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spine of the scapula
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Terms in this set (80)
*runs at an oblique angle to the body from acromion to the medial border.
*attachment site for posterior deltoid (origin) and middle and lower fibers of trapezius (insertion)
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1. prone. lay hand across upper back and slide your fingertips inferiorly until they roll over the superficial spine.
2. strum your fingers vertically, palpating its width and edges. palpate laterally to acromion and medially toward vertebral column
*parallel to vertebral column
*measure 5-7inches long
*attachment site for rhomboids and serratus anterior
*deep to trap
*winged scapula: medial border falls away from the rib cage and visibly protrudes posteriorly
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1. prone. place pt hand in the small of his back to raise the medial border off the ribs. for more exposure, scoop and raise the shoulder with one hand.
2. locate the spine of the scapula and glide fingertips medially until they slide off the spine onto the medial border.
3. follow medial border inferiorly and superiorly; note that it extends further inferiorly from the spine of the scapula than superiorly
*superficial and located at medial borders lower end
*attachment of teres major
*at the level of T7
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1. prone. Place pt hand in the small of their back. glide fingers inferiorly along the the medial border
2. at the end of the medial border, the edge of the scapula will turn a corner and start to rise superiorly and laterally. this corner is the inferior angle
*located at the superior end of medial border
*attachment site for levator scapula
*deep to the traps
*level of T2
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1. prone. scoop the shoulder with your hand to raise it off the table. this will soften the overlying muscles.
2. locate the medial border. slide your fingertips superiorly along the border to find the superior angle.
3. you may need to move an inch superior to the spine of the scapula to reach the superior angle.
*extends superiorly and laterally from the inferior angle toward the axilla.
*attachment for teres major and teres minor
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1. prone. drape the arm off the side of the table. slide your thumb from the inferior angle superiorly along the lateral border.
2. follow the border in the direction of the axilla. if the musculature is too thick to palpate through, try curling your thumb underneath the tissue.

**[can try with arm in small of back]
*most superior aspect of the lateral border.
*attachment for long head of the triceps
*deep to teres minor and deltoid muscles
1. prone. locate lateral border
2. slide along lateral border to its most superior portion. to access landmark directly, you can compress overlying muscles or CURL UNDERNEATH THEM
*infraspinatus attachment
*triangular area inferior to spine of the scapula
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1. prone. palpate spine of the scapula, its medial border and its lateral border to isolate the infraspinous fossa
2. cradle the inderior angle in the webbing between your index finger and thumb. Your index finger will rest along the medial border, your thumb along the lateral border.
3. place a finger of the opposite hand along the length of the spine of the scapula. the triangular -shaped area you isolate is the infraspinous fossa
*have to go through upper trap to get to this area
1. prone. drop thumbpad inferiorly and laterally from the superior angle into the fossa, or lay your thumb along the spine of the scap and raise it superiorly into the fossa.
2. although the fossa is covered by the trapezius and suprasinpatus muscles, explore as much as you can of its size and shape
3. slide your thumbs laterally, nothing how the fossa becomes thinner and finally ends at the junction of the acromion and the clavicle. (does continue under the acromion but it is inaccessible)
*located on the scapula's anterior (underside) surface next to the rib cage
*attachment of subscapularis
*location of serratus anterior
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Palpation 1 (lateral portion)
1. side lying. allows the scapula to slide away from the rib cage for easier access
2. place thumb at the middle of lateral border. be sure to position thumb anterior to the large mass of muscles along the lateral border
3. FLEX SHOULDER AND PASSIVELY PROTRACT ; slowly sink and curl your thumbpad onto the surface of the fossa. use your other hand to maneuver the arm and scapula for a position that best allows thumb to sink into tissue
Palpation 2 (medial portion)
1. side lying. flex partners shoulder and lay fingertips along medial border. move scapula posteriorly (RETRACTION) bringing medial border off the ribs
2. slowly curl fingers through the rhomboid and trap muscles, under scap and onto fossa
*lateral aspect of the spine of the scapula
*located at the top of the shoulder
*flat surface
*articulates with clavicles lateral head.
*attachment for deltoid (origin) and trap (insertion)
*acromion angle along acromion lateral/posterior aspect
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1. seated. locate spine of scapula.
2. follow spine at is rises superiorly and laterally to the top of the shoulder. explore flat surface
3. explore all sides and its attachment to the clavicle
clavicle*collar bone *lies horizontally across the upper chest and has a gentle "S" shape *deltoid origin, trap insertion, pec major *lateral end is relatively flat and rises slightly higher than the acromion *medial end is round and articulates with the sternum - - - Palpation: 1. seated. locate acromion and walk fingers medially onto the shaft of the clavicle. 2. grasp the clavicle's cylindrical body betweeen your finger and thumb and explore its length from the acromion to the sternum. observe how the acromial end rises superiorly and sternal end curves inferiorly. HAVE PT ELEVATE AND DEPRESS AS YOU PALPATE EITHER END OF CLAVICLEAcromioclavicular joint*small articulation between acromion and the acromial end of the clavicle *anterior and superior surfaces of this thin crevice can be palpated. *shoulder separation - - - Palpation: 1. seated. locate acromion. 2. glide medially toward clavicle. finger will feel a small "step" as you rise up onto the surface of the clavicle. 