What is the proper technique for visual palpation of lymph nodes?

Proper Technique for Visual Palpation of Lymph Nodes

The proper technique for lymph node palpation requires the patient to be sitting upright for examination of axillary, supraclavicular, and infraclavicular lymph nodes, followed by systematic palpation using the finger pads of the middle three fingers in overlapping dime-sized circular motions with three levels of pressure (light, medium, and deep). 1

Patient Positioning

• For lymph node examination: Patient should be sitting upright to properly access and evaluate axillary, supraclavicular, and infraclavicular lymph nodes 1
• For breast tissue examination: Patient should be lying down with ipsilateral arm overhead to flatten breast tissue on the chest wall 1
• If needed, place a small pillow under the shoulder/lower back on the side being examined to evenly distribute tissue 1

Palpation Technique

Hand Position and Movement

• Use the pads (not tips) of the middle three fingers (index, middle, and ring) 1
• Make overlapping dime-sized circular motions 1
• Apply three distinct pressure levels in sequence:
  1. Light pressure (to assess superficial tissue)
  2. Medium pressure (to assess mid-level tissue)
  3. Deep pressure (to assess tissue against chest wall or underlying structures) 1

Systematic Search Pattern

• Use a "vertical strip" pattern to ensure complete coverage of the area 1
• Define the perimeter of examination using anatomical landmarks:
  • For breast tissue: midaxillary line, inframammary ridge at fifth/sixth rib, lateral edge of sternum, clavicle, and back to midaxilla 1
  • For lymph nodes: follow the anatomical distribution of node groups (cervical, axillary, inguinal) 1

Specific Lymph Node Examination Techniques

Cervical Lymph Nodes

• Examine with patient sitting upright
• Palpate systematically through all cervical node groups
• Pay particular attention to supraclavicular and infraclavicular regions

Axillary Lymph Nodes

• Position patient with arm slightly abducted
• Support patient's arm with your hand while palpating with the other
• Examine central, lateral, anterior, posterior, and apical node groups

Inguinal Lymph Nodes

• For penile cancer and lower extremity assessments, thoroughly examine inguinal nodes 1
• Note the diameter, unilateral/bilateral location, number of nodes, and relationship to surrounding structures 1

Documentation and Assessment

When documenting findings, include:

• Size of nodes (diameter in cm)
• Location (unilateral or bilateral)
• Number of nodes identified in each region
• Consistency (soft, firm, hard)
• Mobility/fixation status
• Tenderness
• Relationship to surrounding structures 1

Important Considerations

• Inform patients in advance about the examination process to minimize discomfort and misunderstanding 1
• The detection threshold varies by experience level: consultants can reliably detect nodes ≥0.75 cm, while less experienced practitioners may only detect nodes ≥1.3 cm 2
• Palpation alone has limitations with a sensitivity of approximately 82% compared to more advanced techniques like ultrasound 3
• False-negative findings are common with smaller nodes; all suspicious findings should be confirmed with imaging 4

Common Pitfalls to Avoid

• Inadequate coverage of the examination area
• Insufficient pressure variation (not using all three levels)
• Rushing the examination (a thorough exam takes several minutes)
• Failing to systematically examine all relevant node groups
• Overreliance on palpation alone when suspicious findings are present 1, 5

Remember that while palpation is an essential clinical skill, it should be supplemented with appropriate imaging when suspicious findings are detected, as even experienced clinicians may miss nodes smaller than 0.75 cm 2.