Surface anatomy and palpation.docx

Surface Anatomy and Palpation Manual Dr. Sakher Obaidat Summer 2023
Therapeutic Touch
 Your touch communicates a message- be intentional with your touch and sensitive to the non-verbal cues your patient/
client is communicating.
 Tips:
 Expose the area of interest
 Move perpendicular to the structure of interest
 Touch lightly- less is better (See a light blanching skin when fingers are removed)
Lumbopelvic Region Considerations
Considerations
 Position patient/ client for maximum comfort.
 Explain what you are doing before laying patient/ client prone.
 Drape to maintain modesty.
 This example shows how to drape for surface anatomy of the lumbar spine and posterior hip.

Cervical Spine
Cervical Spine - Bony
Cervical Spine - Bony - Postural Corrections
Cervicothoracic Positioning and Patient Posture
Cues
 For locating surface anatomy structures in the neck and upper back it is important to start with your patient
in a standardized posture
 Align the back of their head with the most dorsal curve of the thorax
 The external auditory meatus and the eye should be level and perpendicular to the horizontal
Cervical Spine - Bony - Spinous Processes
Spinous Process of C2
 Start at the greater occipital protuberance, slide down.
 There will be a space because C1 does not have a spinous process.
 C2- First spinous process palpable below occiput. Note the process is bifid.
Anterior Structures and Related Spinous Processes
 C3- hyoid bone. To identify the hyoid bone, gently place your fingers in the front of the patient's neck and have them
swallow gently to feel it move.

 C4- thyroid cartilage V. From the hyoid bone move down, the next prominence is the thyroid cartilage. There is a small V
shape on the superior aspect of the thyroid cartilage.
 C5- thyroid cartilage body. The body of the thyroid cartilage is a flat surface felt on the lateral aspect and beneath the V.
 C6- first cricoid ring. Inferior to the body of the thyroid cartilage is the first cricoid cartilage ring.
Spinous Process of T1
 While the Patient/client is sitting with arms at side, place fingers dorsally over the spaces between where you believe C7,
T1 and T2 spinous processes to be
 Place the fingertips of your other hand on the manubrium and press dorsally
 Be sure to obtain permission from your patient/ client before placing your fingertips on their manubrium
 The superior most spinous process to move dorsal is T1
Spinous Processes in Prone
 With the patient / client laying prone, Locate the external occipital protuberance and slide down until you feel the first
bony prominence, that is C2
 It is difficult to differentiate C3-C7 spinous processes, better to use the articular pillars
 The spinous processes of C2-C6 are all bifid. C7 is unique in that is has a single projection posteriorly
 Find the spinous process of T1 by placing fingertips over the spinous processes in the region of C7 to T2
 Follow the cranial aspect of the clavicle to place fingertips of the other hand on the manubrium and provide a gentle dorsal
push
 The first spinous process that moves dorsally is T1

Transverse Process of C1
 In the depression between the mastoid process and rami of the mandible, feel for a bony projection, like the
tip of a pencil
 It may help to have the patient/ client protrude their jaw forward
 Attachment site for multiple muscles in the suboccipital region
 Rectus capitis anterior, rectus capitis lateralis, obliquus capitis superior, obliquus capitis inferior, levator
scapula, splenius cervicis all have attachments to C1 transverse process
Transverse Process or C3-C7
 Moving distal from the transverse process of C1
 There is a space where the transverse process of C2 is not easily palpable as it is very short
 The transverse processes of C3-C7 can be felt moving inferiorly
 Note that the transverse processes have a groove for the spinal nerve. This groove creates the anterior and
posterior tubercles of each transverse process and faces more ventrally as you move caudally.
 As the transverse processes often lay beneath the sternocleidomastoid, moving the muscle aside or side
bending the head may aid in palpation success.
 Muscles attaching to the transverse processes include the scalenes, levator scapulae, splenius cervicis and
capitis, semispinalis cervicis and capitis and the deeper transversospinal muscles.
 Palpating the spinal nerve root between the anterior and posterior tubercles can be helpful in locating the
involved spinal root level.

Cervical Spine - Articular Pillars
 From the spinous process, move lateral
 Difficult to differentiate levels
Cervical Spine - Articular Pillars in Prone Position
 Starting at the spinous process, move lateral through the musculature
Cervical Spine - Soft tissue
Cervical Spine - Soft Tissue - Anterolateral
Upper Trapezius
 Have the patient/ client extend and perform ipsilateral side flexion to feel the descending fibers of the trapezius,
commonly called the upper trapezius. These muscle fibers run from the external occipital protuberance , nuchal line and
nuchal ligament to the lateral clavicle and acromion
 The anterior margin of the upper trapezius and the posterior border of the sternocleidomastoid form the borders of the
posterior triangle of the neck
 Structures in the posterior triangle include the splenius capitis, levator scapulae, posterior scalene and medial scalene
when palpating from posterior to anterior.
 Referral Pattern: Trigger points in the upper trapezius can give rise to lateral neck and auricular pattern of neck pain and
headache depending on location of the trigger point
Muscle Origin Insertion Innervation
Upper
Trapezius
External occipital protuberance, medial third of the superior
nuchal line, ligamentum nuchae, and the spine process of C7
Lateral third of the clavicle and the
medial aspect of the acromion process of
the scapula
Spinal accessory cranial
nerve XI, Ventral Rami C2-
C4

Stenocleidomastoid
 Have the patient/ client perform contralateral rotation with slight neck flexion to see the very prominent muscle belly in
the anterolateral aspect. Follow it from its origin on the manubrium and clavicle to its insertion onto the mastoid process.
 The anterior margin of the upper trapezius and the posterior border of the sternocleidomastoid form the borders of the
posterior triangle of the neck
 Structures in the posterior triangle include the splenius capitis, levator scapulae, posterior scalene and medial scalene
when palpating from posterior to anterior.
 Referral Pattern: Trigger points in the sternocleidomastoid can give rise to pain in the felt in occipital, temporal, auricular,
zygomatic and frontal regions of the head depending on location of the trigger point
 Note these vascular structures
 External jugular vein runs superficial to the Sternocleidomastoid from the parotid gland down to the region of the
clavicular head where it pierces the deep cervical fascia to drain into the subclavian vein. Care should be taken when
needling in this area
 Carotid artery can be palpated at the level of C4 (Thyroid cartilage V) and is also the location where the Internal jugular
vein is accessible
SternocleidomastoidSternal head- Manubrium of sternum, Clavicular
head- Superior border of medial 1/3 of clavicle bone
Mastoid process of temporal bone and
lateral half of superior nuchal line
Spinal accessory nerve CN XI
and spinal nerve C2, C3, C4
Splenius Capitis
 Have the patient/ client perform ipsilateral side flexion and rotation while palpating from the spinous processes of C3 to
T3 and nuchal ligament to the insertion into the mastoid and lateral area below the superior nuchal line. This muscle is
deep to the upper trapezius
 Referral Pattern: Trigger points in the splenius capitis can give rise to pain in the vertex

Splenius
Capitis
Spinous processes of C7-T3 and nuchal
ligmanet
Lateral nuchal line and mastoid process of
occipital bone
Dorsal rami of lower cervical nerves,
C3, C4
Levator Scapulae
 Have the patient/ client extend and contralaterally rotate their head or elevate the scapula / side flex the head ipsilaterally
and follow the fibers from the transverse processes of C1-C4 to the superior medial angle of the scapula
 Referral Pattern: Trigger points in the levator scapulae can cause pain in the periscapular, posterior shoulder, posterior
and/ or lateral neck depending on the location of the trigger point
Levator
Scapulae
Posterior tubercles of the transverse
processes of C2-C4
Superior part of the medial border of
the scapula
Anterior primary rami, C3, C4 and dorsal
scapular nerve, C5
Semispinalis Capitis
 Have the patient/ client perform extension of the head while palpating from the occiput, between the superior and inferior
nuchal lines, down to the articular processes of C4 to C6 and transverse processes of C7 to T6.
 Referral Pattern: Trigger points in the semispinalis capitis can give rise to retro orbital and band-form pain around the
forehead.
Semispinalis
Capitis
Transverse processes of C7-T6 and articular
process of C4-C6
Between superior and inferior nuchal lines
of occipital bone
Dorsal rami of middle and lower
cervical spinal nerves
Posterior Scalene

 Have the patient/ client perform ipsilateral lateral flexion and palpate just anterior to the levator scapula to feel the fibers
of the posterior scalene. This muscle runs from the posterior tubercles of the transverse process of C5 and C6 and runs to
the second rib.
 Referral Pattern: Trigger points in the scalene muscles can give rise to periscapular, ant chest wall pain as well as pain
referred down the lateral and posterior arm and into the thumb
Posterior Scalene Transverse processes of C2-C6 Second rib Ventral rami of C4-C7
Middle Scalene
 Have the patient/ client perform ipsilateral lateral flexion and palpate the posterior tubercles of the transverse process of
C2 and C7 and down to the first rib.
Middle Scalene Transverse processes of C3-C5 First rib Ventral rami of C4-C7
Anterior Scalene
 Have the patient/ client perform ipsilateral lateral flexion and palpate posterior to the sternocleidomastoid muscle. The
anterior scalene runs from the anterior tubercles of the transverse processes of C3-C6 to the first rib.
 Thoracic outlet syndrome can arise from hypertonicity of the anterior and middle scalenes as the plexus runs through the
triangle formed by the posterior border of the anterior and anterior border of the middle scalene.
Anterior Scalene Transverse process of C2-C3 First rib Ventral rami of C4-C7

Cervical Spine - Soft Tissue - Posterior Intermediate
Greater Occipital Nerve
 Locate the lateral border of the semispinalis capitis muscle and the medial border of the splenius capitis muscle
 Gently place the finger in the space between the borders to feel the occipital artery's pulse
 Just medial to the artery is the greater occipital nerve
 Pull or tinel the nerve
Lesser Occipital Nerve
 Identify the triangle located between the posterior border of the sternocleidomastoid (SCM) muscle and the anterior
border of the splenius capitis muscle
 Palpate a small fibrous structure and follow it up to the occiput
 The nerve travels beneath the SCM muscle
Semispinalis Capitis Muscle
 Palpate along the transverse processes of C3-T3 to the inferior nuchal line of the occipital bone and fibers running to the
nuchal ligament
Semispinalis
Capitis
Transverse processes of
C3-T3
Inferior nuchal line of occipital bone and fibers running to
the nuchal ligament
Dorsal rami of middle and lower cervical
spinal nerves

