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Functions of the Upper Limb and Activities of Daily Living

Functions of the Upper Limb and Relevant Activities of Daily Living

The upper limb is a mobile, sensory and highly adaptable system. It positions the hand, produces force, manipulates objects, protects the body and communicates non-verbally. Its success is measured not only by range or strength but by whether a person can wash, dress, eat, work, use a phone, care for family and participate in community life.

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From body structure to participation

The ICF approach links body structures/functions to activities and participation. A shoulder restriction is an impairment; difficulty putting on a shirt is an activity limitation; inability to return to a job or caregiving role is a participation restriction. Physiotherapy assessment should connect all three to the patient’s goals and environment.

Learning outcomes

Describe the main functions of the upper limb and the systems that support them.
Analyse reaching, grasping, manipulation, lifting, pushing and protective reactions.
Relate upper-limb movement requirements to basic and instrumental activities of daily living.
Identify how pain, weakness, stiffness, sensory loss, poor coordination and environmental barriers affect function.
Set functional goals and select meaningful assessment and rehabilitation activities.

1. Core functions of the upper limb

Function	What it involves	Example
Positioning/reaching	Scapular control, shoulder elevation/rotation, elbow extension and forearm orientation.	Reaching a shelf, hanging clothes or greeting someone.
Grasping	Hand shaping, thumb opposition, finger flexion, wrist stability and sensory feedback.	Holding a cup, walking aid or cooking utensil.
Precision manipulation	Fine thumb/finger control, intrinsic muscles, visual guidance and tactile discrimination.	Buttoning, writing, tying laces or using a phone.
Power production	Proximal stability, shoulder/elbow extension, wrist positioning and grip force.	Lifting a basin, pushing a door or transferring from a chair.
Support/weight-bearing	Closed-chain shoulder, elbow, wrist and hand control with trunk integration.	Using crutches, pushing up from bed or protecting a fall.
Protection	Rapid extension or flexion and sensory detection of danger.	Bracing during a loss of balance or withdrawing from heat.
Communication	Gestures, sign language, writing, pointing and facial/arm expression.	Signing, waving, indicating pain or giving directions.
Exploration/sensation	Touch, pressure, vibration, temperature and proprioception.	Identifying an object in a pocket or judging grip force.

2. Functional movement chain

Upper-limb function depends on a proximal-to-distal chain. The trunk provides a base; the scapula positions the glenoid; the humerus reaches; the elbow adjusts distance; the forearm rotates; the wrist aligns the hand; the thumb and fingers interact with the object.

Anticipatory postural control: trunk and scapula prepare before the hand moves.
Reach: shoulder and elbow extend toward the target while vision guides direction.
Pre-shaping: wrist and digits open to match the object’s size, shape and orientation.
Contact and grip: tactile/proprioceptive feedback adjusts finger force and thumb opposition.
Manipulation: wrist, thumb and digits move the object; proximal joints stabilise.
Release: extensor and intrinsic control opens the hand at the intended location.
Return/recovery: muscles eccentrically control the limb back to a resting position.

3. Activities of daily living

Basic ADLs are personal self-care activities; instrumental ADLs support independent living in the home and community. The exact task and cultural meaning vary, so ask the patient what matters rather than assuming a standard routine.

Activity	Upper-limb requirements	Common limiting impairment
Eating and drinking	Reach, elbow flexion, forearm supination/pronation, wrist stability, grip and hand-to-mouth control.	Shoulder pain, tremor, weakness, sensory loss or poor coordination.
Bathing and washing	Shoulder elevation/rotation, elbow flexion, hand opening, grip and bilateral coordination.	Limited overhead reach, pain, reduced endurance or unsafe balance.
Grooming	Reach to face/head, sustained grip and fine manipulation.	Restricted shoulder rotation, hand stiffness or fatigue.
Dressing	Reach behind back/head, bilateral hand use, pinch, pull and sequence.	Shoulder stiffness, weakness, neglect, pain or reduced sensation.
Toileting	Trunk/hip positioning plus hand reach, clothing management and hygiene.	Limited shoulder rotation, balance, pain or poor dexterity.
Bed/chair transfers	Weight-bearing through arms, elbow extension, wrist/hand stability and protective reactions.	Weak triceps, painful wrist/shoulder, poor coordination or precautions.
Using a phone	Thumb opposition, finger isolation, sustained grip and visual-motor control.	Median/ulnar dysfunction, tremor or sensory loss.
Cooking	Reach, lift, pour, grip, bilateral stabilisation and heat protection.	Weakness, reduced sensation, limited endurance or unsafe release.
Carrying water/loads	Scapular depression, elbow extension, wrist neutral and power grip.	Pain, reduced grip, nerve injury or poor postural control.
Work/school tasks	Task-specific speed, precision, endurance and cognitive-motor planning.	Repetitive strain, fatigue, reduced dexterity or environmental barriers.

4. Grasp patterns

Pattern	Description	Example	Key requirements
Power grip	Object held against palm with flexed fingers and thumb.	Holding a hoe handle or bucket.	Wrist stability, finger flexors, thumb adduction/opposition and sensation.
Cylindrical grip	Fingers wrap around a cylinder.	Holding a bottle.	Grip strength and appropriate object diameter.
Spherical grip	Digits spread around a round object.	Holding a ball.	Finger abduction, thumb opposition and hand span.
Tip-to-tip pinch	Thumb tip meets another fingertip.	Picking up a bead.	Precision, sensation and intrinsic control.
Pad-to-pad pinch	Finger pad contacts thumb pad.	Turning a small page.	Thumb opposition and stable IP/MCP control.
Key pinch	Thumb pad presses against lateral index finger.	Holding a key or card.	Adductor pollicis, first dorsal interosseous and sensory feedback.
Tripod pinch	Thumb with index/middle fingers.	Writing with a pen.	Thumb opposition, wrist stability and graded force.
Hook grip	Fingers flex without thumb.	Carrying a bag handle.	FDP/FDS strength and protected wrist position.

5. Functional range and movement combinations

Daily tasks use combinations rather than isolated movements. The required range varies with body size, object location and technique; a patient may complete a task through compensation even when a joint is restricted.

Task	Typical movement combination	Observe for compensation
Hand to mouth	Shoulder flexion, elbow flexion, forearm supination, wrist extension and grip.	Trunk flexion, shoulder hiking or excessive wrist motion.
Hand to back of head	Shoulder abduction/external rotation, elbow flexion and forearm control.	Neck flexion, trunk rotation or scapular winging.
Hand behind back	Shoulder extension/internal rotation, elbow flexion and wrist positioning.	Trunk rotation or pelvic tilt.
Push up from chair	Shoulder extension/adduction, elbow extension, wrist extension and hand loading.	Unequal weight shift, painful wrist or trunk thrust.
Reach overhead	Scapular upward rotation, clavicular rotation, shoulder elevation and elbow extension.	Shoulder shrug, lumbar extension or rib flare.
Open a jar	One hand stabilises; other pronates/supinates with wrist and grip torque.	Excessive shoulder movement, pain or dropping object.

6. Assessment of upper-limb function

Activity interview: ask what the person needs and wants to do, where, how often and with whom.
Observation: assess reaching, grasp, release, bilateral use, speed, accuracy, fatigue, pain and safety.
Body-function measures: range, strength, tone, coordination, sensation, swelling, pain and endurance.
Task-specific tests: timed dressing, reach-and-grasp, peg/coin tasks, supported weight-bearing or patient-selected activity.
Patient-reported tools: use validated instruments appropriate to training and setting, such as region-specific disability or upper-limb function questionnaires.
ICF documentation: separate impairment, activity capacity, activity performance, participation and environmental barriers.

7. Rehabilitation planning

Problem	Possible intervention focus	Example goal
Painful shoulder reach	Education, graded range, scapular control, load modification and functional practice.	Reach a shelf at shoulder height to place a light cup with pain ≤3/10.
Weak grip after nerve injury	Protective positioning, sensory re-education, tendon glide and graded grasp.	Hold a phone for five minutes without dropping it.
Stiff hand after fracture	Oedema control, active range, joint protection and task practice.	Fasten three buttons using the affected hand as an assist.
Hemiparetic upper limb	Task-specific bilateral practice, weight-bearing, selective movement and environmental adaptation.	Use the affected hand to stabilise a bowl during a meal.
Reduced endurance	Pacing, interval practice, proximal strengthening and energy conservation.	Prepare a simple meal with planned rest and safe handling.

8. Environmental and cultural factors

Consider cooking methods, water containers, farming tools, school/work tasks, caregiving and transport relevant to the person’s life.
Adapt handle size, object weight, height, seating, lighting and surface before assuming the person needs more muscle strength.
Respect handedness, customary greetings, clothing, privacy and family roles.
Teach safe compensations while continuing to restore the affected limb; do not create unnecessary dependence.
Include family or caregivers only with consent and teach them how to support, not replace, the patient’s effort.

Clinical scenario: returning to work

A market vendor with wrist pain can lift a light cup but cannot pour a jerrycan or count coins rapidly. Analyse the different demands: load, grip diameter, forearm rotation, repetition, precision, rest and environment. Build a graded plan around meaningful tasks, modify the load and work height, teach pacing and monitor symptoms. A strength score alone would miss the participation problem.

9. Examination points and revision questions

High-yield points

Upper-limb function requires proximal stability, distal mobility, vision, sensation and motor planning.
Power grip, precision pinch and weight-bearing use different combinations of muscles and joints.
ADL assessment should identify what the patient can do in a real context, not only isolated range or strength.
ICF links body impairment to activity and participation while considering environmental factors.
Functional goals should be specific, meaningful, measurable and linked to the patient’s life.

List eight functions of the upper limb.
Explain the proximal-to-distal movement chain during reach and grasp.
Compare power grip, tripod pinch, key pinch and hook grip.
Analyse the upper-limb requirements of eating, dressing and pushing from a chair.
Describe how pain, weakness, stiffness and sensory loss affect ADLs.
Write two impairment goals and two activity/participation goals for an upper-limb patient.
Explain how culture and environment should influence functional assessment.

References for further study

Educational note: Functional rehabilitation should be person-centred, culturally respectful and coordinated with the wider rehabilitation team.

Functions of the Upper Limb and Activities of Daily Living Read More »

Surface Landmarks of the Upper Limb: Bones, Vessels and Muscles

Surface Landmarks of the Upper Limb

Surface anatomy turns deep three-dimensional structures into visible or palpable reference points. In the upper limb, accurate landmarking supports range-of-motion measurement, posture and scapular analysis, muscle testing, pulse checks, swelling measurement, splint fabrication and clear documentation. Use the patient’s position, side and consent every time.

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Landmarks are guides, not diagnoses

Palpable structures vary with body habitus, age, posture, muscle tension, injury and anatomical variation. A surface point may represent more than one deeper structure. Use gentle palpation, compare sides, combine findings with movement and sensation, and refer uncertain or high-risk findings for medical assessment or imaging.

Learning outcomes

Locate and describe the principal bony landmarks of the shoulder, arm, forearm and hand.
Palpate the major superficial vessels and identify safe pulse points.
Identify muscles and tendons by position and resisted contraction.
Use landmarks to position a goniometer, measure swelling and describe symptoms.
Apply consent, privacy, infection-prevention and neurovascular safety principles.

1. Surface-marking method

Explain what you will inspect, touch or measure and why; obtain consent and provide a chaperone for sensitive examinations when appropriate.
Expose only the area required and maintain dignity with draping.
Position the patient and record it; a landmark changes when the limb moves.
Inspect colour, swelling, scars, muscle bulk, deformity and asymmetry before palpation.
Use finger pads and gentle pressure; locate bone first, then follow soft-tissue structures.
Ask the patient to move or contract lightly to confirm a muscle/tendon.
Compare sides, measure consistently and avoid marking infected or broken skin.
Document side, position, landmark, distance/angle, symptom response and method.

2. Shoulder-girdle bony landmarks

Landmark	How to locate	Clinical/measurement use
Clavicle	Trace the S-shaped ridge from sternum to acromion.	Alignment, fracture screening, shoulder-girdle posture and SC/AC joint reference.
Sternoclavicular joint	Medial clavicle meets manubrium at the upper sternum.	Clavicular elevation/depression and anterior shoulder pain.
Acromion	Follow the scapular spine laterally to its broad tip.	Shoulder width, glenohumeral axis approximation and deltoid attachment.
Coracoid process	Palpable deep to the anterior deltoid, inferior/medial to the clavicle; palpate gently.	Pectoralis minor, coracobrachialis and biceps short-head reference; avoid aggressive pressure.
Spine of scapula	Posterior ridge running medially from acromion.	Scapular position, posture and muscle attachment.
Medial border/inferior angle	Medial border lies beside thoracic spine; inferior angle moves with arm elevation.	Scapular winging, upward rotation and dyskinesis assessment.
Glenoid region	Deep lateral scapular surface; not directly palpable like acromion.	Use acromion and humeral head as safer surface references.

3. Arm and elbow landmarks

Landmark	Location	Use
Humeral shaft	Firm contour between deltoid and elbow, more palpable medially/laterally than anteriorly.	Alignment, swelling and fracture precautions.
Deltoid tuberosity	Lateral humeral shaft below deltoid bulk; not always directly prominent.	Deltoid insertion and muscle contour.
Medial epicondyle	Prominent medial distal humerus.	Common flexor origin and ulnar nerve lies posteriorly; avoid sustained pressure.
Lateral epicondyle	Prominent lateral distal humerus.	Common extensor origin and elbow-axis reference.
Olecranon	Posterior point of elbow, especially in flexion.	Triceps insertion, elbow range and pressure protection.
Radial head	Just distal to lateral epicondyle; rotate forearm to feel it move.	Elbow joint, pronation/supination and radial-head injury assessment.
Cubital fossa	Triangular anterior elbow region between brachioradialis and pronator teres.	Brachial pulse, venepuncture anatomy and biceps tendon; avoid deep pressure.

