FLASHCARDS

for Palpation,

Trigger Points, and Referral Patterns

JOSEPH E. MUSCOLINO, DC
Instructor, Connecticut Center for Massage Therapy Westport, Connecticut Owner, The Art and Science of Kinesiology Redding, Connecticut

FM_i-xx_A05169.indd i

10/1/08 5:36:15 PM

PART 1: Muscle Palpation Section 1: 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 clients arm abduction with your support hand might be helpful. 2. Palpate the lower trapezius. To locate the lateral border, palpate perpendicular 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 bers (i.e., strum vertically) (Figure B). 4. Repeat for the upper trapezius. 5. To further engage the upper trapezius, ask the client to do slight extension 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 palpate 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. Retracting the scapula engages the entire trapezius, especially the middle trapezius.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 1

P1S01_001-030_A05169.indd 1

10/1/08 5:07:26 PM

Trapezius

The Muscle and Bone Palpation Manual, Figure 10-9, A-C, Page 143

A
Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: Fly like an airplane: If both trapezius muscles are palpated at the same time, both arms out to the sides make the client appear to be ying like an airplane.

P1S01_001-030_A05169.indd 2

10/1/08 5:07:26 PM

PART 1: Muscle Palpation Section 1: Palpation of the Muscles of the Shoulder Girdle

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 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 extension and adduction of the arm at the shoulder joint. This requires the coupled action of downward rotation of the scapula at the scapulocostal joint, which will cause the trapezius to relax (due to reciprocal 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 difcult 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.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 2

P1S01_001-030_A05169.indd 3

10/1/08 5:07:28 PM

Rhomboids

The Muscle and Bone Palpation Manual, Figures 10-14 and 10-15, Pages 146-147

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: Clients hand in the small of the back.

P1S01_001-030_A05169.indd 4

10/1/08 5:07:28 PM

PART 1: Muscle Palpation Section 4: Palpation of the Muscles of the Arm

Coracobrachialis
Starting Position: Client seated with the arm abducted to 90 degrees and laterally rotated at the shoulder joint, and the forearm 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 clients arm Support hand placed on the distal end of the clients arm, just proximal to the elbow joint Palpation Steps: 1. Resist the client from horizontal exion of the arm at the shoulder joint and feel for the contraction of the coracobrachialis. 2. Strumming perpendicular to the 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 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 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 musculocutaneous nerves.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 49

P1S04_089-104_A05169.indd 97

10/1/08 5:09:09 PM

Coracobrachialis

The Muscle and Bone Palpation Manual, Figure 13-26, Page 271

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: Resist horizontal exion of the arm

with the elbow joint exed.

P1S04_089-104_A05169.indd 98

10/1/08 5:09:09 PM

PART 1: Muscle Palpation Section 7: Palpation of the Trunk Muscles

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 nger just lateral to the lateral border of the erector spinae. 2. Direct palpating pressure medially, deep to the erector spinae musculature, and feel for the quadratus lumborum (QL). 3. To engage the QL to be certain that you are on it: ask the client to elevate the pelvis on that side at the lumbosacral joint (Note: This involves 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 toward 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 spinae and then press in rmly with a medial direction to your pressure. 2. Whenever pressing deeply to palpate a muscle, always press in rmly, but slowly.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 85

P1S07_159-194_A05169.indd 169

10/1/08 5:10:42 PM

Quadratus Lumborum (QL)

The Muscle and Bone Palpation Manual, Figures 16-27 and 16-28, Page 366

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: Lateral to the erector spinae and press in medially.

