Directions: Find the midline of the back and palpate down this line. The point of each spinous process will be very palpable along with a depression of soft tissue between each spinous process as you move, either superiorly or inferiorly, from one process to the next.
The spinous processes of the following vertebrae can be located by first identifying skeletal landmarks that are at the same horizontal level as these vertebrae. Once you have found the associated skeletal landmark, work your way medially to find the indicated spinous process.
C7: base of the neck
T2: superior angle of the scapula
T7: inferior angle of the scapula
T12: 12th rib
L4: superior aspect of the iliac crest
Structures That Attach Here: The spinous processes serve as the proximal or distal attachments for numerous muscles and ligaments in each region. For example, muscles of the superficial back, such as the rhomboid major and minor; muscles of the intermediate back, such as the spinalis of erector spinae; and muscles of the deep back, such as semispinalis, multifidus, and rotatores, attach to this landmark. The reader is encouraged to explore corresponding content on the spine for greater depth and breadth of knowledge of the structures that attach to this location.
Transverse Processes of the Vertebrae
How to Palpate
Position of Partner: Prone, standing, sitting
Directions: It’s important to first visualize a vertebra and recognize the distance between a spinous process and the transverse processes of the same vertebrae. Once you have found and palpated a spinous process, move laterally to either side about ½ to 1 inch to feel a transverse process. These processes are not nearly as pronounced as spinous processes, so more pressure will be needed; however, they are palpable.
Structures That Attach Here: The transverse processes serve as the proximal or distal attachments for numerous muscles and ligaments in each region. For example, muscles of the superficial back, such as levator scapulae; muscles of the intermediate back, such as longissumus of erector spinae; and muscles of the deep back, such as transversospinalis group and splenius cervicis; attach to this landmark. The reader is encouraged to explore corresponding content on the spine for greater depth and breadth of knowledge of the structures that attach to this location.
Jugular Notch
How to Palpate
Position of Partner: Supine, sitting, standing
Directions: Face your partner and begin by locating the medial ends of the clavicles. Palpate between the ends of the clavicles and just superior to the top of the sternum to feel the jugular notch, or the depression between these bones.
Sternum
How to Palpate
Position of Partner: Supine, sitting, standing
Directions: Once you have identified the jugular notch, begin to palpate inferiorly where the manubrium of the sternum is located. The manubrium composes the top portion of the sternum. Being mindful not to palpate too laterally where the costochondral cartilage can be felt, continue to palpate inferiorly to the body of the sternum, all the way to the xiphoid process.
Muscles That Attach Here: Sternocleidomastoid, pectoralis major, transversus thoracis, sternohyoid, and sternothyroid
Structures That Attach Here: Sternoclavicular ligament, and costosternal ligament
Ribs
How to Palpate
Position of Partner: Supine, prone, sitting, standing
Directions: Most ribs can be palpated fully from the sternum to their articulation with the thoracic vertebrae posteriorly. Simply pick a particular rib and palpate it fully by moving around the thorax, either anteriorly to posteriorly or vice versa.
Muscles That Attach Here: Latissimus dorsi, intercostals, pectoralis minor, serratus anterior, serratus posterior superior, serratus posterior inferior, iliocostalis, and scalenes
Origin(s): Spinous processes of the thoracic vertebrae, sacrum, sacroiliac ligaments, and the iliac crest of the ilium.
Insertion(s):
Iliocostalis: Angles of lower ribs and transverse processes of cervical spine
Longissimus: Transverse processes of thoracic and cervical spine, mastoid process
Spinalis: Spinous processes of thoracic and cervical spine
Action(s): Extension of the spine
Innervation(s): Dorsal rami of spinal nerves
How to Palpate
Position of Partner: Prone, sitting, standing
Directions: Lateral to either side of the spine are the muscles that compose the erector spinae group. In individuals with more muscle mass, these muscles may appear as a hump on both sides of the spine that are running in a linear direction up and down the length of the spine. To engage these muscles and make them even more palpable, have your partner lie prone on a table. Have them extend their arms and legs straight out, then have them lift their legs and arms off the table a few inches.
Directions: These muscles are found in a similar location to the erector spinae; however, they lie deeper and more medial to the erector spinae. To palpate the area of the muscles, feel immediately lateral to a spinous process on either side.
Splenius Capitis and Cervicis
Origin(s):
Capitis: Nuchal ligament and spinous processes of the cervical vertebrae
Cervicis: Spinous processes of thoracic vertebrae
Insertion(s):
Capitis: Occipital bone and mastoid process of the temporal bone
Cervicis: Transverse processes of cervical vertebrae
Action(s): Extension, rotation, and lateral flexion of the head
Innervation(s): Dorsal rami of spinal nerves
How to Palpate
Position of Partner: Prone, sitting
Directions: First identify the fiber direction of these muscles. They run on the opposite diagonal of the upper trapezius. When starting at the more lateral and superior attachments, like the mastoid process and transverse processes of the cervical vertebrae, continue to palpate by moving inferiorly and medially toward the spinous processes of the cervical and thoracic vertebrae.