3. backtrack slightly. just lateral to the step will be A/C's slender ditch. HAVE PT ELEVATE AND DEPRESS SCAPULASternoclavicular joints*articulation between sternal end of the clavicle and the sternum *wedge-shaped and has a small, impalpable fibrous disc. *only the inferior portion of sternal end makes contact with the sternum at rest. When clavicle is elevated, sternal end pivots on the sternum - - - Palpation: 1. seated. Slide fingers medially along the shaft of the clavicle. 2. just lateral to the body's centerline, the shaft will broaden to become the bulbous sternal end. 3. locate S/C joint by sliding your fingers medially off the sternal end. passively ELEVATE, DEPRESS, ABD scapula. explore changes occurring as SC jointcoracoid process*beak-like projection found inferior to the shaft of the clavicle *often found in the deltopectoral groove-between deltoid and pectoralis major fibers *can be tender *attacment: (clockwise order starting at 4 o'clock) pectoralis minor [medial], coracobrachialis [inferior], short head of biceps brachii [inferior], coracoacromial ligament [lateral], coracoclavicular ligaments [lateral more posterior] --------------- Palpation: 1. seated. lay thumb along the lateral shaft of the clavicle. 2. slide inferiorly off the clavicle NO MORE THAN AN INCH AND A HALF. Locate tip of coracoid process by compressing fingerpads into tissue. 3. sculpt around edges (round and round :))Deltoid tuberosity*located on the lateral side of the mid-humeral shaft. *small, low bump *attachment for deltoid ------ Palpation: 1. seated. Locate acromion 2. slide off the acromion down the lateral aspect of the arm 3. when you reach the HALFWAY point between shoulder and elbow, there will be a small mound on the lateral side of the arm.Greater tubercle / intertubercular groove/ lesser tubercle.*ALL located on proximal humerus deep to deltoid muscle* (horizontal to level of coracoid process) *GT inferior and lateral to acromion; attachment for Infraspinatus, Supraspinatus, Teres minor *LT smaller than greater tubercle; attachment for subscapularis *intertubercular groove is between GT and LT; Long head of biceps ------ Palpation: 1. Supine, shake hands with pt, locate acromion 2. slide off acromion INFERIORLY and LATERALLY approx 1 inch. 3. Solid surface under deltoid is GT 4. Place thumb on GT. 5. Laterally rotate (ER) arm. As the arm rotates, GT will move out from under thumb and be replaced by DITCH of intertubercular groove 6. continue to laterally rotate arm, thumb will rise out of the groove onto LT *BUMP DITCH BUMP*deltoid*triangle shaped *origin of deltoid curves around the spine of the scapula and clavicle, forming "V" shape. ----- Proximal Attachment: Anterior portion - clavicle Middle portion - acromion process of scapula Posterior portion - spine of the scapula Distal Attachment: Deltoid tuberosity of the humerus Action: Anterior portion - flexion, horizontal adduction and internal rotation of the humerus Middle portion - abduction of humerus Posterior portion - extension, horizontal abduction and external rotation of the humerus ------- Palpation: 1. seated. locate the spine of scapula, acromion, and the lateral 1/3 of the clavicle. 2. locate deltoid tuberosity 3. palpate between these landmarks to isolate the superficial, convergent fibers of the deltoid. HAVE PT ABD AND RELAXtrapezius upper fibers*superficial along upper back and neck. *upper and lower fibers are antagonists in elevation and depression of the scapula ------ Proximal Attachment: Superior nuchal line, external occipital protuberance, ligamentum nuchae, spinous process of the seventh cervical and all thoracic vertebrae Distal Attachment: Clavicle, acromion process and spine of scapula Action: (Upper fibers): Elevation and upward rotation of the scapula. *bilaterally extend, contralaterally rotate, and ipsilaterally side bend neck* (Middle fibers): Adducts scapula, (Lower fibers): Depression and upward rotation of the scapula ------- Palpation: 1. prone. these fibers form the easily accessible flap of muscle lying across the top of the shoulder. along the posterior neck they are surprisingly skinny, each being only an inch wide. 2. grasp the superficial tissue on the top of the shoulder and feel the upper trapezius fibers. Take note of their slender quality 3. follow the fibers superiorly toward the base of the head at the occiput. to feel the fibers along the posterior neck contract, stand at the side of the table and ask your partner to extend his head "a quarter of an inch." Follow fibers inferiorly to the lateral claviclemiddle fibers of the trapProximal Attachment: Superior nuchal line, external occipital protuberance, ligamentum nuchae, spinous process of the seventh cervical and all thoracic vertebrae Distal Attachment: Clavicle, acromion process and spine of scapula Action: (Upper fibers): Elevation and upward rotation of the scapula. (Middle fibers): Adducts scapula, (Lower fibers): Depression and upward rotation of the scapula ------ Palpation: 1. prone. locate spine of scapula 2. slide medially from the spine of the scapula onto the trapezius and move your fingers across its fibers. superficial and thin fibers. (Strum superior to inferior) *HAVE PT ADD SCAP - "BRING YOUR SHOULDER UP OFF TABLE"lower fibers of the trapProximal Attachment: Superior nuchal line, external occipital protuberance, ligamentum nuchae, spinous process of the seventh cervical and all thoracic vertebrae Distal Attachment: Clavicle, acromion process and spine of scapula Action: (Upper fibers): Elevation and upward rotation of the scapula. (Middle fibers): Adducts scapula, (Lower fibers): Depression and upward rotation of the scapula ------ palpation 1. prone. locate the edge of the lower fibers by drawing a line from the spine of the scapula to the spinous process of T12 2. palpate along this line and push your fingers into the edge of the lower fibers. ask pt to hold arms out in front of them (like superman) and feel for superficial fibers of the trap. 3. attempt to lift lower fibers between fingers, raising them off underlying musculature.Lattisumus Dorsi*broadest muscle of the back *middle portion is next to lateral border of the scapula * "the wings" -------- Proximal Attachment: Spinous process of lower six thoracic and lumbar vertebrae, iliac crest and lumbar fascia Distal Attachment: Bicipital groove of humerus Action: Extends (extends greatly in a raised position), adducts and medially rotates the arm; draws the shoulder downward and backward --------- Palpation: 1. prone with arm off the side of the table. locate scapula's lateral border 2. using your fingers and thumb, grasp the thick wad of muscle tissue lateral to the lateral border. this is the lat. (maybe some of teres maj) muscle flares off side of the trunk 3. feel lat fibers contract- have pt MEDIALLY ROTATE SHOULDER AGAINST RESISTANCE ("swing your hand up toward your hip")Teres Major*"little lat" *synergist with lat - called the "handcuff muscles" *superficial, located along scapulas lateral border BTWN TERES MINOR AND LAT ------ Proximal Attachment: dorsal surface of inferior angle of the scapula Distal Attachment: Medial bicipital groove of the humerus Action: Internally rotates, adducts, and extends arm ------ Palpation: 1. prone with arm off the side of the table. locate and grasp lat fibers between fingers and thumb. 