After meeting a stranger, you soon begin to palpate their piriformis Topographical Views 276 muscle (located deep in the posterior buttock). You certainly wouldn’t try Exploring the Skin and Fascia 277 this in “everyday life,” but in patient care settings this level of familiarity is Bones of the Pelvis and Thigh 278 commonplace—and welcomed by a client with a hypercontracted piriformis. Bony Landmarks of the Pelvis Touch is a unique privilege afforded to health care providers. As such, we and Thigh 279 need to be mindful of the trust our clients have in us. One way to insure this Overview: Bony Landmark Trails 284 is through good communication skills. For instance, working the adductors Overview: Muscles of the and gluteal region requires a practitioner to provide ample explanation as to Pelvis and Thigh 296 the rationale, need, and goals of working these intimate areas of the body. Synergists—Muscles Working This chapter might pose new challenges for you, as we will be palpating Together 302 structures close to intimate areas. Muscles of the Pelvis and Thigh 306 Ligaments and Other Before proceeding, consider the following questions: Structures of the Pelvis and Thigh 336 EE Have you ever been anxious to undergo a physical exam? Was there anything the practitioner did or could have done to alleviate this anxiety? Consider multiple elements, including both verbal and nonverbal communication, draping, physical pressure, and pace. EE Tissues and landmarks found in the pelvis and thigh tend to be significantly larger than those discussed in previous chapters. How might your palpation techniques need to change? EE Also, how might you properly and comfortably position your patient to access structures needing to be palpated. What pillows, bolsters, or other items could you use at your home, school, or clinic?
275 muscles Posterior view of pelvis, Gluteus maximus Location of the gluteal tuberosity Iliotibial tract Vastus lateralis (deep) istally along the posterior 6.36 relationship to the surrounding showing the gluteal tuberosity’s istally four or five inches Can you press into palpating Can and the are you press you feel area Holding the ankle, flex the knee to 90˚. As your proximal Holding flex the the As knee ankle, proximal your to 90˚. the superficial directly of you surface Are the femur? hand palpates the greater trochanter, use the other hand hand trochanter, the palpates greater Gluteal tuberosity Gluteal Greater trochanter Greater
Slide one or two inches d Slide your fingerpads d Slide your fingerpads shaft of the femur until you feel the solid surface of shaft of the femur feel not like a ridge but the tuberosity (6.37). It might portion of bone. more like a flat, superficial greater trochanter. greater trochanter. along the side of the thigh. There you will feel the along the side of the greater trochanter. hump of the superficial all of its sides. Sculpt around its two-inch-wide surface and explore Sculpt around its two-inch-wide P P
artner prone.Locatetheposteriorsurfaceof oftheiliaccrest. prone.Locatethemiddle artner Gluteal Tuberosity to the posterior The gluteal tuberosity is located distal It is a small ridge surface of the greater trochanter. serving as an attachment fibers of the site for the lower Although it is surrounded by muscle. gluteus maximus tendon and the upper fibers of the the gluteus maximus (6.36), the gluteal tuberosity is vastus lateralis muscles and accessible. relatively superficial 1. 2. Greater Trochanter Greater 287 for more information.) (Refer to p. 1. 2. 3. lateral to the ischial tuberosity (p. 287)? to lateral the (p. ischial tuberosity to to medially the and Do feel rotate the you hip laterally (6.35). back and swivel trochanter forth under fingers? your Greater trochanter Partner prone, trochanter 6.35 movement of the greater rotating the hip to feel the Posterior view 6.37 Gluteal tuberosity Trail GuideTrail the to Body Hip Hike Hip 4 Trail 292
Pelvis & Thigh . . . . gluteus Medius Gluteus Maximus Gluteus which isdeeptothemaximus (6.80).Boththegluteus hip andisalsosuperficial, exceptfortheposteriorportion buttock (6.79). of thegroupandhasfibersthatrundiagonally acrossthe large, superficial gluteusmaximus isthemostposterior region, deeptothesurrounding adipose tissue.The The threeglutealmuscles arelocatedinthebuttock Gluteus Maximus,Medius,andMinimus Gluteals A A O O N N I I The Superior gluteal L4 gluteal Superior greaterofLateral trochanteraspect crestiliac lines,the belowjust glutealilium,anteriorsurfaceGlutealofbetweenposterior and (coxalhip Laterallyrotatethe joint) (coxalhip Extendthe joint) fibers: Posterior (coxalhip rotatethe Medially joint) (coxalhip Flexthe joint) fibers: Anterior : s r e (coxalhip the b Abduct joint) i f l l A L5 glutealInferior tuberosityglutealfibers)tract and (lower(upper Iliotibialfibers) sacroiliacligaments Coccyx,sacrum,crest,ofedge posterioriliac sacrotuberous and (coxalhip the Adduct joint) fibers: Lower (coxalhip the Abduct joint) (coxalhip Laterallyrotatethe joint) (coxalhip Extendthe joint) fibers: All . gluteus mediusislocatedonthelateralsideof gloo -te-us . , S , , 1 5 G Ang , , S , 2 rk 1 . lo-Saxon gloutos uttocks, , . . b for . buttuc . w , . meaning hich . i n . t urn . end . i s . actions ofthegluteusmaximus. medially thehip,thusperforming theopposite rotates of thegreatertrochanter,gluteusminimus flexesand the medius totheanteriorsurface (6.81).Becauseitattaches is inaccessible;however, itsdensefiberscanbefeltbeneath of asthe“deltoid muscle ofthecoxal joint.” multiple directions, thegluteusmedius couldbethought the hip.Withitsconvergentfibersthatpullfemur of in maximus andmedius arestrongextensors and abductors The Gluteus maximus (cut) maximus Gluteus gluteus minimus liesdeeptothegluteusmedius and 6.79 6.80 Posterior view of right buttock right of view Posterior Posterior/lateral view of right buttock right of view Posterior/lateral
