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.