2. move your fingers and thumb medially to where you feel the scapula's lateral border. the muscle fibers that lie medial to the lat and attach to the lateral border is TMAJ 3. follow fibers toward axilla - HAVE PT MEDIALLY ROTATE against resistance.Internal Rotators Shoulder MusclesAnterior deltoid fibers, latissimus dorsi, teres major, subscapularis, pectoralis majorExternal Rotators Shoulder MusclesPosterior deltoid fibers, infraspinatus, teres minorSupraspinatus*deep to upper trap *belly runs under acromion and attaches to humerus's greater tubercle. ---------- Proximal Attachment: Supraspinous fossa of the scapula Distal Attachment: Superior facet of the greater tubercle of the humerus and the capsule of the shoulder joint Action: Assists Deltoid with abduction of the humerus, depression of the humeral head, external rotation of the humerus. (Rotator cuff muscle) --------- Palpation: 1. prone. locate the spine of the scapula. slide your fingers up into the supraspinous fossa 2. palpate through the trap and onto the supraspinous fibers. as you palpate note how the fibers run PARALLEL TO THE SPINE OF SCAP. -- ASK PT TO ABD AND RELAX WITH ARM ON SIDE ON BODY 3. follow bellt laterally until it tucks under the acromioninfraspinatus*medial portion deep to trap. *lateral portion beneath deltoid. *attaches posterior to supraspinatus on greater tubercle. *synergist with teres minor *multipennate fibers and thick, superficial fascia ------ Proximal Attachment: Origin: Infraspinous fossa of the scapula Distal Attachment: Middle facet of the greater tubercle of the humerus and the capsule of the shoulder joint Action: External rotation of the shoulder and acts to stabilize the humeral head. (Rotator cuff muscle) ------ Palpation: 1. prone, with forearm off the side of the table. 2. form a triangle around the infraspinatus by laying a finger along each of these landmarks. 3. ASK PT TO RAISE ELBOW ONE INCH TOWARD CEILING AND RELAX 4. follow laterally as they converge under deltoid to attach to humerusteres minor*small muscle squeezed between infraspinatus and teres major *located high in axilla *antagonist to teres major ----- Proximal Attachment: Dorsal surface of axillary border of the scapula Distal Attachment: Inferior facet of the greater tubercle of the humerus and the capsule of the shoulder joint. Action: Externally rotates the arm and draws the humerus toward the glenoid cavity (Rotator cuff muscle) ------- Palpation: 1. prone with the arm off the side of the table. locate lateral border of the scapula -- specifically superior half slide laterally off the lateral border onto the surface of teres minor 2. compress into and across its tube-shaped belly. move inferiorly and compare it in size to the teres major. reach your thumb up into axilla and grasp the belly of the teres minor as you would a sandwich. 3. ask pt to LATERALLY ROTATE shoulder ("swing your hand up toward your head")Subscapularis*located on scapulas anterior surface. *sandwiched between subscapular fossa and serratus anterior ----- Proximal Attachment: Subscapular fossa of the scapula Distal Attachment: Lesser tubercle of the humerus and the capsule of the shoulder joint Action: Internally rotates and stabilizes the head of the humerus (Rotator cuff muscle) -------- Palpation 1. side lying. flex the shoulder and pull arm anteriorly as much as possible. This will allow easier access to the scapula's anterior surface. 2. hold the arm with one hand while the thumb of the other locates the lateral border. *HINT: SLIDE YOUR THUMB UNDERNEATH LATISSIMUS AND TERES MAJOR AND NOT THROUGH THEM 3. slowly and gently curl your thumb onto the subscapular fossa. -ASK PT TO MEDIALLY ROTATE SHOULDER-Supraspinatus tendon*deep to the acromion *stand behind patient *most commonly tore ----- Palpation: 1. seated. place your pt arm behind her back. this medially rotates and extends the humerus. 2. passively extend the arm as far as is comfortable (BY GRABBING FROM THE ELBOW/FOREARM NOT THE WRIST) for your partner. this brings supraspinatus tendon out from under the acromion, just anterior and inferior to the acromioclavicular (A/C) jointInfraspinatus and Teres minor Tendons*infraspinatus tendon lies deep to the acromion ----- Palpation: 1. Seated. Flex the shoulder to 90 degrees. then Horizontally ADDUCT and laterally rotate slightly (10-20 degrees) 2. although the infraspinatus tendon is deep to the posterior deltoid, this position causes it to move below the acromion and be accessible. 3. Locate acromial angle. Drop inferiorly off the angle and explore region. KEEP HAND ON ELBOW TO SUPPORT THEMSubscapularis tendon*between two heads of biceps brachii ---- Palpation: 1. seated. Place the arm next to the trunk in anatomical position. 2. locate the coracoid process of the scapula. Slide ONE INCH INFERIORLY AND LATERALLY from the coracoid. You will be between the two tendons for biceps brachii. 3. palpate through the deltoid fibers, exploring the deeper tissue which lies along the lesser tubercle of the humerus. This is location of subscap tendon. - can explore more of tendon by moving medially off lesser tubercle.Rhomboid major and minor*located between the scapula and the vertebral column. *named for geometric shape *lie deep to trap. and superficial to erector spinae ---- MAJOR :Proximal Attachment: Spinous process T2 to T5 Distal Attachment: Medial border of scapula between spine and inferior angle Action: Adduction and downward rotation of scapula,*elevation of scapula* MINOR: Proximal Attachment: Nuchal ligament, spinous process of C7 to T1 Distal Attachment: Root of scapular spine Action: Adduction and downward rotation of scapula, *elevation of scapula* ---- Palpation: 1. prone. locate medial border of the scap. and the spinous processes of C7-T5 2. place pt hand in the small of their back and ask them to SLIGHTLY RAISE ELBOW TOWARD CEILING (against resistance)Levator scapula*located at lateral and posterior sides of the neck. *inf portion deep to upper trap *muscle belly is ~ 2 fingers wide with fibers that naturally twist around themselves. *when palpating the origin (transverse processes of cervicle vertebrae) be careful of the brachial plexus. ---- Proximal Attachment: Transverse processes of the first four cervical vertebrae Distal Attachment: Vertebral border of the scapula