Directions: Although the spine of the scapula is covered by musculature, it is very prominent in comparison to the surrounding fossae. Begin by placing your partner in prone position. Make sure they are relaxed so that the muscles that cover the scapula are not engaged, as this would make it more difficult to feel any landmarks deep to those muscles. Feel toward the more superior aspect of the scapula. The spine will feel like a ledge that spans the scapula, from one side to the other, in a diagonal manner. Note in Figure 2.2 the orientation in which the diagonal travels.
Muscles That Attach Here: Deltoid and trapezius
Fossae: Supraspinous fossa
How to Palpate
Position of Partner: Prone, sitting
Directions: After identifying the spine of the scapula, move superior to where a less prominent depression, or drop off, can be felt. Make sure to stay on the scapula while locating this depression.
Muscles That Attach Here: Supraspinatus
Infraspinous Fossa
How to Palpate
Position of Partner: Prone, sitting
Directions: Move inferior to the spine while staying within the borders of the scapula. This large expanse constitutes the infraspinous fossa.
Muscles That Attach Here: Infraspinatus
Subscapular Fossa
How to Palpate
Position of Partner: Supine
Directions: Begin with your partner in a supine position with their shoulder flexed above their head. Cradle their arm so they can relax. This will make it easier for you to access this area. Begin palpating the scapula as it wings out laterally from the thorax. Concentrate on palpating the anterior aspect, which is where the subscapular fossa is located.
Muscles That Attach Here: Subscapularis
Borders and Angles
Inferior Angle
How to Palpate
Position of Partner: Standing, sitting, prone
Directions: Place your partner’s arm behind their back so that their hand is resting on their low back. This will help move the scapula into a position that pops the inferior angle out. Palpate toward the most inferior point of the scapula, where the medial and lateral borders converge to a point.
Muscles That Attach Here: Teres major
Lateral Border
How to Palpate
Position of Partner: Standing, sitting, prone
Directions: Starting at the inferior angle, travel up the lateral side of the scapula until the scapula can no longer be felt. Eventually, as you move toward the shoulder, this border becomes difficult to palpate because of the increase in musculature in this area.
Muscles That Attach Here: Teres minor
Medial Border
How to Palpate
Position of Partner: Standing, sitting, prone
Directions: Start again at the inferior angle and travel up the medial side of the scapula until the border ends.
Muscles That Attach Here: Rhomboids and serratus anterior
Superior Angle
How to Palpate
Position of Partner: Standing, sitting, prone
Directions: Follow the medial border superiorly until this angle change is felt. Palpating this angle can be difficult because thick musculature may exist in this area. Take time to ensure you have reached the superior angle, and not just the midpoint of the spine. If you have reached the superior spine you should be able to palpate inferiorly along the medial border from that point.
Muscles That Attach Here: Levator scapulae
Acromion Process
How to Palpate
Position of Partner: Prone, sitting
Directions: This process of the scapula can be palpated in two ways. First, while your partner is lying prone, palpate the spine of the scapula. Travel all the way to the most lateral aspect of the spine until you are at the top of the shoulder at the acromion process. If you feel a depression where the acromion meets the clavicle, you have gone a little too far. The second approach to finding the acromion process is to face your partner while they are seated facing you. Start by palpating the clavicle and proceed to palpate toward the lateral end of the bone. Palpate past the clavicle, where you will feel a divot and then the start of the acromion.
Muscles That Attach Here: Deltoid and trapezius
Structures That Attach Here: Acromioclavicular ligament, coracoacromial ligament
Coracoid Process
How to Palpate
Position of Partner: Sitting
Directions: While facing your partner, first visualize where the acromion and humeral head are. Begin to palpate by locating the coracoid, inferior to the acromion and medial to the humeral head. Pressure may need to be applied to feel this hook-like prominence floating in this area. Be careful not to palpate too hard and hurt your partner.
Muscles That Attach Here: Coracobrachialis, biceps brachii (short head), pectoralis minor
Structures That Attach Here: Coracoclavicular ligament, coracohumeral ligament
Directions: While facing your partner, begin by palpating the anterior aspect of the humeral head. Find the medial aspect of the humeral head where the tubercles are. These two tubercles are next to each other. The greater tubercle is slightly larger, slightly more superior, and lateral to the lesser tubercle. To ensure you are at the right location, flex your partner’s elbow to 90 degrees and then medially and laterally rotate their shoulder. This will move the humeral head underneath your thumb or fingers. You should feel the tubercles moving side to side as you move your partner in these directions.