Splenius Capitis Muscle
 The splenius capitus muscle arises from the spinous processes of T1-T3 and the midline fascia covering C4-C7
 It inserts into the mastoid process, beneath the sternocleidomastoid (SCM) muscle
Splenius Capitis Spinous processes of T1-T3 and nuchal ligament Mastoid process of occipital bone Dorsal rami of lower cervical nerves, C3, C4
Cervical Spine - Soft Tissue - Deep Posterior
Oblique Capitis Inferior Muscle
 Runs from spinous process of C2 to transverse process of C1
Oblique Capitis Inferior Spinous process of C2 Transverse process of C1 Dorsal rami of lower cervical nerves
Oblique Capitis Superior Muscle
 Runs from the transverse process of C1 to the occipital bone between the inferior and superior nuchal lines
Oblique Capitis Superior Transverse process of C1 Occipital bone between inferior and superior nuchal lines Dorsal rami suboccipital nerve C1

Rectus Capitis Posterior Major Muscle
 Located deep and runs from the spinous process of C2 to deep in the occiput near the foramen magnum
Rectus Capitis Posterior
Major
Spinous process of axis
(C2)
Lateral portion of occipital bone, below inferior nuchal line near
the foramen magnum
Dorsal rami suboccipital
nerve C1
Rectus Capitis Posterior Minor Muscle
 Located deep and runs from the posterior margin of C1 to the medial portion of the occipital bone, below the inferior
nuchal line
Rectus Capitis Posterior
Minor
Posterior tubercle of atlas
(C1)
Medial portion of occipital bone below inferior nuchal
line
Dorsal rami suboccipital nerve
C1
Temporomandibular Joint
Bony Anatomy of TMJ
 With the patient/ client seated or in supine with head resting on pillow, palpate the bony structures which include the
mandible, maxilla and zygoma
 Mandibular structures include the mental protuberance or chin; body, rami and angle that connects these and the
articular condyle and coronoid process at the superior aspect
 Maxilla holds the upper teeth and helps to form the infraorbital fossa

 Zygoma also forms the infra as well as lateral orbital fossa and gives rise to the zygomatic arch
 Zygomatic arch covers the coronoid process and joins the temporal bone which then forms the articular eminence and
fossa for the condyle of the mandible
Masseter Muscle
 Have the patient/ client clench their teeth to feel muscle contraction on the outside cheek area
 Masseter is responsible for clenching teeth and closing jaw
 Referral Pattern: Trigger points in the masseter can give rise to pain over the body and rami of the mandible, pain in the
lateral face as well as the ear canal and eye socket.
 Clenching is a parafunctional behavior that can contribute to myofascial involvement of the masseter.
Temporalis Muscle
 Have the patient/ client clench their teeth to feel muscle contraction near the temple region and then over the temporal
and parietal bones, as it covers a broad area of the skull. The temporalis inserts on the coronoid process of the mandible
and can be palpated by having the patient/ client open their jaw.
 Referral Pattern: Trigger points in the temporalis muscle can result in pain located throughout the temporal region as well
as the maxilla and frontal areas of the face.
Temporomandibular Joint
 Palpate anterior to external auditory meatus to feel the lateral aspect of the temporomandibular joint (TMJ).
 Have the patient/ client open their mouth and you can feel the condyle roll and then slide forward under the eminence.
Closing the mouth reverses the slide and posterior roll.
 Palpate within the external auditory meatus (ear canal) to feel to posterior aspect of the TMJ and retrodiscal structures.
Having the patient/ client open and close the mouth can aid in movement analysis and structure differentiation.

 Referral Pattern: Local pain can occur with joint dysfunction however, myofascial pain of the muscles controlling the TMJ
is more common.
 The retrodiscal laminae is known to be richly innervated. Parafunctional bruxism (grinding the teeth) can cause excess
compression on these structures leading to pain and irritation.
Medial Pterygoid Muscle
 Palpate external onto the medial angle of jaw where the masseter inserts. The deep and superficial heads are not palpable.
 Activate the muscle by asking the patient/ client to Can have them lateral deviate to the contralateral side.
 Referral Pattern: Trigger points in the medial pterygoid can give rise to pain over the TMJ joint as well as over the rami of
the jaw.
Lateral Pterygoid Muscle
 Palpate the posterior aspect of the condyle and have the patient/ client perform lateral deviation to the opposite side. This
allows some palpation of the fibers of the superior head. The inferior head inserts onto the medial aspect of the neck of
the condyle and is seldom palpable.
 The lateral pterygoid helps pull disk back and elevate jaw when the mouth is closing
 Referral Pattern: Trigger points in any head of the lateral pterygoid refer pain to the TMJ joint region as well as under the
zygomatic arch.
 Forward head posture can increase tension in the lateral pterygoid and contribute to pain and guarding.

Thoracic - Bony
Lower and Mid-Thoracic Transverse and Spinous Processes
 Find the tip of the 11th rib at the mid-axillary line and the cranial and caudal borders. Follow this medially until the rib dives under
the soft tissue. This is the posterior angle of the 11th rib.
 The 11th rib angle is at the same level as the transverse process of T11 and is also level with the T10 spinous process.
Palpation Rule
 Rib angle and transverse process are at the same vertebral level
 Spinous process is at the same level as the transverse process one segment below.
Upper Thoracic Transverse and Spinous Processes
 Use the fingers on the ventral aspect of the manubrium while palpating the spinous process in the region of T1. Give a gentle dorsal
pressure on the manubrium to force the T1 segment to translate dorsal.
 The first spinous process to translate dorsally is T1.
 The transverse process of T1 is located at the same level as C7 spinous process and is equal to the width of the C1 transverse process.
Palpation Rule
 Rib angle and transverse process are at the same vertebral - level

Thoracic - Soft Tissue
Iliocostalis Muscle
 Most lateral of the erector spinae muscle group and runs in the lumbar, thoracic and cervical regions
 Arises from Lumbodorsal fascia and inserts into angle of ribs 5-12, transverse processes of L1-4 and lumbodorsal fascia.
 Creates lumbar extension and ipsilateral lumbar side bend
Iliocostalis (Lateral Erector Spinae) Ribs Ribs Dorsal rami of spinal nerves
Longissimus Muscle
 Middle of the erector spinae group and runs Runs longitudinal vertically in the thoracic, cervical and cranial regions
 Arises from transverse processes of L1-5 and sacrum and inserts into transverse process of T1-T12 as well as the rib angles
of ribs 7-12.
 Creates lumbar extension and ipsilateral side bend
Longissimus (Intermediate Erector Spinae) Transverse processes Transverse processes Dorsal rami of spinal nerves
Spinalis Capitis Muscle
 Spinalis group are the most is the Most medial of the erector spinae muscles group
 Capitis: Attaches from the base of spinous process C4 to T6 to insert above the inferior nuchal line
 Creates cranial extension and ipsilateral side bend

Spinalis (Medial Erector Spinae) Spinous processes Spinous processes Dorsal rami of spinal nerves
Spinalis Cervicis Muscle
 Spinalis group are the most is the Most medial of the erector spinae muscles group
 Cervicis: Attaches from the spinous process of T1 – T6 vertebrae to the spinous process of C2-C5 vertebrae
 Creates cervical extension and ipsilateral side bend
Spinalis Thoracis Muscle
 Attaches from the spinous process of T2 – T8 vertebrae to the spinous process of T11 – L2
 Creates thoracic extension and ipsilateral side bend
Multifidi Muscle
 Ask for a small anterior pelvic tilt in prone to activate the muscle contraction while palpating in the gutter between the
spinous process and erector spinae
 Also contracts with abdominal activation or pelvic floor contraction

MultifidiArticular processes of cervical region, tranverse processes of thoracic region, mammillary processes of
lumbar region, posterior superior iliac spine (PSIS), dorsal surface of sacrum, orgin of erector spinae
Spinous
processes
Dorsal rami of
spinal nerves
Serratus Posterior Inferior Muscle
 Originates on Spinous process of T11- L2 and moves cranial and lateral inserting into ribs 9-12
 Palpate during a deep exhalation to feel the contraction.
Serratus Posterior Inferior
Muscle
Spinous processes of L1-
L3
Inferior borders of ribs 9-12, just lateral to the
angles
Intercostal nerves, T9, T10, T11,
T12
Serratus Posterior Superior Muscle
 Starts in the upper back region from nuchal ligament and spinous process of C7-T3 and attaching to ribs 2-5. Finding the
 1st Thoracic Spinous process can help to find the and then transverse processes and then ribs 2-5
Serratus Posterior Superior
Muscle
Lower portion of ligamentum nuchae, spinous
processes of C6-T3
Superior borders of ribs 2-5, just lateral
to the angles
Intercostal nerves, T9, T10,
T11, T12

Thoracic - Skeleton
Thoracic - Skeleton - Lower Thoracic
Lower and Mid-Thoracic TP to SP
 Find the tip of the 11th rib at the mid-axillary line and the cranial and caudal rib borders. Follow this medially until the rib dives
under the soft tissue. This is the posterior angle of the 11th rib.
 The 11th rib angle is at the same level as the transverse process of T11 and the spinous process of T11 is at the same level as the
transverse process of T12
Palpation Rule
Upper Thoracic TP to SP
 Rule: The most posterior aspect of the spinous process is located at the same level as the transverse process of one
segment below
 At T1, it is at the same level as the transverse process of T2
Palpation Rule
 Transverse processes are level with the cranial vertebra’s spinous process.

Shoulder
Shoulder - Bony
Shoulder - Bony - Anterior
Sternal Notch
 Located at the top of to the manubrium and between the left and right clavicles.
Sternoclavicular (SC) Joint
 Palpate the medial end of the clavicle as the patient/ client shrugs their shoulder. This causes the medial end to roll cranial
and slide caudal on the manubrium while the entire clavicle elevates
 The SCJ is a saddle joint between the manubrium and the clavicle that contains an intra-articular disc.
 The SCJ is the only true articulation of the upper limb to the axial skeleton.
 Pathology of the SCJ is possible but rare.
Second Rib
 Identify the first rib that inserts onto the manubrium behind the clavicle then move inferiorly into the first intercostal
space and continue inferiorly until you feel a hard surface, this is the second rib.
 Note that the manubriosternal junction can also be used to find the second rib.
 The soft tissue below the second rib is the second intercostal space and is a common site to palpate when assessing heart
sounds

Acromioclavicular Joint and Clavicle
 Begin at the sternal notch to find the anterior and posterior v-notches that denote the alignment of the AC joint. The AC
joint is the ventral 1cm of this line.
 Posterior v-notch: follow the cranial border of the clavicle until you reach a small notch, this is the posterior v-notch of the
AC joint
 Anterior v-notch: follow the caudal border of the clavicle lateral from the sternum until you reach another notch, this is
the anterior v-notch of the AC joint.
 Pathology: Degenerative changes and joint separation injury can lead to shoulder problems such as subacromial pain
syndrome (SAPS) and rotator cuff tendinopathy or a rotator cuff muscle tear.
Posterior Angle of the Acromion
 From the anterior v-notch of the AC joint, palpate laterally and posteriorly until you reach a sharp angle, this is the
posterior angle of the acromion.
 An important bony landmark to guide manual techniques for the glenohumeral joint.
 Connecting a line from the posterior acromion angle to the lateral tip of the coracoid process defines the anterior-posterior
joint plane of the glenoid.
Coracoid Process
 Place a finger in the soft tissue caudal to the midshaft of the clavicle. Move inferiorly and laterally until you find a bony
prominence, this structure is often tender.
 Attachment Site for: Pectoralis minor, coracobrachialis and short head of bicep brachii.
 Connecting a line from the posterior acromion angle to the lateral tip of the coracoid process defines the anterior-posterior
joint plane of the glenoid.

