Lab 5

Surface Anatomy
Lower Extremity
(2020-2021)

Anatomy team (RS2040)

Department of Rehabilitation Sciences
The Hong Kong Polytechnic University

1
 Instruction (Palpation of Bony Structures)

1. Student work in pairs, alternating their roles and learn from each other:
o One student practices palpation. This student should:
 Pay particular attention to the technique of palpation, applying
the appropriate amount of pressure; take precautions so as not
to cause discomfort;
 Being aware of the partner’s reaction and respond to the
palpation
 Adjust the technique of palpation according to partner’s
comments
o The student being palpated should:
 Focus on the feeling and sensation on the part being palpated.
 Inform the palpator of these sensations (too much pressure
causing pain, too light, too quick, too slow and any other
uncomfortable or unpleasant sensations etc)

2. Appropriately expose the part to be palpated

3. For palpation of most skeletal parts, the muscles must be relaxed.

Contraction of a muscle tends to obscure any bony prominence near it.

2
 Instruction (Muscle Action & Palpation)

1. The practical sessions emphasize in developing both manual and verbal

skills.

2. Students should learn the attachments, nerve supply and actions of the
relevant muscle prior to each session.

3. Students work in pairs and alternate their roles.

4. Each student, while practicing muscle testing should:

o Pay attention in developing:
 The skills in giving instructions to the patient
 The technique of palpating and testing muscle actions
 The technique in testing the normal physiological length of
muscles
 The appropriate hand placement and application of resistance to
muscle contraction
 Appropriate positioning of the subject
 Necessary precautions so as not to cause discomfort
o Be aware of the partner’s reaction and respond to muscle testing
o Adjust the technique of muscle testing according to partner’s com-
ments
o Appropriately expose the part to be tested and palpated

5. Each student, when palpating and testing the strength of a muscle should:
o First note the shape, contour and texture of a normal muscle at rest
3
 o The palpating finger(s) should rest gently on the distal tendon (occa-
sionally on the proximal attachment) of the muscle or on its fleshly
part before and during its contraction
o Instruct the partner clearly and concisely on how to perform the re-
quired active concentric contraction
o Apply resistance to the action in the middle range to bring the muscle
into more prominent contraction
o Practice observing for deviations and substitution
o Allow your partner to relax and rest between each test

6. Each student, while testing the physiological length of a muscle, should:

o Appropriately position the partner
o Stabilize the proximal segment
o Take precaution not to over-stretch the muscle

7. The student partner also has to play an active role during the practical
sessions. The partner should:
o Focus on the feeling and sensation on the part being tested
o Inform the assessor of these sensations:
 Positioning causing discomfort
 Too much pressure causing pain, hand placement inappropriate
 Instructions: too quick, too slow or incomprehensible
 Any other uncomfortable or unpleasant sensations

8. The following sections provide instructions on how to bring the important

muscles into active contraction so that students can practice by themselves at
home, or practice with a partner.
4
 Lab 5: Surface Anatomy I: Lower Extremity
Table 1: Foot Region

Foot Region

1. Head of metatarsals 1-5

 Starting position: High sitting / supine
 Location: At the distal ends of the metatarsals.
 Palpation process: They can be brought into prominence by doing complete flex-
ion (active or passive) of the five metatarsal-phalangeal joints.

2. Tuberosity of 5th metatarsals

 Starting position: High sitting / Supine/ Side-lying
 Location: At the lateral side of the base (proximal end) of the bone
 Palpation process: Palpate along the lateral side of 5th metatarsal. The prominence
proximal to head of 5th metatarsal is tuberosity of 5th metatarsal.

3. Cuboid
 Starting position: High sitting/ Supine/ Side-lying
 Location: At the base of 5th metatarsus.
 Palpation process: Palpate along the lateral border of sole. Cuboid can be found as
the depression proximal to the bony prominence of tuberosity of 5th metatarsal.

4. Medial Cuneiform
 Starting position: Supine/ High sitting/ Side-lying
 Location: Between the navicular tuberosity and base of 1st metatarsal bone
 Palpation process: Palpate along the medial border of sole. Medial Cuneiform can
be found proximal to the first metatarsal bone.

5. Navicular tuberosity
 Starting position: Supine/ High sitting/ Side-lying
 Location: Lies on the medial surface of the bone, anterior to the sustentaculum tali,
about 2.5 cm inferior and anterior to the medial malleolus.
 Palpation process: Palpate along the medial border of sole. Navicular tuberosity
can be found proximal to the first metatarsal bone.

