STATIC PALPATION OF THE SPINEDaniel Redwood, D.C.Kevin R. Mott, D.C.

.

INTRODUCTION

Static palpation of the human spine is an art and a learned skill of examination, via

superficial touch, of the vertebral column, which is comprised of the spine, sacrum and

coccyx. Used primarily as a diagnostic aid or tool, static palpation is concerned with

tactile perception of various osseous landmarks, involving the following: (1) locating

specific vertebral structures, (2) becoming aware of the particular structure’s

characteristics; and (3) assessing the particular structure’s current state or condition.

Static palpation of the human spine is just one component of the diagnostic process and

does not stand alone as all encompassing – there are limitations. Static palpation must,

therefore, be followed by further assessment measures, including kinetic palpation,

orthopedic testing, and x-ray analysis.

The practice of static palpation involves multiple positions for both the examiner and

examinee. Within the chiropractic profession, the most common position for the Doctor

of Chiropractic to assume is a fencer stance parallel to the chiropractic table. With the

patient lying in the prone position upon the table, the doctor uses his or her finger tips or

pads, locating and assessing all parts of the vertebral column. As an alternative method,

the patient may assume the seated position with the doctor standing to either side or

directly behind the patient. The doctor may then proceed to palpate in a fashion similar to

the previous patient position. This alternate doctor-patient position proves most useful for

occiput and cervical spine palpation.

OCCIPUT AND CERVICAL SPINE

The cervical spine has seven (7) vertebrae, including the atypical vertebrae of the upper

cervical complex, comprised of the atlas (C1) and the axis (C2), and the typical vertebrae

C3 through C5. C6 and C7 are additionally classified as atypical cervical spine vertebral

segments because they are transitioning to take on characteristics of the thoracic spine.

Functionally the upper cervical spine also includes the occiput, the posterior cranial bone

that lies superior to the atlas and articulates with it. The normal cervical spine displays a

lordotic curve, with the convexity of the curve to the anterior as seen from a side (lateral)

view. The typical cervical vertebra (best exemplified by C3-C5) is characterized by the

following structural characteristics: (1) rectangular- or oval-shaped vertebral body, (2)

bifid spinous process, (3) three cervical “lips” on the vertebral body – 2 uncinate (lateral)

processes and 1 anterior-inferior process, (4) bilateral transverse processes located

anterior to the superior articular processes, (5) bilateral transverse foramina within each

transverse process, (6) bilateral costotransverse grooves on each transverse process, and

(7) triangular-shaped neural (spinal) foramen.

The atlas (C1) is atypical because it is ring-shaped, displaying an anterior and posterior

arches, and two lateral masses. There is neither a vertebral body nor a spinous process; an

analogous posterior tubercle exists on the posterior arch, however. The axis (C2) is

atypical because it does not possess the two uncinate (lateral) processes. Another unique

attribute of C2 is its odontoid process (dens). C6 and C7 are atypical cervical vertebral

segments because they both lack a bifid spinous process, being similar in this way to the

spinous processes of the thoracic and lumbar vertebrae. Moreover, the transverse

processes of C7 project more laterally than anteriorly, which is also characteristic of

thoracic-spine transverse processes.

External Occipital Protuberance (EOP) – the EOP (also known as the inion, or bump

of knowledge) is located on the midline of the occiput, at the midpoint of the superior

nuchal line. It is helpful to use the EOP as a starting point in locating key structures in the

upper cervical spine.

Palpation: Standing to the side of your seated patient, use the

pads of your index (2nd) and chiropractic index (3rd) fingers to palpate the posterior

midline of the cranium just above the base of the occiput. On most people, the EOP

palpates as a clearly defined bump.

Mastoid Process – located on the temporal bone, the mastoid process is located just

behind the pinna of the ear.