Pelvis &Thigh 6 ✦Pelvis Gluteus medius Femur tract Iliotibial maximus Gluteus medius Gluteus 315
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w it Locating the prominent
tendon(s) of the adductors 6.99 Adductor longus Gracilis The shape and location of 326) the are sartorius (p. Are you on you Are the medial side of the either thigh? Explore similar to the shape and location of the gracilis. side of the to adductors determine if between are you Adductors as a group Adductors longus adductor and Gracilis While your partner contracts, slide your fingers While your partner contracts, slide your proximally to the pubic bone and locate the taut,proximally to the pubic bone and locate and adductor tendon(s) of the gracilis prominent off of (or near) the pubic tubercle. longus extending tissue (6.99). If the distally as it develops into muscle thigh, you angles into the medial belly slowly muscle is slender are palpating adductor longus. If the belly the thigh toward the medial down and continues knee, you are accessing gracilis. rotated. Place your hand along the medial thighrotated. along the medial Place your hand his hip against your partner to adduct and ask your resistance tighten? feel the adductors (6.97). Do you to the adductor tendons. you palpate proximally anterior and posterior exploring Then move distally, adductor bellies. to the edges of the laterally rotated. Place the flat of your hand at the thigh. Ask your partner to of the medial middle adduct his hip slightly. Strum your fingertip across this tendon and follo Strum your fingertip across this tendon P P Ask your partner to alternately adduct and relax as Ask your partner to
flexedandlaterally withthehipslightly artner supine hipslightlyflexedand artner supinewiththe 2. 3. 1. 2. 1. Distinguish between Distinguish the between simply the by two following muscle it is If ASIS, the it leads toward palpating proximally. are you the the the sartorius; pubis, if muscle is toward the gracilis. the hamstrings and quadriceps femoris group (6.98). You You the hamstrings and quadriceps (6.98). femoris group should be.
grasping the highlighted adductors Inferior view, cross section of right thigh, Partner supine, palpating the adductors as a group, line indicating cross section 6.98 6.97 Trail GuideTrail the to Body 322
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Are you between the ASIS and ASIS Is the navel? between you the Are of direction your fingers at fingers your a the slight spine? angle you Have toward Side lying position allows the abdominal contents to the abdominal Side lying position allows from the psoas and, oftentimes, offers a shift away Psoas major Psoas F Slo the abdomen and onto the surface of the psoas. Ask your partner to flex his hip slightly so you can feel for contraction. the psoas’s surrounding tissues, by asking your partner to flex his surrounding If your fingers are accessing the hip ever so slightly. solid contraction (6.131). psoas, you will feel a definite, knees. Locate the navel and between your partner’s your fingerpads hand-on-hand between ASIS, placing (6.132). these points laterally rotated. Support your partner’s thigh by laterally rotated. Support your partner’s and navel the Locate it. thigh underneath your placing hand-on-hand between your fingerpads ASIS, placing these points. your partner exhales (6.131). moving only when upon your partner’s (Compressing in small circles exhalations will assist in moving the abdominal initial further, keep contents to the side.) As you compress fingers your fingerpads stationary your and direct the table. toward downward Check that you are palpating the psoas, not the Check that you are palpating the psoas, With the hips in a flexed position, place a bolster P yourfingersinto breath,curl yourpartner’s ollowing wly compressyourfingerpadsintotheabdomen,
and supine,withthehipslightlyflexed artner less invasive position for your partner. less invasive position for your partner. 2. 3. 1. When accessing either the psoas or iliacus, palpate slowly slowly Whenaccessing psoas the either palpate iliacus, or he point any at partner. If your with communicate and remove your slowly safe, or comfortable does feel not abdominal the to justhands. lateral psoas The lies major strong a feel you beneath pulse directly If 219). aorta (p. fingers them your accessing realign when muscle, the laterally. more 1. 2. compressed slowly, allowing the overlying tissue allowing the to If relax? overlying you slowly, compressed did not feel the try with muscle again contract, the fingers farther inferiorly. repositioned
Partner supine, accessing the 6.131 psoas while your partner flexes his hip Partner side lying with hips flexed, curling your fingers into the abdomen 6.132 Psoas major primarily flexes the hip. But when the femur is stabilized, the psoas, in conjunction with iliacus, can increase the lordotic curvature in the lumbar spine and create anterior tilt (downward rotation) of the pelvis. It has also been theorized that only the superficial fibers of the psoas increase the lordotic curve, whereas the deeper fibers may decrease it. Trail GuideTrail the to Body Location of the umbilicus 334
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