Palpation of the Muscles of the Shoulder Girdle
Trapezius
Starting Position:
• Client prone with arm resting on the table at the side of the body
• Therapist standing to the side of the client
• Palpating hand placed just lateral to the lower thoracic spine (on the
lower trapezius)
Palpation Steps:
1. Ask the client to abduct the arm at the shoulder joint to 90 degrees
with the elbow joint extended, and to slightly retract the scapula at
the scapulocostal joint by pinching the shoulder blade toward the
spine (Figure A). Adding gentle resistance to the client’s arm abduc-
tion with your support hand might be helpful.
2. Palpate the lower trapezius. To locate the lateral border, palpate per-
pendicular to it (Figure A). Once located, palpate the entirety of the
lower trapezius.
3. Repeat for the middle trapezius between the scapula and the spine.
Strum perpendicular to the direction of the fi bers (i.e., strum verti-
cally) (Figure B).
4. Repeat for the upper trapezius.
5. To further engage the upper trapezius, ask the client to do slight ex-
tension of the head and neck at the spinal joints. Then palpate the
entirety of the upper trapezius (Figure C).
6. Once the trapezius has been located, have the client relax it and pal-
pate to assess its baseline tone.
Palpation Note:
1. Abducting the arm at the shoulder joint requires an upward rotation
force by the upper and lower trapezius to stabilize the scapula. Re-
tracting the scapula engages the entire trapezius, especially the mid-
dle trapezius.
Rhomboids
Starting Position:
• Client prone with the hand resting in the small of the back
• Therapist standing to the side of the client
• Palpating hand placed between the spinal column and the scapula at
the midscapular level
Palpation Steps:
1. Ask the client to lift the hand away from the small of the back
(Figure A).
2. Look for the lower border of the rhomboids to become visible (Figure B);
make sure you are not covering the lower border with your palpating
hand).
3. Palpate the rhomboids from the inferior aspect to the superior aspect.
When palpating, strum perpendicular to the direction of the fi bers.
4. Once the rhomboids have been located, have the client relax them and
palpate to assess their baseline tone.
Palpation Notes:
1. Having the client place the hand in the small of the back requires ex-
tension and adduction of the arm at the shoulder joint. This requires
the coupled action of downward rotation of the scapula at the scapu-
locostal joint, which will cause the trapezius to relax (due to recipro-
cal inhibition) so that we can palpate through it. It will also engage
the rhomboids so that their contraction will be clearly felt.
2. The superior border of the rhomboids is more diffi cult to visualize and
palpate than the inferior border. However, it can usually be palpated.
Feel for a gap between the rhomboids and the levator scapulae.
3. It is usually not possible to clearly distinguish the border between the
rhomboid major and rhomboid minor.
Coracobrachialis
Starting Position:
• Client seated with the arm abducted to 90 degrees and laterally ro-
tated at the shoulder joint, and the forearm fl exed at the elbow joint
approximately 90 degrees
• Therapist seated or standing in front of the client
• Palpating hand placed on the medial aspect of the proximal half of
the client’s arm
• Support hand placed on the distal end of the client’s arm, just proxi-
mal to the elbow joint
Palpation Steps:
1. Resist the client from horizontal fl exion of the arm at the shoulder
joint and feel for the contraction of the coracobrachialis.
2. Strumming perpendicular to the fi bers, palpate from attachment to
attachment.
3. Once the coracobrachialis has been located, have the client relax it
and palpate to assess its baseline tone.
Palpation Notes:
1. To easily discern the coracobrachialis from the short head of the
biceps brachii, it is important for the forearm to be passively fl exed
90 degrees or more so that the biceps brachii stays relaxed.
2. If there is doubt as to whether you are on the coracobrachialis or the
short head of the biceps brachii, resist the client from performing
fl exion of the forearm at the elbow joint. This will cause the short head
of the biceps brachii to contract, but not the coracobrachialis. Where
these two muscles overlap, the coracobrachialis is deep (posterior) to
the short head of the biceps brachii.
3. Palpation of the coracobrachialis must be done prudently because of
the presence of the brachial artery and the median, ulnar, and mus-
culocutaneous nerves.
Quadratus Lumborum (QL)
Starting Position:
• Client prone
• Therapist standing to the side of the client
• Palpating hand placed just lateral to the lateral border of the erector
spinae in the lumbar region
• Support hand sometimes placed directly on the palpation hand for
support (not shown)
Palpation Steps:
1. First locate the lateral border of the erector spinae musculature (to do
so, ask the client to raise the head and upper trunk from the table);
then place palpating fi nger just lateral to the lateral border of the
erector spinae.
2. Direct palpating pressure medially, deep to the erector spinae muscu-
lature, and feel for the quadratus lumborum (QL).
3. To engage the QL to be certain that you are on it: ask the client to ele-
vate the pelvis on that side at the lumbosacral joint (Note: This in-
volves moving the pelvis along the plane of the table toward the head;
in other words, the pelvis should not lift up in the air, away from the
table.) and feel for its contraction (Figure A).
4. Once located, palpate medially and superiorly toward the twelfth rib,
medially and inferiorly toward the iliac crest, and directly medially to-
ward the transverse processes of the lumbar spine (Figure B).
5. Once the QL has been located, have the client relax it and palpate to
assess its baseline tone.
