Surface Palp 2

anterior superior iliac spine (ASIS)

• standing or supine

• place hand on side of abdomen, below umbilicus

• compress inferiorly until you feel superficial tip of ASIS

• Is the bone superficial and inferior to the level of the umbilicus?

• The attachment for the inguinal ligament. Creates a noticable bump on the two coxa.

pubic crest

• supine

• set fingertips on umbilicus and move the heel of hand inferiorly until you come in contact with pubic crest

• begin at ASIS and follow inguinal ligament inferiorly and medially at a 45 degree angle to pubic tubercle

• attachment site of inguinal ligament and adductor longus

greater trochanter

• prone

• located the middle of the iliac crest and slide your fingers 4-5 inches distally along the lateral aspect of the thigh until you identify a bony bump

• flex knee at 90 degrees and passively internally and externally rotate the hip. You should feel the greater trochanter move back and forth under your fingers

ischial tuberosity

• prone

• place heel of hand at the center of the gluteal fold and pressure superiorly and medially until you bump into the large bony surface

• are you between the inferior buttock and the proximal thigh?

piriformis

• prone

• BORDERS: coccyx, PSIS, and greater trochanter

• THESE LANDMARKS MAKE A "T"

• flex your partner's knee at 90 degrees and ask them to externally rotate against resistance

Guteus Medius

• sidelying

• place thumb and pointer finger along the iliac crest from PSIS to ASIS, which other hand locates the greater trochanter. Your hands will form a shape like a slice of pie

• ask your partner to abduct their hip and palpate for contraction of the gluteus medius

• ONLY DRAW PROXIMAL PORTION

TFL

• supine

• place hand flat posterior and distal to ASIS and iliac crest

• instruct partner to medially rotate their hip and then relax; you should feel the TFL contract under your hand

• palpate the vertical fibers and outline its width (only draw proximal portion)

sartorius

• supine, figure 4 postion (foot on opposite knee; hip flexed and externally rotated)

• place hand along middle of medial thigh and ask partner to contract sartorius by raising their knee toward the ceiling

• sartorius runs ASIS to pes anserinus

• draw distal 2/3rds

gracilis

• supine with hip flexed and externally rotated

• place flat of your hand at the middle of their medial thigh. Ask partner to adduct their hip slightly as you palpate fr a muscle contraction.

• CHECK: if the muscle you are palpating is slender and leads towards the ASIS, then it is the sartorius; if it leads towards the pubis, then it is the gracilis

adductor longus

• supine with hip flexed and externally rotated

• place flat of hand at the middle of partner's medial thigh

• ask partner to adduct their hip slightly as you palpate for a muscle contraction

• follow adductor longus and gracilis proximally toward the pubic tubercle and notice how the tendons become more prominent adductor longus angles deeper into medial thigh

patella and patella tendon

• supine

• located the patella on the anterior knee and palpate its borders

• palpate distally from the apex of the patella. note a springy tendon and follow the tendon to its distal attachment at the tibial tuberosity

tibial tuberosity and shaft of tibia

• supine or seated with knee flexed

• locate the apex of the patella and slide fingers distally ~3-4 inches along the patella tendon until you reach a superficial bony bump. this is the tibial tuberosity (roughly 1/2 in in diameter)

• continue to palpate inferiorly along the shaft of the tibia. follow it down to medial malleolus (can you feel the patella tendon insert on the tibial tuberosity)

head of fibula

• seated with knee flexed

• locate tibial tuberosity: slide fingers laterally ~3-4 inches. Palpate for an inch-wide bony prominence that is the head of the fibula

• is the bony knob lateral to the tibial tuberosity?

common fibular nerve

• prone with knee flexed

• lies medial to the biceps femoris tendon and lateral to the gastroc. it is accessible along the posterior surface of the fibular head

• roll your thumb side to side palpating the region just below the biceps tendon: should feel like SPAGHETTI NOODLE

• ask partner to flex their knee against resistance- nerve should remain mobile while gastroc contracts

Gerdy's tubercle

• seated or sidelying

• serves as the distal attachment site for the IT band

• slide distally off the lateral tibial plateau on the proximal anterolateral tibia to find the rounded bump