 Pathology: Can be cause of subscapularis tendinopathy in those working across the body
Lesser Tuberosity of the Humerus and Bicipital Groove
 From the coracoid process move laterally until a bony structure is felt, this is the lesser tuberosity of the humerus.
 Attachment site for: Subscapularis muscle
 The bicipital groove is lateral to the lesser tuberosity. To identify the edges of the groove, passively internally and
externally rotate the shoulder
 Site for the tendon of the long head of biceps to run before entering the glenohumeral joint
 Pathology: Degenerative tendinopathy and subacromial pain syndrome (SAPS) of both the long head of biceps and
subscapularis is more prevalent with aging.
Shoulder - Bony - Posterior
Medial Border of Scapula
 Have the patient/ client protract and retract their shoulder while palpating at the scapula and observing the medial border
of the scapula move
 At rest the medial border should be parallel to the spine and lie 3 inches lateral to the vertebral column
 Attachment site for Rhomboid major and minor, levator scapulae, serratus anterior
Inferior Angle of Scapula

 Palpate caudally along the medial border of the scapula until you approach an angle, this is the inferior angle of the
scapula
 Attachment site for: Latissimus Dorsi muscle in some people
Lateral Border of Scapula
 Move laterally and superiorly from the inferior angle of the scapula along the lateral border until it disappears underneath
the latissimus dorsi, teres major, and teres minor muscles
 Attachment site for: Teres major and Teres minor muscles
Spine of Scapula
 Follow the inferior border of the spine of the scapula by palpating medially from the posterior angle of the acromion. The
superior border of the spine of the scapula can be palpated by moving medially from the posterior V of the AC joint.
 Attachment site for: Middle and Lower Trapezius and Posterior deltoid
Shoulder - Soft tissue
Shoulder - Soft Tissue - Anterior
Pectoralis Major and Pectoralis Minor Muscle
 Have your patient press their hand palms together as you observe the axillary region for activation of the pectoralis major
muscle as an be seen at it crosses the axillary region to attach to the humerus
 Have the patient tip the shoulder forward while palpating at the coracoid to identify the pectoralis minor muscle at the
attachment to the coracoid. The pectoralis minor lies deep to the major.
 Pathology of the pectoralis major or minor is rare. Weight lifters might suffer a strain if lifting too heavy a weight.

 Referral Pattern: Trigger points in these muscles can refer pain to the anterior chest and down the medial aspect of the
arm and into the hand.
Pectoralis
Major
Medial 1/2 of the clavicle manubrium and body of the sternum, costal
cartilages of ribs 2-6, sometimes from the rectus sheath of the upper
abdominal wall
Humerus- crest of
greater tubercle
Lateral pectoral nerve, C5, C6, C7
and medial pectoral nerve, C8, T1
Pectoralis
Minor
Anterior surfaces of the sternal ends of ribs 3-5 Coracoid process of
scapula
Medial pectoral nerve, C8,T1
Bicipital Groove and Tendon of Long Head of Biceps Brachii Muscle
 Have the patient abduct their arm in scaption with neutral rotation. Identify the intermuscular septum between the
anterior and middle deltoid
 Hold your index finger in this space and lower the patient’s arm to their side, the biceps tendon will be under your finger
 To ensure that you are on the groove, passively internally and externally rotate their shoulder to feel the edges of the
groove bump into your finger
 Pathology of the biceps long head can include reactive tendinopathy, degenerative tendinopathy and even a tendon tear.
 Referral Pattern: Trigger points in the biceps tend to refer pain locally to the region of this muscle.
Biceps
Brachii
Long head- supraglenoid tubercle of the scapula, short
head- coracoid process of the scapula
Long head- radial tuberosity, short head- bicipital
aponeurosis to the fascia on the medial side of the
forearm
Musculocutaneous nerve,
C5, C6, C7
Sternocleidomastoid (SCM) Muscle
 Have your patient rotate their head away and side flex toward the side of interest. The SCM will pop out and can be
palpated from the mastoid to the attachments onto the clavicle (clavicular head) and manubrium (sternal head).
 Pathology of the sternocleidomastoid is most often a muscle strain associated with whiplash injury or overuse.

 Referral Pattern: Trigger points in the sternocleidomastoid can cause a variety of pain patterns. Pain can be referred to the
jaw and anterior upper neck, lateral head, ear, forehead, temporomandibular joint area and posterior head.
SternocleidomastoidSternal head- Manubrium of sternum, Clavicular head-
Superior border of medial 1/3 of clavicle bone
Mastoid process of temporal bone and
lateral half of superior nuchal line
Spinal accessory nerve CN XI and
spinal nerve C2, C3, C4
Shoulder - Soft Tissue - Lateral
Deltoid Muscle
 Anterior deltoid can be palpated at its origin along the lateral 1/3 of the clavicle as the patient flexes at the shoulder
 Middle deltoid can be palpated at its origin on the scapular spine as the patient abducts the arm
 Posterior deltoid can be palpated at its origin on the scapular spine as the patient extends the arm
 The insertion on the deltoid tubercle can often be tender if there is a shoulder problem.
 Referral Pattern: Trigger points refer pain to the area of the deltoid muscle and into the arm.
 Pathology of the deltoid is seldom the primary issues although it works with the rotator cuff to elevate the arm.
Anterior deltoid Clavicle Humerus- deltoid tuberosity Axillary nerve, C5, C6
Middle deltoid Acromion process and spine of the scapula Deltoid tuberosity of the humerus Axillary nerve, C5, C6
Posterior deltoid Spine of the scapula Deltoid tuberosity of humerus Axillary nerve, C5, C6
Serratus Anterior Muscle
 Have the patient / client “punch” their arms toward the ceiling while lying supine with their shoulder flexed to 90 degrees.
Palpate along the lateral side of ribs 1-8 to feel the muscle contract.

 Referral Pattern: Trigger points in the serratus anterior can refer pain to the axilla, inferior angle of the scapula and down
the medial side of the arm to the hand.
 Pathology of the serratus muscle is not common. Dysfunction from poor coordination can contribute to subacromial pain
syndrome (SAPS) and injury to the long thoracic nerve can lead to winging of the scapula.
Serratus
Anterior
Upper eight ribs and anterior intercostal membranes from
midclavicular line
Anterior medial border of the
scapular
Long thoracic nerve, C5, C6,
C7
Supraspinatus Muscle
 Position the patient / client with their hand resting behind their back. Find the anterior angle of the acromion and move
anteriorly onto the humerus, this is the plateau of the greater tuberosity.
 The tendon lies in the anteromedial 1cm of this superior facet of the greater tuberosity
 The muscle belly is in the supraspinous fossa above the spine of the scapula
 Referral Pattern: Trigger points in the supraspinatus muscle can refer pain to the lateral shoulder and elbow as well as
along the entire lateral aspect of the arm to the wrist.
 Pathology of the supraspinatus is common as it has a small tendon footprint. Reactive tendinopathy to
degenerative tendinopathy is common. A supraspinatus muscle tear is also common and can be from trauma or due
to degeneration.
Supraspinatus Supraspinatus fossa Greater tubercle of the humerus Suprascapular nerve

Shoulder - Soft Tissue - Posterior
Trapezius Muscle
 For the upper trapezius have the patient/ client shrug their shoulders as you palpate from the origin on the occiput and
spinous processes to the insertion on the lateral 1/3 of the clavicle
 For the middle trapezius, have the patient/ client retract their scapula as you palpate at the lateral scapular spine and
acromion and follow these horizontal fibers to the origin on the spinous processes from T1-T4.
 For the lower trapezius have the patient / client depress their shoulder as you palpate from the lateral third of the scapular
spine and follow the muscle fibers downward to it’s origin on T5-T12 spinous processes.
 Referral Pattern: the trapezius muscle often is found to have trigger points. These can refer pain to the periscapular,
posterior shoulder, suboccipital and cervicothoracic junction regions.
 Pathology of the trapezius muscle is most often a trigger point
Upper
Trapezius
External occipital protuberance, medial third of the superior
nuchal line, ligamentum nuchae, and the spine process of C7
Lateral third of the clavicle and the medial
aspect of the acromion process of the scapula
Spinal accessory cranial nerve
XI, Ventral Rami C2-C4
Middle
Trapezius
Spinous processes of T1 and T5 Superior surface of the acromion process of
the scapula and the superior edge of the
scapular spine
Spinal accessory cranial nerve
XI and ventral rami C2 to C4
Lower
Trapezius
Spinous processes of T6 to T12 Base of triangular space of scapula Spinal accessory cranial nerve
XI and ventral rami C2 to C4
Rhomboid Major and Rhomboid Minor Muscles
 Have the patient row with their hand at their side against resistance and the rhomboid will become palpable at the medial
border of the scapula.
 The rhomboid major arises from the spinous process of T2-5 and inserts below the scapular spine on the medial border.

 The minor arises from the C7-T1 spinous process and inserts at the ‘root’ of the scapula- at the scapular spine on the
medial border.
 Referral Pattern: the rhomboids refer pain to the medial periscapular region
 Pathology of the rhomboids is more of a contributor to neck and upper back pain versus an isolated problem.
Rhomboid Major Vertebral spines T2 to T5 Medial border of the scapular, inferior to the scapular spine Dorsal scapular nerve C5
Rhomboid
Minor
Lower ligamentum nuchae, vertebral spines C7 to
T1
Posteromedial border of scapula at level of spine of
scapula
Dorsal scapular nerve C5
Levator Scapulae Muscle
 Have the patient/ client elevate their shoulder as you palpate the superior medial angle of the scapula and follow this up to
the transverse process of C1-C4.
 The levator scapula lies deep to the upper trapezius
 Referral Pattern:the levator scapulae commonly refers pain to the medial scapula and cervicothoracic junction areas.
 Pathology of the levator scapulae is more of a contributor to neck pain and scapular dyskinesis than a stand alone
problem.
Levator
Scapulae
Posterior tubercles of the transverse processes
of C1-C4
Superior part of the medial border of the
scapula
Anterior primary rami, C3, C4 and dorsal scapular
nerve, C5
Teres Major and Teres Minor Muscles
 While palpating the lateral border of the scapula just above the inferior angle, have the patient internally rotate against
slight resistance to identify the teres major.