Palpation: Standing or sitting behind your patient, slide your palpating fingers of both

hands laterally from the EOP until they are even with the most posterior aspect of the

external ear. Then, using the pads of your chiropractic index fingers, slide them gently

downward behind the ear until you feel a curved, dome-shaped structure. This is the

mastoid process. Continue palpating downward until you reach the inferior tip of the

mastoid.

Styloid Process – located on the temporal bone, the styloid process lies immediately

posterior to the jaw and immediately anterior to the inferior tip of the mastoid process.

Because the styloid is small and slender (often compared to the lead of a pencil point), it

is not readily palpable on many people.

Palpation: Using a small palpating surface such as a single finger tip, palpate in the

groove between the inferior mastoid tip and the jaw. If accessed, the styloid will be very

sensitive to the patient. Due to its delicate structure, the styloid is never used as the

contact point for an adjustive thrust.

Transverse Process of Atlas (C1) – the atlas transverse is located slightly inferior and

slightly anterior to the inferior tip of the mastoid process. It projects further laterally than

any other structure in the cervical spine. On palpation, it feels similar to the rubber eraser

on a pencil.

Palpation: Sitting or standing posterior to your seated patient, palpate the structure

bilaterally. To palpate the atlas transverse process, start with your chiropractic index

fingers on the inferior tips of the right and left mastoid processes, move slightly inferiorly

and slightly anteriorly. To precisely locate the atlas TVP, you may need to move your

palpating fingers in small circles, moving the overlying sternocleidomastoid muscle,

until you find the TVP. Do not go so far to the anterior that you reach the styloid, which

is just posterior to the jaw.

Posterior Arch of Atlas, Posterior Tubercle of Atlas – the posterior arch of atlas spans

the distance between the posterior tubercle and the transverse process of the C1 vertebra.

The posterior arch of atlas is analogous to the lamina of all other vertebrae. The posterior

tubercle is analogous to the spinous processes of all other vertebrae, is located at the

posterior midline, and is not usually palpable except on some thin-necked patients.

Palpation of posterior arch: from the EOP, move inferiorly to the groove just below the

base of the occiput. Then find the transverse process of C1, as described above. Palpate

the posterior arch of atlas, which links these two structures.

Spinous Process of Axis (C2) – the C2 spinous process is the first palpable spinous

below the EOP. It is large and relatively wide and is the largest of the cervical spinouses

in thickness and mass. It lies approximately ½” below the depression that lies just

beneath the base of the occiput, or 2-2½” below the EOP.

Palpation: With the patient seated and the doctor standing at the patient’s side, palpate

with the pad of your index finger in an inferior direction from the EOP until you reach

the first clearly palpable midline structure, which is the C2 spinous.

Spinous Processes of C3-C5 – the spinous processes of the mid-cervical vertebrae are

difficult to palpate specifically, due to their relatively small size and the fact that they are

tucked forward as part of the lordotic curve of the cervical spine. Spinous processes from

C2-C5 are bifid, divided into two attached sections as they near the tip. This division is

sometimes palpable, but usually it is not.

Palpation: Stand at the side of the patient (as with C2), and palpate inferiorly from the

prominent C2 spinous, judging the approximate location of the C3-C5 spinous processes

and identifying them specifically when possible.

Spinous Processes of C6-C7 – these spinous processes project more prominently to the

posterior than the C3-C5 spinouses. This is particularly pronounced with C7, which is the

longest of the cervical spinous processes. The C6 spinous is noteworthy for being the

lowest freely moving spinous process in flexion and extension of the cervical spine.

Palpation: To determine which of the lower cervical spinouses is C6, place your 3rd

(chiropractic index) finger on what you expect to be the C7 spinous, and your 2nd (true

index) finger on the spinous above that. Gently extend the patient’s neck. If the superior

of the two contacted spinouses moves away from your palpating index finger while the

inferior one remains stationary, then the upper one is C6 and the lower is C7. If both

remain stationary, then they are likely to be C7 and T1 and you will need to move both

fingers up one level and repeat the above process to confirm the location of C6. The

above procedure may be accomplished with the patient either seated or lying in the prone

position.