Pes Anserinus

• seated with knee bent

• attachment site for sartorius, gastroc, and semitendinosus

• located tibial tuberosity and palpate medially about 1 inch. palpate for a softer region at the super medial tibia

• can you feel the semitendinosus tendon during resisted knee flexion?

lateral femoral epicondyle

• seated with knee flexed

• located on lateral aspect of femur and serves as an attachment site for the LCL. deep to the ITB and biceps femoris tendon

• slide lateral from the patella to the lateral aspect of the femur until you rind a round bony bump

• are you superior to the tibiofemoral joint line?

medial femoral epicondyle

• seated with knee flexed

• deep to the tendon of the sartorius and serves as an attachment for the MCL

• slide medial from the patella to the medial aspect of femur until you find a round bony bump

• are you superior to the tibiofemoral joint line?

adductor tubercle

• seated with knee flexed

• proximal to the medial epicondyle and b/w the vests medals and medial hamstring tendons. serves as an attachment site for the adductor Magnus and may be tender to touch

• slide superiorly from the medial femoral epicondyle. as the edge of the femur drops off into soft tissue, feel for the small point of the tubercle

• CHECK: with your thumb on the superior aspect of the tubercle, does the tendon of the adductor Magnus push into your fingers during resisted hip adduction

LCL

• seated with knee flexed

• it is a superficial, thin strap that runs from the lateral femoral condyle to the fibular head. located b/w the biceps femoris tendon and the ITB

• locate the head of the fibular and the lateral epicondyle. slide your fingers b/w these points and move in a horizontal motion

• CHECK: is it about the width of a pencil and is it anterior to the biceps femoris tendon?

MCL

• seated with knee flexed

• MCL is broader than the LCL and deep to the pes anserinus. may be difficult to isolate

• locate the medial femoral condyle and slide distally into the medial joint space. strum finger tip horizontally across the space, feeling from the broad fibers of the ligament

• CHECK: are you distal to the medial epicondyle

Medial & Lateral Menisci/Joint Line

• Position: seated with knee flexed

• Place your thumbs on either side of the patella and slide inferiorly. You will feel a soft joint space between the tibia and femur.

• Rotate the tibia internally to palpate the anterior portion of the medial meniscus at the medial tibiofemoral joint line.

• Rotate the tibia externally to palpate the anterior portion of the lateral meniscus at the lateral tibiofemoral joint line.

rectus femoris

• supine with pillow under knee

• locate patella and follow rectus femoris proximally as it moves toward the AIIS

• strum fingers horizontally across vertical fibers- should be about 2-3 inches wide

• CONTRACT: ask partner to flex their hip and lift their foot off the table while maintaining slight knee flexion

vastus medialis

• supine with pillow under knee

• instruct partner to fully contract their quads by extending knee

• palpate just medial and proximal to the patella for the teardrop shape

vastus lateralis

• sidling with knees bent

• place flat of hand on lateral side of partner's thigh while they slowly extend their knee

• THE IT TRACT DOES NOT DEFINE THE LATERAL BORDER

• the VL extends beyond the IT band to the biceps femoris

biceps femoris (distal 2/3 of muscle and tendon)

• prone

• lateral half of hamstrings that runs from ischial tuberosity to fibular head

• ask partner to hold their knee about 45 degrees of knee flexion. palpate the lateral side f the knee for a long prominent tendon of the biceps femora and follow it to the head of the fibula

• differentiate the vests laterals with the muscular contraction

semitendinosus and semimembranosus

• prone

• these are the medial half of the hamstrings muscle belly

• semitendinosus is more superficial

• ask partner to hold their knee about 45 degrees of knee flexion. palpate the medial side of the knee for the superficial tendon of the semitendinosus. follow the tendon as it merges to with the pes anserinus

• semimembranosus is tucked deep to the semitendinosus and is often hard to isolate

IT band

• sidelying

• slide anteriorly from the biceps femoris tendon to the lateral thigh; roll fingers horizontally across the tough superficial fibers of the IT band

• follow the IT band as it attaches on the Gerdy's tubercle it becomes broader and thinner as it progresses proximally

tibialis anterior

• supine

• locate shaft of tibia and slide off laterally onto tibia's anterior

• ask partner to dorsiflex their ankle and palpate its long, inch wide muscle belly

