What are the 4 positions of breast examination and their significance?

The Four Positions of Breast Examination

The clinical breast examination involves four distinct patient positions: sitting with hands on hips for visual inspection, sitting upright for lymph node palpation, supine with ipsilateral arm overhead for breast palpation, and supine with additional pillow support under the shoulder/back when needed to flatten thick breast tissue. 1, 2

Position 1: Sitting with Hands on Hips (Visual Inspection)

• The patient sits with hands pushing tightly on hips to contract the pectoralis major muscles, which enhances identification of breast asymmetries, skin changes, and contour abnormalities. 1, 2
• This position allows the examiner to view the breasts from all sides and assess for signs of advanced breast cancer using the acronym BREAST: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast. 1, 2
• The American Cancer Society guidelines note that while multiple positions (hands overhead, hands at sides) may further assist in identifying asymmetries, they do not add substantively to this single recommended position and may reduce time devoted to the more critical palpation component. 1

Position 2: Sitting Upright (Lymph Node Palpation)

• The patient remains sitting upright while the examiner palpates the axillary, supraclavicular, and infraclavicular lymph nodes. 1, 2
• This upright position allows optimal access to the lymph node chains and facilitates thorough examination of regional lymphatic drainage areas. 2

Position 3: Supine with Ipsilateral Arm Overhead (Primary Breast Palpation)

• The patient lies supine with the ipsilateral hand positioned overhead to flatten the breast tissue against the chest wall, thereby reducing the thickness of breast tissue being palpated. 1, 2
• This position is essential for thorough palpation because it distributes breast tissue more evenly across the chest wall, making it easier to detect abnormalities. 1
• The examiner uses the finger pads of the middle three fingers to palpate with overlapping dime-sized circular motions, covering the entire pentagon-shaped area of breast tissue using a vertical strip pattern. 2
• Three levels of pressure (light, medium, and deep) must be applied sequentially at each area to examine tissue at different depths. 2

Position 4: Supine with Pillow Support (For Thick or Large Breasts)

• If the arm-overhead position does not result in relatively even distribution of breast tissue, a small pillow should be placed under the shoulder/lower back on the side being examined to further centralize and flatten the breast. 1
• This modification is critical because the tissue being examined needs to be as thin as possible over the chest wall to maximize detection sensitivity. 1
• This position is particularly important for women with larger breasts or when examining areas that remain thick despite the standard supine positioning. 1

Clinical Significance and Common Pitfalls

• The systematic progression through these four positions ensures comprehensive examination of all breast tissue and regional lymph nodes, which is essential for detecting breast masses that might otherwise be missed. 3, 4
• A common pitfall is failing to inform patients in advance about each position change and what is being assessed, which can cause discomfort and misunderstanding. 1, 2
• Another critical error is inadequate positioning—particularly failing to use the pillow support when needed—which results in incomplete flattening of breast tissue and missed deeper lesions. 1, 2
• The examination should take several minutes per breast for thoroughness; rushing through positions compromises detection sensitivity. 2, 4