Articular Pillars – the articular pillars occur only in the cervical spine between C2-C7.

They are comprised of the superior and inferior articular processes of these vertebrae,

which together form a stacked (though also curved) column.

Palpation: To locate the articular pillar at a particular level of the cervical spine, find the

spinous process of the vertebra, which is on the posterior midline. Then find the most

lateral aspect of the neck at that level. Standing at the side of your seated patient, begin

to palpate at approximately the midpoint between the most posterior and most lateral

points at that level, placing your thumb on the side of the patient closest to you

(ipsilateral) and your chiropractic index finger on the side away from you (contralateral).

The key point is that the articular pillar will palpate as a hard, bony structure, unlike the

softer tissue that surrounds it. You may need to move your palpating fingers laterally or

medially from the starting point in order to locate the articular pillar. The above

procedure may also be accomplished with the patient lying in the prone position.

Vertebra Prominens (VP) – the vertebra prominens (Latin: most prominent vertebra) is

the vertebra near the cervico-thoracic junction that projects the farthest to the posterior. It

can be located visually, by palpation, or with a combination of the two. To be able to

accurately identify the exact levels of the individual thoracic vertebrae, it is important to

determine whether the VP is C7 (as it is in most cases) or T1.

Palpation: Follow the directions above for identifying the spinous processes of C6 and

C7, by finding the most inferior movable spinous process in the cervical spine (C6). If the

VP lies immediately below the movable C6 spinous, the VP is C7. If it lays two levels

below the movable C6 spinous, it is T1.

THORACIC SPINE

The thoracic region is the longest section of the spine, accounting for 12 of the spine’s 24

vertebrae. Because each of the thoracic vertebrae connects to the right and left ribs,

vertebral movement is limited, particularly in flexion and extension. In normal

circumstances, the thoracic spine demonstrates a kyphotic curve, with the convexity of

the curve to the posterior as seen from a side (lateral) view.

The thoracic spine is divided into three zones, each with four vertebrae.

The upper thoracic vertebrae (T1-4) share characteristics with the lower cervicals (long

spinous processes projecting posteriorly and slightly inferiorly). The middle thoracics

(T5-8) provide the best examples of the typical thoracic vertebra, with long spinous

processes that angle sharply downward. This results in significantly overlap of the mid-

thoracic spinous processes , known as imbrication. The lower thoracics (T9-T12)

demonstrate progressively less imbrication, with no imbrication present at T11 and T12.

The lowest thoracic vertebrae show characteristics of the nearby lumbar vertebrae (thick

spinous processes projecting posteriorly).

Thoracic Spinous Processes – correctly identifying the level of a thoracic spinous

process requires either counting downward from T1 (identified in relation to C6 and C7,

as described above) or counting upward from L4 (described below). Locating the spinous

process is necessary before one can locate its corresponding transverse process.

Palpation: using the tip or pad of your index or chiropractic index finger, slide

downward from T1, dipping down into the T1-T2 interspinous space just below it, and

then rising up again as you reach the T2 spinous process. Continue this process all the

way to the T12 spinous process. Another approach is to use the pads of your thumbs as

the doctor’s contact point. You may also alternate thumbs, which decreases the likelihood

of losing your place as you count downward through the thoracic spinous processes.

Thoracic spinous process palpation is best accomplished with the patient lying in the

prone position, however, palpation in the seated position may also be practiced.

Secondary Method for Identifying T1 Spinous Process – there is a less specific

confirmatory method of identifying T1, and thereby distinguishing it from C6.

Palpation: sitting or standing behind your seated patient, place your hands on the

patient’s trapezius muscles, which join the neck and the point (acromion process) of the

shoulder. Stretch your thumbs toward each other medially, perpendicular to the spine.

The thumbs should meet at the T1 spinous process, or immediately below it. This

secondary method for identifying the T1 spinous process may also be used when the

patient is lying in the prone position.