Muscles That Attach to the Greater Tubercle: Supraspinatus, infraspinatus, teres minor
Muscles That Attach to the Lesser Tubercle: Teres major, subscapularis
Intertubercular Sulcus
How to Palpate
Position of Partner: Sitting, standing, supine
Directions: The intertubercular sulcus is a small groove located between the greater and lesser tubercles. When sliding from one tubercle to the other, you may feel as though you are moving a piece of tissue. This is the long head of the biceps brachii, which runs through this sulcus as it ascends to the glenoid cavity of the scapula.
Muscles That Attach Here: Latissimus dorsi, teres major
Structures Located Here: The long head of the biceps brachii runs through this groove.
Deltoid Tuberosity
How to Palpate
Position of Partner: Sitting, standing, supine
Directions: Although you will not feel a prominence or skeletal landmark when feeling for this insertion of the deltoid muscle, you can determine you are in the correct location by finding the tapering of the deltoid muscle at its distal attachment here. Have your partner abduct their shoulder against resistance to engage the muscle and better define its borders. This will make it easier to find the location of the deltoid tuberosity.
Muscles That Attach Here: Deltoid
Clavicle
How to Palpate
Position of Partner: Sitting, standing, supine
Directions: The clavicle is a prominent bone that can be identified with the unaided eye. Palpate the entire clavicle, taking note of the curvature of the bone and the end points at either end.
Muscles That Attach Here: trapezius, deltoid, pectoralis major, sternocleidomastoid, subclavius
Upper Trapezius: occipital bone (external occipital protuberance and nuchal line), ligamentum nuchae
Middle Trapezius: thoracic spinous processes
Lower Trapezius: thoracic spinous processes
Insertion(s)
Upper Trapezius: clavicle
Middle Trapezius: acromion and spine of scapula
Lower Trapezius: spine of scapula
Action(s)
Upper Trapezius: elevates the scapula
Middle Trapezius: retracts the scapula
Lower Trapezius: depresses the scapula
Innervation(s): Spinal accessory nerve (CN XII)
How to Palpate
Position of Partner: Prone, sitting
Directions: Approach this expansive muscle by breaking it down into its three regions. Note the fiber direction of each region and try to palpate in these orientations as you work your way through the tissue. For each section, simply work your way from the origin to the insertion, or insertion to the origin.
Action(s): Extension, adduction, and medial rotation of the shoulder
Innervation(s): Thoracodorsal nerve
How to Palpate
Position of Partner: Prone, sitting
Directions: Begin by palpating the origin of this muscle as it begins near the iliac crest and thoracolumbar fascia. Work your way diagonally to the lower ribs, moving on the continued diagonal around the thorax. Have your partner abduct and medially rotate their shoulder so that you can feel the latissimus dorsi posterior to the shoulder as it creates the posterior border to the axilla.
Deltoid
Origin(s)
Anterior: clavicle
Middle: acromion process of the scapula
Posterior: spine of the scapula
Insertion(s): Deltoid tuberosity
Action
Anterior: flexion and medial rotation of the shoulder
Middle: abduction of the shoulder
Posterior: extension and lateral rotation of the shoulder
Innervation(s): Axillary nerve
How to Palpate
Position of Partner: Sitting, supine, prone
Directions: Because this muscle is so expansive, it is important to break it up into regions even for palpation purposes.
Beginning with the anterior portion, palpate from just inferior to the mid-clavicle and work your way laterally until you find yourself at the humeral head. Then descend with the fibers toward the deltoid tuberosity.
For the middle portion, begin at the acromion process and work your way laterally and eventually descend to the deltoid tuberosity.
Finally, for the distal portion of the deltoid, begin by palpating the spine of the scapula. Then work your way laterally to the posterior aspect of the shoulder and then descend to the deltoid tuberosity.
