Lab 13

Surface Anatomy
Head, Spine and Trunk
(2020-2021)

Anatomy team (RS2040)

Department of Rehabilitation Sciences
The Hong Kong Polytechnic University

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 Instruction (Palpation of Bony Structures)

1. Student work in pairs, alternating their roles and learn from each other:
o One student practices palpation. This student should:
 Pay particular attention to the technique of palpation, applying
the appropriate amount of pressure; take precautions so as not
to cause discomfort;
 Being aware of the partner’s reaction and respond to the
palpation
 Adjust the technique of palpation according to partner’s
comments
o The student being palpated should:
 Focus on the feeling and sensation on the part being palpated.
 Inform the palpator of these sensations (too much pressure
causing pain, too light, too quick, too slow and any other
uncomfortable or unpleasant sensations etc)

2. Appropriately expose the part to be palpated.

3. For palpation of most skeletal parts, the muscles must be relaxed.

Contraction of a muscle tends to obscure any bony prominence near it.

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 Instruction (Muscle Action & Palpation)

1. The practical sessions emphasize in developing both manual and verbal

skills.

2. Students should learn the attachments, nerve supply and actions of the
relevant muscle prior to each session.

3. Students work in pairs and alternate their roles.

4. Each student, while practicing muscle testing should:

o Pay attention in developing:
 The skills in giving instructions to the patient
 The technique of palpating and testing muscle actions
 The technique in testing the normal physiological length of
muscles
 The appropriate hand placement and application of resistance to
muscle contraction
 Appropriate positioning of the subject
 Necessary precautions so as not to cause discomfort
o Be aware of the partner’s reaction and respond to muscle testing
o Adjust the technique of muscle testing according to partner’s com-
ments
o Appropriately expose the part to be tested and palpated

5. Each student, when palpating and testing the strength of a muscle should:
o First note the shape, contour and texture of a normal muscle at rest

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 o The palpating finger(s) should rest gently on the distal tendon (occa-
sionally on the proximal attachment) of the muscle or on its fleshly
part before and during its contraction
o Instruct the partner clearly and concisely on how to perform the re-
quired active concentric contraction
o Apply resistance to the action in the middle range to bring the muscle
into more prominent contraction
o Practice observing for deviations and substitution
o Allow your partner to relax and rest between each test

6. Each student, while testing the physiological length of a muscle, should:

o Appropriately position the partner
o Stabilize the proximal segment
o Take precaution not to over-stretch the muscle

7. The student partner also has to play an active role during the practical ses
sions. The partner should:
o Focus on the feeling and sensation on the part being tested
o Inform the assessor of these sensations:
 Positioning causing discomfort
 Too much pressure causing pain, hand placement inappropriate
 Instructions: too quick, too slow or incomprehensible
 Any other uncomfortable or unpleasant sensations

8. The following sections provide instructions on how to bring the important

muscles into active contraction so that students can practice by themselves at
home, or practice with a partner.

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Laboratory 13: Surface Anatomy III (Head, Spine & Trunk)

Table 1: Trunk Region

Trunk Region

1. Suprasternal notch (jugular notch)

 Starting position: Sitting/Supine
 Location: At the middle portion of the superior border of manubrium (between
the sternal ends of the clavicles), opposite the lower border of T2
 Palpation process: Locate the upper border of manubrium. The depression while
palpating upwards is the suprasternal notch

2. Sternal angle (angle of Louis)

 Starting position: Sitting/ Supine
 Location: At the junction of the manubrium and sternal body, lies opposite the
intervertebral disc between T4 and T5. Rib 2 articulates with the sternum at this
junction. It is the level of bifurcation of the trachea and the separation of the
superior and inferior mediastinum
 Palpation process: Palpate downwards from jugular notch. Prominence about
3.75 cm inferior to jugular notch is the sternal angle

3. Xiphisternal joint
 Starting position: Sitting/ Supine
 Location: Junction between the body of sternum and xiphoid process
 Palpation process: Palpate downwards along the sternum until a little gap is felt

4. Subcostal angle
 Starting position: Sitting/ Supine
 Location: Formed by the convergence of the costal cartilages of ribs 10, 9, 8 and
7 toward the sternum. Xiphoid process lies at the point of the angle
 Palpation process: Palpate along the lower border of rib 10 to the mid-point
anteriorly from both sides

