The location of the inferior angle of the scapula in relation to the spine in the upright position: a systematic review of the literature and meta-analysis

Effectiveness of Ultrasound Imaging in Assessing the Palpation Skills of Rotating Physicians

As an important means of physical examination, palpation is usually limited to the physical examination before surgery and used as an auxiliary method for disease diagnosis in the field of surgery. In practice, palpation is also used in every aspect of the surgical procedure, and its application is of great significance to surgery. The purpose of this study was to investigate the ability of ultrasound imaging to assess the ability of rotating physicians to locate musculoskeletal structures by palpation. Rotating physicians were asked to palpate and locate the long head tendon of the biceps (LHB), posterior tibialis (TPT), acromioclavicular joint (ACJ), and medial tibiofemoral joint (TFJ) spaces on two volunteer models. After positioning, a truncated steel needle was attached to the skin and parallel to the palpable structure, and the position of the steel needle relative to the designated structure was assessed by ultrasound imaging, using the Cohen kappa test to study the inter-rater agreement. The results showed that the assessor’s Kappa coefficient for judging the location of all structures was 0.816, LHB was 1.00, TPT was 0.912, ACJ gap was 0.796, and TFJ medial space was 0.844, and the success rate of palpation for TPT was 62.2%, TFJ medial space was 37.8%, ACJ clearance was 24.3%, and LHB was 8.1%. In conclusion, the teaching methods of anatomy and palpation skills need further improvement, and ultrasound imaging is an effective tool for assessing palpation skills.

Using ultrasound imaging to assess novice physiotherapy students' ability to locate musculoskeletal structures with palpation

OBJECTIVE

Use ultrasound imaging to assess success rates of novice physiotherapy students attempting to locate two tendons and two joint spaces using palpation.

DESIGN

Cross-sectional study.

SETTING

Master of physiotherapy program at an academic institution.

PARTICIPANTS

Twenty-two end of first-year physiotherapy students.

METHODS

Participants were asked to palpate and locate the long head of the biceps (LHBT) and tibialis posterior (PTT) tendons as well as the acromioclavicular joint (ACJ) and medial tibiofemoral joint (TFJ) spaces on two human models. A truncated needle was taped onto the skin, parallel to the palpated structure. Ultrasound imaging was used to assess the position of the needle relative to the structures.

MAIN OUTCOME MEASURES

Success or failure was determined based on a judgment call on the needle position relative to the targeted structure on the ultrasound images. Inter-evaluator agreement for judgment criteria was investigated using Cohen's kappa tests and success rates subsequently calculated.

RESULTS

Kappa coefficients were 1.00 for all structures collectively, 1.00 for LHBT and PTT tendons, 1.006 for ACJ, and 0.79 for TFJ. Palpation success rates were: 9% for LHBT, 64% for PTT, 23% for ACJ, and 31% for medial TFJ.

CONCLUSION

These results highlight the fact that there is room for improvement in anatomy and palpation skill teaching methods and ultrasound imaging is valuable tool to assess this important skill.

The impact on anatomical landmark identification after an ultrasound-guided palpation intervention: a pilot study

Background

To determine whether a discrepancy exists in identifying three musculoskeletal landmarks (medial meniscus, lateral malleolus and lateral epicondyle of the humerus) and whether ultrasound-guided (US-guided) palpation intervention can reduce that discrepancy and improve localization for chiropractic interns.

Methods

Sixteen chiropractic interns were asked to identify three subcutaneous anatomical landmarks before/ after the intervention and at a 3-day follow-up. The intervention was a three-minute US-guided demonstration of the landmarks after the intern’s initial localization. The primary outcome measure was the change in distance between the intern’s landmark identification. Non-normal data were analyzed with the Friedman’s and Wilcoxon signed rank tests. Discrepancy between examiner-determined landmarks and intern-identified landmarks at the initial time point was assessed with a 1-sample Wilcoxon signed rank test.

Results

All locations demonstrated an initial discrepancy between examiner-determined landmarks and intern-identified landmarks at the initial time point. Overall, a statistically significant difference was noted in the identification of the medial meniscus (p = 0.012) and lateral malleolus (p = 0.001), but not at the lateral epicondyle (p = 0.086). For the before and immediately after comparison, a significant improvement was found with the medial meniscus (p = 0.005) and lateral malleolus (p = 0.002). The 3-day post-intervention comparison found an improvement only for the lateral malleolus (p = 0.008).