4. Forearm, wrist and hand landmarks

Landmark	Location/technique	Clinical use
Radial shaft/styloid	Thumb-side forearm and distal lateral wrist.	Radial pulse, goniometer alignment and wrist deviation.
Ulnar shaft/styloid	Little-finger side; styloid is prominent distally.	Ulnar-sided wrist pain, DRUJ and wrist-axis references.
Lister’s tubercle	Dorsal distal radius.	Extensor pollicis longus pulley and wrist orientation.
Pisiform	Small pea-shaped bone at ulnar-volar wrist.	FCU insertion and Guyon-canal orientation.
Scaphoid/anatomical snuffbox	Depression on radial wrist when thumb is extended; tenderness requires caution.	Scaphoid injury screening and radial artery relationship.
Metacarpal heads	Knuckles on the dorsum of the hand.	MCP alignment, swelling and grip posture.
Phalangeal joints	PIP and DIP creases of digits; thumb has one IP joint.	Hand range, tendon glide and deformity documentation.
Thenar/hypothenar eminences	Muscle masses at thumb/little-finger sides of palm.	Intrinsic muscle bulk and median/ulnar nerve screening.

5. Superficial vessels and pulse points

5.1 Arterial landmarks

Brachial pulse: medial arm and cubital fossa, just medial to the biceps tendon; use gentle pressure and never compress both arms simultaneously.
Radial pulse: anterior wrist on the thumb side, lateral to flexor carpi radialis tendon.
Ulnar pulse: anterior wrist on the little-finger side, deeper and often less distinct.
Palmar perfusion: inspect colour, warmth, capillary refill and symmetry; specialist tests are required for detailed arterial patency.

5.2 Venous landmarks

Vein	Surface course	Safety
Cephalic	Lateral forearm/arm, then deltopectoral groove.	Common access route; anatomy varies and nearby nerves must be respected.
Basilic	Medial forearm/arm, becoming deep near the mid-arm.	Close to neurovascular structures after piercing fascia.
Median cubital	Oblique connection across cubital fossa.	Common venepuncture site; do not use physiotherapy palpation as venepuncture.
Dorsal venous network	Visible on dorsum of hand, especially with dependency or warmth.	Observe swelling and skin changes without excessive pressure.

6. Palpating muscles and tendons

A muscle becomes easier to identify when the patient performs a low-load action against gravity or light resistance. Explain the movement, stabilise the joint and palpate the muscle belly or tendon while watching for substitution.

Structure	Position/test movement	Surface clue
Deltoid	Abduct arm in the scapular plane against light resistance.	Large cap over shoulder; middle fibres fill the lateral contour.
Biceps	Flex elbow with forearm supinated.	Anterior arm belly and distal tendon in cubital fossa.
Triceps	Extend elbow against resistance.	Posterior arm bulk and olecranon tendon.
Brachioradialis	Flex elbow with forearm midway between pronation/supination.	Prominent lateral forearm muscle toward radial styloid.
Flexor carpi radialis	Flex and radially deviate wrist.	Tendon at volar radial wrist.
Flexor carpi ulnaris	Flex and ulnarly deviate wrist.	Tendon toward pisiform.
Extensor digitorum	Extend MCP joints against gentle resistance.	Dorsal forearm tendons become visible toward knuckles.
First dorsal interosseous	Abduct index finger against resistance.	Muscle belly in first web space.

7. Landmarks for measurement

Goniometry: use acromion/epicondyles/styloids or agreed joint axes; document the patient position and whether the movement is active or passive.
Scapular distance: measure from fixed thoracic references only with a consistent arm position; scapulae move with elevation.
Oedema: use circumferential points measured from a fixed landmark, identical tape tension and the same time of day when possible.
Muscle length: identify the relevant joints and stabilise proximal segments so compensations do not disguise restriction.
Hand function: document grip position, finger joint angles, thumb opposition and object size during tasks.

Clinical scenario: wrist swelling after injury

Inspect colour, temperature, deformity and skin integrity; palpate only gently after checking fracture precautions; compare radial/ulnar pulses and sensation; measure circumference at marked points; record pain and movement limitation. Severe pain, deformity, neurovascular change or disproportionate swelling requires urgent review rather than repeated measurement.

8. Neurovascular safety during palpation

Do not compress the medial epicondyle region for a prolonged time because the ulnar nerve is superficial.
Protect the radial artery in the snuffbox and the brachial artery in the cubital fossa.
Check distal pulse, colour, warmth, capillary refill, sensation and active movement after injury or immobilisation.
Do not mark broken, infected, irradiated or fragile skin with ordinary marker.
Stop for severe pain, paraesthesia, dizziness, sudden colour change or a new neurological deficit.

9. Examination points and revision questions

High-yield points

Acromion, coracoid, scapular spine and inferior angle are key shoulder landmarks.
Medial/lateral epicondyles, olecranon, radial head and cubital fossa orient the elbow.
Radial and ulnar styloids, pisiform, snuffbox and metacarpal heads guide wrist/hand assessment.
Brachial, radial and ulnar pulses must be interpreted with colour, temperature, sensation and movement.
Muscle palpation is confirmed by a controlled contraction, not by location alone.

Describe how to locate the acromion, coracoid, scapular spine and inferior angle.
Explain the relationship of the ulnar nerve to the medial epicondyle.
Locate the brachial, radial and ulnar pulses safely.
Describe how to identify the cephalic, basilic and median cubital veins.
Explain how to palpate deltoid, biceps, triceps and first dorsal interosseous.
List six safety precautions for upper-limb surface examination.

References for further study

Educational note: Palpation and neurovascular assessment are supervised practical skills. Follow local consent, privacy, infection-prevention and referral policies.

Surface Landmarks of the Upper Limb: Bones, Vessels and Muscles Read More »

Upper-Limb Myotomes and Dermatomes: C4 to T2 Clinical Distribution

Myotome and Dermatome Distributions of the Upper Limb

Myotomes and dermatomes connect spinal nerve roots to movement and sensation. A myotome is the group of muscles or movement predominantly supplied by one spinal nerve root. A dermatome is an area of skin predominantly supplied by one dorsal root. Because neighbouring roots overlap, clinical examination looks for patterns rather than a single isolated point.

Add labelled upper-limb myotome and dermatome maps here

Add your labelled myotome and dermatome maps here.

Root patterns versus peripheral-nerve patterns

A C7 radiculopathy may weaken several muscles supplied by different peripheral nerves but sharing C7 fibres; a radial-nerve lesion weakens muscles supplied by the radial nerve across one or more roots. Similarly, a dermatome follows a root while a named cutaneous nerve follows a peripheral pathway. Always interpret motor, sensory, reflex and functional findings together.

Learning outcomes

Define myotome, dermatome, spinal nerve root, peripheral nerve and reflex arc.
State the clinically tested upper-limb myotomes from C4 to T1.
Locate key upper-limb dermatome points from C4 to T2.
Use reflexes and pattern recognition to distinguish root from peripheral-nerve involvement.
Perform and document a safe neurological screen for physiotherapy referral.

1. Myotomes

Myotomes are best tested with resisted movements that isolate a root as much as possible. No movement is supplied by only one root; use a dominant root value as a clinical shorthand.

Root	Key movement/myotome	Useful muscles	Important peripheral nerves
C4	Scapular elevation/shoulder shrug and diaphragmatic contribution.	Trapezius/diaphragm (with C3–5).	Spinal accessory plus cervical/phrenic contributions.
C5	Shoulder abduction; some shoulder external rotation.	Deltoid, supraspinatus, infraspinatus.	Axillary and suprascapular.
C6	Elbow flexion and wrist extension; forearm supination.	Biceps, brachioradialis, wrist extensors.	Musculocutaneous and radial.
C7	Elbow extension; wrist/finger extension; some wrist flexion.	Triceps, extensor digitorum, wrist flexors/extensors.	Radial, median and ulnar contributions.
C8	Finger flexion, thumb extension and grip.	FDP, FPL, finger extensors.	Median, ulnar and radial.
T1	Finger abduction/adduction and intrinsic hand control.	Dorsal/palmar interossei, adductor pollicis.	Deep ulnar.
T2	Upper medial arm/axillary sensory transition; no single standard limb movement.	Intercostal/axillary-region muscles.	Intercostobrachial and thoracic contributions.

1.1 How to test a myotome

Explain the test, position the patient and stabilise the adjacent segment.
Demonstrate the movement and test active range before resistance.
Apply gradual resistance in a safe direction; compare sides and note pain, tremor and fatigue.
Test a second muscle supplied by the same root but a different peripheral nerve.
Document position, resistance, side, grade/quality, pain and sensory/reflex findings.

2. Dermatomes

Dermatome maps differ slightly between references because roots overlap and individuals vary. Use standard key points and compare sides. A single normal sensation does not exclude radiculopathy; a pattern across multiple points is more meaningful.

Root	Key dermatome area	Practical sensory point
C4	Lower neck and top of shoulder.	Skin over the acromioclavicular/shoulder-tip region.
C5	Lateral upper arm.	Skin over the deltoid region above the elbow.
C6	Lateral forearm and thumb side of hand.	Thumb pulp or radial forearm.
C7	Middle of the hand and posterior central arm/forearm.	Middle-finger pulp.
C8	Medial forearm and little-finger side of hand.	Little-finger pulp.
T1	Medial forearm to medial upper arm.	Medial forearm above the elbow.
T2	Axilla and upper medial arm.	Axillary fold/upper medial arm, with sensitivity and privacy.

2.1 Sensory examination principles

Explain the stimulus and ask the patient to close the eyes only after consent.
Compare left and right at corresponding points; test light touch first and stronger modalities only when appropriate.
Map the border of altered sensation rather than recording “numb arm.”
Protect an insensate limb from heat, pressure, sharp edges and prolonged loading.
Consider peripheral nerve territories, dermatomes, central lesions, diabetic neuropathy and non-organic patterns.

3. Reflexes supporting root localisation

Reflex	Spinal levels	Peripheral nerve/muscle	Technique and interpretation
Biceps	C5–C6, mainly C5	Musculocutaneous; biceps	Tap tendon in cubital fossa while elbow is relaxed; compare sides.
Brachioradialis	C5–C6, mainly C6	Radial; brachioradialis	Tap tendon near radial styloid; observe elbow flexion/supination response.
Triceps	C6–C8, mainly C7	Radial; triceps	Tap tendon above olecranon with arm supported.

Reflexes can be reduced by root/nerve/peripheral lesions and increased by upper motor-neuron lesions. Temperature, anxiety, medication, age and technique affect responses; interpret with the complete neurological examination.

4. Root, plexus and peripheral-nerve comparison

Pattern	Motor findings	Sensory findings	Clue
Radiculopathy	Several muscles from the same root, possibly different peripheral nerves.	Dermatomal, often with neck pain/radiation.	Reflex change and spinal provocation may support root involvement.
Plexopathy	Mixed peripheral-nerve distribution from a plexus region.	Overlapping root/nerve territories.	Traction, tumour, surgery or thoracic-outlet mechanism.
Mononeuropathy	Muscles supplied by one named nerve.	Named-nerve cutaneous area; roots may span several levels.	Entrapment or local trauma along nerve course.
Polyneuropathy	Often bilateral distal weakness.	Stocking/glove or length-dependent pattern.	Systemic/metabolic disease; refer for medical assessment.
Central lesion	Pattern may not respect one root/nerve; tone/reflexes may change.	Higher cortical or tract pattern.	Associated speech, face, leg or coordination findings.

5. Physiotherapy application

Use myotomes and dermatomes to identify the likely level of impairment, not to make a diagnosis in isolation.
Protect skin and joints when sensation or motor control is reduced.
Choose strengthening and motor-retraining tasks that are safe for the involved root/nerve and tissue stage.
Use visual feedback, graded sensory input and task practice when proprioception or cutaneous sensation is impaired.
Document functional consequences: dropping objects, difficulty dressing, loss of pinch, altered gait with an arm problem or inability to use an assistive device.

Scenario: cervical radiculopathy pattern

A patient reports neck pain radiating to the thumb, weak elbow flexion and reduced biceps reflex. Test cervical movement cautiously, compare C5–C6 myotomes, examine the radial and median nerve territories, assess red flags and document the pattern. Severe progressive weakness, gait change, bowel/bladder symptoms, trauma, fever or systemic illness requires urgent referral.

6. Common pitfalls

Calling the thumb “C7” because the patient describes hand numbness without mapping the area.
Using one muscle to represent a whole root when the muscle has dual or multiple root supply.
Confusing radial-nerve sensory loss with C7 dermatome loss.
Ignoring pain inhibition, limited joint range or effort when interpreting weakness.
Assuming a normal light-touch point excludes a root lesion because dermatomes overlap.

7. Examination points and revision questions

High-yield points

C5: shoulder abduction; C6: elbow flexion/wrist extension; C7: elbow extension; C8: finger flexion; T1: finger abduction/adduction.
C5 is lateral upper arm, C6 thumb/radial forearm, C7 middle finger, C8 little finger/medial hand, T1 medial forearm.
Biceps reflex is mainly C5–6, brachioradialis C6 and triceps C7.
Root and peripheral nerve maps overlap; localise using multiple findings.

Define a myotome and a dermatome.
List the key upper-limb movements for C5–T1.
Map C4–T2 sensory key points.
Compare a C7 radiculopathy with a radial-nerve lesion.
Explain the role of biceps, brachioradialis and triceps reflexes.
Describe a safe neurological screen for a patient with neck-to-arm pain.

References for further study

Educational note: Neurological testing should be supervised and interpreted with the history, full examination and local referral protocols.

Upper-Limb Myotomes and Dermatomes: C4 to T2 Clinical Distribution Read More »

Arterial, Venous and Lymphatic Systems of the Upper Limb

The upper limb depends on a coordinated vascular and lymphatic network. Arteries deliver oxygenated blood under pressure, veins return blood to the heart and lymphatic vessels return protein-rich interstitial fluid while supporting immune surveillance. Knowledge of these pathways is essential for pulse assessment, wound healing, oedema management, vascular access, dialysis precautions and safe exercise.