5. Costal margin
 Starting position: Sitting
 Location: Lower boundary of the thorax formed by cartilages of ribs 7, 8, 9 and
10 in front, 11 and 12 behind. The lowest part of the costal margin formed by the
10th rib and lies at the level of L3
 Palpation process: Palpate the lower border of the lowest rib. Palpate along lower
border of rib 10 from the lateral lowest point anteriorly

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6. Rib 1
 Starting position: Sitting/ Supine
 Location: Deep to the clavicle, difficult to palpate.
 Palpation process: Palpate at the supraclavicular fossa

7. Rib 2
 Starting position: Sitting
 Location: Cartilage of 2nd rib is attached to the sternum at the level of sternal
angle
 Palpation process: Find the sternal angle. The 2nd rib can be find palpating
laterally from sterna angle at the same level

8. Palpate ribs 3-12

 Starting position: Sitting/side-lying
 Location: Below rib 2, until costal margin
 Palpation process: Identify rib 2, count downwards. Move your fingers gently
over each rib and then intercostal space, one at a time. Mark each rib or inter-
costal space with the finger of the other hand and holding it until the position of
the next rib or intercostal space is located

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Table 2: Vertebral Column

Vertebral Column

1. Count the spinous processes from C1 to L5 and from L5 to C1, making special note
of:
o C1-6, C7, T1, T3, T7, L4, L5, S1-4, S2
 Starting position: Prone
 Location: Spinous process of most of the vertebrae can be palpated in the
midline posteriorly
 Palpation process: Place index finger on the skin in the midline on the posterior
surface of the neck. Move your fingers gently up and down 3-4 cm at a time,
marking each spinous process with the finger of the other hand and holding it
until the position of the next spinous process is located
o Cl-6: covered by ligamentum nuchae.
o C7: first spinous process easily felt.
o T1: below C7
o T3: at the level of scapular spine, with arm by the side
o T7: at the level of inferior angle of scapula, with arm by the side
o L4: at the level of the most superior part of the iliac crest
o L5: at the level of the tubercle of the iliac crest
o SI-4: fused together to form the median sacral crest
o S2: at the level of PSIS

2. Palpate transverse process of C1

 Starting position: Sitting
 Location: The depression anterior and inferior the mastoid process
 Palpation process: Palpate at 1 cm anterior and inferior to the tips of mastoid
process of the skull

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Table 3: Skull

Skull

1. External occipital protuberance

 Starting position: Sitting
 Location: Prominence in the midline at the junction of head and neck
 Palpation process: Palpate upwards from the midline of cervical spine until a
prominence on the skull is felt.

2. Superior nuchal line

 Starting position: Sitting
 Location: Curved ridge, runs laterally from the external occipital protuber-
ance
 Palpation process: Identify the external occipital protuberance and palpate
laterally until the prominent line disappear

3. Vertex
 Starting position: Sitting
 Location: Highest point of the skull in sagittal plane
 Palpation process: Find the highest point of head on median plane. (Note that
the head should not be in rotation, flexion/extension and side-flexion)

4. Superciliary ridge
 Starting position: Sitting
 Location: Between and deep to these ridges lies the frontal air sinuses
 Palpation process: Bone at the level of eyebrows

5. Mastoid process
 Starting position: Sitting
 Location: Posterior to the ear lobe
 Palpation process: Palpate the tip of mastoid process

6. External acoustic meatus

 Starting position: Sitting
 Location: External opening for the ear, located posterior to the TMJ
 Palpation process: View from lateral side of head

7. Zygomatic arch
 Starting position: Sitting
 Location: The superficial zygomatic arch forms the cheekbone. It is com-
posed by the temporal and zygomatic bones. It is an attachment site for the
masseter muscle

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  Palpation process: Palpate along the entire extent from the lateral inferior part
of the orbit to the external ear

8. Hyoid bone
 Starting position: Sitting/ Supine
 Location: Located superior to the thyroid cartilage. It is located at superior as-
pect of the anterior neck region lies opposite C3. It serves as an attachment
site for the supra and infrahyoid muscle
 Palpation process: Locate the thyroid cartilage and hyoid bone is located su-
perior the thyroid cartilage. It can be pushed from side to side

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Table 4: Muscle of Vertebral Column

Muscles of Vertebral Column

1. Latissimus dorsi
 Starting position: Prone with arms by the side of the body
 Location: Lateral to lateral border of scapula
 Palpation process: Subject extends, adducts the medially rotated arm by lift-
ing the arm away from the plinth.