Levator Scapulae
Origin(s): Cervical transverse processes
Insertion(s): Superior angle of the scapula
Action(s): Elevation and downward rotation of the scapula
Innervation(s): Dorsal scapular nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: For this small muscle, simply palpate from its origin to insertion or vice versa. Although this muscle is deep to the trapezius at its inferior attachment, it is the most superficial muscle along its orientation within the neck. When palpating the border of the upper trapezius within this region, the levator scapulae can be directly palpated anterior to this border in the cervical region.
Action(s): Retraction and downward rotation of the scapula
Innervation(s): Dorsal scapular nerve
How to Palpate
Position of Partner: Prone, sitting
Directions: Although the rhomboids are located deep to the trapezius, you can palpate them by pressing deep on the trapezius along the origin and insertion of the rhomboid minor and major, respectively. Palpate from their origin to insertion, or vice versa, and recognize that the rhomboid minor is superior to the rhomboid major, but that these muscles otherwise have similar fiber orientation.
Supraspinatus
Origin(s): Supraspinous fossa of the scapula
Insertion(s): Greater tubercle of the humerus
Action(s): Abduction
Innervation(s): Suprascapular nerve
How to Palpate
Position of Partner: Prone, sitting
Directions: Begin by locating the spine of the scapula. Next, move superiorly while remaining on the scapula, and palpate this portion of the bone, the supraspinous fossa, where the muscle is located.
Infraspinatus
Origin(s): Infraspinous fossa of the scapula
Insertion(s): Greater tubercle of the humerus
Action(s): Lateral rotation of the shoulder
Innervation(s): Suprascapular nerve
How to Palpate
Position of Partner: Prone, sitting
Directions: After locating the spine of the scapula, move inferiorly while remaining on the scapula and palpate this portion of the bone, the infraspinous fossa, where the muscle is located.
Teres Minor
Origin(s): Lateral border of the scapula
Insertion(s): Greater tubercle of the humerus
Action(s): Lateral rotation of the shoulder
Innervation(s): Axillary nerve
How to Palpate
Position of Partner: Prone, sitting
Directions: First, locate the infraspinatus muscle. Next, move slightly inferiorly and laterally until you are palpating the lateral border of the scapula. This is where the muscle begins. Continue to move laterally over the thorax while ascending to the shoulder. Eventually this muscle, along with the latissimus dorsi, will form the posterior wall of the axilla and become more difficult to trace.
Teres Major
Origin(s): Inferior angle of the scapula
Insertion(s): Intertubercular sulcus of the humerus
Action(s): Medial rotation and adduction of the shoulder
Innervation(s): Lower subscapular nerve
How to Palpate
Position of Partner: Prone, sitting
Directions: First, locate the origin of this muscle at the inferior angle of the scapula. Next, palpate the belly of the muscle by moving laterally toward the shoulder. Eventually this muscle becomes hard to trace as it dives anteriorly to insert on the humerus.
Subscapularis
Origin(s): Subscapular fossa of the scapula
Insertion(s): Lesser tubercle of the humerus
Action(s): Medial rotation of the shoulder
Innervation(s): Upper and lower subscapular nerves
How to Palpate
Position of Partner: Supine
Directions: Begin with your partner in a supine position with their shoulder flexed above their head. Cradle their arm so that they can relax. This will make it easier for you to access the area of this muscle. Begin palpating the scapula as it wings out laterally from the thorax. Concentrate on palpating the anterior aspect, which is where the subscapularis is located.
Pectoralis Major
Origin(s)
Clavicular Head: clavicle
Sternocostal Head: sternum, first six costal cartilages, and aponeurosis of external oblique muscle
Insertion(s): Intertubercular sulcus of the humerus
Action(s): Adduction, flexion, and medial rotation of the shoulder; protraction of the scapula
Innervation(s): Lateral and medial pectoral nerves
How to Palpate
Position of Partner: Supine, sitting
Directions: Because this muscle is in a potentially sensitive area, it’s especially important to have consent to palpate and to also discuss with your partner what you are doing while palpating this area. Begin by palpating the areas of the origin of this muscle, from the clavicle to the sternum, and then working your way laterally to its insertion on the humerus.
Pectoralis Minor
Origin(s): Ribs 3–5
Insertion(s): Medial border and coracoid process of the scapula
Action(s): Depression, protraction, and downward rotation of the scapula
Innervation(s): Medial pectoral nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Because of the location and positioning of this muscle below the pectoralis major, it’s difficult to palpate. To tackle this muscle through palpation, begin at the coracoid process and work your way down to the upper ribs. To help provide you with the best ability to palpate this muscle, place your partner’s shoulder in a slightly protracted position to ensure relaxation of the pectoralis major.