 Then have the patient / client externally rotated against resistance as you palpate proximal of the teres major on the
lateral border of the scapula
 Referral Pattern: the teres muscles can refer pain to the proximal humerus and upper arm as well as down the dorsal arm
and forearm.
 Pathology of the teres muscles is uncommon
Teres major Dorsal surface of the inferior angle of the scapula Crest of the lesser tubercle of the humerus Lower subscapular nerve, C5, C6
Teres minor Middle part of the lateral border of the scapula Humerus- inferior aspect of greater tubercle Axillary nerve, C5, C6
Latissimus Dorsi Muscle
 Move inferior and lateral to the inferior angle of the scapula as the patient/ client extends and internally rotates their
shoulder
 For some, this muscle can also be felt in the posterior wall of the axilla
 The tendon can be traced into the intertubercular groove of the humerus
 Referral Pattern: the latissimus dorsi can refer pain to the inferior angle of the scapula and anterior shoulder as well as in
the lateral abdomen above the iliac crest as well as down the medial aspect of the arm, depending on the location of the
trigger point.
 Pathology of the latissimus dorsi is uncommon.
Latissimus
Dorsi
Vertebral spines from T7 to sacrum, posterior third of iliac crest, lower 3 or 4 ribs, and
from the inferior angle of the scapula
Floor of inter tubercular
groove
Thoracodorsal nerve, C6,
C7, C8
Infraspinatus Muscle
 Have the patient / client seated and leaning onto their forearms such that the shoulder is flexed to 60 deg and slightly
adducted slightly, and ER. Find the posterior angle of the acromion and draw a line to the axilla.

 The infraspinatus myotendinous junction is 1” down this line, find the insertion onto the middle facet by moving
anteriorly toward the humerus
 Take care to move anterior vs. around the humerus.Confirm by asking gentle ER.
 Referral Pattern: the infraspinatus can refer pain to the medial scapula, arm and lateral forearm regions and into the
lateral side of the hand, both palmer and dorsal aspects.
 Pathology of the infraspinatus is most often a reactive or degenerative tendinopathy that can contribute to subacromial
pain syndrome (SAPS).
Infraspinatus Infraspinous fossa of the scapula Humerus- greater tubercle Suprascapular nerve, C5, C6
Elbow
Elbow - Bony
Lateral Epicondyle
 Large lateral prominence of the distal end of the humerus
 Attachment site for:
 ECRB (anterior aspect of epicondyle)
 ED (inferior aspect of epicondyle)
 ECU (posterior aspect of lateral epicondyle)
Lateral Supracondylar Ridge
 Superior to the lateral epicondyle along the humerus
 Extensor carpi radialis brevis (ECRB)

 Extensor digitorum (ED)
 Extensor carpi ulnaris (ECU)
Radial Head
 Palpate while the forearm is in neutral
 Beginning at the lateral epicondyle slide distal to the humeroradial joint and onto the radial head
 You can feel it move as the patient supinates and pronates the forearm
Medial Epicondyle
 Large medial prominence on distal end of the humerus
 Significantly larger than the lateral epicondyle
 Wrist and finger flexor tendons
Medial Supracondylar Ridge
 Superior to the medial epicondyle along the humerus, relatively short
 Pronator teres (base of medial supracondylar ridge)
Olecranon
 Posterior most aspect of the elbow on the proximal ulna

 Attachment site for
 Anconeus
Olecranon Fossa
 Distal end of posterior humerus
 Not palpable as it is covered by fat tissue as well as the triceps tendon
Ulnar Ridge
 Posterior aspect of the ulna from the olecranon to the styloid process of the ulna
Elbow - Soft tissue
Elbow - Soft Tissue- Lateral Ligaments
Annular Ligament
 Wraps around the radial head, starting and ending on the ulna
 Holds the radial head onto the ulna
 Pathology: ‘Nursemaid’s elbow’ (or pulled elbow) is subluxation of the radius from the ulna due to the toddler being lifted
by pulling on the radius
Lateral Radial Collateral Ligament

 Fans out from the lateral epicondyle to the annular ligament
 Referral pattern: Pain is in the lateral elbow
 Pathology: This can be torn by excessive varus stress and then can lead to elbow instability.
Anconeus Muscle
 Have the patient extend their elbow against resistance as you feel for the muscle belly on the lateral side of the elbow, just
proximal and posterior to the radial head
 Originates on lateral epicondyle of humerus
 Inserts on olecranon of ulna
 Referral pattern: Can refer to lateral epicondyle
 Pathology: An infrequent cause of lateral epicondylalgia
Anconeus Lateral epicondyle of humerus Lateral side of olecranon process and upper posterior surface of ulna Radial nerve C6, C7, C8
Supinator Muscle
 Have the patient supinate their forearm while palpate along the ulnar ridge, just distal to the anconeus muscle insertion,
to feel the muscle activation
 Can also be felt underneath the muscle bellies of ED and ECRB
 Referral pattern: Pain in the lateral and anterior elbow as well as the dorsal web space.
 Pathology: Can be a cause of radial nerve entrapment - Deep Branch or Posterior Interosseous Nerve (PIN) that can lead
to weakness of central wrist and thumb extensor muscles.

SupinatorDeep portion- supinator crest and fossa of ulna, Superficial part-
lateral epicondyle and lateral ligament of elbow and annular
ligament
Neck and shaft of radius, between
anterior and posterior oblique lines
Posterior interosseous nerve, C5, C6
(Deep branch of radial nerve)
Elbow - Soft Tissue - Medial Ligaments
Ulnar Collateral Ligament (UCL)
 This fan shaped ligament on the medial aspect of the elbow is composed of 3 bands; the anterior, posterior and transverse
bands
 Anterior band goes from the anterior aspect of the medial epicondyle of the humerus to the medial aspect of the coronoid
process of the ulnar. It is the strongest and thickest part of the UCL and resists most of the valgus forces at the elbow.
 The anterior band is in line with the ulna when the elbow is flexed to 90 degrees
 Posterior band goes from the posterior aspect of the medial epicondyle of the humerus to the medial margin of the
olecranon process. Provides valgus restraint when the elbow flexed.
 The posterior band is oriented vertically when the elbow is flexed to 90 degrees
 Transverse band goes from the medial olecranon process of the ulna to the coronoid process of the ulna to reinforce the
insertions of the anterior and posterior bands.
 Referral pattern: Pain is in the medial elbow
 Pathology: This can be torn by excessive valgus stress, such as with throwing and then can lead to elbow instability. It is
also known as a ‘Tommy John Injury’ and ‘Little League Elbow’.
Ulnar Nerve

 Palpate in the groove (cubital tunnel) between the medial epicondyle and the olecranon process with the 2nd and 3rd
digits using a rolling motion over the nerve
 Pathology: Cubital tunnel syndrome is a peripheral nerve compression of the ulnar nerve characterized by paresthesias in
the ulnar side of the hand and intrinsic muscle weakness. This compression occurs within the tunnel or adjacent soft
tissue structures.
Elbow - Soft Tissue - Anterior
Biceps Brachii Muscle
 Distal tendon can be palpated within the cubital fossa by having the patient / client flex their elbow against resistance.
Follow this down to the insertion onto the radial tuberosity
 Follow tendon proximal to find the muscle belly and insertions of the separate heads
 Long head originates on the supraglenoid tubercle of the scapula
 Short head originates on coracoid process of the scapula
 Referral pattern: Pain is in the arm with trigger points in the mid-belly of either long or short head.
 Pathology: Seldom a problem at the elbow however, a tear of the distal biceps tendon causes significant elbow flexion
weakness and requires surgical reconstruction
Biceps
Brachii
Long head- supraglenoid tubercle of the scapula, short
head- coracoid process of the scapula
Long head- radial tuberosity, short head- bicipital
aponeurosis to the fascia on the medial side of the
forearm
Musculocutaneous nerve,
C5, C6, C7
Bicipital Aponeurosis
 Follow biceps brachii tendon distal until it divides in the middle of the cubital fossa and gives a fibrous sheath to the ulna
and into the medial forearm fascia

Brachialis Muscle
 Originates on the midshaft of the anterior humerus and inserts onto the ulnar tuberosity
 Located under the biceps muscle belly it is easiest to palpate on the lateral side
 Referral pattern: Trigger points can refer pain into the first metacarpal region as well as into the anterior shoulder and
elbow
 Pathology: A tear of the brachialis is rare
BrachialisAnterior lower half of humerus and medial and lateral
intermuscular septa
Coronoid process and
tuberosity of ulna
Musculocutaneous nerve, C5, C6 and small supply
from radial nerve, C7
Cubital Fossa
 Triangular space on the anterior elbow bordered laterally by the brachioradialis, medially by the pronator teres and with
the base defined by a line drawn between the two epicondyles
 Also known as the coronoid fossa
 Structures in the cubital fossa from lateral to medial: biceps tendon, brachial artery, median nerve, musculocutaneous
nerve
Median Nerve
 Goes through the two heads of the pronator teres Goes through the two heads of the pronator teres and is a round, tubular
structure lying directly medial or deep to the brachial artery
 Pathology: The median nerve can be compressed at two different locations in the yellow giving rise to Pronator Teres
Syndrome and Anterior Interosseous Nerve Syndrome.

