Breast Examination Technique

Updated: Jan 22, 2016
  • Author: Sara J Grethlein, MD; Chief Editor: Christine Isaacs, MD  more...
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Technique

Approach Considerations

Several different palpation techniques can be used for clinical breast examination. Limited comparative data on the efficacy of these techniques are available. Key elements of a successful examination include careful observation and systematic palpation.

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Observation

First, with the patient sitting up with arms at her sides, the clinician observes the shape, color, and skin characteristics of the breasts. It is important to note skin retraction, ulceration, erythema, or crusting of the nipples and to note and either establish or compare with the baseline whether the nipples are inverted, everted, or flat.

Next, the patient is asked to raise her arms over her head. The clinician should note the movement of the breast tissue as she does this and observe for any tethering of breast tissue to the chest wall. The clinician may also ask the patient to arch her back with hands on her hips, again observing for the movement of the breast tissue.

Breast exam 1
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Palpation

With the patient sitting up, palpation is started.

The clinician should the flats of the finger pads, not the tips, for enhanced sensitivity and should remain cognizant of the patient’s nipple and avoid incidental contact with his or her hand.

The examiner is responsible for evaluating all tissue between the skin and the chest wall.

Although it is possible to repeat the palpation pattern using different degrees of pressure (and therefore depth of tissue being assessed), a more efficient approach is to spiral in each position from superficial to deep, paying attention to the tissue at each level.

Palpation is begun at the medial portion of the chest wall below the clavicle and progresses down and up in a “vertical strips” pattern.

The examiner should slide from palpation position to position rather than lifting his or her hand.

Palpation is repeated on the opposite breast.

In this position, it is difficult to have confidence in the examination of the underside of the breast in full-breasted patients.

vertical strips and spokes of the wheel vertical strips and spokes of the wheel
Breast exam 2

Next, the patient is asked to lie flat with the arm of the breast being examined behind the patient's head. This stretches out the breast tissue against the chest wall and is particularly helpful in examining the lower quadrants.

The breast is palpated following a “spokes of the wheel” pattern. The areola and subareolar breast tissue in is included in the palpation pattern.

Attempting to “milk” the breast is unnecessary unless the patient has described a discharge.

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Examination of Associated Structures

When performing a breast examination for the purpose of cancer screening, it is appropriate to include an evaluation of the supraclavicular and axillary nodal groups.

Examination of the axilla is best performed with the patient sitting upright. The patient is asked to raise her arm. The anterior wall of the axilla is formed by the pectoralis major muscle. With palm facing forward, the examiner inserts his or her hand into the axilla, just posterior to the pectoralis major and parallel to the plane of the muscle. The patient lowers her arm with the examiner’s hand in place. The examiner then rotates his or her palm perpendicular to the plane and sweeps downward. Pathologic lymph nodes may be palpated and may "pop" during the downward sweep.

Examination of the supraclavicular nodes is best performed with the patient sitting upright. Beginning medially within the supraclavicular fossa, the examiner palpates the supraclavicular fossa thoroughly to its lateral boundaries. Nodes that are hard, fixed to the underlying structures, or greater than 1 cm may be pathologic and warrant further investigation.

Breast exam 3
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Documentation

If an abnormality is identified, it is important to record it accurately.

Using the nipple as the center of a clock face, any lesion is described by its clock position, distance from the nipple, and relative depth from the skin. It is useful to draw a simple diagram of the abnormalities identified.

Abnormalities should be described by their contour (linear, round, or lobulated), texture (fluctuant, soft, firm, rock hard), mobility (eg, fixed to the underlying tissue), and standard findings for inflammation, if present (warm, red, tender). It is also important to note any associated skin changes such as peau d'orange or ulceration.

Peau d'orange Peau d'orange

Documentation of a normal breast examination includes a description of symmetry, contour, and the presence of any lesions. Normal tissue is usually soft and may be finely granular. Asymmetry of breast size may be a normal variant.

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