Serratus Anterior
Origin(s): Ribs 1–9
Insertion(s): Medial border of the scapula
Innervation(s): Long thoracic nerve
Action(s): Protraction and upward rotation of the scapula
How to Palpate
Position of Partner: Supine, sitting
Directions: First, find the lateral border of the scapula. Although the serratus anterior does not have an attachment to the lateral border, this is where you can begin to feel the muscle after it has journeyed under the scapula from its insertion on the medial border of the scapula. Continue to palpate the muscle around the thorax until it blends into the ribs. Simultaneous palpation of the muscle during manually resisted scapular protraction and/or upward rotation may accentuate the ability to appreciate this structure.
Biceps Brachii
Origin(s)
Long Head: supraglenoid tubercle of the scapula
Short Head: coracoid process of the scapula
Insertion(s): Radial tuberosity
Action(s): Elbow flexion and supination, shoulder flexion
Innervation(s): Musculocutaneous nerve
How to Palpate
Position of Partner: Sitting
Directions: Beginning with the proximal portion of the muscle, palpate the long head of the biceps brachii within the intertubercular sulcus. Descend the long head until you’ve approached the muscle belly. Next, travel back to the other origin of the biceps brachii at the coracoid process, where the short head of the biceps brachii originates. Descend to the muscle belly and continue toward the insertion at the proximal radius. Alternatively, you may instruct your partner to perform active elbow flexion against resistance to better appreciate the observation and borders of the muscle bellies.
Coracobrachialis
Origin(s): Coracoid process of the scapula
Insertion(s): Humerus
Action(s): Flexion and adduction of the shoulder
Innervation(s): Musculocutaneous nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Have your partner in supine position. Start your palpation journey at the coracoid process and then descend the brachial region while taking care to remain medial to the muscle belly of the biceps brachii. The coracobrachialis ends around mid-humerus, as should your palpation of this muscle. Instructing the patient to perform active shoulder flexion and adduction against resistance may provide necessary nuance to appreciate the muscle from adjacent structures.
Brachialis
Origin(s): Humerus
Insertion(s): Coronoid process of the ulna and ulnar tuberosity
Action(s): Elbow flexion
Innervation(s): Musculocutaneous nerve
How to Palpate
Position of Partner: Sitting
Directions: Begin about mid-humerus on the lateral side of the arm. Try to palpate between the biceps brachii and the humerus. This muscle is deep to the biceps brachii, so you will be able to palpate only the small portion of the muscle belly that is accessible on the lateral side.
Triceps Brachii
Origin(s)
Long Head: infraglenoid tubercle of the scapula
Lateral Head: humerus
Medial Head: humerus
Insertion(s): Olecranon process of the ulna
Action(s): Elbow extension; shoulder extension
Innervation(s): Radial nerve
How to Palpate
Position of Partner: Sitting, prone
Directions: Have your partner in seated or prone position. Beginning with the proximal end of the muscle, start around the posterior shoulder and descend with your palpations. Cover the whole posterior aspect of the brachial region and end at the point of your elbow, at the olecranon process.
Directions: Start at the medial end of the clavicle and palpate toward the sternum. A step-off will be palpable as you move from the rounded end of the clavicle toward the flat manubrium of the sternum. In this area of indentation is where the sternoclavicular joint exists.
Acromioclavicular Joint
How to Palpate
Position of Partner: Supine, sitting
Directions: Begin by palpating either the distal end of the clavicle or the acromion process. Travel toward the other bone until you feel a difference in curvature of the bones. This joint may be visually identified before even palpating because of its prominence.
Acromioclavicular Ligament
How to Palpate
Position of Partner: Supine, sitting
Directions: As you palpate the acromioclavicular joint, you are subsequently palpating the acromioclavicular ligament, which bridges the two articulating bones. The ligament itself, like many ligaments, will not be distinct, so it is important to make sure you are palpating the correct location, based on your anatomical knowledge.
Coracoacromial Ligament
How to Palpate
Position of Partner: Supine, sitting
Directions: Simply palpate between the two articulating bones, the coracoid, and the acromion process, to palpate the connecting ligament.
