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Scalenes
The scalene muscles (anterior scalene, middle scalene, posterior scalene
and scalenus minimus) attach to your top two ribs and to several neck
vertebrae, resulting in muscle fibers of varying lengths. Since trigger
points typically occur at the midpoint in muscle fibers, the scalenes
can have trigger points along nearly the entire length of the cervical
spine (see Figure 5, opposite page).
Although the scalenes help stabilize and flex the neck, their main job
is to raise the upper two ribs on each side as an aid to breathing.
They’re active to some degree in every inhalation, and they work
extremely hard when your breathing is labored during vigorous activity.
Habitual breathing primarily with the chest, instead of primarily with
the diaphragm, can severely tax the scalene muscles. Nervous
hyperventilation stresses them, too. The struggle for breath in people
who suffer from asthma or emphysema can promote scalene trigger points,
as can a bad cough from pneumonia, bronchitis, allergies or a common
cold. Playing a musical wind instrument commonly fosters scalene
trouble.
Scalene muscles help manage the weight of the head. Anything that
creates an imbalance puts an additional burden on them. For this reason,
it’s wise to be aware of posture that may be holding the head off
center. Slouching or habitually carrying your head forward is sure to
keep trigger points going in these muscles.
Many ordinary activities cause scalene trouble when overdone to the
point of strain. Working for long hours with the arms out in front of
the body can be very stressful for them. Pulling, lifting and carrying
heavy loads can be bad. Carrying a heavy backpack is especially rough
for the scalenes and for several other muscles not designed for mule
duty, such as the trapezius, pectoralis minor and sternocleidomastoid.
The scalenes are also among the muscles most abused in sports
activities. As with the sternocleidomastoids, the violent movement of
the head during a fall or an auto accident can be expected to bring
about trigger points in the scalenes. Apparent neurological symptoms in
the upper back, shoulder, arms and hands that mysteriously persist after
such incidents often can be traced to the scalenes.
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| Figure
4. Kneading the SCM between fingers and thumb. |
Figure
5. Three of the four scalene muscles with sample trigger points
(the collarbone has been removed). |
The following case histories are a sampling of the diversity of problems
that can originate in the scalene muscles:
Betsy, age 32, a
postal employee, was rear-ended while delivering the mail. It was only
a minor accident, but it left her with periodic disabling spasms in
the right side of her neck, which almost any little strain would set
off. When she had a flare-up, she was unable to work, and it typically
took several days to recover. Hong Sun, age 31, a
ballet dancer, complained of a constant ache in his upper back at the
inner edge of his left shoulder blade. It felt good to reach over his
shoulder and massage the place with his fingers, but it didn’t stop
the pain. He had had the irritating problem for several years. Amy, age 17, had been
a serious student of the cello, but she quit playing because of
weakness and numbness in her shoulders, arms and hands. Thousands of
dollars of medical tests had turned up no clear cause. Her parents
believed the problem might be related to an accident in the swimming
pool that had strained her neck. Gerhardt, age 56, had
suffered shooting pains in his left shoulder and upper arm ever since
taking a fall on the ice a year and a half earlier. The pain increased
when he carried or tried to lift anything. Physical therapy made the
pain worse. Connie, 49, a potter,
had pain in her shoulder and all down her right arm. It was always
worse in the morning and often awakened her at night. Her forearm and
hand were numb most of the time, and the hand frequently felt swollen.
She was concerned that she wasn’t going to be able to continue her
work and support herself if the trouble got any worse.
Symptoms created by scalene
trigger points are easily misinterpreted (see Figures 6 and 7, Page 60).
Their referred pain to the upper back is almost always wrongly blamed on
the rhomboid muscles. Pain referred to the chest from the scalenes is
commonly mistaken for angina. Pain sent to the shoulders is almost
universally mislabeled bursitis or tendonitis. Pain down the front and
back of the upper arms is mistakenly treated as muscle strain in the
biceps or triceps.