Secondary Method for Identifying T3 and T4 Spinous Processes – the medial tip of

the spine of the scapula is located approximately at the level of the T4 spinous process

when the patient is seated or standing, and at the level of the T3 spinous process when

the patient is prone.

Secondary Method for Identifying T6 and T7 Spinous Processes – the inferior medial

angle (tip) of the scapula is located approximately at the level of the T7 spinous process

when the patient is seated or standing, and at the level of the T6 spinous process when

the patient is prone.

Upper Thoracic Transverse Processes – to identify the transverse processes of T1-T4,

first locate the T1 spinous process as described above. For T2-T4, count down to the

desired spinous process. With the patient prone, place one thumb on the spinous process.

Keep it there while palpating superiorly with your other thumb to locate the spinous

process immediately above it (e.g., one thumb on the T3 spinous and the other on the T2

spinous). Next, move the superior thumb laterally approximately 1-1½” to find the

transverse process. Remember that this is the transverse process of the more inferior of

the two vertebrae. Press down on the transverse process. If the spinous process of the

more inferior vertebra (under your more inferiorly placed thumb) moves in response to

movement of the transverse process, you have correctly identified the location transverse

process. If not, continue to palpate in small circles until you succeed.

Middle Thoracic Transverse Processes – to compensate for the length and downward

angulation of the mid-thoracic vertebrae, you will need to palpate further superiorward to

locate the desired transverse process than is the case for the upper and lower thoracic

zones.

Palpation: To identify the transverse processes of T5-T8, first locate the T1 spinous

process as described above. Count down to the desired spinous process. (Alternately, you

can count up from the L4 spinous process, as described below). With the patient prone,

place one thumb on the spinous process of the vertebra being evaluated. Keep that thumb

there while palpating superiorly with your other thumb. Rather than palpating for the

spinous of the immediately superior vertebra, continue further superiorward until you

reach the interspinous space immediately above that spinous. For example, to locate the

T7 transverse process, you would place one thumb on the T7 spinous process, and move

the other thumb into the T6-T7 interspinous space, then over the T6 spinous process,

finally arriving at the T5-T6 interspinous space. (Be certain to view these structures on a

model spine to aid your visualization when you palpate). The remainder of the palpation

is exactly the same as for the upper and lower thoracic vertebrae. Move your superior

thumb laterally approximately 1-1½” to find the transverse process. Remember that this

is the transverse process of the vertebra where you started this palpation, in this case T7.

Press down on the spot that you believe to be the location of the transverse process. If the

spinous process under your more inferiorly placed thumb moves in response to

movement of the transverse process, you have correctly identified the location transverse

process. If not, continue to palpate in small circles until you succeed.

Lower Thoracic Transverse Processes – to locate the transverse processes of T9-T12,

either count downward from the T1 spinous process as described above or count upward

from the L4 spinous process as described below. With the patient prone, after you locate

the spinous process of the vertebra being evaluated, place one thumb on its spinous

process. Keep it there while palpating superiorly with your other thumb to locate the

spinous process immediately above it (e.g., one thumb on the T11 spinous and the other

on the T10 spinous). Next, move the superior thumb laterally approximately 1-1½” to

find the transverse process. Remember that this is the transverse process of the more

inferior of the two vertebrae. Press down on the transverse process. If the spinous process

of the more inferior vertebra (under your more inferiorly placed thumb) moves in

response to movement of the transverse process, you have correctly located the transverse

process. If not, continue to palpate in small circles until you succeed.

Laminae of the Thoracic Spine – to locate the lamina of a thoracic vertebra, first locate

the vertebral segment’s spinous process and transverse process. Then, bisect the oblique

line that joins these two structures, arriving at the midpoint of the lamina.

