Palpation; Movement Analysis; Strengthening Exercises; Lifts

Ulnar Nerve Test

1) Start with the elbow on this one. Now you are looking for pain in the pinky or ring finger. 2)Elbow stays bent on this one, unlike the median nerve where you extend it. 3) Then depress the scapula, symptoms? 4) Then you pronate the forearm, symptoms? 5) Then extend the wrist, with a little bit of ulnar deviation as well. 6) Then extend the fingers and make sure to extend the pinky and the ring finger, stop wherever there are symptoms -so if there is pain in the pinky, that is the distal component. You would then have them side bend the head towards or away; better, worse, the same?

***For a neural tissue tension test to be positive three things must occur:

1. It has to reproduce the patient's symptoms/pain 2. It has to be different from side to side 3. It has to be changed (better or worse) by a distant component *remember, if there is NO change by a distal component then that means the test is negative. -for neural tension to be present it then all 3 of these things must occur.

Clavicle

A crank shaped bone on the anterior superior aspect of the chest. To palpate move medial to the acromion until a bulge is felt. Generally the clavicle will sit slightly higher than the acromion. You may have patient abduct shoulder in order to feel clavicle rotate posterior. Clavicle is convex anterior medially and concave anterior laterally.

Tubercle of Radius (Lister's Tubercle)

A structure about one-third of the way across the dorsum of the wrist from the radial styloid process. This structure feels like a small longitudinal bony prominence or nodule.

IT band

A thick fibrous band of tissue that has fibers from the gluteus maximus, medius, and tensor fascia lata. Proximal attachment is at the iliac crest while the distal insertion is at Gerdy's tubercle on the proximal lateral tibia.

Lateral Tibial Plateau and Condyle

Allow fingers to rest in the indentation lateral to the infrapatellar ligament. Palpate laterally along the sharp edge. Can palpate back posteriorly to the lateral collateral ligament. The condyle is the upper most portion of the condyle.

Coracoid Process

An important structure as it is the attachment of several structures. Attached to the coracoid process are the coracobrachalis muscle, the short head of the biceps brachii, the pec minor muscle and the coracoacromial ligament. If you can find the acromioclavicular joint and drop about 2 cm medial and inferior you will palpate the corocoid. This structure is almost always tender to palpation, even without pathology.

Infrapatellar Tendon

Band-like structure running from inferior aspect of patella to the tibial tubercle. Area of tenderness in adolescents may be from apophysitis at tibial tubercle termed "Osgood Schlatters Disease" or at the inferior pole of the patella known as "Sindig Larsen Johanasons Disease". If severe tendonitis may feel thickness.

Glute Med

Bony landmarks are the anterior part of the iliac crest and superior border of the greater trochanter. Ask subject to abduct leg (from sidelying) in the frontal plane. Slight hip extension will better isolate this muscle.

Semitendinosus

Cord-like on medial posterior aspect of the knee. More sinewy than the semimembranosus. This muscle lies posterior and on top of the semimembranosus.

Hughston's Exercise #2

Excellent exercise for Supraspinatus (shoulder abductor) -Pt. instructions to say: 1) Raise your arm so it is parallel to the floor and perpendicular to your body, thumb pointing up (towards ceiling) 2) Bring your arm up and squeeze the shoulder blades together. 3) Pause for 2 seconds 4) Return to the starting position. Make sure you go all the way back down to the floor

Hughston's Exercise #5

Excellent exercise for infraspinatus and teres minor (external rotators) -Description: With elbow bent at 90, rotate the humerus bringing the hand as high as possible. Pause for 2 seconds then lower. -Pt. instructions to say: Bring the arm back to the position of #1, bend the elbow. Externally rotate (like cocking to throw a ball). Return to the starting position. You may need to move over on the table, so a portion of your upper arm is supported.

Supraspinatus

Fills the supraspinatus fossa and covered by the upper trapezius. The origin of the supraspinatus is the supraspinatus fossa. The insertion of the supraspinatus is the top of the greater tubercle of the humerus. You can palpate through the trapezius to feel the supraspinatus muscle and fossa.

Lateral Border of Scapula

Find the inferior medial angle of the scapula and move superior and laterally along scapula. As you move superior and laterally you first palpate the teres major and then the teres minor.

Medial Malleolus

Follow the tibia distally to its most prominent distal. Medial malleolus is the proximal attachment of the medial collateral ligaments of the ankle.

