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.

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.
• 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.