Add a labelled upper-limb arteries veins and lymphatics diagram here

Add your labelled vascular and lymphatic image here.

Clinical safety first

Do not massage, compress or exercise an acutely swollen, hot, red or painful limb until serious causes such as infection, arterial compromise or venous thrombosis have been considered. Protect fistulas, grafts, surgical sites and intravenous lines. Compare sides, document objective findings and escalate unexpected vascular changes promptly.

Learning outcomes

Trace arterial blood flow from the subclavian artery to the hand.
Describe superficial and deep venous return and clinically important anastomoses.
Explain superficial/deep lymphatic drainage, axillary node groups and terminal lymph ducts.
Relate vascular anatomy to pulses, blood pressure, venous access, healing and exercise.
Recognise red flags for arterial insufficiency, venous thrombosis, infection and lymphoedema.

1. Arterial supply

The arterial pathway is continuous: subclavian → axillary → brachial → radial and ulnar → palmar arches → digital arteries. Arterial branches vary, but the main relationships are predictable enough to guide examination and imaging.

1.1 Subclavian artery

On the right, the subclavian artery arises from the brachiocephalic trunk; on the left, it arises from the aortic arch. It passes laterally over the first rib and becomes the axillary artery at the lateral border of the first rib. The subclavian gives branches to the neck, thoracic wall and scapular region, including the vertebral and thyrocervical systems.

1.2 Axillary artery

The axillary artery extends from the first rib to the inferior border of teres major. Pectoralis minor divides it into three parts.

Part	Branches	Supply/clinical relevance
First part, medial to pectoralis minor	Superior thoracic artery.	Upper thoracic wall and first two intercostal spaces.
Second part, behind pectoralis minor	Thoracoacromial trunk and lateral thoracic artery.	Pectoral, deltoid and lateral thoracic regions; close to cords of brachial plexus.
Third part, lateral to pectoralis minor	Subscapular, anterior circumflex humeral and posterior circumflex humeral arteries.	Scapular and shoulder anastomoses; posterior circumflex artery accompanies axillary nerve.

1.3 Brachial artery

The brachial artery begins at the lower border of teres major and travels along the medial/anterior arm. It ends in the cubital fossa by dividing into the radial and ulnar arteries. The profunda brachii accompanies the radial nerve in the radial groove; superior and inferior ulnar collateral arteries contribute to elbow anastomoses.

It is palpable in the medial arm and antecubital fossa.
It is used for blood-pressure auscultation and is vulnerable in supracondylar humeral fractures.
Collateral vessels around the elbow help maintain flow during flexion, but do not assume collateral circulation is adequate after trauma.

1.4 Radial and ulnar arteries

Artery	Course and branches	Clinical landmark
Radial	Runs along lateral forearm; gives recurrent branch, travels around wrist through anatomical snuffbox and mainly forms deep palmar arch.	Radial pulse at anterior wrist, lateral to flexor carpi radialis tendon.
Ulnar	Runs medial forearm with ulnar nerve distally; gives common interosseous artery and mainly forms superficial palmar arch.	Ulnar pulse is deeper and less commonly palpated at wrist.
Palmar arches	Superficial and deep arches connect radial and ulnar systems; give common/proper digital arteries.	Support hand perfusion; assess capillary refill, colour and temperature.

2. Arterial anastomoses and assessment

Anastomoses around the scapula, elbow and wrist provide alternative routes, but their capacity depends on vessel health and the speed of occlusion. Assess perfusion systematically.

Inspect colour, temperature, skin integrity, hair pattern and nail changes.
Palpate radial/ulnar pulses where indicated and compare both sides.
Assess capillary refill, sensation, movement and pain.
Use Doppler or specialist vascular testing only within training and facility resources.
Document side, position, time, findings and any exercise-related change.

Sudden pallor, coolness, severe pain, absent pulse, paraesthesia or paralysis is an emergency pattern. Stop treatment and activate the appropriate pathway.

3. Venous drainage

Venous return occurs through superficial veins in subcutaneous tissue and deep veins accompanying arteries. Valves, muscle contraction, respiratory pressure changes and venous tone move blood toward the heart.

3.1 Superficial veins

Vein	Course	Clinical use
Dorsal venous network	Receives digital veins on the back of the hand.	Origin of cephalic and basilic pathways; visible with dependency/heat.
Cephalic vein	Lateral/radial forearm and arm; ascends in deltopectoral groove and pierces clavipectoral fascia to join axillary vein.	Common venous-access route; protect from injury and recognise variation.
Basilic vein	Medial/ulnar hand and forearm; pierces deep fascia and joins brachial veins to form axillary vein near lower teres major.	Used for access and dialysis planning; medial position is close to nerves/arteries after deepening.
Median cubital vein	Connects cephalic and basilic veins in cubital fossa.	Common venepuncture site; confirm anatomy and avoid the brachial artery/median nerve beneath.
Median antebrachial vein	Variable vein on anterior forearm that may join basilic, cephalic or median cubital vein.	Variation is common; never assume the pattern is identical in every person.

3.2 Deep veins

Radial and ulnar venae comitantes accompany the arteries and unite as brachial veins. Brachial veins join the basilic vein to form the axillary vein. The axillary vein becomes subclavian at the lateral border of the first rib; subclavian joins internal jugular to form the brachiocephalic vein, and the two brachiocephalic veins form the superior vena cava.

The upper-limb muscle pump is especially important during movement and gripping.
Prolonged immobility, dehydration, cancer, surgery and venous injury can increase thrombosis risk.
Sudden unilateral swelling, warmth, tenderness, colour change or unexplained breathlessness requires urgent medical assessment.

4. Lymphatic drainage

Lymphatic capillaries collect excess interstitial fluid, proteins and cellular debris. Collecting vessels have valves and smooth muscle; lymph is propelled by intrinsic contraction, skeletal-muscle and respiratory pumps, arterial pulsation and external tissue movement.

4.1 Upper-limb lymph pathways

Superficial lymphatics: accompany superficial veins. Medial-hand/ulnar-side vessels commonly follow basilic pathways toward cubital and humeral (lateral) axillary nodes; lateral/radial-side vessels may follow cephalic pathways toward deltopectoral/infraclavicular and apical nodes.
Deep lymphatics: accompany deep neurovascular bundles and drain muscles, joints and deep tissues toward axillary nodes.
Axillary nodes: include humeral/lateral, pectoral/anterior, subscapular/posterior, central and apical groups.
Terminal drainage: the right upper limb ultimately drains through the right lymphatic duct; the left upper limb through the thoracic duct, both entering the venous angles.

Axillary node group	Receives	Importance
Humeral/lateral	Most lymph from upper limb.	First regional filter for limb infection or malignancy.
Pectoral/anterior	Anterior thoracic wall and breast; some upper-limb pathways.	Relevant after breast surgery and lymphoedema.
Subscapular/posterior	Posterior thoracic wall and scapular region.	Drains posterior tissues and participates in collateral pathways.
Central	Receives from pectoral, subscapular and humeral groups.	Passes lymph toward apical nodes.
Apical	Receives central and cephalic/infraclavicular routes.	Drains to subclavian trunk and venous angle.

5. Lymphoedema and physiotherapy

Lymphoedema is abnormal accumulation of protein-rich interstitial fluid after lymphatic overload, damage or obstruction. It may be primary or secondary to surgery, radiotherapy, cancer, infection, trauma, obesity or chronic inflammation.

Assessment area	What to document
History	Onset, surgery/radiation, infection, cancer, trauma, pain, heaviness, tightness and progression.
Inspection	Symmetry, skin texture, pitting/non-pitting, folds, papillomatosis, wounds and colour.
Measurement	Consistent circumferential points, limb volume method, photographs only with consent.
Function	Reach, grip, dressing, work, sleep, self-care and participation.
Risk screen	Cellulitis, thrombosis, arterial disease, heart/renal failure, uncontrolled infection and acute inflammation.

Education includes skin care, infection prevention, gradual movement and appropriate compression advice by trained clinicians.
Exercise can support lymph flow through muscle and respiratory pumps but must be dosed to symptoms and comorbidities.
Manual lymph drainage and compression require specialised assessment; do not apply routine massage to unexplained swelling.

Clinical scenario: swollen arm after breast surgery

A patient develops heaviness and increasing arm circumference weeks after axillary surgery. Inspect the incision and skin, ask about fever and redness, compare measurements and screen function. If cellulitis, thrombosis, acute pain or sudden progression is suspected, seek medical review before compression or exercise. If stable, coordinate a lymphoedema referral and teach skin protection and gentle movement according to the plan.

6. Vascular access and dialysis precautions

Do not take blood pressure, draw blood or apply tight compression over an arteriovenous fistula/graft unless the renal team directs otherwise.
Check for a prescribed thrill/bruit only if trained; report absent thrill, pain, swelling, bleeding or colour change urgently.
Protect PICC lines, cannulas and dressings from traction, kinking and contamination during exercise.
After vascular surgery or trauma, follow weight-bearing and movement restrictions and monitor distal perfusion.

7. Examination points and revision questions

High-yield points

Subclavian becomes axillary at the first rib; axillary becomes brachial at the lower border of teres major.
Brachial divides into radial and ulnar arteries in the cubital fossa.
Cephalic is lateral; basilic is medial; median cubital connects them in the cubital fossa.
Most upper-limb lymph drains to axillary nodes; right and left terminal pathways differ.
Sudden vascular change or unexplained swelling is not a routine physiotherapy finding.

Trace arterial flow from the subclavian artery to the digital arteries.
Compare the cephalic, basilic and median cubital veins.
Describe axillary lymph-node groups and the final ducts.
Explain the muscle and respiratory pumps in lymph return.
List signs requiring urgent referral in a swollen or painful upper limb.
State precautions for an AV fistula, graft, PICC or postoperative axilla.

References for further study

Educational note: Vascular and lymphatic assessment and treatment require appropriate training and referral pathways.

Arterial, Venous and Lymphatic Systems of the Upper Limb Read More »

Peripheral Nerves of the Upper Limb: Radial, Median, Ulnar, Axillary and More

Peripheral Nerves of the Upper Limb

Peripheral nerves carry motor commands to muscles, sensory information to the central nervous system and autonomic fibres to vessels and glands. This page focuses on the spinal accessory, phrenic, radial, ulnar, median, musculocutaneous and axillary nerves requested in the curriculum. For each nerve, learn its roots, course, motor supply, sensory territory, key examination and common clinical problems.

Add your labelled peripheral-nerve image here.

Peripheral nerve, root and plexus are not the same

A spinal root carries fibres from one spinal level; a plexus mixes several roots; a peripheral nerve carries a new combination to muscles and skin. A C6 root lesion, median nerve lesion and lateral-cord lesion can therefore overlap but are not identical. Test more than one muscle and one sensory point, compare sides and consider the whole pattern.

Learning outcomes

Trace the course and root values of the major upper-limb nerves.
Identify the motor, sensory and important autonomic functions of each nerve.
Perform a safe, structured motor, sensory, reflex and functional screen.
Recognise common entrapment sites, injury mechanisms and urgent referral findings.
Relate nerve deficits to physiotherapy treatment, splinting, exercise and ADLs.

1. General peripheral-nerve assessment

History: mechanism, onset, pain quality, numbness, weakness, night symptoms, work/repetitive loading, surgery and systemic disease.
Inspection: posture, muscle wasting, fasciculations, scapular position, hand posture, colour, swelling and skin injury.
Motor screen: test movements supplied by different nerves and roots; observe range, force, timing and fatigue.
Sensory screen: light touch, pinprick, vibration or proprioception according to training; compare named-nerve and dermatome patterns.
Reflexes: biceps (C5–6, musculocutaneous), brachioradialis (C6, radial) and triceps (C7–8, radial) where appropriate.
Neurodynamic/entrapment tests: only when trained, indicated and safe; do not provoke severe symptoms.
Function and safety: grip, reach, dressing, transfers, protective sensation, skin care and work demands.

2. Spinal accessory nerve (cranial nerve XI)

The spinal accessory nerve has a cranial component that joins the vagus and a spinal component arising from upper cervical spinal cord segments. The spinal part exits the skull through the jugular foramen, crosses the posterior triangle and supplies sternocleidomastoid and trapezius.

Feature	Details
Motor supply	Sternocleidomastoid and trapezius.
Actions tested	Head rotation against resistance; shoulder elevation/shrug; scapular upward rotation and retraction.
Injury risks	Posterior-triangle surgery, lymph-node biopsy, penetrating trauma or traction.
Possible findings	Shoulder droop, weak shrug, difficulty elevating arm above shoulder, lateral scapular displacement and fatigue.
Physiotherapy priorities	Protect the shoulder, retrain scapular control, prevent secondary pain and refer for neurological/surgical review.

3. Phrenic nerve

The phrenic nerve arises mainly from C4 with contributions from C3 and C5. It descends on the anterior scalene, enters the thorax and travels to the diaphragm. It provides the principal motor supply to the diaphragm and sensory fibres to central diaphragmatic pleura, fibrous pericardium and parts of the peritoneum.

Motor: diaphragm contraction increases thoracic volume for inspiration.
Sensory: irritation of diaphragmatic or pericardial structures can be referred to the shoulder region through C3–5.
Injury/impairment: reduced hemidiaphragm movement, orthopnoea, paradoxical motion or ventilatory compromise.
Physiotherapy: monitor respiratory rate, work of breathing, chest expansion and oxygenation; escalate new respiratory weakness urgently.

4. Musculocutaneous nerve

The musculocutaneous nerve arises from the lateral cord (C5–7), pierces coracobrachialis and travels between biceps and brachialis. It continues as the lateral cutaneous nerve of the forearm.

Feature	Details
Motor	Coracobrachialis, biceps brachii and brachialis; therefore shoulder flexion assistance, elbow flexion and supination.
Sensory	Lateral/anterior forearm through the lateral cutaneous nerve.
Mechanisms	Shoulder trauma, penetrating injury, coracobrachialis compression or traction.
Examination	Resisted elbow flexion in supination, resisted supination and sensation on lateral forearm; compare biceps reflex.
Functional effect	Difficulty lifting, bringing objects to the mouth and turning a palm upward.