Conclusion

This pilot study demonstrated palpatory discrepancy at identifying all three landmarks. Our data suggests that US-guided palpation intervention seems to improve an intern’s ability to palpate two landmarks (medial meniscus and lateral malleolus) post-intervention.

Would adopting a revised landmark rule for the spinal level of the iliac crests improve the accuracy of lumbar level identification?

This is a secondary analysis of two previous systematic reviews demonstrating cephalad bias in using palpation to enumerate lumbopelvic levels, based on the conventional landmark rule that the spinal level of the palpated iliac crests=L4. Our study included 7 articles which enumerated lumbopelvic levels based on this rule, and furthermore reported data such that the direction and magnitude of errors could be abstracted from the article. The primary goal was to determine if enumeration accuracy would have improved had examiners known that the spinal level of palpated crests was closer to the L3-4 or L3 spinal level, as shown in our previous review. For the articles included, the mean error in spinal level enumeration diminished from 0.79 to -0.21 spinal levels, while accuracy increased from 26.3% to 46.9%. Since accuracy remained <50%, further refinements in iliac crest palpation are unlikely to improve enumeration accuracy, suggesting another method might best be sought.

Scapular Upward Rotator Morphologic Characteristics in Individuals With and Without Forward Head Posture: A Case-Control Study

OBJECTIVES

There are several reports suggesting that forward head posture contributes to alterations in scapular kinematics and muscle activity, leading to the development of shoulder problems. Currently, it is unknown whether forward head posture alters the thickness of the scapular muscles. The aim of this study was to compare the thickness of the serratus anterior and upper and lower trapezius muscles at rest and during loaded isometric contractions in individuals with and without forward head posture.

METHODS

Twenty individuals with forward head posture and 20 individuals with normal head posture participated in this case-control study. Three separate ultrasound images of the serratus anterior and upper and lower trapezius muscles were captured under 2 randomized conditions: at rest and during a loaded isometric contraction.

RESULTS

The thickness of each muscle significantly increased from rest to the loaded isometric contraction (P < .001). The only difference between the groups was that the thickness of the serratus anterior muscle at rest in the normal-posture group was larger than that in the forward-posture group (P = .01).

CONCLUSIONS

Forward head posture appears to be related to atrophy of the serratus anterior muscle, which may contribute to the development of shoulder problems. Further research is required to identify more about the association of forward head posture with the imbalance of shoulder girdle muscles and the impact of head posture on upper quadrant pain.

Accuracy of Motion Palpation Flexion-Extension Test in Identifying the Seventh Cervical Spinal Process

Objective

The aim of this study was to evaluate the accuracy of a motion palpation procedure, the flexion-extension test, in localizing the spinous process of the seventh cervical vertebra (C7).

Methods

We analyzed 101 adult participants with metal markers that permitted the identification of the C7 spinous process. This analysis occurred during a flexion-extension test and was confirmed by radiography. Data sample characteristics were analyzed by descriptive statistics, and the relationship between independent variables (weight, height, sex, age, and body mass index [BMI]) and dependent variables (coincidence between the most prominent vertebra and the stationary vertebra, as determined by the flexion-extension test) was determined via logistic regression.

Results

The sample population was 48.5% male with a mean age of 56.8 years (standard deviation, ±14.9) and a mean BMI of 25.54 kg/m² (standard deviation, ±5.5). In 54.5% of cases, the C7 spinous process was correctly identified by the flexion-extension test. The agreement between the flexion-extension test and radiography in accuracy of localization of the C7 spinous process was significant (P = .021), as was the correct localization of C7 (P = .05).

Conclusion

The localization of the C7 spinous process was more accurate in individuals with a BMI <25 kg/m² and whose most prominent vertebra coincided with the stationary vertebra as determined by the flexion-extension test.

Systematic review and meta-analyses of the difference between the spinal level of the palpated and imaged iliac crests

OBJECTIVE

The purpose of this study was to undertake a systematic review of the literature to determine and compare, for patient sub-groups, the spinal level of the iliac crests as commonly measured through manual palpation and radiographic imaging procedures.