Hughston's Exercise #1

Good exercise overall for all Rotator Cuff muscles -Pt. instructions to say: 1) Raise your arm so it is parallel to the floor and perpendicular to your body, thumb pointing forward (towards your head) 2) Bring your arm up into 90 degrees pure abduction and squeeze the shoulder blades together 3) Pause for 2 seconds 4) Return to the starting position. Make sure you go all the way back down to the floor

Bilateral bridge

Good for glutes, core, hamstrings, adductors Starting position was hook-lying with the knees at 90° of flexion, hips at 45° of flexion, 0° of rotation and abduction, trunk in neutral, and feet flat on the table. The subject then pushed both feet into the table to raise the pelvis until a position of 90° of knee flexion was achieved bilaterally before returning to the starting position. The hips remained at 0° of rotation and abduction during the exercise, with the trunk in neutral.

Glute Max

Have patient lie prone with the hip abducted and externally rotated and the knee flexed. Resist hip extension and palpate mid posterior buttock.

Ischial Tuberosity

Have your patient lie on the contralateral side with their knee slightly flexed. Palpate with your thumbs at the level of the gluteal folds until you feel a prominence.

Bicipital Groove

Hold patient's arm in mid-position. Move fingers laterally from corocoid process, past the lesser tuberosity and into the bicipital groove. It contains the tendon of the long head of the biceps. This groove is covered by the transverse humeral ligament that can sometimes be lax and allow the biceps tendon to sublux. If this occurs it will generally sublux medially as the humerus is rotated laterally. Have patient internally rotate and your finger will roll onto the greater tuberosity.

Sciatic Nerve

Locate the mid-position between ischial tuberosity and the greater trochanter. You may be able to roll the nerve under your fingers if you take up the soft tissue slack.

Tibial Tubercle

Locate this structure at the distal end of the infrapatellar tendon.

Lateral Malleolus

Located at the distal end of the fibula and extends distally farther and is also more posterior than the medial malleolus. This distal extension of the lateral malleolus acts somewhat of a deterrent to eversion ankle sprains.

Basic Lift

Most common method of good lifting Used for objects small enough to straddle 1. Get close to the object 2. Stand with a wide stance Put one foot forward and to the side of the object. 3. Keep back straight, push buttocks out, and use legs and hips to lower down 4. Move load as close as possible. 5. Grasp the handles firmly. 6. Put the hand (same side as forward foot) on side of the object furthest from you 7. Put other hand on side of the object closest to you 8. Grasp object firmly with both hands 9. Prepare for lift: look forward 10. Lift upwards following your head and shoulders. Hold load close to body. Lift by extending legs with back straight, buttocks out, and breathe Correct lifting: Head will lift up first, followed by straight back. If hips come up first and must bend back as you straighten up = lifting incorrectly

Spinous Process C7

Normally the longest of all the cervical spinous processes. It is referred to as the prominens. Sometimes it can be of the same length as T1. To determine C7, place one finger on the presumed C7, and one over C6 and T1 and have the patient extend their head slightly. The C6 vertebra will drop off slightly at the beginning of the movement, followed by C7 with a slight increase in extension, and T1 will not drop off at all. T1 is immobilized by the 1st ribs bilaterally.

Greater Trochanter

Start on iliac crest and palpate distally along lateral midline until you reach a small plateau. Have patient internally and externally rotate their thigh to determine the most prominent portion of the trochanter to determine angle of torsion.

Acromion/Acromion Process

The acromion process is an attachment site for several muscles including the deltoid, the pectoralis major and the trapezius. You can find it by palpating the lateral most bony location on the superior shoulder.

Greater Tubercle

The attachment of several key rotator cuff muscles which include the supraspinatus, the teres minor and the infraspinatus. The biceps groove and the greater tubercle. Therefore the most lateral bony prominence is the greater tubercle.

Shoulder Extension (Rows)

Theraband 1) Bands in door squeeze shoulder blades 2) Anterior glide if they're flying forward 3) Good for pec major, posterior delts and lats

Shoulder Flexion

Theraband 1) Punch or true flexion 2) Good for pec major and anterior delts

Shoulder External Rotation

Theraband 1) Watch scapular position for internal and external 2) Stress that the elbow stay bent; towel/pillow will keep them in shoulder flexion 3) Good for infraspinatus and teres minor (external rotators)

Spinous Process of Thoracic Spine

These are longer and more slender than those of the cervical spine. These are usually prominent enough to palpate in respect to each other from cranial to caudal.