5. Axillary nerve

The axillary nerve arises from the posterior cord (C5–6). It passes through the quadrangular space with the posterior circumflex humeral artery, winds around the surgical neck of the humerus and divides into anterior and posterior branches.

Feature	Details
Motor	Deltoid and teres minor; small branch to long head of triceps and shoulder joint.
Sensory	Superior lateral cutaneous nerve of arm—the “regimental badge” area over lower deltoid.
Injury mechanisms	Anterior shoulder dislocation, surgical-neck fracture, quadrangular-space compression or injection injury.
Findings	Weak abduction beyond initiation, flattened deltoid contour, weak external rotation and numbness over lateral shoulder.
Physiotherapy	Protect unstable/fractured shoulder, maintain safe range, monitor sensation and retrain deltoid only within medical restrictions.

6. Radial nerve

The radial nerve is the major branch of the posterior cord (C5–T1). It passes posteriorly in the radial groove with the profunda brachii artery, crosses the lateral elbow and divides into superficial sensory and deep motor branches. The deep branch becomes the posterior interosseous nerve after passing through supinator.

Region	Motor supply	Sensory supply	Clinical point
Arm	Triceps, anconeus, brachioradialis and wrist/finger extensors via branches.	Posterior arm/forearm branches.	Midshaft humeral fracture may injure the nerve in the radial groove.
Deep branch/PIN	Supinator and most posterior forearm extensors.	No significant cutaneous supply.	Motor weakness may occur without numbness; finger extension is affected.
Superficial branch	No major motor supply.	Dorsolateral hand, often sparing fingertips.	Compression near the forearm can cause dorsal hand symptoms.

Examination: elbow extension, wrist extension, finger/thumb extension, brachioradialis reflex and sensation in the first dorsal web space. Wrist drop suggests significant radial-nerve dysfunction but must be localised clinically.

7. Median nerve

The median nerve is formed by lateral and medial roots from the lateral and medial cords (C6–T1, with variable C5 contribution). It descends with the brachial artery, crosses the cubital fossa, enters the forearm between pronator teres heads, passes beneath the flexor retinaculum and divides in the hand.

Region	Motor supply	Sensory supply	Important lesion sites
Forearm	Most flexor–pronator muscles; anterior interosseous branch supplies FPL, pronator quadratus and lateral FDP.	Usually no major forearm skin supply.	Pronator teres, forearm fracture or laceration.
Hand	Thenar muscles and first two lumbricals via recurrent branch/digital branches.	Lateral palm and palmar thumb, index, middle and radial half of ring finger; dorsal fingertips of same digits.	Carpal tunnel, recurrent-branch injury or compression.
Anterior interosseous nerve	Pinch muscles: FPL, pronator quadratus, lateral FDP.	Motor only.	Weak “OK” pinch with flattened thumb/index tip flexion.

Examination: thumb opposition/abduction, index and middle finger flexion, pronation, wrist flexion with radial deviation, sensation at index fingertip and carpal-tunnel provocation only when trained.

8. Ulnar nerve

The ulnar nerve arises from the medial cord (C8–T1, sometimes C7). It descends medial to the brachial artery, passes behind the medial epicondyle, travels between the heads of flexor carpi ulnaris and enters the hand through Guyon’s canal.

Feature	Details
Motor in forearm	Flexor carpi ulnaris and medial half of flexor digitorum profundus.
Motor in hand	Most intrinsic muscles: interossei, hypothenar group, adductor pollicis and medial two lumbricals.
Sensory	Little finger and ulnar half of ring finger on palmar and dorsal aspects, with variation at the wrist.
Entrapment sites	Behind medial epicondyle/cubital tunnel and Guyon’s canal at the wrist.
Findings	Weak finger abduction/adduction, reduced pinch, clawing of ring/little fingers in advanced lesions and sensory change.

Examination: finger abduction/adduction, Froment-type pinch observation, FCU/wrist function and sensation over the little-finger side. Protect the medial elbow from prolonged pressure.

9. Comparing major nerve patterns

Nerve	Movement screen	Sensory key point	Common functional loss
Musculocutaneous	Elbow flexion and supination.	Lateral forearm.	Lifting a cup or turning palm upward.
Axillary	Shoulder abduction/external rotation.	Regimental badge.	Overhead reach and shoulder stability.
Radial	Elbow/wrist/finger extension.	First dorsal web space.	Release, grasp–release and wrist positioning.
Median	Pronation, thumb opposition and precision pinch.	Index fingertip/lateral palmar hand.	Buttoning, writing and picking up small objects.
Ulnar	Finger abduction/adduction and strong pinch.	Little-finger pulp.	Key pinch, spreading fingers and grip shaping.

10. Physiotherapy management principles

Protect the nerve and associated tissues from compression, traction, burns and prolonged awkward posture.
Maintain safe passive range and tendon glide while avoiding overstretching denervated or healing structures.
Use splinting to prevent contracture and support function when prescribed by the rehabilitation team.
Retrain sensation, visual compensation and skin inspection when protective sensation is reduced.
Progress active movement, strengthening and functional practice according to reinnervation, pain, fatigue and medical advice.
Educate about work modification, elbow/wrist positioning, pressure avoidance and when to seek help.

Urgent referral features

Rapidly progressive weakness, severe new sensory loss, vascular colour/temperature change, severe pain after trauma, respiratory compromise, suspected compartment syndrome, open injury or new bowel/bladder or spinal-cord signs require urgent clinical review.

11. Examination points and revision questions

High-yield points

Spinal accessory supplies trapezius/SCM; phrenic supplies the diaphragm.
Axillary nerve winds around the surgical neck; radial nerve lies in the radial groove.
Median nerve supplies most forearm flexors and thenar function; ulnar nerve supplies most intrinsic hand muscles.
Musculocutaneous supplies the anterior arm and continues as lateral cutaneous forearm nerve.
A named-nerve deficit must be distinguished from a root or plexus pattern.

Describe the course, motor and sensory functions of the radial nerve.
Compare median and ulnar nerve motor supply in the forearm and hand.
Explain how an axillary nerve lesion affects shoulder function.
What findings suggest a musculocutaneous lesion?
Why can phrenic nerve dysfunction present as an upper-limb/shoulder complaint?
Design a safe peripheral-nerve screen for a patient after humeral fracture.

References for further study

Educational note: This page supports anatomy learning and does not replace neurological consultation, electrodiagnostic testing or emergency management.

Peripheral Nerves of the Upper Limb: Radial, Median, Ulnar, Axillary and More Read More »

Formation and Structure of the Cervical and Brachial Plexuses

A nerve plexus is a network in which anterior rami of spinal nerves mix and redistribute fibres into peripheral nerves. Plexuses allow one peripheral nerve to contain fibres from several spinal levels, so a single root lesion and a single peripheral-nerve lesion produce different patterns. The cervical plexus serves the neck and diaphragm; the brachial plexus supplies almost the entire upper limb.

Add a labelled cervical and brachial plexus diagram here

Add your labelled plexus diagram here.

Why plexus anatomy matters in physiotherapy

Weakness, numbness, pain and loss of function may arise from the spinal root, plexus, peripheral nerve, muscle, tendon or joint. Understanding the sequence roots → trunks → divisions → cords → terminal nerves helps localise a lesion, select a safe examination and communicate findings accurately.

Learning outcomes

Define a nerve plexus and distinguish a root, trunk, division, cord and terminal nerve.
Describe the formation, branches and distribution of the cervical plexus.
Trace the brachial plexus from C5–T1 roots to terminal nerves.
Relate plexus anatomy to motor, sensory and respiratory functions.
Recognise common plexus injuries and plan a safe physiotherapy examination/referral.

1. General organisation of a spinal nerve

Each spinal nerve is formed by a posterior (dorsal) sensory root and anterior (ventral) motor root. After leaving the intervertebral foramen, it divides into posterior and anterior rami. The anterior rami form plexuses in the cervical, brachial, lumbar and sacral regions, except in the thoracic region where they mainly remain segmental intercostal nerves.

Term	Meaning	Clinical use
Root	Spinal nerve level before the plexus; e.g., C6.	Root lesions follow myotome/dermatome patterns and may alter reflexes.
Trunk	Early merger in a plexus; superior, middle or inferior in the brachial plexus.	Upper/middle/lower trunk injury creates characteristic combined deficits.
Division	Anterior or posterior pathway from each trunk.	Separates fibres destined for flexor/anterior or extensor/posterior regions.
Cord	Lateral, posterior or medial cord named around the axillary artery.	Gives rise to major terminal nerves.
Peripheral nerve	Named mixed nerve carrying motor, sensory and autonomic fibres.	Mononeuropathy produces a nerve-specific pattern.

2. Cervical plexus

The cervical plexus is formed by anterior rami of C1–C4, lying deep to sternocleidomastoid and on the prevertebral muscles. It supplies skin and muscles of the head/neck and contributes the phrenic nerve to the diaphragm. C5 contributes to the phrenic nerve but belongs to the brachial region.

2.1 Cutaneous branches

Nerve	Roots	Area supplied	Clinical relevance
Lesser occipital	C2	Posterolateral scalp behind the ear.	Sensory change in upper neck/occipital region.
Great auricular	C2–3	Skin over parotid, mastoid and lower auricle.	Protect in neck surgery and palpation.
Transverse cervical	C2–3	Anterior neck skin.	Useful reference for cervical sensory testing.
Supraclavicular nerves	C3–4	Skin over clavicle, shoulder and upper chest.	Shoulder-tip sensation is not purely C5; include C3–4.

2.2 Motor branches

Ansa cervicalis (C1–3): supplies most infrahyoid muscles, which stabilise the hyoid and assist swallowing.
C1 fibres travelling with hypoglossal nerve: supply geniohyoid and thyrohyoid.
Branches to prevertebral muscles and scalenes: contribute to neck posture and breathing assistance.
Phrenic nerve (C3–5, mainly C4): motor supply to the diaphragm and sensory supply to central diaphragmatic pleura, pericardium and parts of the peritoneum.

Phrenic memory aid

“C3, 4, 5 keep the diaphragm alive.” A high cervical lesion or phrenic impairment can compromise ventilation; respiratory assessment and urgent escalation are essential.

3. Brachial plexus overview

The brachial plexus is formed by anterior rami of C5, C6, C7, C8 and T1. It begins between anterior and middle scalene muscles, passes behind the clavicle and enters the axilla. It supplies motor and sensory innervation to the pectoral girdle and upper limb, except for trapezius (spinal accessory nerve) and a small area of skin supplied by cervical nerves/intercostobrachial nerve.

3.1 Roots (C5–T1)

Roots are proximal to the trunks and lie in the neck. Important branches include:

Dorsal scapular nerve (C5): rhomboids and levator scapulae.
Long thoracic nerve (C5–7): serratus anterior; injury produces medial scapular winging.
Nerve to subclavius (C5–6): subclavius.

3.2 Trunks

Trunk	Roots	Important branches/clinical pattern
Superior (upper)	C5–6	Suprascapular nerve; nerve to subclavius. Upper-trunk injury affects shoulder abduction/external rotation and elbow flexion.
Middle	C7	Contributes to posterior and anterior divisions; isolated injury is uncommon.
Inferior (lower)	C8–T1	Lower-trunk injury affects intrinsic hand function and medial forearm/hand sensation.

3.3 Divisions

Each trunk divides into an anterior and posterior division behind the clavicle. Anterior divisions generally supply flexor/anterior compartments; posterior divisions generally supply extensor/posterior compartments. The divisions reorganise into three cords around the second part of the axillary artery.

3.4 Cords and branches

Cord	Position	Major branches
Lateral cord	Lateral to axillary artery.	Lateral pectoral, musculocutaneous and lateral root of median nerve.
Medial cord	Medial to axillary artery.	Medial pectoral, medial cutaneous nerves of arm/forearm, ulnar and medial root of median nerve.
Posterior cord	Posterior to axillary artery.	Upper/lower subscapular, thoracodorsal, axillary and radial nerves.

3.5 Terminal nerves

Nerve	Roots/cord	Main motor distribution	Main sensory distribution
Musculocutaneous	C5–7; lateral cord	Anterior arm: coracobrachialis, biceps and brachialis.	Lateral cutaneous forearm.
Axillary	C5–6; posterior cord	Deltoid and teres minor.	Upper lateral arm/regimental-badge area.
Radial	C5–T1; posterior cord	Posterior arm/forearm extensors; supinator via deep branch.	Posterior arm/forearm and dorsolateral hand areas.
Median	C6–T1; lateral + medial roots	Most anterior forearm and thenar muscles.	Lateral palm and palmar thumb, index, middle and radial half ring finger.
Ulnar	C8–T1; medial cord	FCU, medial FDP and most intrinsic hand muscles.	Medial hand and little/radial half ring finger.

4. Plexus relationships and injury mechanisms

Region	Structures at risk	Common mechanism	Possible finding
Neck/interscalene	Roots and trunks between scalenes.	Traction, tumour, cervical rib or compression.	Neck/arm pain, weakness or sensory change in several nerve territories.
Costoclavicular space	Trunks/divisions, subclavian vessels.	Clavicle injury, posture or thoracic outlet compression.	Neurovascular symptoms varying with arm position.
Axilla	Cords around axillary artery.	Shoulder dislocation, traction or axillary surgery.	Combined motor and sensory loss involving multiple terminal nerves.
Birth traction	Upper or lower plexus.	Excessive neck/shoulder traction during delivery.	Erb-type or Klumpke-type posture and weakness; urgent paediatric assessment.