 Pronator Teres Syndrome: compression of the median nerve occurs at the proximal fascial edge that joins the two heads of
the pronator teres. This gives rise to forearm and hand pain as well as mechanical irritation at the elbow- signs and
symptoms that can distinguish this from carpal tunnel syndrome.
 Anterior Interosseous Nerve Syndrome (AIN): this is a motor branch of the median nerve that is compressed beneath the
pronator teres muscle and proximal edge of the flexor digitorum superficialis arch. A true palsy of this nerve gives rise to
weakness in the median nerve innervated pronator quadratus, flexor digitorum profundus and hand intrinsics. Inability to
form the “O.K.-sign” is considered a pathognomonic test
Brachial Artery
 Can be palpated directly medial to the biceps tendon just proximal of the cubital fossa where it then divides into the radial
and ulnar arteries.
 Can also be palpated on the dorsal side of the brachium between the coracobrachialis and the long head of the biceps
Elbow - Soft Tissue – Lateral
Brachioradialis Muscle
 Have the patient resist elbow flexion while the forearm is in a neutral position while palpating along the supracondylar
ridge
 Inserts distally onto the radial styloid process
 Referral pattern: Trigger points can refer pain to the lateral epicondyle and first web space of the hand as well as along the
lateral forearm.
 Pathology: As a powerful elbow flexor, this can be overloaded and contribute to lateral elbow pain or epicondylalgia

Brachioradialis Upper two-thirds of the lateral supracondylar ridge of the humerus Styloid process of the radius Radial nerve, C5, C6
Extensor Carpi Radialis Longus
 Palpate the lateral supracondylar ridge right below the brachialis muscle as the patient/ client radially deviates and
extends their wrist. The and the thick muscle belly will pop out below your fingers
 The short distal tendon inserts onto the base of the 2nd metacarpal
 Referral pattern: Trigger points can refer pain to the lateral epicondyle as well as down the forearm into the area of the
first webspace
 Pathology: This tendon is often a cause or contributor to lateral epicondylalgia. It’s motor function is preserved with PIN
syndrome.
Extensor Carpi Radialis Longus Distal lateral supracondylar ridge Dorsal surface of base of second metacarpal Radial nerve, C6, C7
Extensor Carpi Radialis Brevis
 Inserts on the anterior aspect of the lateral epicondyle below the ECRL
 Have the patient radial deviate and extend their wrist
 Follow the tendon to the muscle belly which is found just distal to the ECRL muscle belly. The ECRB has a very long distal
tendon
 Distal attachment is onto the 3rd metacarpal
 Referral pattern: Trigger points can refer pain to the dorsal wrist and distal forearm.
 Pathology: a common contributor to lateral epicondylalgia

Extensor Carpi Radialis Brevis Lateral epicondyle of humerus Dorsal surface of base of third metacarpal Radial nerve, C6, C7
Extensor Digitorum
 Have the patient / client ‘play the piano’ by alternately flexing and extending the fingers while palpating the
 Follow this down to the muscle belly and distal tendons that insert into the extensor mechanism on the dorsum of the
hand
 Referral pattern: Depending on the trigger point location, pain can be referred to the dorsal arm and hand, lateral
epicondyle and palmar medial wrist
 Pathology: Can contribute to lateral epicondylalgia.
Extensor
Digitorum
Humerus- Lateral epicondyle through common extensor
tendon and adjacent intermuscular septum
Dorsal digital expansion
of digits 2-5
Posterior interosseous nerve, C7, C8
(Branch of radial nerve)
Extensor Carpi Ulnaris
 Palpate the posterior aspect of the lateral epicondyle as the patient/ client performs ulnar deviation and extension at the
wrist. Follow the tendon to the muscle belly, it is dosal on the radial side of to the ulnar ridge The distal attachment is the
base of the 5th metacarpal
 Referral pattern: Trigger points can refer pain to the ulnar side of the dorsal wrist
 Pathology: Can be a source of lateral epicondylalgia.
Extensor Carpi Ulnaris Lateral epicondyle of humerus Dorsal surface of base of fifth metacarpal Radial nerve, C6, C7, C8

Elbow - Soft Tissue - Medial
Pronator Teres
 Palpate just proximal of the common flexor tendon while the patient / client pronates against resistance.
 The ulnar head is deep to the common flexors
 Both heads insert onto the lateral radius
 The median nerve runs between the two heads
 Referral pattern: Trigger points can refer pain to the radial side of the palmar wrist as well as the dorsal forearm.
 Pathology: Hypertrophy of the muscle is thought to contribute to Pronator Teres Syndrome. Eccentric overload
with pronation, especially with repetitive use, contributes to this pathology.
Pronator
Teres
Humeral head- medial epicondyle of humerus and distal supracondylar ridge, Ulnar head-
medial side of coronoid process of ulna
Middle of lateral surface
of radius
Median nerve, C6,
C7
Common Flexor Tendon
 Have the patient/ client slightly flex their wrist and fingers while palpating the anterior aspect of the medial epicondyle
where all of the flexor tendons join, the tendon should become very taught and feel like a pencil.
 Comprised of the following tendons:
 flexor carpi radialis, the
 palmaris longus and the
 flexor carpi ulnaris muscles

 Flexor digitorum superficialis
 Referral pattern: The tendon causes local medial elbow pain. Trigger points can refer pain into various locations based on
the muscle involved:
 Flexor carpi radialis refers pain to the radial side of the palmar wrist
 Palmaris longus refers pain pain into the palm as well as in the forearm
 Flexor carpi ulnaris refers pain into palmar and ulnar side of the wrist
 Flexor digitorum superficialis refers pain into the palmar aspect of the fingers 3-4
 Pathology: Medial epicondylalgia (a.k.a. Golfer’s elbow) is commonly seen at the common flexor tendon attachment.
Elbow - Soft Tissue - Posterior
Triceps Muscle
 Has three heads and is named for each insertion
 Have the patient lean on a table to activate the triceps
 Long head is the most medial and proximal muscle belly of the upper arm
 Medial head is the most distal and lateral muscle belly of the posterior upper arm and can be felt medial and deep to the
lateral head
 Lateral head is the largest muscle belly on the posterior and lateral side of the upper arm
 Referral pattern: Trigger points can refer pain to the posterior arm from shoulder to wrist, occasionally this can refer pain
to the trapezius and ulnar side dorsal fingers.
 Pathology: Tendinopathy at the insertion on the olecranon is a rare but possible triceps injury, usually associated with
loaded and fast elbow extension.

Triceps
Brachii
Long head- infraglenoid tubercle of scapula, Lateral head- upper half of
the posterior humerus, Medial head- lower half of the posterior humerus
inferomedial to spiral groove and both intermuscular septa
Humerus- posterior part of the upper
surface of olecranon process of ulna
and posterior capsule
Radial nerve, C7,
C8 from posterior
cord
Olecranon Bursa
 The bursa is superficial to the triceps tendon and olecranon process. It at cannot be palpated unless inflamed
 Pathology: Bursitis occurs with triceps overuse, such and hammering or trauma to the olecranon. Less commonly, it can
also be caused by an infection
Elbow - Nerve Entrapment
Median Nerve
 The nerve can be entrapped at four different locations of the elbow
 First, it dives under the ligament of struthers that connects the epicondylar ridge to the medial epicondyle
 Entrapment here will give rise to motor and sensory findings throughout the flexor forearm and hand as well
as pronation weakness
 Second, is compression underneath a thickened bicipital aponeurosis
 Third, is entrapment between the two heads of the pronator teres, the most common site at the elbow
 This is called pronator teres syndrome and manifests as pain and paresthesia in the forearm and radial hand as well as
weakness in the median nerve intrinsics and pronator quadratus
 This pattern is similar to carpal tunnel syndrome and is a key diagnostic differential
 Fourth, is beneath the pronator teres where the anterior interosseous branch of the median nerve forms
 Entrapment here will give rise to weakness of the intrinsics of the thumb and index finger flexors as well as the inability to
perform the "okay" sign between these digits

Anterior Interosseous Nerve
 Beneath the pronator teres where the anterior interosseous branch of the median nerve forms
 Entrapment here will give rise to weakness of the intrinsics of the thumb and index finger flexors as well as the inability to
perform the "okay" sign between these digits
Radial Nerve - Deep Branch (Posterior Interosseous Nerve)
 The radial nerve is vulnerable to compression as it spirals around the distal humerus to enter the cubital fossa
 After sending motor branches to the supinator and extensor carpi radialis longus muscles, it divides into superficial and
deep branches
 Superficial branch carries sensory only information for the dorsal hand at thenar eminence
 Deep branch continues in the radial tunnel to the proximal edge of the supinator where a fibrous band called the Arcade of
Froshe can cause compression
 The deep branch continues underneath the supinator to the distal edge where it exits to become the posterior interosseous
nerve
Radial Nerve - Superficial Branch
 The radial nerve is vulnerable to compression as it spirals around the distal humerus to enter the cubital fossa
 After sending motor branches to the supinator and extensor carpi radialis longus muscles, it divides into superficial and
deep branches
 Superficial branch carries sensory only information for the dorsal hand at thenar eminence
 Deep branch continues in the radial tunnel to the proximal edge of the supinator where a fibrous band called the Arcade of
Froshe can cause compression

 The deep branch continues underneath the supinator to the distal edge where it exits to become the posterior interosseous
nerve
Ulnar Nerve
 Situated in the groove (cubital tunnel) between the medial epicondyle and the olecranon process
 Can be palpated with the 2nd and 3rd digits using a rolling motion
Wrist & Hand
Wrist & Hand - Bony
Wrist & Hand - Bony - Carpals
Capitate
 The capitate is in line with the 3rd metacarpal and is distal of the lunate.
 Follow the 3rd metacarpal proximally until you feel the bony ridge and then a divot, this indicates the capitate
 The capitate is 2/3rds the distance between the proximal end of the 3rd metacarpal and the distal end of the radius and
covers the entire width of the 3rd metacarpal.
Hamate and Triquetrum
 Both the hamate and the triquetrum are located on the ulnar side of the wrist and are difficult to palpate
 The hamate is at the base of the 4th and 5th metacarpals and extends further proximal at the 4th metacarpal than at the
5th metacarpal
 The hook of the hamate on the palmar aspect

 The joint line between the hamate and triquetrum is hard to identify
 If the patient radially deviates at the wrist while you are feeling the ulnar side of the hand distal to the ulna, you can feel
the triquetrum move into your finger when the patient moves into ulnar deviation
Lunate
 The lunate is proximal of the capitate and distal of the distal radioulnar joint
 Locate the capitate and move proximal toward the DRUJ. This is the lunate. Confirm by passively flexing the patient’s
wrist, the lunate will pop into your finger on the dorsal aspect
 Find the distal radioulnar joint and move distal onto the proximal carpal row, to land on the lunate.
Scaphoid
 Located on the radial aspect of the wrist, is lateral to the lunate
 Place finger distal to the radial styloid process in the space known as the anatomical snuff box. Move the wrist into ulnar
deviation, the bone that pushes into your finger is the scaphoid
Trapezium and First Carpometacarpal (1st CMC) Joint
 The trapezium is located distal of the scaphoid Palpate the scaphoid in the anatomical snuff box while the patient/ client
flexes the thumb with the wrist still in ulnar deviation. The trapezium is stable and the first metacarpal moves at the 1st
metacarpal joint.
 Note that the 1st CMC joint is a saddle joint

