Deep tenderness is best elicited by palpation using the finger to exert firm deep pressure on the painful site. The anatomical area and involved neural segments of tenderness should be determined. While palpating the affected area, the practitioner should be attentive to signs of subjective (e.g., grimacing, groaning, verbal and non-verbal expressions) and objective (e.g., sweating, flushing, tachycardia, muscle spasm) manifestations of pain and determine if any discrepancies exist.
Because the underlying sensitivity of a patient affects his/her expressiveness to painful stimulation, palpation of the patient's opposite symmetric non-painful side should be performed. As a result, the practitioner gains a better understanding of the sensitivity of the patient to noxious and non-noxious stimuli, as well as information about the sensitivity of the painful region.
Tests such as the brush test, pinch test, pinprick test, and scratch test help distinguish whether pain provoked by palpation results from overlying skin or deeper structures. The brush test consists of lightly stroking the skin with a cotton wisp. If the patient reports pain indicative of allodynia, the underlying cause of pain is suggestive of spinal cord dysfunction. The pinch test consists of squeezing skin between the thumb and index finger, first over an adjacent non-painful area, continuing over to the painful location, and then farther past to an asymptomatic region. The pinprick and scratch tests, which are performed as described, provide a means by which to examine a patient's sensation to superficial pain. For a baseline comparison of the effects of all these tests, the practitioner should perform the same tests on the opposite non-painful area as a control.
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