2. Erector spinae
 Starting position: Prone with hands clasped behind head
 Location: Palpate the muscles along the whole length of the spine
 Palpation process: Subject raises head, shoulder and trunk away from the
plinth.

3. Rhomboids
 Starting position: Prone with head rotated to same side, elbow flexed, shoul-
der slightly extended, adducted and laterally rotated
 Location: Between scapula and spinous process
 Palpation process: Examiner applies pressure using the arm as leverage in the
direction of abduction and upward rotation. Both muscles can be felt contract-
ing in this position.

4. Levator scapulae
 Starting position: Sitting
 Location: Palpate this muscle in the neck region just anterior to the trapezius
 Palpation process: Subject rests his forearm on the lumbar region of his back
and head rotated to the same side. From the starting position, subject elevates
the scapula.

5. Trapezius
Superior fibers
 Starting position: Sitting
 Location: Between superior nuchal line and lateral third of clavicle
 Palpation process: Palpate the superior fibers as elevation of the scapula is re-
sisted

Middle fibers
 Starting position: Prone with elbow extended, shoulder abducted to 90°, and
laterally rotated
 Location: Between C7-T3 spinous process and spine of scapula
 Palpation process: Instruct subject to perform scapular adduction and
retraction. The muscle can be brought into stronger contraction by applying
resistance at the forearm in a downward direction toward the plinth. Note the

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 posterior deltoid, teres minor and infraspinatus muscles are in action to stabi-
lize the arm.

Lower fibers
 Starting position: Prone with arm placed diagonally overhead with the shoul-
der laterally rotated and abducted
 Location: Between spinous process of T4-T12 and spine of scapula
 Palpation process: : The lower trapezius is brought into strong contraction as
the subject attempts to lift the arm against resistance applied at the forearm

6. Teres major
 Starting position: Prone with the humerus in a medially rotated position and
hand resting on the posterior iliac crest, head rotated to the same side
 Location: Between dorsal surface of inferior angle of scapula and
intertubercular sulcus of humerus
 Palpation process: Subject performs extension and adduction of the humerus.
Resistance is given in the direction of shoulder abduction and flexion.

7. Serratus anterior
 Starting position: Sitting/ Supine
 Location: Easier to palpate near the origin of the muscle at the side of the
chest (rib 1-8)
 Palpation process: May be seen on a thin subject more easily than it may be
palpated. A portion of the muscle may be seen on the anterolateral thorax
during deep inspiration. The muscle can be brought into a stronger contrac-
tion when the subject first elevates the arm to a horizontal position halfway
between flexion and abduction, then reaches forward so that the scapula
slides forward on the thorax.

8. Pectoralis major and minor

 Starting position: Sitting/ Supine
 Location: Anterior part of chest
 Palpation process:
o Clavicular fibers
 with elbow joint in full extension, shoulder joint 90° flexion,
palpating fingers in the infra-clavicular fossa
 subject moves the arm in a horizontal plane by performing
horizontal adduction, as horizontal adduction is resisted.

o Sternal fibers
 subject's arm is placed obliquely overhead with elbow ex-
tended.

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  the actions of the sternal fibers can be clearly shown as subject
attempts to extend and adduct die shoulder toward the opposite
pelvis against resistance.
o Pectoralis minor may be find between coracoids process and 3-5th
ribs.

9. Rectus abdominis
 Starting position: Supine with hands clasped behind the head
 Location: Middle part of the anterior abdomen
 Palpation process: Trunk-Curl (trunk flexion): Instructs the subject lift the
head, neck and trunk away from the table.

10. External oblique abdominis

 Starting position: Supine with hands clasped behind the head
 Location: Anterolateral part of abdomen
 Palpation process: Instruct subject to raise the head, neck and trunk and turn
towards one side. Contralateral external oblique abdominis, ipsilateral inter-
nal oblique abdominis and rectus abdominis can be palpated.

References:

Anatomy Team: Functional Anatomy Laboratory Handbook 2018-2019. Department of Rehabili-

tation Sciences, The Hong Kong Polytechnic University; 2019

Kendall FP, McCreary EK, Provance PG. Muscles, Testing and Function: With Posture and
Pain. 5th edition. Lippincott Williams & Wikins; 2005

Clarkson HM. Musculoskeletal Assessment: Joint Motion and Muscle Testing. 3rd edition. Lip-
pincott Williams & Wilkins; 2013

MAGEE, David J. Orthopedic physical assessment.6th edition. Elsevier Health Sciences; 2014.

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