Deltopectoral Groove
How to Palpate
Position of Partner: Supine, sitting
Directions: This groove can be felt between the borders of the deltoid and pectoralis major muscles. Find the anterior border of the anterior deltoid and palpate along this ridge. To make this border more prominent, you can have your partner perform shoulder flexion while you provide resistance.
Note: This is where the cephalic vein runs superficially.
For passive and resistive ranges, ensure the patient is seated or lying down in a manner that provides you with a vantage point with overhead positions of their arm.
Abduction and Adduction
As with flexion and extension ranges, ensure the patient is situated in a position that provides you with the ability to work with their arm overhead.
Lateral (External) Rotation and Medial (Internal) Rotation
There are many ways in which these ranges can be performed and assessed. Consistency with how your assessment is performed is important to ensure reliability and an accurate assessment.
Horizontal Abduction and Adduction
Make sure your patient has their shoulder flexed to 90 degrees and extended straight out in front of them as they move it in the transverse plane while not rotating their shoulder and remaining neutral.
Background: A sprain is an injury to a ligament at a joint. There are different levels of severity of a sprain ranging from grade 1 to grade 3. A grade 1 sprain occurs when the fibers of the ligament simply become stretched, while a grade 2 sprain involves a partial tear of the ligament. A grade 3 sprain is the most severe type of sprain: the ligament becomes fully torn.
A sprain to the acromioclavicular ligament of the acromioclavicular joint can occur when someone falls on their shoulder or when they fall on their outstretched arm. Depending on the severity of the sprain, sometimes a visible deformity can be observed at the joint. This would indicate there has been separation of the acromion from the clavicle.
Background: Inflammation of a tendon is referred to as tendonitis. Typically, tendonitis coincides with overuse of the affected muscle through repetitive motions, which can result in inflammation, pain, and weakness of the muscle.
This injury can occur at the proximal end of the muscle through repetitive overhead motions of the arm. As the shoulder flexes or abducts, the long head of the biceps brachii can become impinged upon in the space underneath the subacromial arch. Underneath this arch is a small area in which several structures, including the long head of the biceps brachii, the supraspinatus tendon, and the subacromial bursa, are packed beneath the acromion process and distal end of the clavicle. When the arm moves into an overhead position, this space becomes smaller, and the structures that run through it can be impinged.
SLAP Tear
Background: Damage to the glenoid labrum, within the shoulder complex, can occur over time with repetitive motions, or acutely in a traumatic incident.
A superior labrum anterior posterior tear (SLAP) is a common glenoid labral tear in individuals with a primary complaint of shoulder pain. This type of labrum tear may present with an array of different symptoms, including clicking, locking, or pain with shoulder movement, along with a decrease in strength of surrounding muscles. Both conservative and surgical treatment options are available for this injury.
Review Questions: Skeletal Landmarks of the Shoulder and Arm
When palpating the medial border, what skeletal structure can be felt if you move to the superior end of the border?
Which structure is more lateral, the greater or lesser tubercle of the humerus?
The subscapular fossa is located on the (anterior / posterior / superior) side of the scapula.
How is the landmark of a “tuberosity” created (e.g., deltoid tuberosity)?
Which ligament spans the acromioclavicular joint?
The fossa is found superior to the spine of the scapula.
When palpating the spine of the scapula toward its lateral end, what other skeletal structure can be felt?
The clavicle articulates with two bones: the (sternum / scapula) toward its medial end, and the (sternum / scapula) toward its lateral end.
The can be found between the greater and lesser tubercles on the humerus.
Describe what a fossa looks and/or feels like on a bone.
Review Questions: Musculature of the Shoulder and Arm
Identify three muscles that attach to the coracoid process.
The biceps brachii inserts on the .
Which tendon can be found running through the intertubercular sulcus?
True/False: The upper fibers of the trapezius are antagonistic to the lower fibers of the trapezius.
The rhomboid minor and major muscles are deep to which muscle?
The anterior deltoid rotates the shoulder.
Identify all the flexors of the shoulder.
Which muscle originates at the infraglenoid tubercle of the scapula?
The medial pectoral nerve is the only nerve that innervates the (pectoralis minor / pectoralis major / coracobrachialis).
The middle deltoid acts to the shoulder and originates at the