Teres Minor

This muscle has an origin along the dorsal surface of the lateral border of the scapula, while its insertion is on the lower portion of the greater tubercle. To palpate follow the lateral angle of the scapula the first muscle you will find is the teres major. As you palpate superiorly the next muscle you come to will be the teres minor.

Infraspinatus

This muscle is located in the infraspinatus fossa on the posterior inferior surface of the scapula, below the supraspinatus fossa. The infraspinatus insertion is on the middle of the greater tubercle of the humerus. To palpate have the patient either seated or prone on the table. Palpate along spine of scapula laterally then move the fingers inferiorly in the infraspinatus fossa.

Lumbar Transverse Processes

Typically positioned in a horizontal position. L3 is usually the longest and L1 the shortest. These are more difficult to palpate in the lumbar spine due to the amount of muscle mass in this area.

Piriformis

Very deep and hard to palpate. PSIS to the greater trochanter.

Iliac Crest

Very prominent and easy to palpate. Extend your fingers and place your index fingers of each hand at the level of the waist on each side laterally. Press medially and inferiorly until you feel a firm ridge under your index fingers. Following this level around posteriorly corresponds with the L4-5 interspace level posteriorly.

Straight Leg Raise Test

1) Bring them up passively into a straight leg raise; watching them to see if they are saying it hurts, or if they don't let you know bringing them up, raise like a hamstring stretch until you feel that tension arise; symptoms down the leg? -some people may have symptoms right here and you would stop there, this would indicate sciatic tension 2) Then, let the leg rest on your shoulder so that you can control the foot easier; dorsiflex, symptoms? 3) Then you can get the big toe involved as well, symptoms? Tibial nerve: -from that same straight leg position rested on your shoulder, you can dorsiflex and evert (TED); Tibial nerve is right down the calf; symptoms? Sural nerve: -from the same straight leg position rested on shoulder you would dorsiflex and invert the foot (SID); symptoms? Fibular/Peroneal nerve: -fibular nerve is more lateral than the tibial nerve, thats why it becomes a plantar flexor position (FIP or PIP); depending on what you call the nerve) you plantar flex and invert the foot; symptoms? -if you were doing a SLR neural test, and the pt. said it hurt at the ankle, tell them to flex the head up (like a curl up) and see if it is better, worse, the same; the head is a distal component. -if they come in and say they have low back pain during the SLR test, take away the foot by removing any dorsiflexion, thats a distal component.

Radial Nerve Test

1) Have the patient at a diagonal. This allows you to depress the scapular with your thigh. When you do this then you can control elbow with one hand and wrist with the other. 2) Looking for symptoms on the back of the hand with this test. 3) You have to look back over your shoulder to see their face and get their feedback so this one is a little bit more difficult. 4) Again you start with the elbow bent. 10 degrees of abduction; symptoms? 5) Extend at the elbow; symptoms? 6) Little bit of pronation; symptoms? 7) Little bit of radial deviation; symptoms? 8) Then you want to make sure that all the fingers and the thumbs are flexed; have them make a fist and make sure the thumb is tucked, symptoms?

Lower Limb: Slump Test

1) Have the patient sit on the edge of the bed and scoot back so the backs of the knees hit the bed. 2) Tell them to relax, and bring the legs together for them then let them fall back naturally 3) First ask if there are any symptoms while they are just sitting there; if no then move on, sit on the bed next to the patient 4) Tell them to slump, make sure they are slumping the way you want them to be. (think of pillsbury doughboy thing); any symptoms with the slump? 5) Make sure the neck flexes next 6) Put your hand on the back of the cervical spine and head so you can control the slump and flexion of the neck; any symptoms? 7) Then you can either passively or actively extend the leg at the knee on the tested side (the side they are experiencing the symptoms on). Symptoms? 8) Then bring the toes towards the nose; symptoms? -lets say this hurts in this patient at this last point; pain is in the calf; you let off of the head, but you can still keep them slumped with you arm on the back. -if nothing changes, then its not positive on this side and you would test the other side; if you go to the other side and the same thing happens, then depending on what they are coming in for, gastroc could be tight and thats why they could be having calf pain. -if there is a change, then the neural tension test is positive