6. Locate and palpate the deltoid ligament

 Starting position: Supine/ High sitting/ Side-lying
 Location: Inferior to medial malleolus
 Palpation process: Eversion of foot brings the ligament to prominence

5
7. Locate and palpate the anterior and posterior talofibular ligament
 Starting position: Sitting/ Supine/ Side-lying
 Location:
(1) anterior talofibular ligament lies anterior to lateral malleous;
(2) posterior talofibular ligament lies posterior to lateral malleolus in the
direction pointing towards the heel.
 Palpation process:
(1)Anterior talofibular ligament: Depression is felt anterior to the lateral
malleolus. The ligament can be more easily palpated if the foot is in inversion.
Deep palpation may be required since the ligament is covered by the EDB muscle.
Posterior talofibular ligament: Palpate the site posterior to the lateral malleolus.
Dorsiflexion and inversion will help tight the ligament and allow easier
palpation.

8. Head of talus
 Starting position: Supine/ High sitting
 Location: Lies under the cover of the extensor tendons.
 Palpation process: Passively invert the foot, the dorsal and lateral part of the head
can be seen and felt about 3 cm anterior to the lower end of tibia.

9. Calcaneus: Sustentaculum tali

 Starting position: Supine/ High sitting
 Location: On the medial surface of the calcaneum bone, about 2.5 cm directly
inferior to the medial malleolus
 Palpation process: Locate the medial malleolus and move inferiorly 2. 5cm

10. Palpate the Achilles tendon

 Starting position: Prone
 Location: Inferior third of posterior lower leg
 Palpation process: Palpate in an upward direction from calcaneum bone.

11. Pulse of dorsalis pedis artery

 Starting position: Supine/ High sitting
 Location: Mark as the continuation of the anterior tibial artery, lateral to the ten-
don of EHL in the foot and ends at the proximal end of 1st inter-metatarsal space
 Palpation process: Find the tendon of EHL by resisted great toe extension.
Dorsalis pedis artery is located lateral to EHL tendon. Pulse can be felt along the
whole course (since it is superficial).

12. Pulse of posterior tibial artery

 Starting position: Supine/ High sitting
 Location: Midway between the medial malleolus and the prominence of the heel,
covered by flexor retinaculum
 Palpation process: Foot can inverted in order to relax the flexor retinaculum and
allow palpation through the retinaculum.

6
Table 2: Lower Leg

Lower Leg

1. Palpate the gastrocnemius and soleus

Gastronecmius:
 Starting position: Single leg stance
 Location: Posterior aspect of proximal lower leg
 Palpation process: Instruct the subject to rise on his/her toes. This action is
brought about by all the plantar-flexors of the ankle joint. Palpate and observe
the belly of these muscles.
Soleus:
 Starting position: Sitting, with the knee flexed and heel not in contact with the
floor
 Location: Posterior aspect of proximal lower leg
 Palpation process: Identify their common distal tendon (tendo-Achilles) near its
attachment to the posterior surface of the calcaneus. Palpate the soleus as
resisted plantar-flexion at the ankle joint (push the ball of foot against the floor).

2. Fibula: lateral malleolus

 Starting position: Sitting/ Supine/ Side-lying
 Location: At the distal end of the fibula, on the lateral side of the ankle
 Palpation process: Palpate the medial malleolus of the tibia and lateral malleous
at the same time. Note that the lateral malleolus is somewhat more posterior in
position and extends a little farther distally.

3. Fibula: fibula head

 Starting position: Sitting/ Side-lying
 Location: At the proximal end of the fibula.
 Palpation process: Fibula head articulates with the tibia, not the femur. It can be
felt on the postero-lateral side of the leg just distal (about 1.25 cm) and lateral to
the lateral condyle of the tibia

4. Palpate the lateral collateral ligament of knee joint

 Starting position: High sitting/ Supine
 Location: Lateral to the tibiofemoral joint line
 Palpation process: Palpation towards the lateral side from the patella along
tibiofemoral joint line.
5. Tibia: medial malleolus
 Starting position: Sitting/ Side-lying
 Location: At the lower end of tibia, on the medial side of the ankle
 Palpation process: Palpate along medial side of lower leg. The tip is about 1.3
cm proximal to the level of the tip of lateral malleolus.

