At first glance tenderness would seem to be a simple
physical finding. However learning to
accurately and precisely elicit the tenderness associated with a patient’s
perceived pain and primary compliant can be an extraordinarily useful diagnostic tool. Pin pointing the anatomic location of the
patient’s tenderness can lead to a specific diagnosis or at least help direct
the diagnostic workup. During the physical exam tenderness is an unusual and
painful sensitivity to touch, pressure or palpation of a specific anatomical
point. Tenderness should not be confused with pain or a report of discomfort.
Pain is patient's perception; while tenderness
is a sign that is elicited by palpation. Ideally the tenderness reproduces the
pain at least in a small way that the patient is complaining about. A patient will often present with a complaint
like "my hand hurts! “ or “my wrist is painful". In order to establish a differential
diagnosis for this complaint the surgeon or physician must first attempt to
pinpoint the exact origin of this painful complaint in the hand, wrist or upper
extremity. By examining the hand, wrist
and upper extremity until the specific point of tenderness is identified, the
examiner will begin to develop a differential diagnosis to explain the
patient's complaint of pain.
The examiner must understand that palpation that
produces tenderness will often be perceived to radiate and be difficult for the
patient to localize accurately. For
example in a patient that has carpal tunnel syndrome, the mid palmar wrist is frequently
exquisitely tender. When this part of
the wrist is tapped while trying to elicit a Tinel's sign the patient will
perceive pain that usually radiates into
the fingers in the form of paresthesias (tingling) or radiates proximately in
the forearm and even into the arm. Once again
pinpointing the starting point of the discomfort is key to identifying the
underlying explanation for the problem.
Both the examiner and the patient must understand that pain can radiate
and how this can complicate the precise location of the original tenderness.
The examiner must also appreciate that the hand and
wrist structures are in layers and that the palpation of the specific spot on
the skin surface may cause tenderness to be observed and pain to be perceived
by the patient because of an inflamed tendon immediately under the skin or
because of a undiagnosed fracture which is actually deep to the tendon. The examiner must remember when pressure is
applied to one structure you may be actually pushing on two structures. For
example, applying pressure on the flexor carpi radialis tendon can simultaneously
apply pressure to the tuberosity of the scaphoid. Thus a positive response could be interpreted
as tendinitis or a scaphoid injury. In order to identify the exact source the
tenderness the examiner may have to palpate from different directions and
correlate the physical findings with other studies such as x-rays.
Also when the
examiner is holding the patient's wrist or hand, the fingers or thumb of the
examiner that are applying counter pressure to stabilized the hand or wrist may
actually be causing a pressure that is eliciting the tenderness that the
patient perceives as pain instead of a different palpating thumb or finger that the
examiner is attempting to using to initiate the tenderness response.
Finally tenderness
like the degree of perceived pain can vary considerably from patient to
patient despite the presence of identical pathology. A trigger finger may cause pain that one
patient scores as 2/10 while a second patient with the same complaint may score
the pain as 9/10. Because of this it is
important to use the patient as his or her own internal control by simultaneously
comparing palpation of the uninjured hand or wrist with the injured hand. Applying pressure to the uninjured Lister's
tubercle will often elicit tenderness and a complaint of pain even when there
is no injury or pathology in the area whatsoever. It is useful sometimes to show this to the
patient so they understand that the tenderness that the examiner is trying to identify should cause a pain perception
that is greater than the discomfort created by palpating this uninjured point which is being used as a baseline.
A sophisticated
examination for tenderness does not simply apply pressure diffusely to an
entire hand wrist and forearm or elbow. The
examiner should be aware of the common pinpoint locations of tenderness that
are associated with specific anatomic
sites and the potential pathological diagnoses frequently seen at these sites. In the images below note the diagnoses and
precise pinpointed location of tenderness typically associated with the
diagnosis. In addition to the pinpoint
location on the surface of the skin also appreciate the pinpoint sites location
in reference to the underlying skeleton and joints. This detailed examination which strives to
identify specific points of tenderness will quickly help the examiner develop a
differential diagnosis to explain the tenderness and the patient's complaint and perceived pain.