Shoulder Internal Rotation

Theraband 1) Watch scapular position for internal and external 2) Stress that the elbow stay bent; towel/pillow will keep them in shoulder flexion 3) Good for subscapularis (internal rotator)

Shoulder Abduction

Theraband Good for supraspinatus (abductor)

Movement Analysis of Hip Extension

-Client is prone while the PT hands palpate erector spinae with thumb and little finger of one hand -Palpate the glutemax and hamstring with the thumb and little finger of the other hand -Instruct client to extend and lift hip off the table Normal firing pattern: 1) Glute max 2) Opposite Erector 3) Same erector and hamstring Altered firing pattern: -weak agonist = glute max -overactive antagonist = psoas -overactive stabilizer = erector Symptoms: -low back pain -buttock pain -recurrent hamstring strains Exercises to improve: -Weak agonist: glute sets or donkey kicks to improve glute max -Overactive antagonist: hip flexion first, sitting on edge of a table bring the knee above 90 -Overactive stabilizer: crease in back; extension comes from the back first On first visit stretch Psoas: -all these need to retrain glute max

Movement Analysis of Hip Abduction

-Client is side-lying -PT is standing behind client -Palpate QL with one hand -Palpate TFL and glute med with the thumb and index finger of the other hand Normal firing pattern: 1) Glute med 2) TFL / QL same time Altered firing pattern: -weak agonist = glute med -overactive antagonist = adductors -overactive synergist = TFL -overactive stabilizer = QL -overactive neutralizer = piriformis Symptoms: -low back pain -SI joint pain -buttock pain -lateral knee pain -anterior knee pain -shin splints -plantar fasciitis Exercises to improve: -Weak agonist: clams to strengthen glute med -3 way hip would be good for all the muscles and for hip stabilization strength as well

Movement Analysis of Trunk Flexion

-Client is supine with hips and knees at 90 -Instruct to perform a normal curl up -PT is assessing ability of abs to functionally stabilize the lumbo-pelvic-hip complex Normal firing pattern: -client should be able to maintain a drawing in maneuver while performing curl up -inability to maintain drawing in = altered firing Altered firing pattern: -weak agonist = ab complex -overactive antagonist = erector spinae -overactive synergist = psoas Symptoms: -low back pain -buttock pain -facet syndrome -facet instability

Median Nerve Test

1) The depression at the shoulder takes care of the nerve at the scapula 2) Elbow bent, and walk the arm up with your leg to about 110 degrees of abduction at the shoulder (just make sure you come past 90); then ask, do you have any symptoms there? 3) Next you externally rotate the elbow; symptoms? 3) Then its wrist, then hand; you can do hand and wrist together if you want to. Make sure when extending the fingers to put pressure on the index finger and the thumb especially; symptoms? 4) Wherever they have symptoms, you want to have them change a distal component. 5) In this case if the pain is felt in the hand, you could have them move their head towards the tested arm, or away from the tested arm (side bend towards or away) 6) If the pain was at the hand you could also just let off the pressure of depressing the scapula. The scapula is still distal to the hand as well -looking for any change at ANY distal component. If you have them side bend the head towards and there is no change then you need to have them side bend away and check that too. Don't just do one of the two. -any time there is a change in symptoms when moving a distal component the test is POSITIVE for neural tension (better or worse, and must be different between sides). -on the lab exam do not need to test both sides, but make sure to tell Mike that you would test both sides with a real patient.

Medial Tibial Plateau and Condyle

Allow fingers to rest in the indentation medial to the infrapatellar ligament. You should be able to feel the sharp edge of the medial tibial plateau. The plateau itself serves as one point of attachment for the medial meniscus. The condyle is the upper most portion of the plateau.

Ulnar Styloid Process

Also known as the posteromedial eminence. It forms a beak at the end of the ulna. Notice that the ulnar styloid process does not extend as far as the radial. The ulnar styloid is also more prominent and thicker than the radial. Ulnar styloid is also displaced slightly posteriorly and medially than the radial counterpart

Cuboid/ Cuboid Groove

As you palpate just proximal to the styloid process you will find a groove on the cuboid bone which is created by the tendon of the peroneus longus muscle tendon as it runs to the medial plantar aspect of the foot.