Trapezoid
 The trapezoid is at the base of the 2nd metacarpal
 Palpate proximally along the 2nd metacarpal until you fall off the bony ridge onto the carpal bone, which is the trapezoid
Wrist & Hand - Bony – Dorsal
Base of Metacarpals 2-5
 Palpate the shafts of the metacarpals on the dorsal aspect of the hand
 Move proximally until you feel a bony ridge, which is the base of the metacarpals
Distal Radioulnar Joint
 Following the distal end of the ulnar dorsally, you will be able to find the junction between the radius and the ulna
 A good landmark to use is the extensor digiti minimi by asking your patient to extend their little finger, you will feel the
tendon where it crosses the joint line between the radius and ulna
Head of Ulna
 Can be palpated just proximal and dorsal to the ulnar styloid process
 This is the prominent bump that sticks out on the dorsum of the wrist

Lister’s Tubercle
 The bony prominence on the dorsal aspect of the radius inline with the 2nd and 3rd metacarpals
 Separates the extensor pollicus longus muscle from the extensor carpi radialis longus muscle
Radial Styloid Process
 Palpate the most distal aspect of the radius on the radial stide
 Can palpate the distal end of the radius there the styloid procecss is by radially and ulnarly deviating the wrist
Ulnar Styloid Process
 Follow the ulnar ridge distally until you feel a bony projection on the most distal aspect of the ulna
 Can be palpated more easily by radially deviating the patient’s wrist
Wrist & Hand - Bony – Palmar
Carpal Tunnel (Palmar Carpal Ligament)
 Cues
 The scaphoid tubercle can be palpated on the palmar side of the radial aspect of the carpals while performing radial and ulnar
deviation, it is the bony prominence that pusches into your finger when the patient goes into radial deviation
 The tubercle of the trapezium is at the base of the 1st metacarpal and is more challenging to find due to it being covered by the thenar
eminence
 The pisiform is a round movable bone that sits within the extensor carpi ulnaris tendon and is found at the distal end of the ulna

 The hook of the hamate can be found by taking your first distal phalynx and moving from the pisiform toward the thenar crease, push
into the skin and you will feel a small hard structure
 These 4 structures are the attachment sites for the carpal tunnel, also known as the palmar carpal ligament
Wrist & Hand - Bony - Phalanges
Joints of Phalanges
 Cues
 The 2nd-5th digits have metacarpal phalangeal joints, proximal interphalangeal joints and distal phalangeal joints
 The 1st digit only has a metacarpal phalangeal joint and am interphalangeal joint
 The joints of the phalanges can be found by flexing and extending the patients digit and finding the joint line where the digit bends
Lumbar
Lumbar - Bony
Posterior Superior Iliac Crest (PSIS), Spinous process of L5-S4, and Sacral
Cornua
Cues
 The first structure to find is the posterior superior iliac spine (PSIS).
 There are two strategies for identifying that.
 Start by finding the iliac crest by coming into the soft tissue of the waist and pushing down.
 You want to be perpendicular to the structure to identify the cranial margin of the iliac crest.

 Follow that around.
 At the medial aspect, it dives fairly abruptly caudally.
 Find the most caudal and distal margin of the PSIS.
 Repeat on the other side.
 It is important when palapating through the soft tissue to let the tissue relax before you making the mark.
 Use the caudal border of the PSIS to draw a helper’s line and that should intersect S2.
 Use that location to up into the lumbar spine or further down to find the sacral cornua.
 From S2, find S1 and L5.
 Using the iliac crest to find L4 would not be accurate because her L4 segment is here.
 It is much more accurate if we use PSIS to locate S2.
 From S2 caudally, find S3, S4, and there is no S5.
 Instead, we see the sacral cornua, which are the sacral horns.
 Those are used then to identify the opening, should a patient need a caudal epidural.
Attachment site for
 Piriformis Muscle
 Gluteus Maximus Muscle
Spinous and Transverse Processes
Cues
 After finding the PSIS S2 line, find S1 and L5.
 The lumbar spinous processes are the easiest to locate at the lateral aspect to find the separation between each segment.
 There is L4, L3, L2, and L1.

 The lumbar spine’s transverse processes are located directly lateral.
 So the transverse process for L5 would be in this location.
 For L4, in the midpoint of the spinous process, L3, L2, and L1.
Attachment site for
 Erector Spinae Muscles
 Iliocostalis
 Longissimus
 Spinalis
Lumbar - Soft Tissue
Greater Trochanter
 Locate the cranial end of the greater trochanter by placing a hand at the lateral aspect of the hip and ask for external and internal
rotation of the leg to find the top. Mark the location without moving the skin.
Ischial Tuberosity
 Locate the ischial tuberosity caudally by placing a hand at the midpoint of the buttock and pressing superiorly. Identify the bony
prominence and mark the caudal aspect.
Attachment sites for:
 Gluteus Medius Muscle (superior and lateral aspect of greater trochanter)
 Gluteus Minimus Muscle (anterolateral aspect of greater trochanter)

 Piriformis Muscle (superior and medial aspect of greater trochanter)
 Obterator Externus and Internus
 Semimembranosus Muscle (lateral aspect of ischial tuberosity)
 Semitendinosus Muscle (medial aspect of ischial tuberosity) Biceps Femoris Muscle (medial aspect of ischial tuberosity)
Helper Lines
 Use the bony landmarks to draw several helper lines.
 From the PSIS, draw a line down to the sacral cornua and connect them.
 Connect the PSIS to the top of the greater trochanter.
 Lastly, connect the PSIS down to the midpoint of the ischial tuberosity.
Piriformis Muscle
 Palpate between the borders of the piriformis. The cranial border of the piriformis is located along the line from PSIS to the greater
trochanter.
 The caudal border of the piriformis is located by connects a point marking the cranial two-thirds along the line from PSIS to the
sacral cornua.
Referral Pattern
 Trigger points in the piriformis cause deep gluteal and posterior leg pain.
Pathology
 Piriformis Syndrome is a condition in which the sciatic nerve is compressed as it pierces the piriformis muscle giving rise to pain and
paresthesias in the sciatica distribution

Piriformis Anterior sacrum lateral to sacral foramina Femur- Greater Trochanter Ventral Rami, L5 S1, S2
Quadratus Lumborum
 Palpate the space from the iliac crest to lower ribs as the patient/ client elevates (hikes) the hip to feel the quadratus
lumborum fibers. These fibers arise from the iliac crest and iliolumbar ligament and insert into T12 and L1-4 transverse processes.
Referral Pattern
 Trigger points can refer pain to the paraspinal, buttock and lateral hip regions.
Pathology
 Can be a common contributor to lumbopelvic pain.
Quadratus Lumborum Posterior border of iliac crest Inferior border of 12th rib Ventral Rami, T12, L1, L2, L3, L4
Sciatic Nerve
 Palpate in the middle third of the caudal border of the piriformis to find the sciatic nerve. The sciatic nerve runs to the lateral aspect
of the ischial tuberosity and down the midline of the thigh.
Pathology:
 Irritation of the nerve will cause pain and paresthesias in the buttock and down the leg and weakness of any muscle innervation by
the sciatic nerve.

Inferior Gluteal Nerve
 Palpate the Inferior gluteal nerve at the intersection of the helper line connecting PSIS to ischial tuberosity with the caudal border of
the piriformis.
Pathology:
 Irritation of the inferior gluteal nerve will contribute to pain and paresthesias in the buttock and weakness in the gluteus maximus.
Superior Gluteal Nerve
 Palpate the superior gluteal nerve as it exits at a point ⅓ of the way along the superior border of piriformis muscle.
Pathology:
 Irritation or injury to the superior gluteal nerve will cause pain and paresthesia in the lateral hip and thigh in addition to weakness of
the gluteus medius and minimus and tensor fascia latae.
Sacroiliac - Skeleton
Posterior Sacroiliac Ligament (Long SI Ligament)
 Runs from the posterior superior iliac spine (PSIS) to the sacrum near S3-4
 It helps to control counter nutation in the SI joint
 The deep layers of the ligament cannot be palpated

Sacrospinous Ligament
 Runs deep in the middle of the buttock from a broad origin on the sacrum and coccyx
 It runs laterally to insert onto the posterior inferior ischial spine (PIIS)
Sacrotuberous Ligament
 Runs in a distal and lateral direction from its origin at the S3-4 sacral region to insert on the ischial tuberosity
 It controls nutation in the SI joint
Sacroiliac - Soft Tissue
Posterior Sacroiliac Ligament (Long SI Ligament)
 Runs from the posterior superior iliac spine (PSIS) to the sacrum near S3-4
 It helps to control counter nutation in the SI joint
 As it runs parallel to the sacrum, palpating perpendicular to the line from the PSIS to the sacral apex will make it easier to identify
 Dysfunction into counter nutation can cause palpable pain
Sacrospinous Ligament
 Runs deep in the middle of the buttock from a broad origin on the sacrum and coccyx, deep to the sacrotuberous ligament
 It narrows as it runs laterally to insert onto the posterior inferior ischial spine (PIIS)
 It is slightly caudal and parallel to the inferior border of the piriformis versus the down-sloping orientation of the sacrotuberous
ligament

 Allow the fingers to sink through the gluteal muscles to identify this fibrous ligament that forms the lesser sciatic foramen
Sacrotuberous Ligament
 Runs from the sacrum S3-4 region to the ischial tuberosity
 To find the ischial tuberosity, use a flat palpation in the midline of the buttock to locate this rounded bony prominence
 This ligament runs lateral and distal to control nutation in the sacroiliac joint
 Deep palpation with the fingertips can identify ligamentous tension that occurs from an anterior ilial rotation
Hip
Hip - Bony
Hip - Bony - Anterior
Positioning for Anterior Hip Palpation
 Flex the patient’s knee and let the knee come to rest against your torso or on top of a pillow ( with slight external rotation- the faber
position).
Anterior Superior Iliac Spine (ASIS)
 Ask the patient/ client to point to the bone at the front of their hips. The anterior superior iliac spine (ASIS) is the most prominent
anterior aspect of the ilium.
Attachment site for
 Inguinal Ligament

 Sartorius Muscle
Iliac Crest
 With a flat hand at the waist angle, move caudal to palpate the brim of the pelvic, the iliac crest.
 This broad rounded brim of the pelvis extends from the ASIS anteriorly to the PSIS posteriorly. It is most easily palpated by moving
perpendicular to the crest, falling off the medial and lateral edges.
Attachment site for
 Lumbodorsal Fascia
 Quadratus Lumborum
 Abdominal Obliques
 Transversus Abdominis
 Tensor Fascia Latae
 Gluteus Maximus
 Erector Spinae
Pubic Tubercle
 It is important to let the patient/ client know what you are doing and get permission.
 To preserve modesty, have the patient/ client cover their mons pubis or penis and testicles.
 Using the pads of the fingers, begin at the ASIS and move distal and medial along the inguinal ligament to reach the pubic tubercle.
 A small sharp prominence can be felt on the anterior-superior pubis where the inguinal ligament attaches.