between the superior angle and the spine Action: Elevation and downward rotation of the scapula.; bilaterally extend the head and neck. Unilaterally: ipsilateral side bend/ flex the neck; ipsilateral rotation of head and neck ---- Palpation: 1. prone. locate the upper fibers of the trap 2. roll two fingers anteriorly off the trapezius and press into the tissue of the neck 3. gently strum your fingers anteriorly and posteriorly across the levator fibers. often you will feel a distinct band of tissue that leads superiorly toward the lateral neck and inferiorly under the trap. 4. place your fingertips on the levator and ASK PT TO ELEVATE AND RELAX SCAPSerratus Anterior*"well developed on superhero's" *lies along posterior and lateral ribcage. *most of the muscle is deep to the scapula, lat, or pec major. (belly below axilla is palpable. *antagonist to rhomboids. *stand on opposite side of where you are palpating. *SCAPULAR WINGING if SA is weak. ---- Proximal Attachment: Outer surface of upper 8th through 9th ribs Distal Attachment: Costal surface of vertebral border of scapula Action: Abduction and upward rotation of scapula. (protraction) ---- Palpation: 1. supine. isolate the location of the serratus by abducting the arm slightly and locating the lower edge of the pec major. Locate anterior surface of lat. 2. place fingerpads along the side of the ribs between the pectoralis major and lat. 3. strum fingers across ribs and palpate for the serratus anterior fibers. - ASK PT TO ABD/PROTRACT SCAP AGAINST YOUR RESISTANCEpectoralis major*clavicular, sternal, and costal fibers. *upper and lower fibers perform opposing actions (muscle is an antagonist to itself *COSTROCHONDRITIS: inflammation of the (sternum) rib cartilage, pain around sternum (after illness [severe cold/heavy coughing] or unknown) *people tear pecs ---- Proximal Attachment: Sternal half of clavicle, sternum to 7th rib and cartilages of 1st through 7th ribs. Distal Attachment: Lateral bicipital groove of the humerus Action: clavicular head: Adducts and internally rotates arm, flexes humerus, sternal head: extends humerus. ---- Palpation 1 (origin): 1. supine. with partner's shoulder slightly abducted, sit or stand facing him 2. locate medial shaft of the clavicle and move inferiorly onto the clavicular fibers. 3. explore the surface of the pec major. follow the fibers laterally as they blend with the deltoid and attach at the greater tubercle. 4. grasp belly by sinking thumb into axilla. ASK PT TO MEDIALLY ROTATE AGAINST RESIST ("press your hand toward your belly") ---- Palpation 2 (insertion): 1. side lying. supporting partners arm. flex the shoulder and pull it anteriorly toward you. this position not only brings the pectoralis major off the chest wall, but also allows the breast tissue to fall away from area you're palpating. 2. grasping pec major, explore its mass from the ribs to humerus. Passively flex/ext shoulder. *palpate origin and insertion*pectoralis minor*next to ribcage, deep to pec major *fibers are perpendicular to pec major. *helps elevate ribs for inhalation. *brachial plexus, axillary artery & vein cross under pec minor. *Tightness can cause rounded shoulder forward head ---- Proximal Attachment: Upper margins of third through fifth rib Insertion: Coracoid Process of the scapula Action: Draws the scapula forward and downward, *abduction, depression* ---- Palpation: 1. supine. abduct the arm and place your fingerpads at the lateral edge of the pectoalis major. 2. slowly and gently slide under the pectoralis major, following along the surface of the ribs 3. eventually come in contact with small wall of muscle lying next to ribs. *ASK PT TO DEPRESS SCAPULA* "ever so slightly press shoulder down toward your hip."biceps brachii*most powerful supinator *superficial on the anterior arm *tendon of the long head passes through the intertubercular groove of the humerus (groove helps stabilize tendon as it rises over top of shoulder) *distal tendon of the biceps dives into the antecubital space (inner elbow) to attach at the radius. ---- Proximal Attachment: Long head - Supraglenoid tubercle of the scapula Short head - Coracoid process of the scapula Distal Attachment: Radial tuberosity and bicipital aponeurosis Action: Flexes and supinates the forearm, flexion of the arm (long head flexes the shoulder) ---- Palpation: 1. seated. bend the elbow and shake hands with your partner. 2. ask your partner to flex his elbow against your resistance. palpate the anterior surface of the arm and locate the hard, round belly of the biceps. 3. follow the belly distally to the inner elbow. note how the muscle belly thins, becoming a solid, distinct tendon. then follow the biceps proximally to where it tucks beneath the anterior fibers of the deltoid.Tendon of the long head of the biceps brachii*located in the intertubercular groove of the humerus *runs parallel to the superficial deltoid fibers *Ruptured tendons: proximal or distal (usually long head); known as a "popeye deformity"; particularly found in older males ---- Palpation: 1. locate the intertubercular groove (BUMP, DITCH, BUMP) 2. ask partner to gently flex elbow against resistance in order to feel biceps become taut in the intertubercular grooveDistal tendon of the bicepsPalpation 1. with elbow flexed, shake hands with partner. As locate biceps distal tendon, ask partner to flex elbow against your resistance to make tendon more discernible. 2. Slide over tendon's medial aspect and explore for bicipital aponeurosis. When biceps contracts, it is sometimes visible. Follow this fascial strip as far as you can around the medial forearm.Triceps brachii*only muscle found on posterior arm *antagonist at the elbow and shoulder to the biceps *long head "weaves" between the teres major and minor *lateral head is superfical beside deltoid *medial is mostly under long head ---- Proximal Attachment: Long head - infraglenoid tubercle of the scapula Medial head - inferior and posterior surface humerus Lateral head -posterior and lateral surface humerus Distal Attachment: Olecranon process of the ulna Action: Extends the elbow/extends shoulder from flexed position ---- Palpation: 1. prone. bring arm off the side of the table and palpate the posterior aspect of the arm. outline the edge of the posterior deltoid and then explore the size and shape of triceps 2. locate the olecranon process to outline the distal tendon of the triceps. ASK PT TO EXTEND ELBOW AS YOU RESIST AT THE FOREARM. slide your other hand off the olecranon process proximally and onto triceps tendon. 