skin’s ability to function as an organ because the skin is the largest organ in the body.

    01:02 You want to check for friction.

    01:04 You want to make sure that there’s moisture.

    01:06 You may want to check skin turgor and make sure that you have proper response and look for any acute changes in color, any lesions, or anything else that may lead you to need to investigate further.

    01:21 When testing skin drag, it’s basically pulling the skin and making sure that it moves comfortably and moves accurately.

    01:28 You may note asymmetry, you may note atrophy, or you may note chronic changes, hardening, thinning, or flaking of the skin.

    01:38 Once you get to the fascia, you want to observe if there’s any swelling, any warmth that comes out, any redness, tenderness, temperature changes, and what the skin drag is like, what the texture is like, and what the turgor is like, what the rebound is.

    01:55 When you get to the subcutaneous tissue that’s underneath the skin, contact it with light pressure, look at what fat tissue there is and how confluent or maybe how lumpy bumpy, or segmented it is, where does it go and can you feel pulses or other things in the area.

    02:12 Allow for general movement both of the skin and the muscles, and I usually check the feet to see if there’s any tenderness, swelling, and any other abnormalities of the feet.

    02:25 When you get to the deep fascia, you want to contact with medium pressure.

    02:29 You may want to get up to 5 pounds of pressure and check for smoothness, continuousness, firmness, toughness and just see how the functioning of the tissue goes.

    02:39 When you get to the muscle layer, you want to make contact with medium pressure, generally about 9 pounds.

    02:44 Palpate through the deep fascia. Make sure you feel the muscle.

    02:47 Make sure you feel the shape of the muscle, how it feels, and what it feels like, how substantial is it versus how atrophied might it be, and you may want to follow the fibers of some muscles just to see what the muscles feel like. Does it feel different in different places? You may feel tendons and ligaments which can give you information. Often times they get injured and we do know that meniscal tears, ligament tears, and tendon tears all contribute to edema and other changes in the body.

    03:18 Once you feel deeper, you’ll get to the bone nd you can feel whether or not the bones feel lighter, heavier because different bones will have a different feel to them.

    03:28 Make sure you contact with pressure enough to feel the bone but not enough pressure to cause pain or discomfort.

    03:35 When you do feel the bone, you don’t want to do it too long because people are going to be uncomfortable and it’s going to be an unpleasant experience, but you can follow the contour of the bone a little bit just to make sure that you get a sense of what it feels like.

    03:46 Pay attention to joint capsules and joint spaces and compare the density of different tissues.

    03:52 Make sure there’s some consistency and the palpation of the body makes sense to you, or if not, that you explore further.

    04:00 Remember that you’re dealing with living tissue.

    04:02 It feels different for the person than it does for you.

    04:06 Be respectful but use palpation to its maximal benefit.

    About the Lecture

    The lecture Layer by Layer Palpation by Tyler Cymet, DO, FACOFP is from the course Osteopathic Principles and Tenets.

    Included Quiz Questions

    1. 9 lb.
    2. 3 lb.
    3. 2 lb.
    4. 5 lb.
    5. 1 lb.
    1. Elasticity of the skin
    2. Scarring of the skin
    3. Fascial changes of the skin
    4. Hydration changes of the skin
    5. Pigmentation changes of the skin

    Author of lecture Layer by Layer Palpation

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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