Suboccipitals (Rectus Capitis Posterior Major, Rectus Capitis Minor, Obliquus Capitis Superior, and Obliquus Capitis Inferior)
Location: Inferior occipital bone to the first two cervical vertebrae
Action(s): Ipsilateral rotation, ipsilateral flexion, and extension of the head
Innervation(s): Suboccipital nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: To palpate all the suboccipital muscles as a group, use the external occipital protuberance as a superior landmark. This protuberance is the large bump found on the occipital bone. Move inferiorly to this protuberance about 2–3 inches, while also moving laterally to capture all the muscles of this group.
Quadratus Lumborum
Origin(s): Iliac crest
Insertion(s): 12th rib and lumbar vertebrae
Action(s): Lateral flexion of the spine
Innervation(s): Ventral rami of spinal nerves
How to Palpate
Position of Partner: Prone, sitting, side-lying
Directions: To palpate the quadratus lumborum, begin by appreciating the origin and insertion of the muscle from the iliac crest to the 12th rib and lumbar vertebrae. Palpate along these landmarks, taking note that superficial back muscles overlay this muscle.
Rectus Abdominis
Origin(s): Pubic bone
Insertion(s): Ribs and xiphoid process of sternum
Action(s): Flexion of the spine
Innervation(s): Intercostal nerves (T6–T11) and subcostal nerve (T12)
How to Palpate
Position of Partner: Supine
Directions: Palpate from one end of the muscle, either its origin or insertion, to the other end. Gauge your pressure along the way to ensure you’re not palpating too deeply into the abdomen.
External Oblique
Origin(s): Ribs
Insertion(s): Xiphoid process, iliac crest, pubic bone, linea alba, inguinal ligament, and anterior superior iliac spine
Action(s): Flexion of the spine and contralateral rotation of the spine
Innervation(s): Intercostal nerves (T7–T11) and subcostal nerve (T12)
How to Palpate
Position of Partner: Supine
Directions: Begin by identifying the fiber direction of the muscle that you will palpate along. With your partner in a supine position, palpate laterally to the rectus abdominis. The muscle fibers of the external oblique run from a superolateral to inferomedial direction along a diagonal.
Internal Oblique
Origin(s): Inguinal ligament and iliac crest
Insertion(s): Linea alba and pubic bone
Action(s): Ipsilateral rotation of the spine
Innervation(s): Intercostal nerves (T7–T11) and subcostal nerve (T12)
How to Palpate
Position of Partner: Supine
Directions: Palpate this muscle in a similar manner to the external oblique. Begin by identifying the fiber direction of this muscle, which runs in the opposite direction of the external oblique. With your partner in a supine position, palpate laterally to the rectus abdominis. The muscle fibers of the internal oblique run from a superomedial to inferolateral direction along a diagonal.
Transverse Abdominis
Origin(s): Iliac crest, inguinal ligament, thoracolumbar fascia
Insertion(s): Xiphoid process of the sternum, linea alba, and pubic bone
Action(s): Compression of the abdomen
Innervation(s): Intercostal nerves (T6–T11) and subcostal nerve (T12)
How to Palpate
Position of Partner: Supine
Directions: Because this is the deepest abdominal layer, it is very difficult to palpate this muscle. When attempting to do so, it’s important to visualize the breadth of this muscle and work in the transverse direction along the direction of the fibers working between all of its attachment sites.
Diaphragm
Attachments: Lumbar vertebrae, costal cartilages and ribs, and xiphoid process of the sternum
Action(s): Increase intra-abdominal pressure
Innervation(s): Phrenic nerve
How to Palpate
Position of Partner: Supine
Directions: This muscle runs circumferentially around the inside of the thorax; however, it is possible to palpate the edges of the muscle anteriorly where it meets the ribs. Begin your palpation by finding the edges of the costal margins, and then wrap your fingers under these margins while your partner relaxes their musculature as much as possible. Having your partner take a deep breath in will help you access this muscle while you’re palpating the appropriate area.
Attachments: These muscles attach from one to the next rib
Action(s): Elevation or depression of the ribs
Innervation(s): Intercostal nerves
How to Palpate
Position of Partner: Supine
Directions: Because these muscles run between the ribs, simply locate an intercostal space, and palpate the soft tissue area between the ribs. When palpating this area, you are palpating all three layers of the intercostals.