METHODS

Relevant citations were retrieved by searching the PubMed, ICL, CINAHL, AMED, Osteopathic Research Web, OstMed, and MANTIS biomedical databases, and included articles were rated for quality. Search terms included Tuffier*, intercristal line, intercrestal line, Jacoby's line, lumbar spine, lumbar landmark, pelvic landmark, palpation, and TL (Tuffier's Line). Meta-analyses were performed on the full datasets as well as subsets based on various patient demographics.

RESULTS

Original search strategies retrieved 1301 citations; 47 articles were used for qualitative synthesis and 31 for meta-analyses. Across these studies imaged crests were found to be most consistent with and closest to the L4-5 interspace in females and L4 spinous process in males. In comparison, the spinal level for the palpated crests was nearest to the L3-4 interspace in males and females. The palpated crest line was 0.7 levels cephalad to the imaged crest line in males, and 1.0 levels cephalad to the imaged line in females.

DISCUSSION AND CONCLUSIONS

During manual palpation, the examiner's fingers contact soft tissue overlying the iliac crests, thereby usually identifying the L3-4 spinal level rather than the assumed L4-5 level. Palpating iliac crests to guide anesthetic injections or manual therapy without appreciating these findings can be hazardous or lead to suboptimal patient care.

Development of a new palpation method using alternative landmarks for the determination of thoracic transverse processes: An in vitro study

Palpation methods (PMs) have been proposed to guide clinicians in locating the thoracic transverse processes (TTPs). However, no studies have assessed the validity of TTPs palpation or the added value of musculoskeletal ultrasound (MSU). The objectives of the present study were (1) to explore the validity of TTPs location using palpation as commonly performed by clinicians, (2) to develop an accurate and valid PM, and (3) to assess the added value of MSU. A standardized procedure was used on six cadavers. It consisted in the insertion of markers through the T3, T5, T6 and T8 TTPs and spinous processes, which were identified using palpation and MSU. First, a fresh cadaver was used to explore the validity of the common palpation method. Since poor validity was observed, one intermediate and a final PMs were tested on a total of five Thiel-embalmed specimens. A descriptive analysis was performed and agreement between MSU and the final PM was determined. The final PM led to the proper determination of all TTPs on three specimens with a mean error of 4 ± 1.8 mm in relation to the TTPs center. The coefficient of variations and root mean square errors were ≤0.15 and 0.21 mm, respectively. Bland-Altman plot showed no differences between palpation and MSU. In conclusion, this study reports the validity of a new PM using multiple landmarks to guide TTPs determination and for which MSU does not seem to add value in accuracy. These results may have important clinical implications for clinicians using palpation.

Reliability and Validity of the Measurement of Scapular Position Using the Protractor Method

BACKGROUND

The protractor method is a proposed clinical assessment tool, the first to measure vertical scapular position, that directly compares scapular and spinal landmarks. This tool has the potential to reliably and accurately measure excessive scapular elevation or depression.

OBJECTIVE

The purpose of this study was to determine reliability and validity of the protractor method to measure resting scapular position.

DESIGN

An interrater and intratester reliability and validity study was conducted.

METHODS

Testing was conducted on the same day by 2 physical therapists who were blinded to each other's results. The vertical distances between the spinous process of C7 and the superior margin of the medial aspect of the spine of the scapula (C7 method) and the spinous process of T8 and the inferior angle of the scapula (T8 method) were palpated and measured on the symptomatic shoulder in 34 people with current shoulder pain using the protractor method. Measurements were compared with 2-dimensional camera analysis to assess validity.

RESULTS

For intertester reliability, the standard error of measure, minimal detectable change, and intraclass correlation coefficient were 6.3 mm, 17.3 mm, and .78, respectively, for the C7 method and 5.7 mm, 15.7 mm, and .82, respectively, for the T8 method. For intratester reliability, the standard error of measure, minimal detectable change, and intraclass correlation coefficient were <0.9 mm, <2.5 mm, and .99, respectively. For validity, significant correlations (r) and mean differences were .83 and 10.1 mm, respectively, for the C7 method and .92 and 2.2 mm, respectively, for the T8 method.

LIMITATION

The results of this study are limited to static measurement of the scapula in one plane.

CONCLUSION

Both protractor methods were shown to have good reliability and acceptable validity, with the T8 method demonstrating superior clinical utility. The clinical use of the T8 method is recommended for measurement of excessive resting scapular elevation or depression.