5. Physiotherapy examination of a suspected plexus lesion

Take a mechanism and time course: trauma, traction, surgery, birth injury, tumour, repetitive compression or gradual onset.
Inspect posture, scapular position, muscle bulk, limb colour, swelling and protective positioning.
Screen active movement by root and peripheral nerve, comparing sides.
Map light touch/pinprick in dermatomes and named nerve territories where trained.
Check reflexes, pain behaviour, autonomic/vascular signs and functional tasks.
Protect insensate skin and weak joints; avoid aggressive stretching or loading.
Refer urgently for rapidly progressive weakness, respiratory compromise, severe trauma, vascular change or suspected spinal cord involvement.

Clinical scenario: winged scapula after surgery

A patient reports difficulty raising the arm and the medial border of the scapula lifts away from the thorax during wall push-up. Consider long thoracic nerve/serratus anterior dysfunction, but also assess pain, rotator cuff, spinal accessory function and shoulder mechanics. Document the movement, fatigue, sensory findings and functional effect; refer for medical/neurophysiological evaluation rather than treating the winging as an isolated posture problem.

6. Examination points and revision questions

High-yield points

The cervical plexus is C1–4; the phrenic nerve is mainly C4 with C3 and C5 contributions.
The brachial plexus is C5–T1 and organised as roots, trunks, divisions, cords and branches.
The lateral, medial and posterior cords are named in relation to the axillary artery.
Long thoracic nerve injury weakens serratus anterior; spinal accessory injury affects trapezius; phrenic injury affects diaphragm.
Root, plexus and peripheral nerve lesions produce different combinations of weakness and sensory loss.

Describe the formation and branches of the cervical plexus.
Trace C5–T1 through the roots, trunks, divisions and cords of the brachial plexus.
List the terminal branches of each brachial cord.
Compare an upper-trunk, lower-trunk and long-thoracic-nerve lesion.
Explain why one peripheral nerve can contain fibres from multiple spinal roots.
Design a safe motor and sensory screen for a suspected plexus injury.

References for further study

Educational note: Neurological examination and nerve mobilisation require supervised instruction. Follow local referral and emergency procedures.

Formation and Structure of the Cervical and Brachial Plexuses Read More »

Upper-Limb Muscles: Positions, Attachments, Contractions and Actions

Position, Attachments, Contractions and Actions of Upper-Limb Muscles

Upper-limb muscles are arranged to stabilise the shoulder, move the arm, position the forearm and control the wrist and fingers. A muscle’s position, attachments, fibre direction, nerve supply and line of pull determine its action. Physiotherapy assessment adds the context: a muscle may act concentrically, eccentrically or isometrically depending on the task.

Add a labelled diagram of upper-limb muscles here

Add your labelled upper-limb muscle image here.

How to study every muscle

For each muscle, learn P-A-I-N-A-C: Position/compartment, proximal Attachment, distal Insertion, Nerve, primary Action and the Contraction used in a real task. “Origin” and “insertion” are useful study labels, but during a closed-chain exercise either attachment may be relatively fixed.

Learning outcomes

Locate the major muscles of the pectoral girdle, shoulder, arm, forearm and hand.
State their proximal and distal attachments, innervation and principal actions.
Distinguish concentric, eccentric and isometric contractions in functional tasks.
Relate muscle architecture and line of pull to posture, movement, weakness and compensation.
Apply muscle anatomy to testing, exercise selection, motor control and daily activities.

1. Contraction principles

Contraction	What happens	Upper-limb example
Concentric	Muscle tension exceeds external load and the muscle shortens.	Biceps shortens to lift a cup toward the mouth.
Eccentric	Muscle remains active while lengthening under load.	Triceps controls elbow flexion as a person lowers a cup.
Isometric	Tension develops with little visible change in muscle length or joint angle.	Rotator cuff holds the humeral head centred while the arm is supported.
Isokinetic	Movement occurs at a controlled angular velocity with specialised equipment.	Laboratory or clinic dynamometer testing of elbow or shoulder strength.

Muscle force depends on recruitment, firing frequency, length–tension relationship, contraction velocity, moment arm, fatigue, pain and the external load. A weak movement may reflect muscle injury, nerve lesion, pain inhibition, poor leverage or a joint restriction rather than a primary muscle problem.

2. Muscles of the pectoral girdle

Muscle	Position and attachments	Innervation	Main actions
Trapezius	Superficial posterior neck/back; proximal: external occipital protuberance, nuchal ligament and C7–T12 spines; distal: lateral clavicle, acromion and scapular spine.	Spinal accessory nerve (XI) motor; C3–4 proprioception.	Upper fibres elevate, lower fibres depress, middle fibres retract; upper/lower fibres upwardly rotate scapula; stabilises the girdle.
Levator scapulae	Posterolateral neck; transverse processes C1–4 to superior medial border of scapula.	Dorsal scapular nerve and C3–4.	Elevates and downwardly rotates scapula; assists ipsilateral neck flexion.
Rhomboid minor	Deep to trapezius; C7–T1 spines to medial border at root of scapular spine.	Dorsal scapular nerve.	Retracts, downwardly rotates and fixes scapula to thorax.
Rhomboid major	T2–T5 spines to medial border from scapular spine to inferior angle.	Dorsal scapular nerve.	Retracts, downwardly rotates and stabilises scapula.
Serratus anterior	Superolateral thorax; ribs 1–8/9 to anterior surface of medial border and inferior angle.	Long thoracic nerve (C5–7).	Protracts and upwardly rotates scapula; holds it against thorax; lower fibres assist depression.
Pectoralis minor	Deep anterior chest; ribs 3–5 to coracoid process.	Medial pectoral nerve.	Depresses/protracts and downwardly rotates scapula; elevates ribs when scapula is fixed.
Subclavius	First rib/costal cartilage to inferior middle clavicle.	Nerve to subclavius.	Anchors and depresses clavicle; protects the SC region.

3. Muscles crossing the shoulder

Muscle	Proximal attachment	Distal attachment	Nerve	Principal action
Pectoralis major	Medial clavicle, sternum and upper costal cartilages.	Lateral lip of intertubercular sulcus.	Lateral and medial pectoral nerves.	Adducts and internally rotates arm; clavicular head flexes; sternocostal head extends a flexed arm.
Latissimus dorsi	Lower thoracic spines, thoracolumbar fascia, iliac crest and lower ribs.	Floor of intertubercular sulcus.	Thoracodorsal nerve.	Extends, adducts and internally rotates arm; assists climbing and pushing.
Deltoid	Lateral clavicle, acromion and scapular spine.	Deltoid tuberosity of humerus.	Axillary nerve.	Middle fibres abduct; anterior fibres flex/internal rotate; posterior fibres extend/external rotate.
Teres major	Posterior inferior angle/lateral border of scapula.	Medial lip of intertubercular sulcus.	Lower subscapular nerve.	Adducts, extends and internally rotates arm.
Coracobrachialis	Coracoid process.	Middle medial humeral shaft.	Musculocutaneous nerve.	Flexes and adducts arm; resists shoulder dislocation.
Long head of biceps	Supraglenoid tubercle and superior labrum.	Radial tuberosity and bicipital aponeurosis.	Musculocutaneous nerve.	Flexes elbow/supinates forearm; assists shoulder flexion and stability.

4. Rotator cuff and shoulder stabilisers

Muscle	Attachment	Nerve	Action and testing idea
Supraspinatus	Supraspinous fossa to superior facet of greater tubercle.	Suprascapular nerve (C5–6).	Initiates abduction and compresses the humeral head; assess with resisted abduction/scaption.
Infraspinatus	Infraspinous fossa to middle facet of greater tubercle.	Suprascapular nerve (C5–6).	External rotation and posterior stability.
Teres minor	Lateral scapular border to inferior facet of greater tubercle.	Axillary nerve (C5–6).	External rotation and adduction; assess with resisted external rotation.
Subscapularis	Subscapular fossa to lesser tubercle.	Upper/lower subscapular nerves.	Internal rotation and anterior stability.
Long head of triceps	Infraglenoid tubercle to olecranon.	Radial nerve.	Extends/adducts shoulder and extends elbow.

Rotator-cuff muscles do not merely produce rotation; they centre the humeral head while larger muscles generate torque. Poor scapular control, fatigue, pain or altered thoracic posture can increase subacromial loading.

5. Muscles of the arm

5.1 Anterior compartment

Muscle	Attachments	Nerve	Action
Biceps brachii	Long head: supraglenoid tubercle; short head: coracoid; both to radial tuberosity/aponeurosis.	Musculocutaneous.	Powerful supination and elbow flexion; assists shoulder flexion.
Brachialis	Distal anterior humerus to ulnar tuberosity/coronoid.	Musculocutaneous, with radial contribution.	Primary elbow flexor in all forearm positions.
Coracobrachialis	Coracoid to middle medial humerus.	Musculocutaneous.	Flexes/adducts shoulder and stabilises the humeral head.

5.2 Posterior compartment

Muscle	Attachments	Nerve	Action
Triceps brachii	Long: infraglenoid tubercle; lateral: posterior humerus above radial groove; medial: posterior humerus below groove; all to olecranon.	Radial.	Elbow extension; long head assists shoulder extension/adduction.
Anconeus	Lateral epicondyle to lateral olecranon/proximal posterior ulna.	Radial.	Assists extension, stabilises elbow and abducts ulna slightly during pronation.

6. Forearm muscles

The anterior compartment is predominantly flexor–pronator and supplied by the median nerve or its anterior interosseous branch, with the ulnar nerve supplying flexor carpi ulnaris and the medial half of flexor digitorum profundus. The posterior/lateral compartment is predominantly extensor–supinator and supplied by the radial nerve or posterior interosseous nerve.

6.1 Anterior flexor–pronator muscles

Muscle	Proximal → distal attachment	Nerve	Action
Pronator teres	Medial epicondyle/coronoid → lateral mid-radius.	Median.	Pronation; weak elbow flexion.
Flexor carpi radialis	Medial epicondyle → bases of 2nd/3rd metacarpals.	Median.	Wrist flexion and radial deviation.
Palmaris longus	Medial epicondyle → palmar aponeurosis/flexor retinaculum.	Median.	Tenses palm and assists wrist flexion; may be absent.
Flexor carpi ulnaris	Medial epicondyle, olecranon and posterior ulna → pisiform, pisohamate and base 5th metacarpal.	Ulnar.	Wrist flexion and ulnar deviation.
Flexor digitorum superficialis	Medial epicondyle/coronoid/radius → middle phalanges 2–5.	Median.	Flexes PIP joints; assists MCP and wrist flexion.
Flexor digitorum profundus	Anterior/medial ulna and interosseous membrane → distal phalanges 2–5.	Lateral half AIN; medial half ulnar.	Flexes DIP joints and assists grip.
Flexor pollicis longus	Anterior radius/interosseous membrane → distal phalanx of thumb.	Anterior interosseous (median).	Flexes thumb IP joint.
Pronator quadratus	Distal anterior ulna → distal anterior radius.	Anterior interosseous (median).	Primary pronator; stabilises distal radioulnar joint.

6.2 Lateral/posterior extensor–supinator muscles

Muscle	Proximal → distal attachment	Nerve	Action
Brachioradialis	Lateral supracondylar ridge → distal radius near styloid.	Radial.	Flexes elbow in mid-prone position; returns forearm to neutral.
Extensor carpi radialis longus	Lateral supracondylar ridge → base 2nd metacarpal.	Radial.	Extends and abducts wrist.
Extensor carpi radialis brevis	Lateral epicondyle → base 3rd metacarpal.	Deep radial.	Extends and abducts wrist; stabilises during grip.
Extensor digitorum	Lateral epicondyle → extensor expansions digits 2–5.	Posterior interosseous.	Extends MCP and assists IP extension.
Extensor digiti minimi	Lateral epicondyle → little-finger expansion.	Posterior interosseous.	Extends fifth digit.
Extensor carpi ulnaris	Lateral epicondyle/posterior ulna → base 5th metacarpal.	Posterior interosseous.	Extends and adducts wrist.
Supinator	Lateral epicondyle, annular ligament and ulna → proximal radius.	Deep radial.	Supinates forearm, especially with elbow extended.
Abductor pollicis longus	Posterior radius/ulna/interosseous membrane → base 1st metacarpal.	Posterior interosseous.	Abducts/extends thumb at CMC.
Extensor pollicis brevis	Posterior radius/interosseous membrane → proximal thumb phalanx.	Posterior interosseous.	Extends thumb MCP.
Extensor pollicis longus	Posterior ulna/interosseous membrane → distal thumb phalanx.	Posterior interosseous.	Extends thumb IP; forms medial snuffbox border.
Extensor indicis	Posterior distal ulna/interosseous membrane → index expansion.	Posterior interosseous.	Extends index finger independently.

7. Intrinsic muscles of the hand

Group	Muscles/attachments	Nerve	Actions
Thenar	Abductor pollicis brevis, flexor pollicis brevis and opponens pollicis from flexor retinaculum/carpals to thumb.	Recurrent median mainly; deep ulnar contribution to deep flexor pollicis brevis.	Thumb abduction, flexion and opposition.
Adductor pollicis	Oblique/transverse metacarpal attachments to proximal thumb phalanx.	Deep ulnar.	Adducts thumb and provides pinch force.
Hypothenar	Abductor, flexor and opponens digiti minimi from pisiform/hamate to fifth digit.	Deep ulnar.	Moves and cups the little-finger side of the hand.
Lumbricals	From FDP tendons to extensor expansions of digits 2–5.	Lateral two median; medial two deep ulnar.	Flex MCP while extending IP joints; important for precision posture.
Dorsal interossei	Between metacarpals to proximal phalanges/extensor expansions.	Deep ulnar.	Abduct fingers; assist MCP flexion/IP extension.
Palmar interossei	Palmar metacarpals to proximal phalanges/extensor expansions.	Deep ulnar.	Adduct fingers; assist MCP flexion/IP extension.

The intrinsic muscles position the fingers for writing, buttoning and precision pinch. Extrinsic flexors and extensors generate larger excursion and force; intrinsic and extrinsic muscles must be balanced for efficient hand function.