• follow the muscle distally as it becomes thick , tendinous cord that runs to the medial side of the foot and attaches to the medial cuneiform

• CHECK: as partner dorsiflexes and relaxes, can you see and feel the tendon as it cross the top of the ankle?

gastrocnemius

• standing

• have partner stand on toes. palpate the posterior leg and knee to identify 2 heads. follow the muscle distally, noting how the medial head extends further distal than the lateral head. follow the muscle belly of the gastroc as it blends into the achilles tendon

soleus

• prone with knee flexed 90 degrees

• with the knee flexed, the gastroc is shortened and is ineffective as a plantar flexor.

• isolate the soleus by asking your partner to plantar flex against your resistance

• note that the soleus is longer and wider than the gastroc

medial malleolus

• seated or supine

• palpate for a large, round bony structure at the medial side of the ankle. identify the anterior, inferior and posterior borders

• CHECK: can you slide proximally to connect the medial malleolus with the shaft of the tibia?

sustentaculum tali

• supine or seated, ankle in neutral postion

• on the medial side of the calcaneus approximately 1 inch distal to the medial malleolus

• Method 1: slide 1" distal to the medial malleolus to identify the small ridge of the sustentaculum tali

• Method 2: Begin at the medial sole of the foot directly distal to the inferior tip of the medial malleolus with the foot in a neutral position.

• Palpate proximally to the first bony landmark you identify - this should be the sustentaculum tali

• CHECK: are you distal to the medial malleolus?

navicular bone and tuberosity

• seated or supine

• The dorsal surface is palpable, and the superficial navicular tuberosity can be identified at the medial aspect of the bone

• Slide proximally along the medial side of the foot.

• You will pass over the medial cuneiform and noticeable bump of the navicular tuberosity. The tuberosity is about 1-2 inches from the medial malleolus

• From the navicular tuberosity, slide dorsally to palpate the dorsal surface of the navicular bone

• CHECK: Does the bone you are palpating project moremedially than the surfaces of the other boneson the medial foot?

head of talus

• supine or seated with ankle in neutral postion

• Locate the navicular tuberosity. Slide proximally off the tubercle to the head of the talus. The talar head may feel like a slight depression compared to the navicular tuberosity

• If you evert the foot, the talar head should become more prominent under your fingers

• CHECK: does the taller head become more prominent with eversion?

trochlea of talus

• supine or seated

• Passively invert and plantarflex the foot. Draw or imagine a horizontal line connecting the medial and lateral malleoli

• Drop inferiorly off the center line, palpating for a bony prominence. The trochlea will be deep to the overlying tendons and more prominent near the lateral malleolus

• CHECK: Is the tissue you are palpating hard and immovable like bone, or firm and mobile like tendon?

medial tubercle of the talus

• supine or seated

• Locate the medial malleolus. Instead of sliding straight distally for the sustentaculum tali, slide at a 45 degree angle posteriorly off the inferior tip of the malleolus. Palpate for a small bump that may be tender to palpation

• CHECK: Passively plantarflex and dorsiflex the ankle. Does the medial tubercle seem to slide in a small arc around the medial malleolus?

Spring ligament

• supine or seated

• stretches between the navicular tuberosity and the sustentaculum tali. It plays an important role in stabilizing the medial longitudinal arch of the foot

• Passively invert the foot and locate the navicular tuberosity and sustentaculum tali. Palpate between these bony landmarks to identify the spring ligament as a taut band

• CHECK: Are you between the sustentaculum tali and the navicular tuberosity?; Can you roll your fingertip across the surface of the ligament?

tarsal tunnel (posterior tibial a)

• supine or seated with ankle dorsiflexed

• Palpate between the medial malleolus and the medial side of the calcaneus.

• You should be able to identify the pulse point for the posterior tibial artery.

• If you tap gently over this region, you may elicit a tingling sensation from the tibial nerve

first metatarsal

• seated or supine

• Locate the first metatarsal shaft along the medial side of the foot.

• Palpate proximally to identify the bony enlargement of the metatarsal base.

