FLASHCARDS
for Palpation,
Trigger Points,
and Referral
Patterns
JOSEPH E. MUSCOLINO, DC
Instructor, Connecticut Center for Massage Therapy
Westport, Connecticut
Owner, The Art and Science of Kinesiology
Redding, Connecticut
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PART 1: Muscle Palpation
Section 1: Palpation of the Muscles of the Shoulder Girdle
Trapezius
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client prone with arm resting on the table at the side of the body
• Therapist standing to the side of the client
• Palpating hand placed just lateral to the lower thoracic spine (on the
lower trapezius)
Palpation Steps:
1. Ask the client to abduct the arm at the shoulder joint to 90 degrees
with the elbow joint extended, and to slightly retract the scapula at
the scapulocostal joint by pinching the shoulder blade toward the
spine (Figure A). Adding gentle resistance to the client’s arm abduction with your support hand might be helpful.
2. Palpate the lower trapezius. To locate the lateral border, palpate perpendicular to it (Figure A). Once located, palpate the entirety of the
lower trapezius.
3. Repeat for the middle trapezius between the scapula and the spine.
Strum perpendicular to the direction of the fibers (i.e., strum vertically) (Figure B).
4. Repeat for the upper trapezius.
5. To further engage the upper trapezius, ask the client to do slight extension of the head and neck at the spinal joints. Then palpate the
entirety of the upper trapezius (Figure C).
6. Once the trapezius has been located, have the client relax it and palpate to assess its baseline tone.
Palpation Note:
1. Abducting the arm at the shoulder joint requires an upward rotation
force by the upper and lower trapezius to stabilize the scapula. Retracting the scapula engages the entire trapezius, especially the middle trapezius.
CARD # 1
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Trapezius
B
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 10-9, A-C, Page 143
A
C
Palpation Key: Fly like an airplane: If both trapezius muscles are
palpated at the same time, both arms out to the sides make the client
appear to be flying like an airplane.
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PART 1: Muscle Palpation
Section 1: Palpation of the Muscles of the Shoulder Girdle
Rhomboids
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client prone with the hand resting in the small of the back
• Therapist standing to the side of the client
• Palpating hand placed between the spinal column and the scapula at
the midscapular level
Palpation Steps:
1. Ask the client to lift the hand away from the small of the back
(Figure A).
2. Look for the lower border of the rhomboids to become visible (Figure B);
make sure you are not covering the lower border with your palpating
hand).
3. Palpate the rhomboids from the inferior aspect to the superior aspect.
When palpating, strum perpendicular to the direction of the fibers.
4. Once the rhomboids have been located, have the client relax them and
palpate to assess their baseline tone.
Palpation Notes:
1. Having the client place the hand in the small of the back requires extension and adduction of the arm at the shoulder joint. This requires
the coupled action of downward rotation of the scapula at the scapulocostal joint, which will cause the trapezius to relax (due to reciprocal inhibition) so that we can palpate through it. It will also engage
the rhomboids so that their contraction will be clearly felt.
2. The superior border of the rhomboids is more difficult to visualize and
palpate than the inferior border. However, it can usually be palpated.
Feel for a gap between the rhomboids and the levator scapulae.
3. It is usually not possible to clearly distinguish the border between the
rhomboid major and rhomboid minor.
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A
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figures 10-14 and 10-15, Pages 146-147
Rhomboids
B
Palpation Key: Client’s hand in the small of the back.
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PART 1: Muscle Palpation
Section 4: Palpation of the Muscles of the Arm
Coracobrachialis
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client seated with the arm abducted to 90 degrees and laterally rotated at the shoulder joint, and the forearm flexed at the elbow joint
approximately 90 degrees
• Therapist seated or standing in front of the client
• Palpating hand placed on the medial aspect of the proximal half of
the client’s arm
• Support hand placed on the distal end of the client’s arm, just proximal to the elbow joint
Palpation Steps:
1. Resist the client from horizontal flexion of the arm at the shoulder
joint and feel for the contraction of the coracobrachialis.
2. Strumming perpendicular to the fibers, palpate from attachment to
attachment.