Levator Scap

Attached to the transverse processes of C1-4 and the superior medial aspect of the scapula. Tenderness is often noted over its distal attachment on the superior medial border of the scapula. Palpate along the superior medial border of the scapula with the patient in the supine or prone position. Have the patient turn their head in the opposite direction to increase the tension on the muscle.

Biceps Femoris

Best found with the patient in prone. It is the cordlike structure proximal to the fibular head. Origin is the ischial tuberosity and sacrotuberous ligament while its insertion is the fibular head, the fibula and the lateral collateral ligament

Semimembranosus

Between and under semitendinosus and gracilis. This muscle also has attachment sites to MCL, Medial meniscus, and the popliteus muscle.

Anatomical Snuffbox

Bordered medially by the extensor pollicis longus, laterally by the extensor pollicis brevis and the abductor pollicis longus. It can best be seen by having the patient actively extend the thumb. The scaphoid can be palpated inside the snuffbox.

Radial Styloid Process

Distal and most lateral portion of the radius. Attaches to the first row of carpal bones. Inferior surface of the distal end of the radius articulates laterally with the scaphoid and medially with the lunate when held in anatomical position of full supination.

TFL

Easiest to palpate in sidelying. Allow the subject to flex their hip slightly. Abduction in this plane will make the TFL more prominent. Anterior of greater troch

Erector Spinae Muscles

Easily palpable just lateral to the spinous processes. Their lateral border appears to be a groove. Often tender and in spasm in patients with acute low back pain.

Hughston's Exercise #3

Excellent exercise for supraspinatus, teres minor, and especially infraspinatus (internal and external rotators) -Pt. instructions to say: 1) With thumb pointed up, lift arm at 90 degrees pure abduction. Pause for 2 seconds then lower.

Hughston's Exercise #4

Excellent exercise overall for all Rotator Cuff muscles -Description: With thumb pointed up, lift arm with hand at eye level. Pause for 2 seconds then lower.

Hughston's Exercise #6

Exercise STRICTLY for teres minor (external rotator) -Description: With thumb pointed out, lift arm in extension. Pause for 2 seconds then lower. -Pt. instructions to say: Bring your arm to your side, thumb pointing away from your body (palm towards floor). Bring the arm up as far as possible. Return to the starting position.

Medial Femoral Condyle

Find the medial femoral condyle superior to the medial tibial plateau. Can palpate directly medially to the patella with the knee flexed. With the knee in 90° of knee flexion a large majority of the MFC can be palpated. Condyle is also palpable along its sharp medial edge, proximally as far as the superior position of the patella and distally to the junction of the tibia and femur.

Lateral Femoral Condyle

Fine the lateral femoral condyle superior to the lateral tibial plateau. Can palpate directly laterally to the patella with the knee flexed.

ASIS

Follow the iliac crest around anteriorly until you reach this easily palpable structure. Very prominent on the anterior side of the pelvis. Check for symmetry side to side by palpating most inferior portion of the ASIS.

PSIS

Follow the iliac crest around posteriorly and inferiorly until you reach this structure. It is usually slightly prominent and slightly inferior to the normal dimple in this region. The PSIS is typically located at the level of S2.

Lumbar Spinous Processes

From the PSIS move your fingers in a medial and superior direction at a 30 degree angle - you will then be on L5 spinous process. You can also use the L4-5 interspace as previously described and count accordingly. L1 can be located by first finding the 12th rib and moving your fingers medially and down one level.

Hip abduction in sidelying

GOOD FOR GLUT MED 1) Starting position was lying on a treatment table, on the side opposite the tested limb. 2) The table was placed along a wall. 3) The lower extremity on the table was flexed to 45° at the hip and 90° at the knee. 4) The subject's back and plantar foot were against the wall for control of position and movement. 5) The subject then abducted the tested hip to approximately 30° and then returned the limb to the table. 6) To control for the correct movement, the subject kept the heel in light contact with the wall (via a towel) while sliding it along the wall, with the toes pointed horizontally away from the wall.

Gasctroc/soleus

Gastrocnemius muscle arises from two heads of the condyles of the femur and insert into the Achilles tendon on the posterior aspect of the calcaneus. Soleus lies deep to the gastroc, originating on the tibia and fibula. Together known as the triceps surea.