LUMBAR SPINE

The lumbar spine consists of 5 vertebrae. The typical lumbar vertebrae have spinous

processes that are flat and broad, and are much shorter than the typical thoracic spinous

processes. This pattern, combined with the lordotic curve of the lumbar spine makes it

difficult in some cases to palpate the lumbar interspinous spaces. Only the lumbar

vertebrae have a mamillary process, a bilateral structure located on the posterior superior

lateral aspect of the superior articular process. The mamillary process is difficult to

palpate directly, since it is located more than an inch below the surface of the skin;

several muscle layers overlie this osseous structure.

Lumbar Spinous Processes (L1-L4) – to locate each of the lumbar spinous processes,

start by locating the L4 spinous process. To do so, place the index finger of each hand on

the respective iliac crest. While gripping the iliac crest, stretch your thumbs toward each

other in a direction perpendicular to the spine. The thumbs will usually meet at the level

of the L4 spinous process, or in some cases slightly below it at the L4-L5 interspinous

space. Once you have located the L4 spinous, count upward to identify the spinous

processes between L1 and L4. This procedure can be performed with the patient lying in

the prone position or seated upright.

Spinous Process of L5 -- to identify the L5 spinous process, slide your thumb

inferiorward from the L4 spinous process (location as described above). In a minority of

cases, the L5 spinous process will be readily palpable. In most cases, it is not. To identify

the L5 spinous in these cases, press your thumb fairly firmly on the spot where you

believe the L5 spinous will be located. Ask your patient to cough, which will usually

cause the L5 spinous to rise up momentarily against your palpating thumb. If you are still

unable to feel the L5 spinous process, move your thumb further in an inferior direction

until you reach the firm, broad bony landmark of the sacral base. The L5-S1 interspace is

directly above the sacral base, and the L5 spinous process is directly above that and

inferior to the L4 spinous process. This procedure can be performed with the patient lying

in the prone position or seated upright.

Mamillary Processes of Lumbar Vertebrae (L1-L5) – to locate the right or left

mamillary process of a lumbar vertebra, first locate the spinous process of that vertebra

(as described above). Stand or sit on the side ipsilateral to the mamillary process you

wish to identify. For example, to find the right mamillary process of L3, first locate the

L3 spinous process. Standing or sitting on the right side of the patient, place the pad of

your left chiropractic index finger on the spinous process of L3 and place the pad of your

left index finger on the spinous process of L2. Then, keeping your chiropractic index

finger on the L3 spinous, rotate your index finger 45º to the right while maintaining the

same distance between the two fingers. When this 45º turn is complete, your index finger

will be over the right mamillary process of L3. This procedure can be performed with the

patient lying in the prone position or seated upright.

PELVIS

The pelvis consists of the sacrum, two (2) innominate bones and the coccyx.

Functionally, the pelvis serves as a support for the vertebral column, withstanding the

compressive forces of the trunk via the 5th lumbar vertebra. Anatomically, the pelvis

serves as an articulating connection between the trunk and lower limbs, absorbing the

always present ground reaction forces. With regard to static palpation of the pelvis, the

following posterior structures are assessed: sacrum, posterior superior iliac spine (PSIS),

posterior inferior iliac spine (PIIS), ischial spine and ischial tuberosity.

Sacrum – the sacrum is located immediately inferior to the 5th lumbar vertebra, forming a

base upon which the vertebral column lies. The shape of the sacrum resembles an

inverted triangle, with its base situated superiorly and its apex inferiorly. The adult

sacrum consists of five (5) fused segments and displays a kyphotic curve, with the

convexity to the posterior as seen from a side (lateral) view. Gender variances exist with

regard to sacral shape. The normal male sacrum is narrower and longer than the female

pelvis. The normal female sacrum is wider and shorter than the male sacrum. Because the

sacrum is a fused structure, there are no spinous or transverse processes. Instead,

remnants of these vertebral structures exist; and are represented by the median sacral

crest, formed by four (4) sacral tubercles, and the lateral sacral crest. The median sacral

crest is important in static palpation because the sacral tubercles that comprise it serve as

landmarks to identify important osseous features of the ilia. The bilateral sacral ala

(wings) are important features of the sacral base; they serve as a stable contact point in

chiropractic adjustive technique.