3. with pt still contracting, widen your fingers and palpate the medial and lateral heads on either side of the tendontendon of the long head of triceps brachii*triceps is the only muscle on the posterior arm that runs superiorly along the proximal and medial aspect of the arm. *crosses over teres major and under teres minor ---- Palpation: 1. prone. place one hand on the proximal elbow and ask your partner to bring his elbow toward the ceiling against resistance. (contracts long head triceps) 2. locate its belly along the proximal and medial aspect of the arm. follow muscle proximally by strumming across the belly. it will disappear under posterior deltoid toward infraglenoid tubercle. 3. relaxed arm, press through post delt and strum across skinny tendon. **follow tendon to division of teres muscles. HAVE PT IR/ER SHOULDER to differentiate teres muscles **coracobrachialis*small, tubular muscle located in the axilla. *"armpit" muscle *secondary flexor and adductor of the shoulder. *deep to pec major and anterior deltoid *anterior to axillary artery and brachial plexus ---- Proximal Attachment: Coracoid process of scapula Distal Attachment: Medial border of the humerus Action: Flexion and adduction of the humerus ---- Palpation: 1. supine. laterally rotate and abduct the shoulder to 45 degrees. locate the fibers of the pectoralis major. this tissue forms the axilla's anterior wall and will be a reference point for locating the coracobrachialis. 2. lay one hand along the medial side of the arm and move your fingers into the armpit 3. have pt HORIZONTALLY ADDUCT GENTLY AGAINST RESISTANCE. isolate the solid edge of the pectoalis major and then slide off the pec major fibers posteriorly (into axilla) and explore slender, contracting belly.coracoclavicular ligament**NOT ON SKILLS CHECK BUT CAN BE ON FINAL** *composed of 2 smaller ligaments : trapezoid and conoid *both stretch from coracoid process of scapula to the inferior surface of the clavicle. *stability for A/C joint *form strong bridge between scapula and clavicle. *palpate between clavicle and coracoid process ---- Palpation: 1. seated or supine. abduct and medially rotate the shoulder. this position brings the ligaments more to the surface. 2. locate the coracoid process of the scpaula and the shaft of the clavicle 3. palpate in the space between these landmarks. roll thumb across fibers -should feel like solid, taut bandsCoracoacromial ligament**NOT ON SKILLS CHECK BUT CAN BE ON FINAL** *attaches the same bone upon itself (scapula to scapula) -acromion to coracoid process *forms the coracoacromial arch across the top of the shoulder; helps protect rotator cuff tendons and subacromial bursa from direct trauma by acromion *deep to deltoid **causes the bulk of shoulder issues - impingement syndrome ---- Palpation: 1. supine or seated. locate coracoid process. locate anterior edge of the acromion 2. palpating deep to the deltoid fibers, explore between these landmarks for the wide band of the coracoacromial ligament. strum across fibers 3. to bring ligament closer to surface, try extending the arm. this rolls humeral head anteriorly and press the ligament forward.subacromial bursa*subacromial bursitis *also known as subdeltoid bursa *lateral portion creates smooth surface for acromion and deltoid to glide over head of the humerus and rotator cuff tendons. *medial part cushions coracoacromial ligament from supraspinatus tendon *extension of the shoulder brings bursa forward. abduction will compress the bursa (pain and tenderness w/ abd indicates bursitis) ---- Palpation: 1. partner seated, stand behind and locate acromion 2. drop fingers off anterior edge of the acromion. slowly extend the shoulder by pulling the elbow posteriorly; bring bursa out from under acromion. palpating at the depth between deltoid and rotator cuff tendons 3. PALPATE GENTLYSternocleidomastoid*located on lateral and anterior aspects of the neck *superficial and often visible when head is turned to the side in "Lord Byron-like fashion" *clavicular head is flat *sternal head is slender *both heads merge to attach behind the ear at the mastoid process *carotid artery passes deep and medial to SCM; external jugular vein lies superficial to it *roughly 2-3in space between clavicle attachments of SCM and trapezius *Torticollis of infants "wry neck": baby lays on one side of neck or eats on one side predominately. Adults known to get idiopathic torticollis: wake up the next morning and neck flexed to one side, but adult doesn't know why* - - - Proximal Attachment: Sternal head-anterior surface of manubrium Clavicular head- superior surface, medial 1/3 of clavicle Distal Attachment: lateral half of superior nuchal line of occiput Unilateral Action: ipsilateral side-bending and contralateral rotation Bilateral Action: flexion of head - - - Palpation 1. supine. Stand at head of table. Locate the mastoid process of the temporal bone, medial clavicle, and top of sternum. 2. Draw line between these landmarks and note how both SCMs form a V on the front of the neck. 3. Ask partner to raise head very slightly off the table and you palpate the SCM. To make more distinct, rotate head slightly to the opposite side and then ask partner to flex neck. 4. palpate along borders of SCM, following it behind the earlobe and then down to the clavicle. Sculpt around tendons.Scalenes (as a group)*sandwiched between SCM and anterior flap of trapezius on anterior, lateral neck. *fibers begin at side of cervical vertebrae, dive underneath the clavicle and attach to first and second ribs *help with elevating upper ribs during normal inhalation * cervical nerves go between anterior and posterior tubercles of transverse processes *TOS (Thoracic Outlet Syndrome): entrapment occurring between anterior and middle scalene, between clavicle and 1st rib, or under pect minor* - - - Palpation 1. partner supine. Stand at head of table. Cradle the head (passively flexing it) to allow for easier palpation, place fingers along anterior and lateral sides of the neck between SCM and trapezius. 2. with pads of fingers, use gentle pressure to palpate stringy, superficial muscle bellies in this triangle. *can ask partner to inhale deeply in upper chest without using diaphragm (basically from the mouth)*Anterior and middle scalenes*anterior: partially tucked under SCM *middle: slightly larger than anterior and lies lateral to the anterior *large branches of brachial plexus and subclavian artery pass through a small gap between anterior and middle scalenes *individual nerves of brachial plexus may penetrate through or in front of the anterior scalene - - - Anterior Scalene Proximal Attachment: anterior tubercles, transverse processes C3 to C6 Distal Attachment: scalene tubercle of 1st rib Unilateral Action: elevate 1st rib Bilateral Action: flexion of neck Middle Scalene Proximal Attachment: posterior tubercles of transverse processes C2 to C7 Distal Attachment: superior surface of 1st rib Unilateral Action: ipsilateral side-bending and rotate cervical vertebrae Bilateral Action: flexion of neck - - - Palpation 1. Partner supine. Anterior scalene lies partially deep to lateral edge of SCM, so rotate head slightly to opposite side to better expose it. Gently palpate under SCM's lateral edge and roll across the belly as it tucks under clavicle. 