Hip hike

Good for glute max, glute med, psoas, QL, erector spinae, adductors Starting position was standing on an elevated platform, with the knees and hips at 0° in the sagittal and coronal planes, and the feet/toes pointed straight ahead in midline. The subject remained weight bearing on the tested lower limb while alternately raising and lowering the other limb off the edge of the platform (by raising and lowering the pelvis), maintaining the knees at 0°.

Sidestep with elastic resistance around the thighs in a squatted position

Good for glute med Starting position was in a squatted position, as described above for the squat. The subject then stepped to the side with one limb, followed in the same direction by the other limb, both step lengths approximately 50% of the starting-position distance between the feet (see squat). Knees were kept aligned with the ipsilateral second toe. If a sidestep with each limb in succession was considered a stride, then the subject performed a total of 2 strides in one direction, followed by 2 strides in the opposite direction to return to the starting position. This activity cycle was performed a total of 3 times. The same method of elastic resis- tance was used in this exercise as in the clam exercise, because there was otherwise little resistance to the sideways movement Lateral side stepping and monster walk. Make sure that toes point forward so they are using the hip abductors and not external rotators

Hip extension in quadruped on elbows with knee extending

Good for glutes Starting position was quadruped, with the upper body supported by the elbows and forearms, and the knees and elbows at approximately 90° of flexion. The subject then lifted the tested lower limb up and backward, extending the hip and knee to 0°, and then returned to the starting position. Watch to make sure they arent compensating with their back a whole lot. The back has to move but it shouldnt be moving first

Hip extension in quadruped on elbows with knee flexed

Good for glutes This exercise was performed in the same manner as described for quadruped with knee extending, except that the subject maintained the knee in 90° of flexion throughout the exercise Donkey kick: may be better over the edge of the table to eliminate back accessory movement. Laying prone on edge of the table

Unilateral bridge

Good for glutes, core, hamstrings, adductors Single leg better at activating abductors Starting position was unilateral hook-lying, as that described for the bilateral bridge, except that the non-tested lower limb remained on the table (0° at the hip and knee). The subject then pushed with the tested limb's foot into the table to raise the pelvis until a position of 90° of knee flexion was achieved ipsilaterally, before returning to the starting position. The non- tested lower limb moved up and down with the pelvis, without changing the positions of its joints. The hips remained at 0° of rotation and abduction during the exercise, with the pelvis and trunk in neutral.

Squat

Good for glutes, hamstrings, quads Starting position was standing with the knees and hips at 0° in the sagittal plane, with slight hip external rotation, such that the feet/toes pointed laterally from midline approximately 15°. The distance between the feet in the coronal plane was two thirds of the length from the greater trochanter to the floor (measured in the erect standing position), so that the hips were in slight abduction. Subjects then squatted so that the knees and hips were at approximately 90° of flexion, with the knees moving in a direction parallel to the toes (ie, over the second toe of the ipsilateral limb).

Forward step-up

Good for quads, glute max, hamstrings Starting position was with the foot of the tested limb on a step, at a height resulting in approximately 90° of knee flexion with the tibia vertical. The subject then pushed the tested foot down on the step to raise the nontested foot off the floor to the level of the step, without resting the nontested foot on the step. At this point, the subject was in unilateral weight bearing on the tested limb such that the tested limb's knee and hip were both at 0°, with the trunk erect. The subject then returned to the starting position. During the entire exercise, the body was maintained in the sagittal plane, with the tested limb's knee over the ipsilateral toes.

Clam in sidelying

Good for the glute med/max Starting position was lying on a treatment table on the side opposite the tested limb. The table was placed along a wall. Both limbs were flexed to 45° at the hip and 90° at the knee, with the tested limb on top of the other limb. The subject's back and plantar surface of the foot were placed against the wall for control of position and movement. The subject raised the tested limb's knee up off the other limb, such that the hip was in 30° of abduction, before returning to the starting position while keep- ing both heels in contact with each other and the wall. Subjects performed this activity with blue-colored Thera-Band (The Hy- genic Corporation, Akron, OH) tubing around the distal thighs, with no stretch or slack on the tubing prior to raising the limb. The elastic resistance was used because the motion involved is a multiplanar arc that is only minimally resisted by gravity.

Medial Border of Scapula

Move superiorly from the medial aspect of the spine of the scapula until you palpate the superior angle, which is located at the level of the 2nd thoracic vertebra. The levator scapula is attached here and this area is often tender to palpation. The inferior angle of the scapula is located at the level of T7. The medial border of the scapula should be 3 inches from the spinous processes of the thoracic spine.

