Directions: Locate the temporomandibular joint, which is located anterior to the tragus, or middle, of the external ear. Instruct your partner to open and close their mouth while you palpate for the condyle of the mandible, which rotates and anteriorly slides during the opening of the mouth.
Muscles That Attach Here: Lateral pterygoid
Angle
How to Palpate
Position of Partner: Sitting
Directions: Locate the superior ramus of the condyle and palpate inferiorly toward the angle. This is the point of the mandible where it changes direction. Appreciate the rounded angle of the mandible as it serves as the transition toward the mandibular body.
Muscles That Attach Here: Masseter
Structure That Attaches Here: Stylomandibular ligament
Ramus
How to Palpate
Position of Partner: Sitting
Directions: Locate the condyle and angle of the mandible using the strategies above and palpate toward the midpoint of these structures along the broad ramus of the mandible.
Muscles That Attach Here: Masseter, medial pterygoid, temporalis
Mental Protuberance
How to Palpate
Position of Partner: Sitting
Directions: Locate the midpoint of the right and left halves of the mandible, located anteriorly along the sagittal plane of the face. Palpate the anterior chin, appreciating the slight ridge here, which is the mental protuberance.
Body
How to Palpate
Position of Partner: Sitting
Directions: Appreciate the mental protuberance and the angle of the mandible’s boundaries to the body of the mandible. Palpate along the mandible toward the midpoint of both structures, identifying the broad mandibular body along this pathway.
Muscles That Attach Here: Mylohyoid, geniohyoid
Hyoid
How to Palpate
Position of Partner: Sitting, supine
Directions: Palpate the thyroid cartilage, where the laryngeal prominence, or Adam’s apple, can be identified along the midline of the anterior neck. Slide superiorly along the midline of the neck until you palpate the skeletal body of the hyoid. Alternatively, you may begin at the midpoint of the chin and palpate inferiorly until the hyoid bone is identified. Be aware that this may be an uncomfortable palpation for your partner, so monitor their comfort as you proceed through the process of locating this bone.
Directions: Begin by locating the sternoclavicular joint, which serves as the midpoint for the distal attachments of the sternocleidomastoid at the medial clavicle and manubrium. Instruct your partner to rotate their head to the contralateral side (e.g., if palpating on your partner’s right, instruct them to look left), and visually locate the sternocleidomastoid as it contracts and becomes more prominent while facilitating this motion. Then palpate along this muscle toward its origin at the mastoid process and the superior nuchal line.
Action(s): Scapular elevation, cervical side bending
Innervation(s): Spinal accessory nerve (CN XI)
How to Palpate
Position of Partner: Sitting, prone
Directions: Begin by palpating along the acromion process and lateral clavicle and instruct your partner to elevate their ipsilateral shoulder. Palpate along the muscle belly of the upper trapezius as it attaches to the cervical spine and cranium at the nuchal line, nuchal ligament, and external occipital protuberance.
Scalenes
Origin(s):
Anterior: Transverse process C3-6
Middle and Posterior: Transverse process of C5-7
Insertion(s):
Anterior and Middle: 1st rib
Posterior: 2nd rib
Action(s):
Anterior and Middle: Cervical flexion, 1st rib elevation
Posterior: Cervical side bending, 2nd rib elevation during inspiration
Innervation(s): Anterior rami
How to Palpate
Position of Partner: Supine
Directions: While your partner is in supine position, support the head with one hand and locate the posterior triangle of the lateral aspect of the neck. This triangle is formed by the sternocleidomastoid, the upper trapezius, and the clavicle. Once this triangle is visualized, palpate deep into the triangle to access the scalenes. The anterior and middle scalenes can be best appreciated due to their anatomical arrangement and can be followed to their insertion on the first rib.
Masseter
Origin(s): Zygomatic bone
Insertion(s): Angle and ramus of the mandible
Action(s): Mandible elevation
Innervation(s): Trigeminal nerve (CN V)
How to Palpate
Position of Partner: Sitting
Directions: Palpate the angle of the mandible using the instructions above and instruct your partner to clench their teeth. Palpate superiorly toward the zygomatic bone along the broad, thick masseter muscle.
Temporalis
Origin(s): Temporal fossa of the temporal bone
Insertion(s): Coronoid process and ramus of the mandible
Action(s): Mandible elevation
Innervation(s): Trigeminal nerve (CN V)
How to Palpate
Position of Partner: Sitting, supine
Directions: Place your fingers on the lateral aspect of the cranium, located approximately two to three finger breadths superior to the zygomatic arch or posterior-superior to the lateral aspect of the orbit. Instruct your partner to clench their teeth to appreciate a contraction of the temporalis muscle.