P1S07_159-194_A05169.indd 170

10/1/08 5:10:42 PM

PART 1: Muscle Palpation Section 7: Palpation of the Trunk Muscles

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 external abdominal oblique (Figure A). 2. Try to feel for the diagonal orientation of the external abdominal oblique bers by strumming perpendicular to them. 3. Continue palpating the external abdominal oblique toward its superior and inferior attachments. 4. Repeat the same procedure for the internal abdominal oblique, asking the client to instead 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 abdominal oblique), try to have the client do as little exion as possible, or both abdominal obliques will contract. 2. The ber direction of the external abdominal oblique is similar to the orientation of a coat pocket. 3. Feeling the ber direction of each of the abdominal obliques and distinguishing between the external and internal abdominal obliques on one side can be challenging.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 92

P1S07_159-194_A05169.indd 183

10/1/08 5:10:55 PM

External and Internal Abdominal Obliques

The Muscle and Bone Palpation Manual, Figure 16-53, A-B, Page 379

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: Flex and contralaterally rotate for the external

abdominal oblique; ex and ipsilaterally rotate for the internal abdominal oblique.

P1S07_159-194_A05169.indd 184

10/1/08 5:10:56 PM

PART 1: Muscle Palpation Section 8: Palpation of the Pelvic Muscles

Piriformis
Starting Position: Client prone with the leg 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 nding the point on the lateral sacrum that is halfway between 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 clients thigh involves the clients 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 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 palpate 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 clients lateral rotation of the thigh at the hip joint, do not let the client contract too forcefully, or the more supercial gluteus maximus (also a lateral rotator) may be engaged, blocking palpation of the deeper piriformis.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 101

P1S08_195-206_A05169.indd 201

10/1/08 5:11:17 PM

Piriformis

The Muscle and Bone Palpation Manual, Figure 17-22, Page 407

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: Find the midpoint of the lateral border of the sacrum.
Then draw a line from there to the greater trochanter.

P1S08_195-206_A05169.indd 202

10/1/08 5:11:17 PM

PART 1: Muscle Palpation Section 10: Palpation of the Leg Muscles

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 dorsiexing 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 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 supercial 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 adjacent 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.

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

CARD # 116

P1S10_231-254_A05169.indd 231

10/1/08 5:11:59 PM

Tibialis Anterior

The Muscle and Bone Palpation Manual, Figures 19-7 and 19-8, Pages 456-457

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Palpation Key: First look for the distal tendon.

P1S10_231-254_A05169.indd 232

10/1/08 5:12:00 PM

10/1/08 5:13:10 PM

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

P2_277-416_A05169.indd 283

The Muscle and Bone Palpation Manual, Figure 7-7, Page 72

Supraspinous fossa Superior angle Superior border

Infraspinous fossa

Spine of scapula Acromion process

Medial border Lateral border

PART 2: Bone Palpation

Upper Extremity Section 1: Shoulder Girdle

CARD # 142 A
Posterolateral view

Inferior angle

Posterolateral view of the scapula.

PART 2: Bone Palpation Upper Extremity Section 1: Shoulder Girdle

The Muscle and Bone Palpation Manual, Figure 7-8, A-B, Page 72

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Posterolateral view

Posterolateral view

Acromion process and spine of the scapula: The spine of the scapula is the posterior continuation of the acromion process. To locate the spine of the scapula, begin on the acromion process (A) and continue palpating along it posteriorly. The spine of the scapula (B) can be palpated all the way to the medial border of the scapula. The spine of the scapula can be best palpated if you strum it perpendicularly by moving your palpating ngers up and down across it as you work your way posteriorly.

CARD # 142 B

P2_277-416_A05169.indd 284

10/1/08 5:13:11 PM

PART 2: Bone Palpation Upper Extremity Section 1: Shoulder Girdle

The Muscle and Bone Palpation Manual, Figure 7-9, Page 73

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Posterolateral view

Supraspinous fossa: To palpate the supraspinous fossa of the scapula, locate the spine of the scapula and drop just off it superiorly. Palpate along the superior border of the spine of the scapula within the supraspinous fossa.