Lesser Tubercle

Once you have found the greater tubercle and then bicipital groove, move slightly medial to those structures and you will be on the lesser tubercle. Attachment site for subscapularis

Lateral Epicondyle

Palpate lateral side of humerus until bulge is felt at distal aspect. The lateral epicondyle is not as large as the medial epicondyle. The wrist extensor muscles originate from the lateral epicondyle.

AC Joint

Palpate laterally along the clavicle to the most lateral aspect of the clavicle. You will feel where the clavicle is slightly superior to the acromion when you feel your fingers run across the ridge.

Medial Epicondyle

Palpate medial side of arm until bulge is felt on distal part of humerus. The medial epicondyle is large and subcutaneous with its bony contours easily standing out around other surrounding tissues. Tenderness, warmth, and color may indicate medial epicondylitis. Originating from the medial epicondyle are the wrist flexor and forearm pronator muscles.

ILA

Palpate on the inferior ILAs on both sides to determine relative superior/inferior position. A difference of a quarter inch or more may suggest the sacrum is side bent.

Spine of the Scapula

Palpate the posterior aspect of the acromion and follow medially along The ridge of the spine of the scapula as it tapers and ends at the level of the spinous process of the 3rd thoracic vertebra

Mastoid Process

Place fingers directly under the patient's earlobes feeling a rounded prominence on each side under fingers.

Transverse Process C1

Place fingers just inferior to the mastoid process. Although they can be deep, be careful not to press too firmly since they are often tender to palpation.

Spinous Process C2

Place fingers on the inion and move inferiorly into an indentation. As you continue to move inferiorly, the first rounded prominence that you feel is the spinous process of C2.

Quadratus Lumborum

Place hands over the posterior aspect of the iliac crest. Press medially in the space below rib cage and feel the tension of this muscle. The muscle can be made more distinct by asking the patient to lift the pelvis toward the thorax. Between superior iliac crest and 12th rib

Spinous Process C3-C7

Place middle fingers in the upper portion of the midline of the posterior aspect of the neck. You will feel blunt prominences under your fingers. You can start counting the spinous processes from C2 caudally. The normal spine has a natural lordosis. Notice that the spinous processes of C3, C4, and C5 are deeper and closer together, making them difficult to differentiate individually.

Inion

Place your fingers on medial aspect of the base of the skull and move slightly superiorly into the hair line and feel for a rounded prominence. Sometimes referred to as the "bump of knowledge"

Occiput

Place your hands under the base of the patient's head and allow fingertips to rest on the most inferior aspect.

Actions of the Rotator Cuff Muscles

Supraspinatus: abduction Infraspinatus: external rotation Teres Minor: external rotation Subscapularis: internal rotation

Sacral Sulcus

Starting at the PSIS, palpate slightly above and medial to it on the sacrum adjacent to the ilium. Palpation of the sulcus is used to evaluate the position of the sacral base. If both are "deep" the sacrum is in sacral flexion (nutation), "shallow" is indicative of sacral extension (counternutation). A deep sulcus on one side with a shallow sulcus on the other indicates sacral rotation.

Forward lunge with erect trunk

Starting position was standing with the knees and hips at 0° in the sagittal and coronal planes, with the feet/toes pointed straight ahead in midline. The subject then stepped forward with the tested limb to position it at 90° of knee and hip flexion, with the other limb at 90° of knee flexion and 0° at the hip (knee not contacting the floor). The knees moved over the second toe of the ipsilateral limb so that the limbs moved in the sagittal plane. The floor was marked to facilitate correct foot and knee placement, and a pillow was placed as a contact guide for the knee of the nontested limb. Good for glutes, hamstrings, quads

Psoas

The muscle belly is more prominent by resisting hip flexion. It can be palpated deep to the superficial abdominal muscles by palpating medial to the ASIS and lateral to the rectus abdominus. Have the patient resist knee flexion to make it pop

Navicular

The navicular bone and the tubercle is the first bone past the talus as you move distally down the foot. The navicular tubercle is the large prominence on the medial side of the foot that you will palpate. The navicular bone articulates with five other bones including the talar head proximally and the three cuneiforms distally.