Palpation Notes:
1. To successfully palpate the QL, you must be lateral to the erector spi-
nae and then press in fi rmly with a medial direction to your pressure.
2. Whenever pressing deeply to palpate a muscle, always press in fi rmly,
but slowly.
External and Internal Abdominal Obliques
Starting Position:
• Client supine with a small roll under the knees
• Therapist standing to the side of the client
• Palpating hand placed on the anterolateral abdominal wall
Palpation Steps:
1. With palpating hand on the anterolateral abdominal wall between the
iliac crest and the lower ribs (be sure that you are lateral to the rectus
abdominis), ask the client to rotate the trunk to the opposite side of
the body (contralateral rotation) and feel for the contraction of the ex-
ternal abdominal oblique (Figure A).
2. Try to feel for the diagonal orientation of the external abdominal
oblique fi bers by strumming perpendicular to them.
3. Continue palpating the external abdominal oblique toward its supe-
rior and inferior attachments.
4. Repeat the same procedure for the internal abdominal oblique, asking
the client to instead fl ex and ipsilaterally rotate the trunk at the spinal
joints (Figure B).
5. Once the external abdominal and internal abdominal obliques have
been located, have the client relax them and palpate to assess their
baseline tone.
Palpation Notes:
1. When asking the client to contralaterally rotate (to isolate the external
abdominal oblique) and ipsilaterally rotate (to isolate the internal ab-
dominal oblique), try to have the client do as little fl exion as possible,
or both abdominal obliques will contract.
2. The fi ber direction of the external abdominal oblique is similar to the
orientation of a coat pocket.
3. Feeling the fi ber direction of each of the abdominal obliques and dis-
tinguishing between the external and internal abdominal obliques on
one side can be challenging.
PIRIFORMIS
Starting Position:
• Client prone with the leg fl exed to 90 degrees at the knee joint
• Therapist standing to the side of the client
• Palpating hand placed just lateral to the sacrum, halfway between
the posterior superior iliac spine (PSIS) and the apex of the sacrum
• Support hand placed on the medial surface of the distal leg, just
proximal to the ankle joint
Palpation Steps:
1. Begin by fi nding the point on the lateral sacrum that is halfway be-
tween the PSIS and the apex of the sacrum. Drop just off the sacrum
laterally at this point and you will be on the piriformis.
2. Resist the client from laterally rotating the thigh at the hip joint and
feel for the contraction of the piriformis. Note: Lateral rotation of the
client’s thigh involves the client’s foot moving medially toward the
midline (and opposite side) of the body.
3. Continue palpating the piriformis laterally toward the superior border
of the greater trochanter of the femur by strumming perpendicular to
the fi bers as the client alternately contracts (against resistance) and
relaxes the piriformis.
4. Once the piriformis has been located, have the client relax it and pal-
pate to assess its baseline tone.
Palpation Notes:
1. It can be challenging to discern the borders between the piriformis
and the gluteus medius superiorly and superior gemellus inferiorly.
2. When giving resistance to the client’s lateral rotation of the thigh at
the hip joint, do not let the client contract too forcefully, or the more
superfi cial gluteus maximus (also a lateral rotator) may be engaged,
blocking palpation of the deeper piriformis.
Tibialis Anterior
Starting Position:
• Client supine
• Therapist standing to the side of the client
• Palpating hand not yet placed on the client
• Support hand placed on the medial side of the distal foot
Palpation Steps:
1. Resist the client from dorsifl exing and inverting the foot and look for
the distal tendon of the tibialis anterior on the medial side of the foot;
it is usually visible (Figure A).
2. Palpate the distal tendon by strumming perpendicularly across it.
Continue palpating the tibialis anterior proximally to the lateral tibial
condyle by strumming perpendicular to the fi bers. Its belly is located
directly lateral to the border of the tibia in the anterior leg (Figure B).
3. Once the tibialis anterior has been located, have the client relax it and
palpate to assess its baseline tone.
Palpation Notes:
1. As with all superfi cial muscles, it is always best to look before placing
your palpating hand over the muscle; otherwise your hand may block
you seeing and locating the muscle or its tendon.
2. The distal tendon of the tibialis anterior is usually very prominent and
visible. The belly is also usually prominent and visible directly lateral
to the shaft of the tibia in the anterior leg. If the tendon and belly are
not visible, they can usually be easily palpated by strumming
perpendicularly.
3. To clearly discern the border between the tibialis anterior and the ad-
jacent extensor digitorum longus (EDL), use inversion and eversion.
Inversion will engage the tibialis anterior but not the EDL; eversion
will engage the EDL but not the tibialis anterior.
TRIGGER POINTS
Sternocleidomastoid (SCM)
Anterolateral views illustrating common sternocleidomastoid (SCM) TrPs
and their corresponding referral zones. A, Sternal head. B, Clavicular
head.
Scalene
Anterior view illustrating common scalene TrPs and their correspond-
ing referral zone. B, Posterior view showing the remainder of the referral
zone
Piriformis
Posterior view of common piriformis TrPs and their corresponding referral
zones.
Hamstring Group
Posterior views of common lateral and medial hamstring TrPs and their
corresponding referral zones. A, Lateral hamstring (biceps femoris).
B, Medial hamstrings (semitendinosus and semimembranosus).
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