Directions: This muscle can be palpated extraorally or intraorally. All intraoral palpation should be completed after appropriately donning medical gloves. Extraoral palpation is performed with your partner’s head in slight flexion and pressing upward at the angle of the inner surface of the mandible. Intraoral palpation is achieved by sliding a finger along the inner portion of the molars until you palpate the muscle tissue located along the inner portion of the ramus.
Lateral Pterygoid
Origin(s): Sphenoid
Insertion(s): Temporomandibular joint, condyloid process of mandible
Directions: Conflicting evidence exists regarding reliable palpation of the lateral pterygoid. Proposed palpation procedures would require supine positioning of the patient. Wearing a medical glove, slide a finger along the lateral aspect of the upper molars. Continue in a posterior-superior direction toward the condyloid process.
Directions: Begin by locating the tragus of the external ear, and palpate anteromedially until you meet the mandibular condyle, located at the inferior aspect of the temporomandibular joint. Instruct your partner to open and close their mouth, appreciating the degree of movement of the condyle on the articular eminence, thus appreciating the degree of movement of this joint.
Directions: Orient to the anterior neck, through its superior and inferior borders, the chin and jugular notch, respectively. Follow superior to inferior, or inferior to superior, along the midline of the neck. Locate a prominent ridge along the anterior neck, located approximately two-thirds of the length of the neck, superior to the jugular notch. The laryngeal prominence is colloquially known as the “Adam’s apple.”
Carotid Artery
How to Palpate
Position of Partner: Supine, sitting
Directions: Locate the anteromedial aspect of the sternocleidomastoid and the trachea at the level of the cricoid cartilage. You may move from medial to lateral, or lateral to medial, targeting the middle third of the neck. Gently palpate the carotid artery.
This motion occurs at the subtalar joint, so it’s important to focus on the hindfoot when assessing these ranges. For instance, when performing a passive range of motion assessment for these ranges, it’s important to grab the hind heel and move it in the frontal plane in the direction of inversion and eversion.
Cervical Rotation
Flexion and extension occur at the metatarsophalangeal and interphalangeal joints. Depending on the purpose of these assessments, it may be appropriate to isolate individual joints or to assess all toes at once.
Background: Whiplash is the most common type of injury following a motor vehicle accident. Whiplash occurs when an individual experiences rapid movement of the neck (e.g., neck flexion to neck extension) and typically results in neck pain, decreased range of motion of the cervical spine, and/or functional activity deficits. Muscles, ligaments, and cervical facet joints of the cervical spine may be implicated in a whiplash injury. Whiplash is typically treated through physical therapy and medical management.
Temporomandibular Joint (TMJ) Pain
Background: Temporomandibular joint pain is a multifactorial musculoskeletal pain condition affecting muscular and/or articular structures of the temporomandibular joint. In addition to pathoanatomical structures, temporomandibular joint pain may be secondary to parafunctional behaviors, psychological distress, or psychosocial dysfunction. An assessment of range of motion and palpation of muscle tissue of the face and TMJ are typically performed to develop a plan of care for these patient populations.
Spinal Accessory Nerve Palsy
Background: A spinal accessory nerve palsy is a transient or permanent loss of nerve function typically due to trauma or a surgical procedure. Muscle weakness in tissues innervated by the spinal accessory nerve, pain in the neck/shoulder complex, and altered shoulder motion are typical physical examination findings. The spinal accessory nerve innervates the trapezius and sternocleidomastoid. In addition to a thorough review of a patient’s medical information and subjective history, a physical examination may assist in the differential diagnosis process.
Review Questions: Skeletal Landmarks of the Head and Neck
The masseter, medial pterygoid, and temporalis attach to what bony structure?
The (angle / condyle) is located between the ramus and body of the mandible.
The hyoid is located (superior / inferior) to the laryngeal prominence.
Describe how you would palpate the temporomandibular joint.
During lateral deviation to the right, the right TMJ glides (laterally / medially), and the left TMJ glides (laterally / medially).
Review Questions: Musculature of the Head and Neck
The spinal accessory nerve innervates the (sternocleidomastoid / scales / masseter).
What muscles are responsible for mandible elevation?
Which of the following motions occurs in the frontal plane? (Cervical flexion / cervical extension / cervical side bending)
What is the action(s) of the lateral pterygoid?
Unilateral contraction of the sternocleidomastoid results in (ipsilateral / contralateral) cervical rotation.