8. Contractions in everyday tasks

Task	Concentric examples	Eccentric examples	Isometric/stabilising examples
Reaching to a shelf	Deltoid, serratus anterior and rotator cuff elevate the limb.	Posterior shoulder muscles control return.	Rotator cuff centres humeral head; trunk stabilises.
Drinking from a cup	Biceps flexes elbow; wrist/finger flexors grip.	Triceps controls lowering; wrist extensors balance grip.	Scapular muscles hold the shoulder base.
Pushing a door	Pectoralis major/triceps/serratus generate push.	Shoulder stabilisers control recoil.	Wrist and hand co-contract to transmit force.
Typing	Small finger movements alternate rapidly.	Extensors control key release.	Forearm and shoulder stabilisers maintain position.

9. Practical assessment and exercise application

Inspect muscle bulk, posture, scapular position, involuntary movement and substitution patterns.
Test active range before resisted testing; compare sides and account for pain, fear and fatigue.
Use a consistent position and lever arm for manual muscle testing; document grade, pain and quality.
Choose open-chain or closed-chain exercise according to the goal, tissue status and function.
Progress load, range, speed, repetitions and task complexity gradually; allow recovery.
Consider nerve roots and peripheral nerve supply when weakness follows a non-muscular pattern.

Clinical scenario: weak shoulder elevation

A patient cannot lift the arm above shoulder height. Observe scapular winging, active versus passive range, pain, deltoid contour and sensation over the lateral shoulder. Compare resisted abduction, external rotation and scapular control. Do not label it a “rotator-cuff tear” from one test; document findings, protect the patient and refer for appropriate clinical evaluation.

10. Examination points and revision questions

High-yield points

Scapular muscles provide the mobile base; rotator cuff muscles centre the humeral head.
The anterior arm is mainly musculocutaneous-innervated flexors; the posterior arm is radial-innervated extensors.
Forearm flexor–pronators are mainly median/ulnar supplied; extensors are radial/posterior interosseous supplied.
Intrinsic hand muscles coordinate precision grip, thumb opposition and MCP flexion with IP extension.
Concentric, eccentric and isometric actions must be identified within the task, not by muscle name alone.

Give the attachments, innervation and actions of the rotator cuff muscles.
Compare the three heads of triceps and the actions of biceps and brachialis.
Describe the forearm flexor–pronator and extensor–supinator compartments.
Explain the roles of lumbricals and interossei in hand function.
For reaching, drinking and pushing, identify concentric, eccentric and isometric contractions.
Explain how pain, nerve injury or joint restriction can mimic muscle weakness.

References for further study

Educational note: Muscle testing and exercise prescription require supervised skills training and awareness of injury, surgical and cardiopulmonary precautions.

Upper-Limb Muscles: Positions, Attachments, Contractions and Actions Read More »

The Structure of Joints of the Upper Limb: Shoulder, Elbow, Wrist and Hand

The Structure of Joints of the Upper Limb

The upper limb sacrifices some stability for exceptional mobility. Its joints form a linked chain from the sternum to the fingertips: sternoclavicular, acromioclavicular, scapulothoracic, glenohumeral, elbow, radioulnar, wrist and hand joints. Understanding each joint’s surfaces, capsule, ligaments, movement and stability helps the physiotherapist connect pain or restriction to functional tasks.

Add a labelled diagram of upper-limb joints here

Add your labelled upper-limb joints image here.

Learning outcomes

Classify upper-limb joints and identify their articular surfaces.
Describe the capsule, ligaments, movements and stabilisers of the shoulder girdle and glenohumeral joint.
Explain the elbow complex, proximal/distal radioulnar joints, wrist and hand joints.
Relate joint design to mobility, stability, arthrokinematics and common injuries.
Apply joint anatomy to assessment, exercise selection, mobilisation precautions and activities of daily living.

1. Joint principles

A joint is a junction between bones or cartilages. Fibrous and cartilaginous joints provide little movement and stability; synovial joints have a cavity, articular cartilage, capsule and synovial fluid. The upper limb contains both true synovial joints and the functional scapulothoracic articulation.

Feature of a synovial joint	Function	Physiotherapy relevance
Hyaline articular cartilage	Low-friction surface and load distribution.	Cartilage damage may cause pain, stiffness and altered loading.
Fibrous capsule	Encloses the joint and limits excessive translation.	Capsular shortening produces characteristic movement restriction.
Synovial membrane/fluid	Lubrication, nourishment and waste removal.	Inflammation can cause effusion, warmth and pain.
Ligaments	Guide and restrain movement; provide proprioception.	Sprains compromise stability; healing requires graded loading.
Labrum/disc/meniscus	Deepen a socket, improve congruence or distribute load.	Labral or disc injury may cause catching, instability or reduced function.
Muscles/tendons	Dynamic stability and movement.	Strength, timing and motor control often determine practical stability.

2. Shoulder girdle joints

2.1 Sternoclavicular joint

The sternoclavicular (SC) joint is a saddle-type synovial joint between the medial clavicle, clavicular notch of the manubrium and first costal cartilage. An articular disc divides the joint and improves congruence. It is the only bony connection between the upper limb and axial skeleton.

Ligaments: anterior/posterior sternoclavicular, interclavicular and costoclavicular ligaments.
Movements: elevation/depression, protraction/retraction and axial rotation of the clavicle.
Clinical point: the strong costoclavicular ligament and disc protect the joint, but trauma can displace the clavicle; posterior displacement may threaten mediastinal structures.

2.2 Acromioclavicular joint

The acromioclavicular (AC) joint is a plane synovial joint between the lateral clavicle and acromion. It permits small gliding and rotation that are essential for full overhead elevation.

Acromioclavicular capsule/ligament: local restraint.
Coracoclavicular ligament: conoid and trapezoid parts suspend the scapula from the clavicle and resist separation.
Injury: an AC sprain or “shoulder separation” may disrupt the coracoclavicular complex; assess contour, pain and function without forcing loading.

2.3 Scapulothoracic articulation

This is a functional gliding interface between the anterior scapula, subscapular tissues and thoracic wall, not a conventional synovial joint. The serratus anterior, trapezius, rhomboids, levator scapulae and pectoralis minor control its movement.

Scapular movement	Functional example	Main contributors
Elevation/depression	Shoulder shrug or lowering a load.	Upper trapezius/levator; lower trapezius and depression control.
Protraction/retraction	Reaching forward or pulling an object.	Serratus anterior/pectoralis minor; trapezius/rhomboids.
Upward/downward rotation	Overhead reach or returning the arm.	Upper/lower trapezius with serratus anterior; rhomboids/levator/pectoralis minor assist downward rotation.
Anterior/posterior tilt	Scapula adapts to humeral elevation and thoracic posture.	Balance of serratus, trapezius, pectoralis minor and trunk position.

3. Glenohumeral (shoulder) joint

The glenohumeral joint is a ball-and-socket synovial joint between the humeral head and the shallow glenoid cavity. It offers flexion, extension, abduction, adduction, internal/external rotation and circumduction, but its mobility makes it vulnerable to instability.

3.1 Stabilising structures

Glenoid labrum: fibrocartilaginous rim that deepens the socket and provides attachment for the capsule and long head of biceps.
Joint capsule: loose inferiorly to allow elevation; attaches around the glenoid and anatomical neck.
Glenohumeral ligaments: superior, middle and inferior bands reinforce the anterior capsule; the inferior complex is important in abduction/external rotation.
Coracohumeral ligament: supports the superior capsule and rotator-interval region.
Coracoacromial arch: protects the superior joint but may contribute to subacromial compression in some conditions.
Rotator cuff: supraspinatus, infraspinatus, teres minor and subscapularis compress the humeral head into the glenoid and guide rotation.
Long head of biceps: passes through the joint region and intertubercular groove; assists dynamic stability and shoulder flexion.

3.2 Movement and arthrokinematics

Movement	Prime contributors	Key joint/clinical point
Flexion	Anterior deltoid, clavicular pectoralis major, coracobrachialis, biceps.	Requires scapular upward rotation for full range.
Extension	Posterior deltoid, latissimus dorsi, teres major, long head triceps.	Posterior capsule and anterior structures may limit end range.
Abduction	Supraspinatus initiates; deltoid continues.	Scapulohumeral rhythm combines glenohumeral and scapular motion.
Adduction	Pectoralis major, latissimus dorsi, teres major, long head triceps.	Closed-chain adduction helps push and weight-bearing tasks.
External rotation	Infraspinatus, teres minor, posterior deltoid.	Important for reaching behind the head; vulnerable in anterior instability.
Internal rotation	Subscapularis, pectoralis major, latissimus dorsi, teres major, anterior deltoid.	Needed for dressing, grooming and reaching the back.

In a convex-on-concave open-chain movement, the humeral head rolls and glides in opposite directions; in closed-chain tasks, the glenoid moves on the humeral head. Apply this principle cautiously because real movement includes translation, rotation, soft-tissue deformation and scapular motion.

4. Elbow complex

The elbow complex comprises the humeroulnar, humeroradial and proximal radioulnar joints within a common capsule. Together they position the hand by flexing/ extending the elbow and rotating the forearm.

Joint	Articular surfaces	Main role
Humeroulnar	Trochlea and trochlear notch of ulna.	Stable hinge for flexion and extension.
Humeroradial	Capitulum and radial head.	Shares load and guides elbow motion; accommodates forearm rotation.
Proximal radioulnar	Radial head and radial notch/annular ligament.	Pivot for pronation and supination.

4.1 Stability and movement

Medial and lateral collateral ligaments resist valgus and varus stress.
The annular ligament holds the radial head against the ulna while allowing rotation.
Olecranon and coronoid processes provide bony stability; the capsule is loose anteriorly/posteriorly.
Flexion is produced mainly by brachialis, biceps and brachioradialis; extension by triceps and anconeus.
Pronation uses pronator teres and pronator quadratus; supination uses biceps and supinator.

The carrying angle is the lateral deviation of the forearm relative to the arm in extension and supination. It varies with sex, age, position and measurement method; document the method instead of assuming a single normal value.

5. Distal radioulnar joint and interosseous membrane

The distal radioulnar joint is a pivot-type synovial joint between the ulnar head and the ulnar notch of the radius. The triangular fibrocartilage complex (TFCC) stabilises the ulnar side of the wrist and separates the ulna from the carpus. The interosseous membrane links the shafts, transmits load and provides a broad attachment surface.

During pronation/supination, the radius rotates around the relatively stable ulna.
Disruption of the interosseous membrane or TFCC can cause pain, weakness and instability with gripping or rotation.
Assess elbow position, wrist load and forearm rotation separately during functional tasks.

6. Wrist and hand joints

6.1 Wrist

The radiocarpal joint is formed mainly by the distal radius and articular disc with the scaphoid, lunate and triquetrum. The ulna does not directly articulate with the carpal row. The midcarpal joint between proximal and distal carpal rows contributes substantially to flexion, extension and deviation.

Movement	Main contribution	Functional example
Flexion	Radiocarpal and midcarpal motion.	Holding a bowl close to the body.
Extension	Radiocarpal and midcarpal motion.	Push-up support or pushing a door.
Radial deviation	Movement toward thumb side.	Positioning a spoon or turning a key.
Ulnar deviation	Movement toward little-finger side.	Using a hammer or steering wheel.

6.2 Carpometacarpal and hand joints

Thumb CMC: saddle joint between trapezium and first metacarpal; flexion, extension, abduction, adduction and opposition enable pinch.
Digits 2–5 CMC: relatively stable plane joints that form the base of the hand arch.
MCP joints: condyloid joints permitting flexion/extension and abduction/adduction; collateral ligaments tighten in flexion.
Interphalangeal joints: hinge joints; PIP and DIP flexion/extension in digits 2–5, one IP joint in the thumb.
Palmar plates and collateral ligaments: reinforce the volar side and guide joint motion.

7. Joint function in physiotherapy

Assessment question	What joint anatomy contributes
Is the restriction capsular?	A joint capsule, synovium, ligaments and muscle may all limit motion; compare the pattern and end feel.
Is stability adequate?	Consider static restraints, labrum/TFCC, muscle timing, proprioception and load.
Is the movement isolated?	Check adjacent joints and compensations; shoulder elevation includes clavicle, scapula, humerus and thorax.
Can the patient load the joint?	Consider tissue healing, pain, swelling, bone quality, surgical restrictions and functional need.

8. Common clinical patterns

Anterior shoulder dislocation: often occurs in abduction/external rotation; protect the joint, assess axillary sensation and follow reduction/immobilisation orders.
Adhesive capsulitis: pain and capsular restriction, commonly affecting external rotation, abduction and flexion; rule out other causes.
AC sprain: pain at the AC region, especially cross-body movement; grade and management require clinical assessment.
Lateral epicondylalgia: pain near common extensor origin, often load-related; assess the whole kinetic chain.
Elbow stiffness: can quickly affect hand-to-mouth, dressing and reaching; protect healing structures while restoring motion.
Carpal tunnel/hand stiffness: joint position, tendon glide, nerve sensitivity and swelling may interact.

9. Practical learning activities

Identify the SC, AC, glenohumeral, humeroulnar, radioulnar, radiocarpal, CMC, MCP and IP joints on a model.
Observe scapulohumeral rhythm during slow arm elevation and note clavicular and scapular contributions.
Compare open-chain shoulder rotation with closed-chain hand-on-wall movement.
Demonstrate how elbow flexion and forearm rotation position the hand for feeding and grooming.
Practise documenting a joint range with position, side, movement, pain, end feel and functional effect.

10. Examination points and revision questions

High-yield points

The SC joint is the only true bony link between upper limb and axial skeleton.
Glenohumeral mobility depends on the labrum, capsule, ligaments, rotator cuff and scapular control.
The elbow complex includes humeroulnar, humeroradial and proximal radioulnar joints.
The radius rotates around the ulna during pronation and supination.
Thumb opposition depends on the saddle CMC joint and coordinated intrinsic/extrinsic muscles.

Describe the joints of the shoulder girdle and explain scapulohumeral rhythm.
Discuss the stabilising structures of the glenohumeral joint.
Compare the three joints of the elbow complex.
Explain the roles of the TFCC and interosseous membrane.
Describe the wrist, thumb CMC, MCP and interphalangeal joints.
Relate joint mobility and stability to reaching, pushing, gripping and dressing.