CARD # 143 A

P2_277-416_A05169.indd 285

10/1/08 5:13:12 PM

PART 2: Bone Palpation Upper Extremity Section 1: Shoulder Girdle

The Muscle and Bone Palpation Manual, Figure 7-10, Page 73

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Posterolateral view

Infraspinous fossa of the scapula: To palpate the infraspinous fossa of the scapula, locate the spine of the scapula and drop just off it inferiorly. The infraspinous fossa is larger than the supraspinous fossa.

CARD # 143 B

P2_277-416_A05169.indd 286

10/1/08 5:13:13 PM

PART 2: Bone Palpation Axial Body Section 4: Posterior Neck

The Muscle and Bone Palpation Manual, Figure 8-18, Page 102

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Lateral view

Spinous processes of C2 through C7: The spinous processes (SPs) of the cervical spine are palpated in the midline of the posterior neck. The most prominent cervical SPs are the second and seventh (C7 is called the vertebra prominens). Begin at the external occipital protuberance of the occiput (see Flashcard #172B); then drop inferiorly onto the cervical spine, feeling for the SP of C2. As with most cervical SPs, it is bid (it has two points). Continue palpating inferiorly, feeling for additional cervical SPs. Note: C1 (the atlas) does not have a SP; it has a posterior tubercle. To palpate the posterior tubercle of C1, palpate between the SP of C2 and the occiput, pressing anteriorly into the soft tissue.

CARD # 175 B

P2_277-416_A05169.indd 350

10/1/08 5:13:59 PM

PART 2: Bone Palpation Axial Body Section 4: Posterior Neck

The Muscle and Bone Palpation Manual, Figure 8-19, Page 103

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Lateral view

Articular processes (facet joints) of the cervical spine: The inferior and superior articular processes of the cervical spine create what is called the cervical pillar (articular pillar) due to the manner in which they stack upon one other. They are easily palpable at the lateral side of the laminar groove (approximately 1 inch [2.5 cm] lateral to the spinous processes). The client must be supine and relaxed for palpation to be successful. Begin palpation at the spinous process of C2 (see Flashcard #175B) and palpate laterally for the articular process of C2. Continue to palpate inferiorly until you reach the bottom of the neck. Note: The articular processes of the cervical spine are an excellent contact point when performing specic joint mobilizations to the cervical spine.

CARD # 176 A

P2_277-416_A05169.indd 351

10/1/08 5:14:01 PM

PART 3: Trigger Points Section 2: Neck

Sternocleidomastoid (SCM)
The Muscle and Bone Palpation Manual, Figure 11-8, A-B, Page 188

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Anterolateral views illustrating common sternocleidomastoid (SCM) TrPs and their corresponding referral zones. A, Sternal head. B, Clavicular head. TrP Trigger Point

CARD # 214 A

P3_417-478_A05169.indd 427

10/1/08 5:15:12 PM

PART 3: Trigger Points Section 2: Neck

Scalenes
The Muscle and Bone Palpation Manual, Figure 11-15, A-B, Page 192

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

A, Anterior view illustrating common scalene TrPs and their corresponding referral zone. B, Posterior view showing the remainder of the referral zone.

TrP Trigger Point

CARD # 214 B

P3_417-478_A05169.indd 428

10/1/08 5:15:13 PM

PART 3: Trigger Points Section 7: Pelvis

Piriformis

The Muscle and Bone Palpation Manual, Figure 17-24, Page 408

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

Posterior view of common piriformis TrPs and their corresponding referral zones. TrP Trigger Point

CARD # 232 A

P3_417-478_A05169.indd 463

10/1/08 5:15:35 PM

PART 3: Trigger Points Section 8: Thigh

Hamstring Group
The Muscle and Bone Palpation Manual, Figure 18-10, A-B, Page 422

Copyright 2009 Mosby, Inc., an afliate of Elsevier, Inc.

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). TrP Trigger Point

CARD # 232 B

P3_417-478_A05169.indd 464

10/1/08 5:15:36 PM