3. Once the coracobrachialis has been located, have the client relax it
and palpate to assess its baseline tone.
Palpation Notes:
1. To easily discern the coracobrachialis from the short head of the
biceps brachii, it is important for the forearm to be passively flexed
90 degrees or more so that the biceps brachii stays relaxed.
2. If there is doubt as to whether you are on the coracobrachialis or the
short head of the biceps brachii, resist the client from performing
flexion of the forearm at the elbow joint. This will cause the short head
of the biceps brachii to contract, but not the coracobrachialis. Where
these two muscles overlap, the coracobrachialis is deep (posterior) to
the short head of the biceps brachii.
3. Palpation of the coracobrachialis must be done prudently because of
the presence of the brachial artery and the median, ulnar, and musculocutaneous nerves.
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Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 13-26, Page 271
Coracobrachialis
Palpation Key: Resist horizontal flexion of the arm
with the elbow joint flexed.
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PART 1: Muscle Palpation
Section 7: Palpation of the Trunk Muscles
Quadratus Lumborum (QL)
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client prone
• Therapist standing to the side of the client
• Palpating hand placed just lateral to the lateral border of the erector
spinae in the lumbar region
• Support hand sometimes placed directly on the palpation hand for
support (not shown)
Palpation Steps:
1. First locate the lateral border of the erector spinae musculature (to do
so, ask the client to raise the head and upper trunk from the table);
then place palpating finger just lateral to the lateral border of the
erector spinae.
2. Direct palpating pressure medially, deep to the erector spinae musculature, and feel for the quadratus lumborum (QL).
3. To engage the QL to be certain that you are on it: ask the client to elevate the pelvis on that side at the lumbosacral joint (Note: This involves moving the pelvis along the plane of the table toward the head;
in other words, the pelvis should not lift up in the air, away from the
table.) and feel for its contraction (Figure A).
4. Once located, palpate medially and superiorly toward the twelfth rib,
medially and inferiorly toward the iliac crest, and directly medially toward the transverse processes of the lumbar spine (Figure B).
5. Once the QL has been located, have the client relax it and palpate to
assess its baseline tone.
Palpation Notes:
1. To successfully palpate the QL, you must be lateral to the erector spinae and then press in firmly with a medial direction to your pressure.
2. Whenever pressing deeply to palpate a muscle, always press in firmly,
but slowly.
CARD # 85
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A
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figures 16-27 and 16-28, Page 366
Quadratus Lumborum (QL)
B
Palpation Key: Lateral to the erector spinae and press in medially.
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PART 1: Muscle Palpation
Section 7: Palpation of the Trunk Muscles
External and Internal Abdominal Obliques
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client supine with a small roll under the knees
• Therapist standing to the side of the client
• Palpating hand placed on the anterolateral abdominal wall
Palpation Steps:
1. With palpating hand on the anterolateral abdominal wall between the
iliac crest and the lower ribs (be sure that you are lateral to the rectus
abdominis), ask the client to rotate the trunk to the opposite side of
the body (contralateral rotation) and feel for the contraction of the external abdominal oblique (Figure A).
2. Try to feel for the diagonal orientation of the external abdominal
oblique fibers by strumming perpendicular to them.
3. Continue palpating the external abdominal oblique toward its superior and inferior attachments.
4. Repeat the same procedure for the internal abdominal oblique, asking
the client to instead flex and ipsilaterally rotate the trunk at the spinal
joints (Figure B).
5. Once the external abdominal and internal abdominal obliques have
been located, have the client relax them and palpate to assess their
baseline tone.
Palpation Notes:
1. When asking the client to contralaterally rotate (to isolate the external
abdominal oblique) and ipsilaterally rotate (to isolate the internal abdominal oblique), try to have the client do as little flexion as possible,
or both abdominal obliques will contract.
2. The fiber direction of the external abdominal oblique is similar to the
orientation of a coat pocket.
3. Feeling the fiber direction of each of the abdominal obliques and distinguishing between the external and internal abdominal obliques on
one side can be challenging.