2. follow it inferiorly as it tucks under clavicle 3. move laterally to explore middle scalene, noting similar shaped belly *ask partner to flex head slightly*Posterior scalene*smaller. Located between middle scalene and levator scapula *positioned deeper than the others - - - Proximal Attachment: posterior tubercles of transverse processes, C4 to C6 Distal Attachment: outer surface of 2nd rib Unilateral Action: flexion and rotation of cervical vertebrae Bilateral Action: flexion of neck - - - Palpation 1. Partner supine. Posterior scalene extend laterally off the neck and is squeezed between middle scalene and levator scap 2. locate middle scalene and levator scap. Place finer between these bellies and sink inferiorly 3. slowly strum across thin band of tissue running laterally from the transverse processes to the second rib *distinguish between posterior scalene and levator scap by locating posterior scalene and asking partner to elevate scapula. There should be no contraction of the scalene since it doesn't do that action. Ask partner to slowly inhale into upper chest and posterior scalene should contract*olecranon process* proximal end of ulna *articulates w/ distal humerus *attachment for triceps brachii *point of elbow *olecranon buritis ___ Palpation: 1. seated. shake hands w/ partner and explore large, superficial knob at elbow. palpate angular surface and sides. 2. passively flex and extend elbow to notice how it feels in various postitionsolecranon fossa*large cavity on posterior distal end of humerus *accommodates olecranon process when elbow is extended *a little spongy *deep to triceps brachii tendon ___ Palpation: 1. flex elbow and locate olecranon process 2. roll finger proximally on top of process and press through triceps tendon and into fossa 3. small, crescent-shaped ditch will only be accessibleepicondyles of humerus*distal end of humerus that broadens medially and laterally *medially from olecranon process (medial epicondyle) *medial epicondyle superficial w/ protruding, spherical shape designed to accommodate tendons or wrist and finger flexors *medial epicondylities (golfer's elbow) *ulnar nerve which creates the "funny bone" sensation when struck is between the medial epicondyle and the olecranon process in the cubital tunnel. *common flexor tendon comes off of medial epicondyle *laterally from olecranon (lateral epicondyle) *lateral epicondyle smaller and attachment site for tendons of the wrist and finger extensors *lateral epicondylitis (tennis elbow) *common extensor tendon comes off of lateral epicondyle - - - Palpation 1. partner seated. shake hands and locate olecranon process. 2.Slide medially off the olecranon. you will encounter a small ditch before rising up onto large, superficial medial epicondyle. Explore bulbous shape. 3.Return to olecranon. slide laterally to the lateral epicondyle. Note it's smaller than medial epicondyle.supracondylar ridges of the humerus*extend proximally from the epicondyles of the humerus. (lateral superficial, while medial sinks into arm situated close to ulnar nerve) *attachment sites for forearm muscles -lateral: ECRB, ECRL, brachioradialis; "knife-like" ---- Palpation: 1. seated. shake hands and locate medial epicondyle 2. move proximally from the medial epicondyle. 3. repeat the same for the lateral supracondylar ridgeshaft of the ulna*extends from the olecranon process to the head of the ulna. *has superficial palpable edge. *runs along forearms posterior/medial aspect ---- Palpation: 1. shaking hands, locate olecranon process. slide fingers distally along the shaft. 2. to define shape and location, roll fingers across edge and follow it down the length of the forearmHead of the ulna*superficial knob visible along the posterior/medial side of the wrist (disrupt placement of watch) *bulbous, most distal process ---- Palpation: 1. slide your fingers distally along the ulnar shaft. 2. just proximal to the wrist, the shaft will bulge to become the head of the ulna. bulbous headStyloid process of the ulna*sharper and more pronounced than radial styloid process *toothlike projection pointing ditally off head of the ulna. *posterior/medial side of the wrist. *tendons of forearm muscles pass behind them ---- Palpation: 1. shake hands. passively adduct the wrist to softern surrounding tendons. 2. use thumb to locate the posterior aspect of the ulnar head. slide distally off the head to palpate the small tip of styloid process.Head of the radius*distal to humerus's lateral epicondyle. *forms radius's proximal end and has a circular, bell shape *head is stabilized by the annular ligament- *disloacations* *radial head fractures *pivoting point for pronation and supination of the forearm. *deep to supinator/ext muscles ---- Palpation: 1. shake hands and locate lateral epicondyle 2. slide distally off the lateral epicondyle, across the small ditch between the humerus and radius and onto the head of the radius 3. head of the radius is the only bony structure in the vicinity. explore ring-shaped surfaceShaft of the radius*lateral side of the forearm. *mostly buried under muscle ---- Palpation: 1. Flex elbow to 90 degrees and put forearm in neutral position. 2. Locate head of the radius. slide distally off the head, noting how the radius sinks beneath the forearm muscles. continue down the forearm and feel the radius become superficial near the wrist. 3. along the distal forearm, explore all sides of the superficial shaft of the radiusSyloid process of the radius*wider and more substantial mound of bone than styloid of ulna *larger and extends farther distally than ulna styloid process *surrounded by extensor tendons and attachment site for brachioradialis *COLLES: fracture of radial styloid process *FOOSH injury (fall on outstretched hand) --- Palpation: 1. begin by grasping distal radial shaft between your thumb and finger. slide distally, noting how the radius broadens in all directions 2. palpate along the lateral side of the radius to tip of styloidLister's tubercle*dorsal surface of radial styloid process *also known as dorsal tubercle *EPL wraps around it *"oblong" shape, acts as a hook for extensor pollicis longus "PULLEY FOR EPL" *trailmark for finding lunate and capitate ----- Palpation: 1. use your thumb, locate the dorsal surface of the styloid process of the radius 2. slide thumb in the direction of the head of the ulna and explore for the oblong knob of Lister's tubercle 3. the tubercle will be felt directly across from the head of the ulna - perhaps an inch awayPisiform*attachment site for flexor carpi ulnaris/abd digiti minimi *medial attachment for flexor retinaculum *protrudes on ulnar/palmar surface of the wrist. *distal to the flexor crease *boundary of tunnel of guyon: ulnar N and A pass through ---- Palpation: 1. locate flexor crease of pt wrist. then slide over to the "pinky" side of the crease. 