Palpation: With the patient lying in the prone position, first locate the L4 spinous

process (as described above) followed by the L5 spinous process (as described above).

Next, feel for the sacral base immediately inferior to the 5th lumbar spinous. Palpate the

contour of the sacrum, revealing an inverted triangular shape. Once the limits of the

sacrum have been ascertained, the median sacral crest can be palpated, starting with the

1st sacral tubercle, which is located approximately ½” inferior to L5. Moving inferiorly

about ¼” from the S1 tubercle is the S2 tubercle. Alternately, the S2 tubercle can be

directly palpated by moving about ¾” inferiorly from the 5th lumbar spinous. Moving

inferiorly another ¼” from the S2 tubercle is the location of the S3 tubercle and slightly

below this lies the S4 tubercle.

Sacral Ala – to locate the posterior aspect of the sacral ala on a patient lying prone, first

locate the PSIS on the ilium (as described below). Then, move slightly medially and

slightly superiorly, arriving at the sacral ala.

Ilia – the right and left iliac bones lie laterally to the centrally located sacrum. The ilium

is one of three sections of the innominate bone; the other two are the ischium and pubis.

The sacroiliac (SI) joint is a bilateral structure bound by the sacrum on its medial surface

and the two ilia on its lateral surface. The posterior superior iliac spine (PSIS) and the

posterior inferior iliac spine (PIIS) can both be palpated on the bilateral ilia with a fair

degree of accuracy. Other prominent osseous landmarks that can be palpated statically

include the ischial spine and ischial tuberosity, which are both features of the ischium.

Posterior Superior Iliac Spine (PSIS) – the PSIS is located at the superior aspect of the

SI joint, which is anatomically the posterior-most part of the iliac crest. On most

patients, it is represented topographically as a pair of dimples in the skin.

Palpation: With the patient lying in the prone position, locate the S2 tubercle on the

sacrum (as described above). From the S2 tubercle, move laterally 1-1½” to find the

PSIS. With some patients, you may need to move superiorly slightly in order to be

directly over the PSIS.

Posterior Inferior Iliac Spine (PIIS) – the PIIS is located laterally and inferiorly from

the PSIS, and is much smaller than the PSIS. The PIIS can be difficult to palpate on some

patients due to the overlying gluteal musculature, specifically the gluteus maximus

muscle.Palpation: With the patient lying in the prone position, locate the S3 tubercle on

the sacrum (as described above). From the S3 tubercle, move laterally 1½-2” to find the

PIIS. Alternately, locate the PSIS (as described above) and move laterally ½” (over the

bony ridge of the PSIS) and 1-2” inferiorly to find the PIIS.

Ischial Spine – to locate the spine of the ischium, first locate the PSIS and ischial

tuberosity (as described below). Then, bisect an imaginary line connecting these two

osseous structures, arriving at the ischial spine. You may need to palpate slightly

inferiorly to be directly over the ischial spine.

Ischial Tuberosity – to locate the ischial tuberosity on a patient lying prone, first observe

the area of transition between the gluteal and hamstring muscles, at the inferior border of

the buttocks. Then, palpate for the bony prominence at the level of the gluteal fold,

approximately at the middle of the buttock (halfway between the medial and lateral

borders of the buttock).

CONCLUSION

Static palpation of the spine is an art and learned skill. The ultimate goal that chiropractic

students must strive for during their introductory palpation experience is to enhance their

psychomotor skills by increasing tactile perception, letting their fingers become their

“new” eyes. Attainment of this goal does not, occur overnight or during the course of a

15-week college trimester. It is a life-long task marked by increased sensitivities and

perceptions through persistent practice, leading to steadily increasing confidence.