A Palpation Exercise: Identifying Cranial Landmarks

As publishers rationalise their range of titles - faced as they are with pirate sites where free-downloads are available, as well as the burgeoning ebook phenomenon, one of my favourite books is soon to vanish :  "Cranial Manipulation: Theory & Practice" (2nd edition 2007).
A quick glance on Amazon today shows that copies are still available...but when they have gone, that's it...for what I unashamedly believe to be the best book on the subject.
To quote from one brief review:

"By far the best basic book I have read on the subject. Filled with research references, clear descriptions of anatomy, functional rationale and skill-building exercises."
Russell Stolzoff, Certified Advanced Rolfer, Rolf Movement Practitioner

Meanwhile...since the rights to the book will soon be mine again I have chosen to lift an exercise from it (and some illustrations) - based on the original work of that great osteopathic physician, Philip Greenman (2003). 

This exercise can be seen as means of improving the ability to locate features of cranial anatomy..... or simply as a way to enhance basic  palpation skills. It can take anything from 10 to 15 minute to perform thoroughly - or can be completed rapidly in 2 to 3 minutes....it's up to you.
I suggest you use the illustrations above to help negotiate the landmarks if you are unfamiliar with them.

·  Sit at the head of the table with your partner lying face upwards, no pillow.

·  Palpate the vertex of the skull with your thumb or fingerpads. Moving them gently from side to side, feel the serrated contours of the sagittal suture. Locate the posterior aspect of the sagittal suture, the L-shaped lambda.

·  Follow the sagittal suture from where it begins at the lambda, where the parietal and occipital bones meet. Try to note irregularities, asymmetries (for example, one side being raised compared with the other), areas of contrast in terms of hardness/softness, etc. Palpate with fingers or thumbs lightly criss-crossing the suture, moving anteriorly in this manner until you reach the bregma, a triangular depression, the junction of the sagittal and the coronal sutures. It is normal for the posterior third of the suture to feel more ‘open’ than the anterior third. This is due to the size of the serrations rather than being an abnormality.

·  Starting from the bregma, lying in a slight depression, palpate bilaterally (both ways at the same time) sideways along the coronal suture. You are feeling the junction between the parietal and the frontal bones. Compare what one fingerpad feels with what the other is sensing, trying to determine any indication of the frontal or the parietal bone being more prominent on one side compared with the other, assessing for irregularities, hard and soft areas, rigidity, etc., seeking evidence of any asymmetry. Pick (1999) describes the area between the bregma and the great wing as feeling ‘like an open trench’, as though the suture has ‘spread apart’.

·  As you come to the end of the coronal suture you will feel a bony prominence and then a depression, the pterion, the junction of the sphenoid, frontal, parietal and temporal bones. Compare one side with the other, carefully, using a feather-light touch.

·  From the pterion move onto the great wing of the sphenoid and palpate its contours and sutures. This is a very important landmark in cranial methodology. Are the two sides of the sphenoid symmetrical; is one side higher or lower on the head? Is there any sense of one side being more ‘rigid’ than the other or more prominent?

·  The sphenofrontal suture between the great wing of the sphenoid and the lower, outer aspect of the frontal bone is relatively easy to palpate as the great wing is flat, while the lateral aspect of frontal bone bulges laterally.

·  The superior aspect of the great wing meets the parietal bone at the sphenoparietal suture.

·  The junction of the posterior aspect of the great wing with the temporal bone is at the sphenosquamous suture, where a slight ridge-like prominence is a normal feature of this intersection.

·  From the great wings return to the pterion and follow the squamoparietal (or parietotemporal) suture between the temporal squama and the parietal bone on each side. This travels backwards and curves over the ear. Use a light fingerpad contact on each side which gently, repetitively and thoughtfully travels superiorly and inferiorly to cross and recross this border. Feel carefully (this is not an easy suture to locate) for the sense of greater fullness as the fingers move superiorly, where the parietal bone overlaps the temporal bone. Sense for irregularities on one side compared with the other, of a sense of rigidity or of soft tissue ‘congestion’, tension or fibrosis in the musculature.

·  At the end of this suture is the asterion, which is the junction of the temporal, parietal and occipital bones. Again compare one side with the other in the ways suggested above. 

Is there symmetry? 

Unusual rigidity? 

Is there any irregularity of feel?

·  Just anterior to the asterion it is possible to palpate a small amount of the suture between the parietal bone and the mastoid process (parietomastoid suture). Compare these for symmetry and irregularities and also for differences in the attachments of the sternomastoid muscles that apply such force at their attachment sites.

·  Moving back to the asterion, feel for the meeting place of the mastoid and the inferior edge of the occiput, the occipitomastoid suture. This feels like a depression or furrow, running along the posteromedial border of the mastoid. Allow your fingers to follow the occipitomastoid suture until it is lost under the soft tissues inserting onto the cranium. Assess these soft tissues bilaterally for evenness of feel.

·  From the asterion move medially and superiorly along the serrated lambdoidal suture. Bilaterally, using the same sutural evaluation method of crossing from side to side of the suture, evaluate for irregularities and asymmetries. It normally feels wide and open.

·  Your fingers will meet when you reach the L-shaped lambda, commonly sensed as a depression, lying on the midline, where the occipital bone meets the sagittal suture. Carefully evaluate the feel of this vital junction for evidence of crowding, distortion or asymmetry. This is close to where you began the palpation exercise.

·  Palpate back down, along the lambdoidal suture, to the asterion on each side and take your searching fingerpads onto the mastoid process. Palpate the mastoids for symmetry. Do they seem to lie at the same angle on each side? Are there signs of soft tissue imbalance (sternomastoid attachments here can produce marked differences of one side from the other)? Are they symmetrical in feel and do they have the same sense of ease when you lightly (half ounce maximum) ease them posteromedially or is one side more resistant?

·  Now move your hands to the face. Starting at the upper outer margin of the orbit, palpate laterally and inferiorly until you feel the frontozygomatic suture, sensing for irregularities.

·  Follow the lateral aspect of the orbit until you find the zygomaticomaxillary suture.

·  Palpate medially along the inferior orbit and up the medial wall to feel the nasomaxillary junction and the frontomaxillary junction. Seek evidence of asymmetry and/or unusual tissue feel.

·  Repeat these palpation moves until you are familiar with the contours, landmarks and feel of the skull in people of all ages and in as many different states of health as possible.

• Greenman, P.E., 2003. Principles of Manual Medicine, third ed.Lippincott Williams and Wilkins, Baltimore. 
• Pick M 1999 Cranial sutures: analysis, morphology and manipulative strategies. Eastland Press, Seattle