CARD # 92
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Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 16-53, A-B, Page 379
External and Internal Abdominal Obliques
A
B
Palpation Key: Flex and contralaterally rotate for the external
abdominal oblique; flex and ipsilaterally rotate
for the internal abdominal oblique.
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PART 1: Muscle Palpation
Section 8: Palpation of the Pelvic Muscles
Piriformis
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client prone with the leg flexed to 90 degrees at the knee joint
• Therapist standing to the side of the client
• Palpating hand placed just lateral to the sacrum, halfway between
the posterior superior iliac spine (PSIS) and the apex of the sacrum
• Support hand placed on the medial surface of the distal leg, just
proximal to the ankle joint
Palpation Steps:
1. Begin by finding the point on the lateral sacrum that is halfway between the PSIS and the apex of the sacrum. Drop just off the sacrum
laterally at this point and you will be on the piriformis.
2. Resist the client from laterally rotating the thigh at the hip joint and
feel for the contraction of the piriformis. Note: Lateral rotation of the
client’s thigh involves the client’s foot moving medially toward the
midline (and opposite side) of the body.
3. Continue palpating the piriformis laterally toward the superior border
of the greater trochanter of the femur by strumming perpendicular to
the fibers as the client alternately contracts (against resistance) and
relaxes the piriformis.
4. Once the piriformis has been located, have the client relax it and palpate to assess its baseline tone.
Palpation Notes:
1. It can be challenging to discern the borders between the piriformis
and the gluteus medius superiorly and superior gemellus inferiorly.
2. When giving resistance to the client’s lateral rotation of the thigh at
the hip joint, do not let the client contract too forcefully, or the more
superficial gluteus maximus (also a lateral rotator) may be engaged,
blocking palpation of the deeper piriformis.
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Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 17-22, Page 407
Piriformis
Palpation Key: Find the midpoint of the lateral border of the sacrum.
Then draw a line from there to the greater trochanter.
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PART 1: Muscle Palpation
Section 10: Palpation of the Leg Muscles
Tibialis Anterior
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Starting Position:
• Client supine
• Therapist standing to the side of the client
• Palpating hand not yet placed on the client
• Support hand placed on the medial side of the distal foot
Palpation Steps:
1. Resist the client from dorsiflexing and inverting the foot and look for
the distal tendon of the tibialis anterior on the medial side of the foot;
it is usually visible (Figure A).
2. Palpate the distal tendon by strumming perpendicularly across it.
Continue palpating the tibialis anterior proximally to the lateral tibial
condyle by strumming perpendicular to the fibers. Its belly is located
directly lateral to the border of the tibia in the anterior leg (Figure B).
3. Once the tibialis anterior has been located, have the client relax it and
palpate to assess its baseline tone.
Palpation Notes:
1. As with all superficial muscles, it is always best to look before placing
your palpating hand over the muscle; otherwise your hand may block
you seeing and locating the muscle or its tendon.
2. The distal tendon of the tibialis anterior is usually very prominent and
visible. The belly is also usually prominent and visible directly lateral
to the shaft of the tibia in the anterior leg. If the tendon and belly are
not visible, they can usually be easily palpated by strumming
perpendicularly.
3. To clearly discern the border between the tibialis anterior and the adjacent extensor digitorum longus (EDL), use inversion and eversion.
Inversion will engage the tibialis anterior but not the EDL; eversion
will engage the EDL but not the tibialis anterior.
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Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figures 19-7 and 19-8, Pages 456-457
Tibialis Anterior
A
B
Palpation Key: First look for the distal tendon.
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Inferior angle
Medial border
Infraspinous
fossa
Posterolateral view of the scapula.
Posterolateral view
Lateral border
Acromion
process
Spine of scapula
Superior border
Superior angle
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
Supraspinous
fossa
The Muscle and Bone Palpation Manual, Figure 7-7, Page 72
PART 2: Bone Palpation
Upper Extremity
Section 1: Shoulder Girdle
CARD # 142 A
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PART 2: Bone Palpation
A
Posterolateral view
B
Posterolateral view
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 7-8, A-B, Page 72
Upper Extremity
Section 1: Shoulder Girdle
Acromion process and spine of the scapula: The spine of the scapula
is the posterior continuation of the acromion process. To locate the spine
of the scapula, begin on the acromion process (A) and continue palpating
along it posteriorly. The spine of the scapula (B) can be palpated all the
way to the medial border of the scapula. The spine of the scapula can be
best palpated if you strum it perpendicularly by moving your palpating
fingers up and down across it as you work your way posteriorly.