Attachment site for
Arcuate Ligament Complex Inguinal Ligament Adductor Longus Muscle Rectus Abdominis Muscle
Hip - Bony - Posterior
Pre-Assessment
 The bony structures related to finding the sciatic nerve and piriformis muscle, which can both be common sites for pathology.
 Explain to the patient that a larger area of the buttock will be exposed and what will be done.
Greater Trochanter
 Get permission and then place a flat broad hand on the lateral aspect of the proximal thigh, feeling for the bony structure that lies
there.
 Internally and externally rotate the thigh as well as move the hand superior and inferior to identify the superior tip of the greater
trochanter as this is used to help distinguish the soft tissue structures in this region.
 Mark the superior tip of the greater trochanter.
Attachment site for
 Gluteus Medius Muscle (superior and lateral aspect of greater trochanter)
 Gluteus Minimus Muscle (anterolateral aspect of greater trochanter)
 Piriformis Muscle (superior and medial aspect of greater trochanter)
 Deep hip External Rotators

Iliac Crest and Posterior Superior Iliac Spine (PSIS)
 The dimples found on some patients do not mark the location of the PSIS.
 The top of the iliac crest is at about the L4-L5 interspace although this can vary between patients.
 Palpate perpendicular to the crest and move dorsal and then distal, until an edge is felt medially and inferiorly.
 To confirm:
 Fall off on the caudal edge by moving the palpating fingers cranially-caudally.
 Then move medially-laterally and fall off the edges.
 Repeat on the other side.
Iliac Crest: Attachment site for
 Lumbodorsal Fascia
 Quadratus Lumborum
 Abdominal Obliques
PSIS: Attachment site for
 Oblique portion of Sacroiliac Ligaments
 Multifidus
Ischial Tuberosity
 Get permission to palpate the ischial tuberosity then place a flat hand at the midpoint of the buttock at the level of the gluteal fold.
Push superiorly to locate the bony prominence and note the dorsal and caudal margins of the ischial tuberosity.

Attachment site for
 Semimembranosus Muscle (lateral aspect of ischial tuberosity) attaches via fascial slip to lateral facet
 Semitendinosus Muscle (medial aspect of ischial tuberosity) - attaches to lateral facet
 Biceps Femoris Muscle (medial aspect of ischial tuberosity) - attaches via fascial slip to lateral facet
Spinous Processes of S2-S4 and Sacral Cornua
 Draw a helper line connecting the caudal borders of each PSIS, the middle of the line marks the spinous process of S2.
 From S2, move caudally to locate S3 and S4.
 There is no S5 spinous process, instead, there are horns or cornua on the right and left side. Between is the sacral hiatus, the opening
where a caudal epidural would be administered.
Attachment site for
 Multifidi Muscle
 Piriformis Muscle
 Gluteus Maximus Muscle
Hip - Soft tissue
Hip - Femoral Triangle
Borders of Femoral Triangle
 To identify the femoral triangle, start by locating the three borders.
 The adductor longus muscle is the medial border.

 The sartorius muscle is the lateral border.
 The superior border is identified by the inguinal ligament.
Contents of Femoral Triangle
 Structures that lie within the femoral triangle consist of the femoral artery, vein, and nerve.
 Palpate the femoral artery directly inferior to the inguinal ligament at midline.
 This is a common site for palpating pulses and it should be felt easily.
 To identify the remaining structures, it is helpful to remember the acronym NAVEL- moving from lateral to medial in the triangle are
the:
 Femoral nerve, artery, vein, empty space, and lymph nodes.
 The floor of the femoral triangle is made up of two muscles, the iliopsoas laterally and the pectineus muscle medially.
Iliopsoas Bursa
 The iliopsoas bursa is located under the iliopsoas muscle as it courses over the superior portion of the pubis and cannot be palpated.
Bony Landmarks
 ASIS
 Superior Pubic Rami
Referral Pattern
 Local pain

Pathology
 Iliopsoas bursitis causes deep groin pain and can be difficult to differentiate from iliopsoas tendinopathy and hip joint pain.
Iliopsoas Muscle
 To identify the iliopsoas, palpate within the triangle as the hip is flexed. The broad, flat tendon of the muscle can be felt.
 This tendon dives deep and attaches to the less trochanter of the femur distally.
 The muscle belly cannot be palpated in the groin, as it originates on the lumbar vertebra and iliac fossa.
Bony Landmarks
 ASIS
 Pubic Tubercle
Referral Pattern
 Trigger point can refer pain to the midline upper thigh as well as in the ipsilateral lumbar paraspinals
Pathology
 Iliopsoas tendinopathy causes groin and medial thigh pain with difficulty performing tasks requiring hip flexion.
 Snapping hip can be attributed to the iliopsoas tendon making a ‘click’ as it moves over the superior pubic rami and femoroacetabular
joint.
Pectineus Muscle

 Located in the medial aspect of the floor of the femoral triangle, the pectineus can be palpated by placing the fingers lateral of the
adductor longus muscle while asking the patient/ client to adduct the thigh against resistance.
 Feel the muscle firm up under during contraction
Bony Landmarks
 Pubic Tubercle
Referral Pattern
 Trigger points will refer pain deep in the groin and medial thigh
Hip - Soft Tissue - Anterior
Adductor Longus Muscle
 Have the patient adduct the thigh against slight resistance while locating the muscle belly on the medial surface of the thigh.
 Follow this muscle proximally to the tendinous insertion on the pubic tubercle.
Bony Landmarks
 Pubic Tubercle
 Femur

Referral Pattern
 Trigger points can refer pain to the groin, anteromedial thigh and into the knee
Pathology
 Tendinopathy can occur from athletics that require kicking and skating. It should be differentiated from an inguinal hernia,
abdominal muscle strain and pubic symphysis dysfunction
Adductor
Longus
By a cordlike tendon from pubic body just inferior to
pubic tubercle and crest
Femur- Middle third of
lines aspera
Anterior division of obturator
nerve, L2, L3, L4
Rectus Femoris Muscle and Tendon
 Palpate for the rectus femoris tendon at the corner of the V formed by the lateral border of the sartorius muscle and the more anterior
border of the TFL muscle.
 Once located, have the patient extend their knee against resistance and feel for the tendon popping into the fingers at To feel for the
insertion onto the anterior inferior iliac spine (AIIS).
Bony Landmarks
 Anterior Inferior Iliac Spine (AIIS)
 Patella
Referral Pattern
 Trigger points can refer pain to the knee and anterior thigh

Pathology
 Tendinopathy will cause pain with hip flexion activities. Avulsion of the insertion onto the AIIS can occur in young
athletes.
Rectus
Femoris
Anterior inferior iliac spine and ilium
above the acetabulum
Quadriceps tendon to base of patella and onto
tibial tuberosity via the patellar ligament
Femoral nerve
L2-L4
Sartorius Muscle
 Have the patient slightly flex and abduct their hip against resistance to activate the sartorius muscle belly. This long, slender muscle
runs inferior-medially across the anterior surface of the thigh from ASIS to the medial tibia as part of the pes anserine group.
Bony Landmarks
 Anterior Superior Iliac Spine (ASIS)
 Tibial Crest and Tibia
Referral Pattern
 Trigger points can refer pain along the course of the muscle (groin to medial knee), depending on the location.
Sartorius Anterior superior iliac spine Proximal tibia, medial to tibial tuberosity Femoral Nerve, L2, L3

Hip - Soft Tissue - Lateral
Gluteus Medius and Gluteus Minimus Muscles
 Gluteus Minimus: Palpate the superior and anterior aspect of the greater trochanter while the patient/ client abducts and internally
rotates their hip.
 The tendon insertion onto the trochanter can be easily palpated. The muscle belly lays deep to the gluteus medius and is behind the
tensor fascia latae.
 Gluteus medius: Palpate in the same way as for the minimus with the hand placed on the superior lateral aspect of the greater
trochanter.
 The muscle belly runs between the iliac crest superiorly, the greater trochanter inferiorly, and the gluteus maximus muscle
posteriorly.
Bony Landmarks for Gluteus Medius and Gluteus Minimus
 Iliac Crest and Ilium
 Greater Trochanter
Referral Pattern
 Gluteus Minimus: Trigger points refer pain to the posterior buttock and iliosacral area.
 Gluteus Medius: Trigger points refer pain to the posterior buttock and down the posterolateral thigh and leg.
Pathology
 Trendeleberg gait deviation can be seen with weakness or dysfunction of the hip abductor muscles.
 Greater trochanteric pain syndrome (GTPS) is a chronic lateral hip pain condition of non-specific etiology.
 Tendinopathy of the gluteus medius and/ or minimus muscle is thought to be a contributor to GTPS

Gluteus
Medius
External surface of ilium between anterior and
inferior gluteal lines
Femur- Lateral surface of greater
trochanter
Superior gluteal nerve,
L4, L5, S1
Gluteus
Minimus
External surface of ilium between anterior
and inferior gluteal lines
Femur- Anterolateral surface of
greater trochanter
L4, L5, S1
Tensor Fascia Latae (TFL) Muscle
 Palpate on the lateral ilium, just behind the ASIS and have the patient flex their hip and internally rotate their leg against resistance.
 Feel the muscle belly pop into the palpating hand and locate the borders of the muscle.
 The TFL attaches more proximally to the ASIS and distally, the TFL runs into the IT band.
Bony Landmarks
 Anterior Superior Iliac Spine (ASIS)
 Iliac Crest
Referral Pattern
 Trigger points in the TFL give rise to trochanter and lateral thigh pain
Pathology
 The TFL can be a contributor to greater trochanteric pain syndrome as well as iliotibial band syndrome.
 Tendinopathy of the TFL can manifest as lateral hip pain.

Tensor Fascia
Latae
Lateral surface of iliac crest from
iliac tubercle to ASIS
Iliotibial tract of fascia
latae
L4,L5,S1
Trochanteric Bursa
 The bursa that surround the greater trochanter are located between the greater trochanter and the superior part of the gluteal and
TFL muscles. The bursa cannot be palpated unless inflamed.
Referral Pattern
 Inflammation or irritation of the bursa can give rise to lateral hip pain.
Pathology
 Bursitis can lead to lateral hip pain as well as be a factor in GTPS.
Hip - Soft Tissue - Posterior
Helper Lines
 Use the bony landmarks to draw helper lines that will help to identify the piriformis muscle, sciatic nerve, and the superior and
inferior gluteal nerves.
 The first line will connect to the caudal end of the PSIS to the sacral cornua.
 Next, connect the PSIS to the greater trochanter.
 Lastly, connect the PSIS down to the ischial tuberosity.