Nerve Glides/Neural Mobilizations

The following can be used as tests to determine if neural tension and/or radiculopathy are present. Additionally, they can also be used as either passive neural mobilizations or as active exercises for the patient to perform. The positions described below for both the upper and lower limbs are the positions where the most tension is placed on that nerve.

Styloid of 5th metatarsal

The location of the styloid process of the 5th metatarsal is the attachment site for the peroneus brevis. A bursa lies over this bone which is subject to inflammation.

Subscapularis

This muscle named from its position on the costal surface of the scapula. It is the largest muscle of the rotator cuff. Its insertion is along the entire costal surface of the scapula except for small space near the glenohumeral joint. The insertion is along the lesser tubercle of the humerus. It is very hard to palpate.

Power Lift

Used for objects too large to straddle Very similar to basic lift Object shifts center of gravity forward, and must push buttocks out to compensate 1. Put one foot in front of other using a wide stance 2. Keep back straight, push buttocks out and use legs and hips to lower 3. Move the load as close as possible 4. Grasp the object firmly with both hands 5. Prepare for the lift: look forward 6. Lift upwards following your head and shoulders. Hold load close to body. Lift by extending legs with back straight, buttocks out (exaggerate this position), and breathe

Tripod Lift

Used for objects with uneven weight distribution Recommended for: People with decreased arm strength Not recommended for people with bad knees 1. Put one foot next to object. Keep back straight, push buttocks out and slowly lower down onto one knee 2. Position object close to knee on ground 3. Grasp object firmly with both hands 4. Slide object from knee on the ground to mid-thigh. Keep head forward, back straight, and buttocks out, and lift object onto opposite thigh 5. Put both forearms under object (with your palms facing upward) and hug object to stomach and chest. 6. Prepare for the lift: look forward. 7. Lift upwards following your head and shoulders. Hold load close to body. Lift by extending legs with back straight, buttocks out, and breathe

Golfers Lift

Used for small light objects in deep bins Pick small objects off floor Recommended for: People with knee problems Decreased leg strength 1. Place hand near edge of a fixed surface 2. Keep back straight and raise one leg straight out behind as you lean down to pick up object. Weight of leg will counterbalance weight of upper body 3. Grasp object firmly 4. Prepare for the lift: look forward. Keep leg raised as you initiate the lift. 5. To lift, push down on fixed surface as you lower leg. Keep back straight and breathe

Partial Squat Lift

Used for small light objects with handles close to knee height 1. Stand with object close to side. 2. Place feet shoulder width apart, with one foot slightly ahead of other 3. Place one hand on fixed surface or on thigh 4. Keep back straight, push buttocks out and slowly lower to reach object's handles 5. Prepare for the lift: Grasp object and look forward 6. For support as you lift, push down on fixed surface 7. Lift upwards following your head and shoulders. Lift by extending legs with back straight, buttocks out, and breathe

Overhead Lift

Used to place objects on overhead shelf. This lift begins with object in hands. Be careful! Overhead lifts increase risk for muscle strain Difficult to maintain balance during lift If possible, avoid this lift Only use when absolutely necessary 1. Hold object very close to body 2. Keep feet shoulder width apart, one foot slightly ahead of other 3. Prepare for lift: look forward 4. Raise object to shelf height using arm and shoulder muscles. Keep object close to body and breathe 5. As you reach the shelf, slowly shift weight from back foot to forward foot. Keep back straight 6. When load reaches edge of shelf, push object onto shelf

Pivot Lift

Used when must lift object and turn to carry it Twisting while lifting can cause serious damage to the tissues of the back Used to avoid twisting while lifting 1. Lift load using any of previous techniques 2. Hold load very close to body at waist level 3. Turn leading foot 90 degrees toward direction you want to turn 4. Bring lagging foot next to leading foot. Do not twist body!

Straight Leg Lift

Used when obstacles prevent from bending knees Be careful! Lifts over obstacles that prevent from bending knees increases risk for muscle strain If possible, avoid this lift. Only use when absolutely necessary 1. Stand as close to object as possible with knees slightly bent 2. Do not bend waist! Push buttocks out 3. If the obstacle is stable, lean legs against obstacle for support. Use legs and hips to lower down to object 5. Grasp object firmly with both hands 6. Prepare for the lift: look forward 7. Lift upwards following your head and shoulders. Hold load close to body. Lift by extending legs with back straight, buttocks out (exaggerate this position), and breathe