7
6. Tibia: anterior border
 Starting position: Sitting/ Supine
 Location: Extends distally from the tuberosity of the tibia to the anterior part of
the medial malleolus
 Palpation process: Palpate downwards from the tibial tuberosity to the anterior
part of the medial malleolus

7. Tibia: tibial tuberosity

 Starting position: Sitting/ Supine
 Location: In the midline, anteriorly, between the two tibial condyle
 Palpation process: Palpate downward from the apex of patella along the patella
tendon. The bony prominence inferior to patella tendon is tibial tuberosity.

8. Palpate the medial collateral ligament

 Starting position: High sitting/ Supine
 Location: Medial aspect of tibiofemoral joint line.
 Palpation process: Palpation towards the medial side from the patella along tibio-
femoral joint line.

9. Palpate the patellar ligament

 Starting position: High sitting (knee flexed)
 Location: Just inferior to apex of patella.
 Palpation process: Found the inferior pole of patella and palpate downwards.

10. Palpate the tibiofemoral joint line

 Starting position: Supine/ Sitting with the knee flexed
 Location: Palpate the joint line and space at the upper margin of the tibial
condyles.
 Palpation process: Palpating fingers on either side of the ligamentum patellae (a
depression). Run your fingers laterally along this depression, and notice the joint
space narrowing as your fingers move posteriorly

11. Palpate the three points & borders of the patella and passively glide the patella medio-
laterally and supero-inferiorly
 Starting position: Supine with the knee in an extended position,
 Location: Can be easily marked by tracing around the perimeter of the patella.
 Palpation process: Instruct subject to relax the quadriceps. The patella can be
moved from side to side on the patellar surface of the femur. The patella can be
glided up and down along the vertical groove of the patellar surface of the femur.

8
Table 3: Thigh

Thigh

1. Femur: femoral condyles

 Starting position: Sitting with the knee flexed to 90°
 Location: Palpate the superior part of tibiofemoral joint line
 Palpation process: The superior part joint line is the femoral condyles

2. Femur: adductor tubercle

 Starting position: Sitting with the knee flexed to 90°
 Location: The most prominent area of the medial epicondyle
 Palpation process: Palpate along the medial side of the thigh from above down-
wards, it is a small tubercle at the lower 1/3 of the thigh

3. Femur: greater trochanter

 Starting position: Standing
 Location: Distal to the mid-portion of iliac crest
 Palpation process: Putting the proximal part of your hand on the midline portion
of the iliac crest, fingers pointing distally. The greater trochanter will be felt with
the tips of the fingers a little posterior to this mid-region of the hip. Do medial
and lateral rotation of the hip joint in order to bring it into greater prominence.

4. Palpate the muscle: quadriceps femoris (vastus lateralis, rectus femoris, vastus medialis)
 Starting position: Sitting
 Location: Anterior thigh
 Palpation process: Palpate various parts of this muscle during resisted knee
Extension, with downward resistance is applied just above the ankle

5. Palpate the muscle: adductor muscle group (adductor magnus)

 Starting position: Supine, both hip joints in abduction
 Location: Palpating fingers on the proximal medial border of thigh
 Palpation process: instruct subject to actively adduct the testing thigh (make sure
the thigh enters the adductor range)

6. Palpate the muscle: Sartorius

 Starting position: Supine/ Sitting with the testing limb in flexion, abduction and
lateral rotation of hip, and knee flexion (‘Figure of 4’ position)
 Location: Palpate the sartorius muscle from its origin on the anterior superior iliac
spine (ASIS) to its insertion point at the pes anserinus.
 Palpation process: Apply resistance just above the anterolateral surface of the
lower thigh in the direction of extension, adduction and medial rotation of the hip
and knee extension. Feel the contraction of muscle.

9
7. Palpate the muscle: biceps femoris
 Starting position: Prone lying
 Location: Posterior thigh
 Palpation process: Instruct the subject to flex the knee against resistance. Palpate
over lateral aspect of the knee

8. Palpate the muscle: semitendinosus/semimembranosus

 Starting position: Prone lying
 Location: Palpate over medial aspect of the knee
 Palpation process: Instruct the subject to flex the knee against resistance.