2. move slightly distal to the crease, roll thumb in small circles. 3. PASSIVELY FLX wrist and pisiform can be wiggled side to side; EXT WRIST becomes immobile (FCU tendon) ; have PT ACTIVELY ULNAR DEVIATETriquetrum*pyramid shaped bone is located on dorsal surface of the pisiform, distal to styloid process of ulna. *in neutral, only the dorsal surface is palpable. abd will make it palpable on ulnar surface ---- Palpation: 1. palm of pt hand facing away from you, locate styloid process of the ulna. slide distally noting slender ditch, before rising to the surface of the triquetrum 2. keep your finger stationary, abd (radial deviate) write and note how it protrudes to the side. Ulnar dev and see how it disappearsHamate*distal to pisiform *hook of hamate is palpable *hook of hamate is other medial attachment for flexor retinactulum *other boundry of the tunnel of guyon *flat surface of hamate body is on dorsal side of hand where bases of 4th & 5th metatarsals merge ---- Palpation: 1. locate pisiform. draw imaginary line from pisiform to the base of the index finger. 2. using thumb, slide off pisiform along line. about 1/2 an inch from pisiform hook of hamateScaphoid*peanut shaped *also known as Navicular *MOST COMMONLY FRACTURED CARPAL- weight bearing bone (traumatized with falls) *radial side of the hand, distal to styloid of radius. *forms floor of anatomical snuff box - bordered by EPL, EPB, APL ---- Palpation: 1. beginning on the wrists radial surface, locate the radial styloid process. slide thumb distally off the process, falling between the superficial tendons and into the natural ditch where scaphoid is 2. maintain your position and passively ulnar deviate. feel for scaphoid to bulge into thumb. radial deviate and feel it disappear. 3. from here, explore scaphoids dorsal and palmar surfaces. on palmar side, along flexor crease, is SCAPHOID TUBERCLE.Trapezium*distal to scaphoid *articulates with base of first metacarpal to form 1st CMC joint (arthritic development possible- mostly middle-age women) *most accessable on radial or dorsal side. isolated proximally from 1st met or distally from scaphoid --- Palpation: 1. palpating along the hand's radial/dorsal side, locate the scaphoid. then slide distally. 2. you might pass trapezium and go up on base of 1st met. to check, as pt to flx/ext thumbscaphoid and trapezium tubercles*lateral attachment sites for the flexor retinaculum *located on the palmar surface near flexor crease. ---- Palpation: 1. locate the radial surface of the scaphoid, along the flexor crease. walk thumb around to the palmar side of the scaphoid. 2. using your thumbpad, explore just distal to the flexor crease for a prominent, bony knob 3. flex wrist slightly to soften the surrounding tissuelunate and capitate*lunate * is most commonly DISLOCATED carpal *distal and medial to lister's tibercle. *wrist flexion makes it palpable *capitate *is LARGEST carpal *distal to lunate *shallow ditch on dorsal surface BOTH: deep to extensor tendons. accessible on dorsal surfaces and isolated between lister's tubercle and shaft of 3rd met. ----- Palpation: 1. locate lister's tubercle and the base of the 3rd metacarpal. wrist slightly ext, lay thumb between points and notice how it falls into a small cavity. this is the correct location 2. set thumb at the proximal end of this cavity. flex the wrist and feel lunate press into your finger. ext wrist and feel carpal disappear. 3. shift your thumb to the distal end of the cavity and notice how it bumps into the base of the 3rd met. passively flex the wrist, noting how the capitate rolls into your finger, "filling" its own cavity.Brachialis*deep to biceps *sandwiched between biceps and triceps *biceps best friend ------ O: Anterior, inferior surface of the humerus I: coronoid process and tuberosity of the ulna A: flexion of the forearm ---- Palpation: 1. shake hands with pt to flex arm to 90 degrees. ask pt to flex elbow against resistance, isolate edges of the biceps brachii 2. with the arm relaxed, slide laterally HALF AN INCH off the distal biceps. as you strum across brachialis solid edge, you can feel a "thump" 3. continuing to strum across its edge, follow it distally to where it disappears into the elbow. 4. locate biceps tendon (distal) and palpate either side of the tendon for part of brachialisBrachioradialis*muscle belly becomes tendinous halfway down forearm *only muscle that runs the whole length of the forearm but does not cross the wrist. *long oval belly forms a helpful diving line between the flexors (medial side) and extensors (lateral side) of the wrist and fingers ---- O: proximal 2/3 of the lateral supracondylar ridge of the humerus I: styloid process of the radius A: flexion of the elbow in neutral (brings forearm back to neutral, so will assist with pronation and supination) ---- Palpation: 1. shake hands with pt and flex the elbow to 90 degrees. forearm in neutral, flex elbow against your resistance 2. look for brachioradialis bulging out on the side of the elbow. if not visible, locate lateral supracondylar ridge of the humerus and slide distally. 3. with pt still contracting, use other hand to palpate belly. pinch between fingers and follow distally as far as possibleDistinguishing between the flexor and extensor groups of the forearm*flexors located on anterior/medial (hairless) *extensors located on posterior/lateral (hairy) *brachioradialis and shaft of ulna used as clear dividing lines between these muscle groups - - - Palpation 1. shake hands with pt and flex elbow to 90 degrees. locate brachioradialis and shaft of ulna. palpate the length of these structures 2. move medially from shaft of ulna onto the flexors. explore this half of forearm, noting girth of these muscles 3. ask pt to slightly flex wrist against resistance and note contraction of the flexors 4. move to the lateral side of shaft of ulna and explore extensor bellies. notice how they are smaller and more sinewy than the flexor bellies. ask pt to extend wrist against resistance, feeling extensors contractExtensor carpi radialis longus and brevis*lateral / posterior to the brachioradialis *bellies become tendinous about 2 inches proximal to the wrist joint *ECRB is most common for lateral epicondylitis ------ ECRL: O: distal 1/3 of lateral supra-condylar ridge of humerus, common extensor tendon I: dorsal base of 2nd metacarpal A: extension and radial deviation of the wrist ECRB: O: distal 1/3 of lateral supracondylar ridge of humerus, common extensor tendon I: dosal surface of base of 3rd metacarpal A: extension and radial deviation of wrist ----- Palpation: 1. shake hands and flex the elbow to 90 degrees. locate brachioradialis and slide laterally off its belly onto the ECR fibers 2. ask pt to abduct (radial deviate) and relax wrist against your resistance. (can also try extending the wrist) 3. follow muscle belly distallyextensor digitorumO: common extensor tendon I: Bases of middle and distal phalanges of 2-5th digits A: ext DIPs, PIPs, and MP's and wrist ---- Palpation: 1. shake hands and flex to 90 degrees. slide laterally off extensor carpi radialis fibers. 