References for further study

Educational note: Joint mobilisation, manipulation and post-injury loading require supervised training and adherence to local protocols.

The Structure of Joints of the Upper Limb: Shoulder, Elbow, Wrist and Hand Read More »

The Structure of Bones of the Upper Limb: Shoulder Girdle, Humerus, Forearm and Hand

The Structure of Bones of the Upper Limb

The upper limb is designed for mobility, reach, manipulation and communication. Its bones form a light but strong framework that positions the hand in space while transferring forces to the axial skeleton through the shoulder girdle. This page follows the limb from proximal to distal: shoulder girdle, humerus, forearm and hand.

Add a labelled diagram of the bones of the upper limb here

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Why physiotherapy students must know the bones

Bone landmarks guide palpation, joint-axis alignment, muscle attachment, fracture precautions, range-of-motion measurement, movement analysis and safe manual handling. A physiotherapist must know not only a bone’s name but also its orientation, articulations, load-bearing surfaces, neurovascular relationships and common injury sites.

Learning outcomes

List the bones of the pectoral girdle, arm, forearm and hand.
Orient the clavicle, scapula, humerus, radius and ulna using reliable landmarks.
Identify the major surfaces, borders, processes, fossae, tubercles and articular areas.
Relate bony attachments to movement, stability and common injuries.
Use bony landmarks for examination, measurement, exercise and patient education.

1. General organisation

Each upper limb has 30 bones distal to the shoulder girdle: one humerus, two forearm bones, eight carpals, five metacarpals and fourteen phalanges. The pectoral girdle adds a clavicle and scapula. The arm is the region between shoulder and elbow; the forearm lies between elbow and wrist; the hand is distal to the wrist.

Region	Bones	Main functional idea
Shoulder girdle	Clavicle and scapula	Connects the limb to the axial skeleton and positions the glenoid cavity.
Arm	Humerus	Single long-bone lever between shoulder and elbow.
Forearm	Radius and ulna	Supports the elbow/wrist and permits pronation–supination.
Hand	Carpals, metacarpals and phalanges	Combines stability, sensation, grasp and fine manipulation.

2. Clavicle

The clavicle is an S-shaped, subcutaneous strut between the manubrium and scapula. It holds the shoulder laterally away from the thorax, transmits forces from the limb to the trunk and protects the neurovascular bundle at the root of the neck.

2.1 Parts and orientation

Sternal (medial) end: bulky and quadrangular; articulates with the clavicular notch of the manubrium and first costal cartilage at the sternoclavicular joint.
Acromial (lateral) end: flatter; articulates with the acromion at the acromioclavicular joint.
Body: medial two-thirds convex anteriorly and lateral third concave anteriorly.
Inferior surface: has the conoid tubercle and trapezoid line for the coracoclavicular ligament, subclavian groove for subclavius and impression for the costoclavicular ligament.

2.2 Attachments and clinical relevance

Attachment/feature	Significance
Sternocleidomastoid	Attaches near the medial clavicle; assists neck and shoulder positioning.
Pectoralis major	Attaches to the anterior medial clavicle; contributes to flexion, adduction and internal rotation of the arm.
Deltoid and trapezius	Attach along the lateral clavicle; coordinate elevation and scapular control.
Subclavius	Attaches to the inferior groove; helps stabilise the clavicle.
Coracoclavicular and acromioclavicular ligaments	Maintain scapular suspension and transfer load across the shoulder girdle.

The middle third is a common fracture site because it is relatively unsupported and exposed. Assess deformity, skin tension, neurovascular status and shoulder function; do not force movement when fracture is suspected.

3. Scapula

The scapula is a flat, triangular bone on the posterolateral thorax, gliding over ribs two to seven. It provides a mobile base for the arm and numerous muscle attachments. The scapula is not directly joined to the thorax by a true synovial joint; the scapulothoracic interface depends on muscles, fascia and the thoracic contour.

3.1 Surfaces, borders and angles

Costal/anterior surface: contains the broad subscapular fossa and ridges for subscapularis.
Dorsal/posterior surface: divided by the spine into the supraspinous and infraspinous fossae.
Superior border: contains the suprascapular notch, converted into a foramen by the superior transverse scapular ligament.
Medial (vertebral) border: runs beside the spine and provides attachments for rhomboids, serratus anterior and parts of levator scapulae.
Lateral (axillary) border: thickened near the glenoid and gives attachment to teres major/minor.
Superior, inferior and lateral angles: the inferior angle moves around the thorax; the lateral angle carries the glenoid cavity.

3.2 Processes and glenoid region

Structure	Description and importance
Spine of scapula	Prominent posterior ridge ending laterally as the acromion; separates supra- and infraspinous fossae.
Acromion	Overhangs the shoulder joint and articulates with the clavicle; attachment for deltoid and trapezius.
Coracoid process	Hook-like anterior projection; attachment for pectoralis minor, coracobrachialis, short head of biceps and coracoclavicular ligaments.
Glenoid cavity	Shallow, pear-shaped articular surface for the humeral head; deepened by the glenoid labrum.
Supraglenoid and infraglenoid tubercles	Origins for long heads of biceps and triceps respectively.
Scapular notch	Route for the suprascapular nerve; compression may weaken supraspinatus and infraspinatus.

Scapular movement includes elevation, depression, protraction, retraction, upward rotation, downward rotation, anterior tilt and posterior tilt. Normal upward rotation requires coordinated trapezius and serratus anterior activity.

4. Humerus

The humerus is the long bone of the arm. Its proximal end participates in the glenohumeral joint; its distal end forms the elbow complex. The shaft is rounded proximally and more triangular distally.

4.1 Proximal humerus

Head: smooth, spherical surface facing medially, superiorly and slightly posteriorly; articulates with the glenoid cavity.
Anatomical neck: groove around the head where the capsule attaches.
Greater tubercle: lateral projection for supraspinatus, infraspinatus and teres minor.
Lesser tubercle: anterior projection for subscapularis.
Intertubercular sulcus: contains the tendon of the long head of biceps; lips give attachment to pectoralis major, teres major and latissimus dorsi.
Surgical neck: common fracture area close to the axillary nerve and posterior circumflex humeral vessels.

4.2 Shaft and distal humerus

Feature	Attachment/relationship	Clinical point
Deltoid tuberosity	Insertion of deltoid.	Forceful deltoid contraction and fractures may affect the radial nerve below.
Radial groove	Radial nerve and profunda brachii artery pass posteriorly.	Mid-shaft fractures can produce wrist/finger extension weakness.
Medial/lateral supracondylar ridges	Attachments for brachialis region and forearm muscle origins.	Distal fractures may threaten brachial artery or median nerve.
Capitulum	Articulates with the head of the radius.	Participates in flexion/extension and forearm rotation.
Trochlea	Spool-shaped surface for the ulna.	Forms the main humeroulnar hinge.
Medial/lateral epicondyles	Common flexor and extensor origins; collateral ligament attachments.	Palpable landmarks in elbow pain and alignment.
Radial, coronoid and olecranon fossae	Receive forearm structures during elbow movement.	Permit flexion and extension without bony impingement.

5. Radius and ulna

The radius lies laterally in anatomical position on the thumb side; the ulna lies medially on the little-finger side. They articulate with each other at proximal and distal radioulnar joints and are linked by the interosseous membrane.

5.1 Ulna

Olecranon: posterior projection forming the point of the elbow and receiving triceps insertion.
Coronoid process and trochlear notch: embrace the trochlea during elbow flexion/extension.
Radial notch: articulates with the radial head.
Ulnar tuberosity: insertion for brachialis.
Ulnar shaft and head: the distal ulna is smaller; the head articulates with the radius but is separated from the carpus by an articular disc.
Styloid process: distal palpable projection and attachment for wrist ligaments.

5.2 Radius

Head: disc-shaped; articulates with the capitulum and radial notch of the ulna.
Neck and radial tuberosity: biceps inserts on the tuberosity, producing flexion and supination.
Interosseous border: attachment for the interosseous membrane.
Distal end: broad, articulates mainly with scaphoid and lunate; has a radial styloid process and ulnar notch.
Dorsal tubercle of Lister: pulley-like landmark guiding the extensor pollicis longus tendon.

During pronation, the radius crosses over the ulna; during supination, the bones are parallel. The interosseous membrane transfers load and provides muscle attachment while allowing rotation.

6. Bones of the hand

6.1 Carpal bones

Eight carpals are arranged in two rows. From lateral (thumb) to medial in the proximal row: scaphoid, lunate, triquetrum, pisiform. In the distal row: trapezium, trapezoid, capitate, hamate. The scaphoid is the main bridge between rows and is vulnerable to fracture; the hook of hamate and pisiform are palpable landmarks.

Carpal feature	Clinical/functional importance
Scaphoid	Articulates with radius; waist fractures risk impaired blood supply and non-union.
Lunate	Central proximal carpal; participates in radiocarpal motion and may dislocate volarly.
Triquetrum/pisiform	Ulnar-side landmarks; pisiform is a sesamoid within flexor carpi ulnaris.
Trapezium	Saddle joint with first metacarpal enables thumb opposition.
Capitate	Largest carpal and central support of the distal row.
Hamate	Hook forms part of the carpal tunnel/Guyon canal boundaries.

6.2 Metacarpals and phalanges

Five metacarpals are numbered from thumb to little finger; each has a base, shaft, neck and head.
Metacarpal heads form the knuckles and articulate with proximal phalanges.
The thumb has two phalanges; each other digit has proximal, middle and distal phalanges.
Distal phalanges support the nail beds and fingertip pulp, which are important for precision pinch and sensation.
Sesamoid bones commonly occur near the thumb metacarpophalangeal joint and improve tendon mechanics.

7. Bony relationships and movement

Movement goal	Bony contributors	Physiotherapy emphasis
Reach overhead	Clavicle elevation/posterior rotation, scapular upward rotation, humeral elevation and thoracic extension.	Assess the whole shoulder complex, not glenohumeral motion alone.
Push from a chair	Scapular protraction, elbow extension, wrist stability and hand contact.	Protect painful wrists, elbows and shoulders; train closed-chain control.
Grip a cup	Carpal stability, metacarpal alignment, finger flexion and thumb opposition.	Assess strength, sensation, joint range and object size.
Pronate/supinate	Radial head rotation, distal radioulnar movement and interosseous membrane.	Check elbow position and avoid substituting shoulder movement.

8. Common injuries and precautions

Clavicle fracture: protect the shoulder, monitor neurovascular status and progress movement only as prescribed.
Proximal humeral fracture/dislocation: protect the axillary nerve and surgical repair; avoid unapproved loading or external rotation.
Humeral shaft fracture: assess radial-nerve function and wrist/finger extension.
Supracondylar/distal humeral injury: urgent attention to brachial artery, median nerve and compartment signs.
Radial-head or olecranon injury: respect elbow stability and forearm rotation restrictions.
Scaphoid fracture: anatomical snuffbox tenderness requires medical assessment even if radiographs are initially negative.
Metacarpal/phalangeal fractures: protect alignment, tendon glide, oedema and functional hand use.

9. Practical learning activities

Handle a model or skeleton and orient the clavicle, scapula, humerus, radius and ulna.
Palpate the acromion, coracoid, spine of scapula, epicondyles, olecranon, radial/ulnar styloids, metacarpal heads and phalanges on a consenting partner.
Draw the carpal rows from lateral to medial and identify the thumb-side and little-finger-side relationships.
Demonstrate pronation and supination with the elbow by the side to show radius crossing and uncrossing the ulna.
Match common fracture sites with nearby nerves or vessels that require monitoring.

10. Examination points and revision questions

High-yield points

Each upper limb contains 30 bones distal to the shoulder girdle.
The clavicle is a strut; the scapula is a mobile muscle-controlled base; the glenoid is shallow to permit mobility.
The humeral surgical neck is close to the axillary nerve; the shaft’s radial groove is close to the radial nerve.
The radius is lateral in anatomical position and crosses the ulna in pronation.
The thumb’s trapezium–first metacarpal saddle joint enables opposition.

List the bones of the upper limb from proximal to distal.
Describe the surfaces, borders, processes and articulations of the scapula.
Compare the proximal and distal features of the humerus.
Explain the functional difference between radius and ulna during pronation and supination.
Name the carpal bones in proximal and distal rows.
Relate the surgical neck, radial groove and scaphoid waist to clinical precautions.
Explain how the bony architecture supports reach, grip and fine manipulation.

References for further study

Educational note: Use supervised practical teaching and local fracture/immobilisation protocols when applying this anatomy to patients.

The Structure of Bones of the Upper Limb: Shoulder Girdle, Humerus, Forearm and Hand Read More »

Surface Marking Principles for Physiotherapy Students

Surface marking is the method of locating and describing deeper anatomical structures by using visible or palpable landmarks on the body. It helps a physiotherapist communicate precisely, plan an examination, place measurement points, describe pain or swelling, identify muscle and joint relationships, and recognise when a finding needs medical referral.

Important limitation

Surface landmarks are guides, not proof of what lies underneath. Body size, age, posture, pregnancy, obesity, injury, oedema, deformity and anatomical variation can change the relationship. Use gentle examination, compare sides, respect privacy and confirm uncertain or high-risk findings through the responsible clinician and appropriate imaging or testing.

Learning outcomes

Define surface anatomy, surface marking, anatomical landmark and line of reference.
Apply anatomical position, planes, directions, regions and movement terminology.
Locate major bony, muscular, vascular and visceral surface landmarks.
Use safe inspection, palpation and measurement techniques in physiotherapy assessment.
Describe findings clearly using reproducible landmarks rather than vague terms.
Recognise limitations, red flags and situations requiring referral or imaging.

1. Basic principles of surface marking

Surface marking translates three-dimensional anatomy into reproducible points, lines, borders and regions on the living body. A good landmark is relatively constant, palpable, easy to describe and clinically useful.