• Palpate distally to identify the bony enlargement of the metatarsal head.

medial, middle, and lateral cuneiforms

• seated or supine

• The medial cuneiform can be palpated on its medial and dorsal sides.

• The middle and lateral cuneiforms are between the medial cuneiform and the cuboid, and are palpable only on their dorsal aspects

• Locate the base of the 1st metatarsal and slide proximally onto the surface of the medial cuneiform. Slide laterally from the medial cuneiform along the dorsal surface of the foot to palpate the middle and lateral cuneiforms

• CHECK: Have your partner dorsiflex to follow the anterior tibialis tendon to the medial cuneiform

Metatarsals 2-5

• seated or supine

• Grasp the foot with both hands and palpate the base, shaft, and head of each metatarsal

tuberosity of 5th metatarsal

• supine or seated

• Locate the shaft of the fifth metatarsal. Follow the shaft proximally to where the base projects laterally

• CHECK: When the ankle is dorsiflexed, are you approximately 2 inches from the lateral malleolus

• CHECK: Does the bony bump you are palpating continuous with the 5th metatarsal?

lateral malleolus

• seated or supine

• Palpate at the lateral ankle for a large, round, bony structure. Identify the anterior, inferior, and posterior borders

• The lateral malleolus should extend more distal than the medial malleolus

• CHECK: Can you slide proximally and connect the lateral malleolus with the shaft of the fibula?

fibular trochlea

• supine or seated with ankle dorsiflexed

• Slide approximately 1 inch distal to the lateral malleolus and palpate for a small ridge protruding from the calcaneus. Passively everting the foot will soften the surrounding tissues

• If you slide off the trochlea distally, you will feel the thick tissues of the foot

• CHECK: have partner evert their foot, can you feel the fibularis tendons pass on either side of the trochlea?

Sinus Tarsi

• seated or supine

• sinus tarsi is a space between the talus and calcaneus

• Begin at the anterior surface of the lateral malleolus and move dorsally and medially until your finger falls into a divot

• CHECK: does the depression become more shallow during eversion?

cuboid

• seated or supine

• From the tuberosity of the fifth metatarsal, slide dorsally and proximally toward the lateral malleolus. The cuboid is roughly ½ inch from the tuberosity of the 5th metatarsal and 1 inch from the lateral malleolus

• CHECK: are you between the tuberosity of the 5th metatarsal and the lateral malleolus?

tibialis anterior tendon

• supine

• Locate the shaft of the tibia and slide laterally onto the tibialis anterior

• ask partner to alternatively dorsiflex and relax to palpate ~1 inch wide muscle belly

• palpate distally as it inserts on the medial cuneiform

• CHECK: Palpate the muscle contraction as your partner dorsiflexes their ankle

Extensor Digitorum Longus Tendon

• supine

• Palpate the distal tendons as your partner extends their toes. Visibly identify and palpate the 4 tendons of the digitorum on the top of the foot

• CHECK: With the ankle dorsiflexed, ask your partner to slowly invert and evert their foot. Do you feel the tibialis contract with inversion and extensor digitorum longus contract with eversion?

Extensor Hallucis Longus Tendon

• supine

• Ask your partner to extend their first toe. Visibly identify and palpate the tendon running along the dorsal surface of the foot to the first toe. Follow the tendon until it reaches the ankle

dorsalis pedis artery

• supine or seated

• Locate the first and second metatarsals. Place two finger pads between the first and second metatarsals to identify the pulse point of the dorsalis pedis artery

• if the pulse is undetectable, move slightly lateral

• CHECK: Are you lateral to the extensor hallucis longus tendon?

fibularis longus and brevis

• sidelying

• Place a finger at the head of the fibula and the lateral malleolus. The fibularis longus and brevis muscle bellies are located between these 2 landmarks

• Ask your partner to alternately evert and relax their ankle. Follow the muscle bellies along the lateral leg distal to where their tendons wrap around the posterior aspect of the lateral malleolus

• Follow the fibularis brevis tendon to the base of the 5th metatarsal

• CHECK: differentiate with the soleus

achilles tendon

• seated or prone

• Palpate the Achilles tendon from its insertion on the calcaneus proximally until it blends with the muscle bellies of the gastrocnemius and soleus