CARD # 142 B
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PART 2: Bone Palpation
Posterolateral view
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 7-9, Page 73
Upper Extremity
Section 1: Shoulder Girdle
Supraspinous fossa: To palpate the supraspinous fossa of the scapula,
locate the spine of the scapula and drop just off it superiorly. Palpate
along the superior border of the spine of the scapula within the supraspinous fossa.
CARD # 143 A
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PART 2: Bone Palpation
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 7-10, Page 73
Upper Extremity
Section 1: Shoulder Girdle
Posterolateral view
Infraspinous fossa of the scapula: To palpate the infraspinous fossa of
the scapula, locate the spine of the scapula and drop just off it inferiorly.
The infraspinous fossa is larger than the supraspinous fossa.
CARD # 143 B
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PART 2: Bone Palpation
Lateral view
Spinous processes of C2 through C7: The spinous processes (SPs) of
the cervical spine are palpated in the midline of the posterior neck. The
most prominent cervical SPs are the second and seventh (C7 is called the
vertebra prominens). Begin at the external occipital protuberance of the
occiput (see Flashcard #172B); then drop inferiorly onto the cervical
spine, feeling for the SP of C2. As with most cervical SPs, it is bifid (it has
two points). Continue palpating inferiorly, feeling for additional cervical
SPs. Note: C1 (the atlas) does not have a SP; it has a posterior tubercle.
To palpate the posterior tubercle of C1, palpate between the SP of C2 and
the occiput, pressing anteriorly into the soft tissue.
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 8-18, Page 102
Axial Body
Section 4: Posterior Neck
CARD # 175 B
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PART 2: Bone Palpation
Lateral view
Articular processes (facet joints) of the cervical spine: The inferior
and superior articular processes of the cervical spine create what is
called the cervical pillar (articular pillar) due to the manner in which they
stack upon one other. They are easily palpable at the lateral side of the
laminar groove (approximately 1 inch [2.5 cm] lateral to the spinous processes). The client must be supine and relaxed for palpation to be successful. Begin palpation at the spinous process of C2 (see Flashcard
#175B) and palpate laterally for the articular process of C2. Continue to
palpate inferiorly until you reach the bottom of the neck. Note: The articular processes of the cervical spine are an excellent contact point when
performing specific joint mobilizations to the cervical spine.
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 8-19, Page 103
Axial Body
Section 4: Posterior Neck
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PART 3: Trigger Points
Section 2: Neck
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 11-8, A-B, Page 188
Sternocleidomastoid (SCM)
A
B
Anterolateral views illustrating common sternocleidomastoid (SCM) TrPs
and their corresponding referral zones. A, Sternal head. B, Clavicular
head.
TrP ⴝ Trigger Point
CARD # 214 A
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PART 3: Trigger Points
Section 2: Neck
A
B
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 11-15, A-B, Page 192
Scalenes
A, Anterior view illustrating common scalene TrPs and their corresponding referral zone. B, Posterior view showing the remainder of the referral
zone.
TrP ⴝ Trigger Point
CARD # 214 B
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PART 3: Trigger Points
Section 7: Pelvis
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 17-24, Page 408
Piriformis
Posterior view of common piriformis TrPs and their corresponding referral
zones.
TrP ⴝ Trigger Point
CARD # 232 A
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PART 3: Trigger Points
Section 8: Thigh
A
B
Copyright © 2009 Mosby, Inc., an affiliate of Elsevier, Inc.
The Muscle and Bone Palpation Manual, Figure 18-10, A-B, Page 422
Hamstring Group
Posterior views of common lateral and medial hamstring TrPs and their
corresponding referral zones. A, Lateral hamstring (biceps femoris).
B, Medial hamstrings (semitendinosus and semimembranosus).
TrP ⴝ Trigger Point
CARD # 232 B
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