1.1 The anatomical position

The reference position is standing upright, head and eyes forward, arms beside the body, palms facing forward, thumbs pointing laterally and feet directed forward. Descriptions are made from the patient’s right and left, not the observer’s. Document the patient’s position because landmarks shift between standing, sitting, supine, prone and side-lying.

1.2 Directional terms

Term	Meaning	Example
Superior/inferior	Towards the head/away from the head	The sternum is superior to the umbilicus.
Anterior/posterior	Towards the front/towards the back	The patella is anterior to the knee joint.
Medial/lateral	Towards/farther from the midline	The sternum is medial to the ribs.
Proximal/distal	Nearer/farther from a limb’s attachment	The elbow is proximal to the wrist.
Superficial/deep	Nearer/farther from the body surface	Skin is superficial to muscle.
Ipsilateral/contralateral	Same side/opposite side	Right hip and right knee are ipsilateral.
Palmar/dorsal	Palm/back of the hand	The palmar surface faces anteriorly in anatomical position.
Plantar/dorsal	Sole/top of the foot	The plantar surface contacts the ground in standing.

1.3 Planes, axes and common movements

Plane/axis	Typical movement or use
Sagittal plane / mediolateral axis	Flexion and extension; side-view posture and range measurement.
Frontal (coronal) plane / anteroposterior axis	Abduction, adduction and lateral flexion; pelvic and shoulder alignment.
Transverse (horizontal) plane / vertical axis	Rotation; trunk, cervical and limb rotational assessment.
Oblique plane	Movement or imaging that follows a diagonal orientation.

2. Safe surface-marking technique

Explain and obtain consent: describe what you need to see, touch or measure and why. Offer a chaperone for sensitive areas.
Prepare the environment: privacy, adequate light, comfortable temperature, clean hands and appropriate draping.
Position the patient: document standing, sitting, supine, prone or side-lying; relax the muscles unless a contraction is being assessed.
Inspect before palpating: note symmetry, swelling, colour, scars, deformity, muscle bulk, posture and movement.
Palpate gently: use the pads of fingers, move from familiar structures to less familiar ones and ask about pain before increasing pressure.
Confirm the landmark: compare with the opposite side, follow the structure along its contour and check the expected movement or relationship.
Mark or measure only when appropriate: use a skin-safe marker, tape or goniometer according to policy; never mark broken or infected skin.
Document precisely: side, position, landmark, distance/angle, symptom response, measurement method and time.
Clean up and reassess: remove markings, restore dignity and report unexpected findings.

Palpation safety

Do not force a painful or unstable region. Use caution with suspected fracture, acute inflammation, vascular compromise, deep-vein thrombosis, open wound, recent surgery, severe osteoporosis or altered sensation. If palpation produces severe pain, neurological symptoms, faintness or unexpected swelling, stop and escalate.

3. Head and neck landmarks

Landmark	How to locate	Physiotherapy/clinical use
External occipital protuberance	Prominence in the midline of the posterior skull.	Reference for the occiput, neck posture and suboccipital region.
Mastoid process	Bony prominence behind the ear.	Temporal-region orientation and attachment area for sternocleidomastoid.
Mandible and angle of mandible	Trace the lower jaw to its posterior angle.	Jaw movement, facial pain and head/neck orientation.
Hyoid bone	Small mobile bone in the anterior neck, usually near C3; palpate gently.	Swallowing, laryngeal movement and suprahyoid/infrahyoid relationships.
Thyroid cartilage	Laryngeal prominence in the midline, usually near C4–C5.	Airway/neck orientation; avoid forceful pressure.
Cricoid cartilage	Firm ring below thyroid cartilage, around C6.	Airway reference; never use surface marking as a substitute for trained airway procedures.
Clavicle	Palpate from the sternum to the acromion.	Shoulder girdle alignment and clavicular fracture assessment.
Spinous process of C7	Most prominent cervical spinous process when the neck flexes.	Posture, cervical–thoracic junction and spinal measurement reference.
Sternocleidomastoid borders	From mastoid to sternum and medial clavicle; ask the patient to rotate the head against light resistance.	Neck posture, muscle length and torticollis assessment.

4. Thoracic surface marking

4.1 Thoracic lines

Midsternal line: vertical line through the centre of the sternum.
Midclavicular line: vertical line through the midpoint of the clavicle; do not assume the nipple is a reliable landmark for every person.
Anterior, mid and posterior axillary lines: reference the front, centre and back of the axillary fold.
Scapular and paravertebral lines: pass through the inferior angle/medial spinal region and beside the vertebral column.

4.2 Bony landmarks and clinical relationships

Landmark	Approximate relationship/use
Jugular (suprasternal) notch	Superior border of the manubrium; reference for the upper sternum and clavicles.
Sternal angle (angle of Louis)	Manubriosternal junction, approximately T4/T5; level of the second costal cartilage and division of the trachea in standard anatomy.
Rib and intercostal spaces	Count from the second rib at the sternal angle; palpate gently and avoid pressing directly over painful ribs.
Xiphoid process	Inferior sternum; variable in shape, so avoid deep pressure.
Scapula	Spine commonly near T3; inferior angle often near T7 at rest, but position changes with arm movement.
Diaphragm/lung bases	Levels vary with breathing, posture and body habitus; do not use a single surface estimate as a diagnosis.

For respiratory assessment, describe findings by side, line and level—for example, “reduced expansion at the right lower posterior chest”—rather than “reduced chest movement.” Use auscultation and medical assessment according to your training and scope.

5. Abdominal surface marking

5.1 Four quadrants

Quadrant	Structures commonly projected here	Clinical use
Right upper quadrant	Liver, gallbladder, duodenum, head of pancreas, right kidney and colon.	Describe pain, tenderness, scars or swelling accurately.
Left upper quadrant	Stomach, spleen, body/tail of pancreas, left kidney and colon.	Relevant to abdominal, splenic and rib-related symptoms.
Right lower quadrant	Caecum, appendix region, terminal ileum, right ureter and reproductive structures.	Report localised pain or guarding promptly.
Left lower quadrant	Descending/sigmoid colon, left ureter and reproductive structures.	Document bowel, pelvic and musculoskeletal symptoms by side.

5.2 Nine abdominal regions

Two vertical midclavicular lines and two horizontal planes divide the abdomen into:

Right	Middle	Left
Right hypochondriac	Epigastric	Left hypochondriac
Right lumbar	Umbilical	Left lumbar
Right iliac/inguinal	Hypogastric/pubic	Left iliac/inguinal

Important horizontal references include the subcostal plane and transtubercular plane; their exact levels vary with body shape. The transpyloric plane is a useful upper-abdominal reference but should be treated as approximate.

5.3 Abdominal and pelvic landmarks

Umbilicus: visible central reference; level changes with age, body shape and pregnancy.
Anterior superior iliac spine (ASIS): prominent anterior pelvic point for leg-length, pelvic alignment and muscle attachment references.
Posterior superior iliac spine (PSIS): palpable posterior pelvic point, often near the dimples above the buttocks.
Iliac crest: superior border of the pelvis; the line between the highest points often approximates L4/L4–L5, but individual variation exists.
Pubic symphysis: anterior midline pelvic joint; assess respectfully and only when clinically indicated.
Inguinal ligament region: runs approximately from ASIS to pubic tubercle; avoid aggressive pressure over vessels and sensitive structures.

6. Spine and posterior trunk

Landmark	Location/relationship	Use
C7 spinous process	Prominent at the cervicothoracic junction during neck flexion.	Posture and spinal alignment measurements.
Scapular spine	Often near T3 at rest.	Scapular position and thoracic posture.
Inferior angle of scapula	Often near T7 at rest, moving with arm elevation.	Scapulohumeral rhythm and thoracic reference.
12th rib	Lowest rib; posteriorly related to the upper lumbar region.	Kidney/flank orientation; palpate carefully.
L4 spinous process/iliac crest line	Intercristal line is an approximate lumbar reference.	Spinal examination and safe measurement—not a substitute for imaging.
Sacrum and PSIS	Posterior midline triangular bone and paired pelvic points.	Pelvic tilt, sacroiliac-region assessment and movement analysis.

Palpate spinal processes in a relaxed position and avoid interpreting tenderness alone as the source of pain. Consider movement, neurological findings, red flags, history and functional impact.

7. Upper-limb surface landmarks

Region	Landmarks and use
Shoulder girdle	Acromion, coracoid process, clavicle, spine and inferior angle of scapula. Use for posture, scapular movement and shoulder range.
Arm and elbow	Medial/lateral epicondyles, olecranon and radial head. Use for elbow axis, muscle/tendon attachment and alignment.
Forearm and wrist	Radial/ulnar shafts and styloid processes; identify the radial pulse on the thumb side.
Hand	Metacarpal heads, MCP/PIP/DIP joints, anatomical snuffbox and thenar/hypothenar eminences.
Vascular/nerve caution	Do not compress a painful swelling, suspected fracture or neurovascular structure. Check colour, warmth, sensation, capillary refill and pulse when indicated.

8. Lower-limb surface landmarks

Landmark	How it helps assessment
ASIS and greater trochanter	Pelvic alignment, hip position, apparent leg-length and muscle attachment references.
Patella and patellar tendon	Knee alignment, tracking and quadriceps/extensor mechanism assessment.
Tibial tuberosity and tibial crest	Anterior knee reference and lower-leg alignment.
Head of fibula	Lateral knee landmark; protect the common fibular nerve around the neck.
Medial/lateral malleoli	Ankle mortise, swelling and ligament region assessment.
Navicular, base of fifth metatarsal and metatarsal heads	Foot posture, arch, loading and footwear assessment.
Calcaneus and Achilles tendon	Heel alignment, tendon continuity and push-off function.
Dorsalis pedis/posterior tibial pulses	Peripheral circulation screening when trained and indicated; compare sides and report abnormal findings.

9. Surface marking for movement and measurement

Goniometry: align the fulcrum over the joint axis and the arms with reproducible proximal and distal landmarks; record position, side and method.
Manual muscle testing: stabilise the correct segment and apply resistance at a consistent lever arm while protecting painful or healing tissues.
Gait and posture analysis: use landmarks such as ASIS, PSIS, greater trochanter, knee joint line, malleoli and scapular points; document footwear and surface.
Chest expansion: place a tape at a consistent level and record breathing instruction, position and measurement difference.
Swelling measurement: mark identical distances from fixed landmarks, use the same tape tension and compare with the opposite side when appropriate.
Palpation of muscle/tendon: ask the patient to perform a gentle contraction or movement to confirm the structure, without provoking injury.

Scenario: locating a knee pain site

Instead of recording “pain around the knee,” identify the side and relationship: anterior joint line, medial tibial plateau, patellar tendon, fibular head or posterior crease. Record the movement or load that reproduces symptoms, swelling, range, neurovascular status and functional limitation. This makes communication and follow-up more reliable.

10. Common errors and how to prevent them

Error	Why it causes problems	Better practice
Using the observer’s left/right	Creates wrong-side documentation.	Use the patient’s right and left consistently.
Palpating without consent or warning	Causes distress and breaches dignity.	Explain, obtain consent, drape and use a chaperone where appropriate.
Assuming a landmark is fixed	Posture, body habitus and movement change relationships.	Record position and confirm with more than one reference.
Pressing over an acute injury	May worsen pain or damage tissue.	Screen history, observe first and use gentle technique/referral.
Marking infected or broken skin	Can spread infection or injure tissue.	Use alternative references and follow infection-prevention policy.
Confusing surface projection with diagnosis	Different organs and tissues can refer pain to the same area.	Integrate history, examination, vital signs and medical investigations.
Not documenting the method	Measurements cannot be reproduced.	Record landmark, position, instrument, side, angle/distance and response.

11. Red flags during surface examination

Unexplained severe or night pain, fever, weight loss or rapidly progressive symptoms.
New neurological weakness, loss of sensation, saddle symptoms or bladder/bowel change.
Acute limb swelling, warmth, redness, disproportionate pain or sudden breathlessness.
Suspected fracture, deformity, dislocation or inability to bear weight after trauma.
New chest pain, fainting, cyanosis or severe respiratory distress.
Abdominal guarding, rigid abdomen, persistent vomiting, gastrointestinal bleeding or sudden severe pain.

Stop the examination, keep the patient safe and activate the appropriate clinical pathway. Do not continue repeated palpation to “find the exact spot” when a red flag is present.

12. Practical learning activities

On a classmate who has given consent, identify C7, the scapular spine, inferior angle, ASIS, PSIS, greater trochanter, patella, tibial tuberosity and malleoli.
Draw the four abdominal quadrants and nine regions, then list two projected organs in each.
Practise describing the same shoulder finding in standing and supine positions, noting what changes.
Perform a mock goniometric measurement with a standardised position and document side, landmarks and angle.
Role-play a patient who develops pain during palpation: practise stopping, explaining, reassessing and escalating.

13. Examination points and revision questions

High-yield points

Surface marking uses visible or palpable landmarks to describe deeper structures.
Always use the patient’s right and left and record the patient’s position.
The sternal angle helps identify the second rib; the iliac crest line is an approximate lumbar reference.
ASIS, PSIS, greater trochanter, patella, malleoli and scapular landmarks are essential in movement assessment.
Landmarks guide examination but do not replace imaging or clinical reasoning.
Consent, privacy, gentle palpation and reproducible documentation are essential professional behaviours.

Define surface anatomy and explain four reasons it is important in physiotherapy.
Describe the anatomical position, planes and directional terms used in surface marking.
Locate and explain the clinical importance of C7, the sternal angle, ASIS, PSIS and the iliac crest.
Describe the four abdominal quadrants and nine abdominal regions.
Explain how to perform safe palpation and document a landmark-based finding.
List six common errors in surface marking and how to prevent them.
Give six red flags that should stop a surface examination and prompt referral.

References for further study

Educational note: Surface marking is a supervised practical skill. Follow local examination, consent, infection-prevention, safeguarding and referral policies.

Surface Marking Principles for Physiotherapy Students Read More »