2. Palpate digitorums flat surface and roll across its fibers 3. isolate belly by asking pt to extend wrist/fingers. also ask pt to wiggle their fingers. follow belly distally as it transforms to tendons. tendons are palpable as they pass beneath extensor retinaculumextensor carpi unlaris*lies beside the ulnar shaft ---- O: common extensor tendon I: base of 5th metacarpal A: extension and ulnar deviation of wrist ---- Palpation: 1. shake hands with pt and flex the elbow to 90 degrees. locate shaft of the ulna. 2. slide laterally off the shaft onto the slender belly of ECU 3. ask pt to adduct (ulnar deviate) against resistance. tissue directly lateral to the ulna tightens (ECU) 4. follow distally past the head of the ulnaflexor carpi radialis and palmaris longusFCR: * medial to pronator teres and brachioradialis O: common flexor tendon I: base of 2nd and 3rd metacarpals A: flexion and radial deciation of the wrist -- Palmaris Longus: *most common tendon used in tommy john syndrome (ulnar collateral ligament repair) *between flexor carpi radialis and flexor carpi unlaris and attaches to palmer aponeurosis O: common flexor tendon from medial epicondyle of humerus I: flexor retinaculum and palmer aponeurosis A: tense the palmer fascia, flex the wrist, may assist to flex the elbow ------ Palpation: 1. flex pt arm to 90 degrees and supinate the forearm. BEGIN AT THE DISTAL TENDONS. ask your partner to flex wrist against resistance. 2. at the center of the wrist will be two superficial tendons, flexor carpi radialis and palmaris longus. palmaris longus may be absent, if present it is the most medial 3. as pt contracts, roll across the tendons and follow them proximally as they expand into muscle bellies. have pt radially deviate and relaxflexor carpi ulnaris*lies close to the ulnar shaft (finger width away) and has a distinct tendon attaching to the pisiform ---- O: humeral head: common flexor tendon ulnar head: olecranon process and dorsal ulna. I: pisiform, hamate, base of 5th metacarpal A: flexion and ulnar deviation of wrist ---- Palpation: 1. shaking hands with pt, flex elbow to 90 degrees and supinate the forearm. begin at distal tendon by locating pisiform 2. slide proximally off the pisiform to the slender, superficial tendon of FCU 3. ask pt to perform ulnar deviation and relax against resistance. follow tendon proximally, strumming across surface. FCU lies roughly a finger with away from the ulnar shaftFlexor digitorum superficialis and profundus*pass through carpal tunnel ---- FDS O: humeral head: common flexor tendon ulnar head: coronoid process of the ulna I: medial and lateral sides of middle phalanges of 2nd-5th digits A: flex PIPs and MP's of 2nd-5th digits, and flexion of wrist ---- FDP O: medial and anterior surface of the ulna, interosseus membrane. I: base of distal phalanges of 2nd-5th digits A: flex DIP, PIP, MP's of 2nd-5th digits, flexion of the wrist: ---- Palpation: 1. begin at wrist, locate tendons of superficial flexors (carpi ulnaris, radialis, and palmaris long) passive flexion of the wrist to soften tissues 2. slowly work your thumb between superficial tendons for the digitorum bellies/tendons. **WIGGLE TIPS OF FINGERSflexor digitorum superficialisO: humeral head: common flexor tendon ulnar head: coronoid process of the ulna I: medial and lateral sides of middle phalanges of 2nd-5th digits A: flx PIPs and MP's of 2nd-5th digits, and flexion of wrist ---- Palpation: 1. contractions are palpable along the medial side of ulnar shaft. have pt simultaneously flex elbow and wrist to 90 degrees. 2. locate ulnar shaft, slideing off its edge into flexors. ask pt to squeeze tips of her 5th finger and thumb together and relax -- then follow with all the digitspronator teres*tucked between brachioradialis and forearm flexors. *only muscle in this area with oblique fibers. *antagonist to biceps (most powerful supinator) *PRONATOR TERES SYNDROME: peripheral nerve entrapment of the median nerve -- looks similar to carpal tunnel ---- O: humeral head: medial epicondyle of humerus and common flexor tendon ulnar head:medial side of coronoid process of the ulna I: middle, lateral surface of radius A: pronation of arm ---- Palpation: 1. shake hands and flex elbow to 90. locate distal tendon of the biceps (flx elbow against resistance) 2. sldie distally off the tendon into the valley between brachioradialis and forearm flexors. sink thumb into space 3. explore for the finger-wide pronator belly running oblique from medial elbow to radiusPronator quadratus*transverse fibers *deep to flexor tendons and major blood/nerves of anterior arm *most lateral portion is accessable *by radial artery - proceed w caution ---- O: distal 1/4 of volar surface of ulna I: distal 1/4 of lateral border, volar surface of radius A: pronation of forearm ---- 1. shake hands. isolate radial artery pulse. locate radial styloid process, sliding to anterior surface 2. before finding quadtratus, flex and pronate the wrist sligtly. then use your thumb to explore band of tissue btwn radius and tendons 3. you might not feel fibers specifically but have pt pronate slightlySupinator*lateral side of the elbow *deep to extensors, superficial to head of radius ---- O: lateral epicondyle of humerus, annular ligament, radial collateral ligament and ulnar fossa I: proximal 1/3 of lateral and anterior surface of radius A: supination of forearm ---- Palpation: 1. shake hands and flex to 90. locate lateral epicondyle of humerus and proximal shaft of radius 2. place fingers between landmarks and palpate through the extensor fibers for the deep supinator belly 3. ask pt to supinate and relax her forearm against resistance. brachioradialis will contract with this movement but it will be superficial while supinator is deep to the extensors