9. Find and palpate the femoral pulse

 Starting position: Supine lying
 Location: The femoral artery corresponds to the upper 2/3 of a line joining a point
midway between the ASIS and pubic symphysis (mid-point of inguinal ligament)
to the adductor tubercle.
 Palpation process: Feel the pulse of the femoral artery in the groin, about four
finger widths to the right or left of the genitals. Deep palpation may be required.

10. Find and palpate the popliteal pulse

 Starting position: Prone/ Sitting
 Location: Identify the boundaries of the popliteal fossa. Popliteal pulse lies within
the popliteal fossa.
 Palpation process: Pulse may be palpated when the subject’s knee is flexed (so
that the fascia and neighboring muscles are relaxed)

11. Trace and palpate the iliotibial tract from the origin to the insertion
 Starting position: Side-lying
 Location: Anterolateral iliac tubercle portion of the external lip of the iliac
crest and inserts at the lateral condyle of the tibia.
 Palpation process: Palpate from iliac crest to the lateral knee along the lateral side
of thigh.

10
Table 4: Pelvis

Pelvis

1. Palpate pubis : pubic crest

 Starting position: Supine
 Location: The most superior part of the pelvis near the midline
 Palpation process: Easily palpated with the abdominal muscles relaxed

2. Palpate pubis: pubic tubercle

 Starting position: Supine
 Location: Lateral end of the pubic crest
 Palpation process: Find the pubic crest and carefully palpate the prominence
lateral to it.

3. Palpate ischium: ischial tuberosity

 Starting position: Sitting
 Location: Bony part that the weight is borne on in sitting is the ischial
tuberosity
 Palpation process: Simply sit on your hand.

4. Identify location of the sciatic nerve (with partner)

 Starting position: Side-lying with hip neutral position
 Location: Sciatic nerve leaves the pelvis through the greater sciatic foramen
below the piriformis, runs to a point mid-way between the ischial tuberosity and
the greater trochanter and continues on the posterior aspect of the thigh until the
lower 1/3.
 Palpation process: Locate the ASIS and Ischia tuberosity first (if the hip is
flexed, the gluteus maximus moves upward and the ischial tuberosity becomes
easily palpable). The line joining ASIS and ischial tuberosity is called Nelaton
line. The mid-point of this line is the tip of greater trochanter. The mid-point
(midway) of the line between tip of greater trochanter and ischial tuberosity is
sciatic nerve.

5. Palpate the gluteus maximus relaxed and contracted from origin to insertion
 Starting position: Prone with knee flexed
 Location: Buttock
 Palpation process: Instruct the subject to extend the hip joint, while applying
resistance to hip extension at the lower 1/2 of the thigh.

11
6. Palpate ilium- iliac crest
 Starting position: Sitting
 Location: Most lateral and superior part of the pelvis
 Palpation process: Palpate along its entire extent, from ASIS to PSIS

7. Palpate ilium- ASIS

 Starting position: Sitting
 Location: Anterior end of the iliac crest
 Palpation process: Palpate along the iliac crest to its most anterior point

8. Palpate ilium- PSIS

 Starting position: Sitting
 Location: A skin depression (dimple) often marks its site, i.e. S2
 Palpation process: Follow the iliac crest posteriorly and feel a prominence 2.5-5
cm lateral to the midline of the body.

9. Locate the region of the inguinal ligament

 Starting position: Supine
 Location: The inguinal ligament connects the ASIS o the pubic tubercle.
 Palpation process: Try to palpate starting from the ASIS if possible.

10. Outline the femoral triangle on your partner and identify the structures within it
 Starting position: Supine
 Location: The femoral triangle is formed by inguinal ligament superiorly,
sartorius laterally, and adductor longus medially.
 Palpation process: Try to identify the 3 borders and identify the content of
femoral triangle

References:

Anatomy Team: Functional Anatomy Laboratory Handbook 2018-2019. Department of Rehabili-

tation Sciences, The Hong Kong Polytechnic University; 2019

Kendall FP, McCreary EK, Provance PG. Muscles, Testing and Function: With Posture and Pain.
5th edition. Lippincott Williams & Wikins; 2005

Clarkson HM. Musculoskeletal Assessment: Joint Motion and Muscle Testing. 3rd edition. Lip-
pincott Williams & Wilkins; 2013

MAGEE, David J. Orthopedic physical assessment.6th edition. Elsevier Health Sciences; 2014.

12