Serratus Posterior Superior
Origin(s): Nuchal ligament and cervical vertebrae
Insertion(s): Ribs (2–5)
Action(s): Elevation of the ribs
Innervation(s): Intercostal nerves
How to Palpate
Position of Partner: Prone
Directions: This muscle is located deep to the rhomboids and runs diagonally in this area. To palpate, begin at its origin and work toward the area of the scapula. At this point the muscle dives deep to the scapula to insert on the ribs, so you will not be able to palpate it any further.
Serratus Posterior Inferior
Origin(s): Thoracic and lumbar vertebrae
Insertion(s): Ribs (9–12)
Action(s): Depressions of the ribs
Innervation(s): Anterior rami of thoracic spinal nerves
How to Palpate
Position of Partner: Prone
Directions: This muscle is located in the lumbar region. Begin by palpating immediately lateral to the lumbar and inferior thoracic vertebrae, and then move even more laterally while moving superiorly to the inferior ribs.
Directions: This ligament spans the external occipital protuberance to the spinous process of C7. It runs in a linear orientation from the tip of one spinous process to the next. To palpate the structure, begin by finding the external occipital protuberance. Then proceed to palpate inferiorly directly down the spinous processes, and gaps between them, of the cervical spine until you reach the large hump of the base of the neck that is created by the C7 spinous process.
Supraspinous Ligament
How to Palpate
Position of Partner: Prone or sitting
Directions: This ligament is continuous with the ligamentum nuchae. It starts at the spinous process of C7 and extends inferiorly down the spine to the sacrum. Begin at the spinous process of C7 and continue to palpate inferiorly along the spinous processes of the spine until the sacrum is reached.
Directions: This fascia is expansive throughout the thoracic and lumbar regions of the spine and serves as an attachment point for many structures. Before beginning to palpate, view Figure 5.13 to observe this structure’s diamond shape. Then, with your partner in a prone position, visualize this large diamond on their lower back. To palpate the structure, slowly work your way throughout the entirety of this diamond region.
Table 5.1 Range of Motion for the Spine, Thorax & Abdomen
Joint Actions
Tips for ROM Assessment
Picture of Joint Action
Flexion and Extension of the Spine
For active ranges of flexion and extension of the spine, always make sure you have set up a safe environment for your partner to perform these motions in. If they are standing, make sure they have a table, object, or yourself to assist with their balance.
Lateral Flexion of the Spine
When assessing these ranges, it’s important to ensure the person is moving within the frontal plane to prevent other movements from occurring.
Rotation of the Spine
Each region of the spine (i.e., cervical, thoracic, and lumbar) has different ranges when it comes to rotation. It may be appropriate to address the rotation of each region separately, or to assess the ability of the spine to rotate as a whole.
Background: The term hernia describes a structure displaced from its original position. A herniated disc refers to an intervertebral disc that has shifted out of its place between two vertebral bodies. When this structure moves out of place, it can potentially push into a nerve nearby, causing irritation of the nerve and related symptoms elsewhere in the body.
Background: The separation or tearing of the rectus abdominis muscle is called diastasis recti. This commonly occurs with pregnancy as the growing abdomen stretches abdominal muscles to their limit and beyond. With targeted exercises and physical therapy, this issue can be reduced conservatively; however, surgery may sometimes be warranted.
Review Questions: Skeletal Landmarks of the Spine, Thorax, and Abdomen
How many vertebrae can be found in the cervical, thoracic, and lumbar regions respectively?
The transverse process points out laterally in the (frontal / sagittal / transverse) plane.
The spinous process can be found on the (anterior / posterior) side of a vertebrae.
The most inferior portion of the sternum is the .
There are pairs of ribs within the body.
The last rib is lateral to which vertebrae?
How many ribs directly attach to the sternum, and are therefore named true ribs?
The foramen, formed by the stacking of one vertebra on top of another, which can be seen in a sagittal view is the foramen.
The superior articulating processes of one vertebra communicate with the of the next superior vertebra.
The inferior angle is lateral to which vertebrae?
Review Questions: Musculature of the Spine, Thorax, and Abdomen
The most lateral muscle of the erector spinae group is the .
The serratus posterior superior acts to the ribs, while the serratus posterior inferior acts to them.
The internal oblique is (superficial / deep) to the transverse abdominis.
The supraspinous ligament begins at which vertebrae?
Which muscle attaches to the mastoid process of the temporal bone and acts to move the head?
The quadratus lumborum originates on the (pubic bone / iliac crest / sacrum).
What are the three muscles that compose the transversospinalis group?
The external oblique helps with rotation, while the internal oblique helps with .
The phrenic nerve innervates which muscle of the abdomen?
Name the muscles that run from one rib to the next and help with respiration.