Gluteus Maximus
 With the patient prone or in sidelaying, palpate the fullest area of the buttock as the patient/ client extends the hip.
 Follow the muscle fibers proximal to the sacrum and posterior ilium and distal to the greater trochanter and iliotibial band.
Bony Landmarks
 Sacrum
 Posterior iliac crest
 Greater trochanter
 Soft tissue attachment onto iliotibial band
Referral Pattern
 Trigger points in the gluteus maximus can refer pain to the posterior buttock and anal region. These can be a reason for pelvic muscle
dysfunction and pain.
Pathology
 Tendinopathy and bursitis can be conditions that involve the gluteus maximus.
Gluteus
Maximus
Posterior gluteal line and crest of ilium, fascia of gluteus
medius and erector spinae, dorsal surface sacrum and
coccyx, sacrotuberous ligament
Femur- Gluteal tuberosity
and posterior portion of
iliotibial band
Inferior gluteal
nerve, L5, S1, S2

Hamstrings Muscles and Tendons (Biceps Femoris, Semimembranosus, and
Semitendinosus)
Proximal Attachment
 Palpate the ischial tuberosity and have the patient extend the hip. The proximal attachments of the hamstrings can be palpated at the
distal aspect.
 A fascial slip that contains the sciatic nerve, and to which the hamstring tendons can sometimes insert, can be found lateral to the
ischial tuberosity.
Distal Attachments
 Biceps Femoris: Palpate the lateral aspect of the knee while the patient /client flexes the knee and externally rotates the leg against
resistance. Follow the tendon of the muscle to the insertion onto the fibular head.
 Semimembranosus and Semitendinosus: With the patient still actively flexing the knee, palpate the medial knee and ask for internal
rotation of the leg.
 The semitendinosus tendon is prominent and superficial to the semimembranosus muscle and tendon. The semitendinosus tendon
travels to the proximal medial tibia, to join the pes anserine group
Landmarks for Biceps Femoris
 Ischial Tuberosity
 Fibular Head
 Lateral Extensor Retinaculum
Landmarks for Semimembranosus
 Tibia

Landmarks for Semitendinosus
 Tibial and Medial aspect of crest of tibia
Referral Pattern
 Trigger points in the Biceps Femoris refer pain to lateral knee and posterior thigh.
 Trigger points in the Semimembranosus and Semitendinosus refer pain to the medial thigh and ischial tuberosity.
Pathology
 Tendinopathy can occur in any of the hamstring muscles; the Biceps Femoris tendinopathy tends to occur distally while the medial
hamstring tendinopathy occurs in the proximal aspect.
Hamstrings - Biceps
Femoris
Ischial tuberosity Head of fibula Tibial division of sciatic
nerve, L5, S1, S2
Hamstrings -
Semitendinosus
Low medial aspect of ischial
tuberosity
Medial surface of tibia Tibial division of sciatic
nerve, L5, S1, S2
Hamstrings -
Semimembranosus
Upper lateral aspect of
ischial tuberosity
Posteromedial aspect of
medial condyle of tibi
Tibial division of sciatic
nerve, L5, S1, S2
Piriformis Muscle
 The helper line from PSIS to the sacral cornua will be divided into thirds.
 The cranial two-thirds of that line will be connected out to the greater trochanter.
 This will provide the superior and inferior borders of the piriformis muscle.

Bony Landmarks
 Posterior Superior Iliac Spine (PSIS)
 Sacral Cornua
 Greater Trochanter
Piriformis Anterior sacrum lateral to sacral foramina Femur- Greater Trochanter Ventral Rami, L5 S1, S2
Posterior Hip Nerves (Sciatic Nerve, Superior Gluteal Nerve, and Inferior
Gluteal Nerve)
 Divide the superior and inferior border of the piriformis muscle into thirds.
 In the middle third section, would be the exit of the sciatic nerve beneath the muscle.
 The sciatic nerve will run down lateral to ischial tuberosity and down the posterior thigh.
 The intersection between the piriformis and the helper line connecting the PSIS to the ischial tuberosity is where the inferior gluteal
nerve exits.
 Locate the superior gluteal nerve by identifying the superior border of the piriformis muscle.
 The nerve should be located at the one-third mark from the PSIS.
Bony Landmarks for Sciatic Nerve
Popliteal Fossa and Popliteal Artery

 Popliteal fossa: This space on the posterior aspect of the knee is bordered by the medial and lateral heads of the gastrocnemius, the
biceps femoris, and the semimembranosus.
 Popliteal artery: Within the popliteal fossa, the popliteal artery can be felt by palpating deep in the midline of the popliteal fossa.
Hip - Nerve Entrapment
To find the nerves that can be entrapped in the anterior thigh, you want to locate the ASIS, the pubic tubercle, and the
inguinal ligament that spans between them.
Finding the femoral artery can help you locate the femoral nerve, and lateral of that, between the ASIS and femoral
nerve should be your lateral femoral cutaneous nerve that gives rise to sensation in the anterolateral thigh. This nerve
has a variable course. Sometimes it can be closer to the ASIS. The most common location is about two centimeters
medial of the ASIS.
The other structure you can locate in the anterior medial thigh is the obturator nerve. It exits through the obturator canal
and gives rise to sensation in the medial aspect of the thigh after having given all its motor branches.
Knee
Knee - Bony
Fibular Head
 Palpate the fibular head distally and slightly posterior to the lateral tibial plateau.
Attachment site for
 Lateral Collateral Ligament (LCL)

 Biceps Femoris Muscle
 Iliotibial Tract / Band
 Arcuate Ligament Complex
Gerdy’s Tubercle
 From the anterolateral tibial plateau, palpate distally to a small, rounded prominence on the proximal tibia which is the lateral
tibial tubercle.
Attachment site for
 Iliotibial Band (ITB)
 Patellar Retinacula
Lateral Femoral Condyle and Epicondyle
 Palpate the lateral tibiofemoral joint then move proximal to the lateral femoral condyle, then move further proxmial to, find a
rounded process which is the lateral femoral epicondyle
Attachment site for
 Articular Cartilage
 Lateral Collateral Ligament (LCL)

Knee - Bony - Medial
Adductor Tubercle
 A small, sharp prominence located on the superior aspect of the medial femoral epicondyle.
 The inferior aspect is the medial femoral epicondyle while the superior aspect is the adductor tubercle
Attachment site for
 Adductor Magnus Muscle
Medial Femoral Epicondyle
 Palpate the edge of the medial femoral condyle medially and move, proximally until a bony prominence is felt. This is the medial
femoral epicondyle.
Attachment site for
 Medial Collateral Ligament (MCL)
Knee - Soft tissue
Knee - Soft Tissue - Anterior
Patellar Tendon

 With the knee flexed, palpate distally from the patellar apex and feel the flat tendinous structure as it travels distally to insert on the
tibial tuberosity.
 The patellar tendon is sometimes called the patellar ligament as it attaches the patella to the tibial tuberosity
 The quadriceps muscle and tendon are the proximal of the patellar tendon
Bony Landmarks
 Patella
 Tibial Tuberosity
Pathology
 Tendinopathy can be reactive or degenerative in nature and give rise to anterior knee pain and dysfunction with knee bending
activity.
Quadriceps Muscle
 With the knee still extended, palpate the muscle bellies of the vastus lateralis which lies laterally, the vastus medialis which lies
medially, and the rectus femoris muscle which lies between them.
 Distally, the quadriceps muscle attaches to a broad retinaculum before it inserts onto the patella.
Vastus Lateralis Bony Landmarks
 Patella
 Iliotibial Tract
Vastus Intermedius Bony Landmarks
 Femur

 Patella
Vastus Medialis Bony Landmarks
 Patella
 Femur
Referral Pattern
 Trigger points in the quadriceps mostly refer pain in the region where the muscle belly is located. The Vastus lateralis can refer pain
to the hip and down to the lateral and posterior knee.
Pathology
 Tendinopathy typically occurs in the patellar tendon aspect. Quadriceps strain can occur with eccentric overloading into
knee flexion.
Vastus
Medialis
Medial supracondylar line, medial lip linea aspera,
pectineal line, medial part of intertrochanteric line
of femur
Medial border of patella and
tibia tuberosity via patellar
ligament
Femoral nerve,
L2, L3, L4
Vastus
Intermedius
Upper 2/3 anterior and lateral surface of femur to
lateral lip of linea aspera
Base of patella and tibial
tuberosity via patellar ligament
Femoral nerve,
L2, L3, L4
Vastus
Lateralis
Lateral lip linea aspera, gluteal tuberosity, greater
trochanter, and lateral part of intertrochanteric line
Base of patella and tibial
tuberosity via patellar ligament
Femoral nerve,
L2, L3, L4
Quadriceps Tendon

 Palpate the quadriceps tendon at the level of the patella by having the patient actively extend their knee against resistance to make it
more prominent. Follow the edges proximal to the myotendinous junction.
Bony Landmarks
 Patella
Knee - Soft Tissue - Lateral
Biceps Femoris Muscle
 Biceps Femoris: Palpate the lateral aspect of the knee while the patient /client flexes the knee and externally rotates the leg against
resistance. Follow the tendon of the muscle to the insertion onto the fibular head.
 The biceps femoris fibers are split by the lateral collateral ligament (LCL) as it runs distally to attach to the head of the fibula and to
the posterior surface of the lateral tibial plateau.
Bony Landmarks
 Fibular Head
 Lateral Extensor Retinaculum
Referral Pattern
 Trigger points in the Biceps Femoris refer pain to lateral knee and posterior thigh.

Pathology
 Biceps Femoris tendinopathy tends to occur near the knee
Hamstrings - Biceps Femoris Ischial tuberosity Head of fibula Tibial division of sciatic nerve, L5, S1, S2
Common Fibular Nerve
 Palpate lateral and distal to the fibular head to feel the nerve as it wraps around the fibula
 After branching off the sciatic nerve, the common fibular nerve travels with the biceps femoris, giving motor innervation to the short
head before wrapping around the fibula.
Pathology
Neuropathy of the common fibular nerve leads to weakness or palsy of the muscles in the anterior and lateral leg
compartments as well as sensory loss in the lower ⅔’s of the lateral leg and dorsum of the foot.
Lateral Collateral Ligament (LCL)
 Put the leg in the figure-four position while palpating above the lateral tibial plateau until a thin ligamentous structure is felt.
 Palpate the edges of the ligament by letting the fingers fall off anteriorly and posteriorly.
Pathology
 Varus stress to the knee can lead to a sprain or tear of the LCL.

Surface anatomy and palpation.docx

Surface anatomy and palpation.docx

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