As with the SCM, scalene trigger points cause symptoms other than pain
that are also prone to misdiagnosis. Trigger points shorten the scalene
muscles, tending to keep the first rib pulled up against the collarbone,
which squeezes the blood vessels and nerves that pass through the area
on their way to the arm. The impeded blood flow and disturbed nerve
impulses cause swelling and numbness in the arm and hand. This
collection of symptoms is properly termed thoracic outlet syndrome,
although they’re very often incorrectly diagnosed as carpal tunnel
syndrome. Scalene-induced weakness in the forearms and hands that makes
you unexpectedly drop things is likely to be ascribed to a neurological
defect. Restlessness in the neck and shoulder, a classic sign of scalene
trigger points, is often written off as a nervous tic.1 Given that all these effects occur so far from their source and are so
variable, it’s no wonder that their cause is so often misunderstood.
Fortunately, once you understand that all these things can be coming
from the scalene muscles in your neck, the solution is remarkably
simple.
Success in finding and dealing effectively with the scalenes, however,
depends on understanding their relationship to the SCM muscle. Note that
the anterior scalene is almost completely hidden by the SCM, lying
between the SCM and the neck vertebrae (see Figure 8). The middle
scalene is immediately under the skin on the side of the neck behind the
anterior scalene. The posterior scalene lies in an almost horizontal
position behind the middle scalene in the soft triangular depression
just above the collarbone and below the front edge of the trapezius. The
fourth scalene muscle, the vertically oriented scalenus minimus, is
located behind the anterior scalene. Scalenus minimus muscles are absent
in many people.
The scalenes cling closely to the neck and feel much firmer than the
normally soft SCMs. Pressure on an active scalene trigger point can make
you duck and cringe, evoking a spooky kind of pain that feels like
you’re pressing on a nerve. If the trigger point is active enough, you
may feel the referred pain or other symptom being reproduced or
accentuated.
To massage the anterior scalene, the chief troublemaker, you have to get
your fingers between the SCM and the neck vertebrae. To do this, first
grasp the SCM between the fingers and thumb of your opposite hand, as if
you were going to massage it. Then let go with your thumb and pull the
SCM firmly toward the windpipe with your fingers. The idea is to get
your fingertips as far around in front of the vertebral column as you
can (see Figure 9, opposite page). In this position, you can press the
anterior scalene against the vertebral column with the tips of your
fingers. If you have scalenus minimus muscles, the pressure will be
transferred to them through the anterior muscle.
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Figure 6. Scalene referred pain
pattern (front view). |
Figure 7. Scalene referred pain
pattern (back view). |
Figure 8. Location of scalene
muscles behind the sternocleidomastoid. |
For the massage stroke itself, push your fingertips across the anterior
scalene toward the side of the neck, moving the skin of the neck with
the fingers. At the end of the stroke, which will be only an inch long,
release the pressure, reset your fingers behind the SCM and repeat.
Execute this stroke all along the length of your neck, from behind the
corner of your jaw, down to the collarbone. You’ll find some of your
worst scalene trigger points behind the SCM where it attaches to the
collarbone (see Figure 10). To massage the middle scalene, use this same
stroke on the side of the neck. The middle scalene is easy to find but
usually has far fewer problems than the anterior and posterior scalene
muscles.
In massaging the posterior scalene, push your middle finger under the
front edge of the trapezius muscle near where it attaches to the
collarbone (see Figure 11). Exert downward pressure and drag your finger
toward your throat parallel to the collarbone. This stroke is also about
an inch long and should move the skin with it. The posterior scalene can
have trigger points when the other scalene muscles don’t. With
self-applied massage, as with any other modality, pain and discomfort
can be reduced by consciously relaxing the part being worked with.
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| Figure
9. Anterior scalene massage: Set the fingertips behind the SCM,
and stroke torward the side of the neck. |
Figure
10. Anterior scalene massage behind the SCM's attachment to the
collarbone. |
Figure
11. Postreior scalene massage where the trapezius joins the
collarbone. |
I hope that after you’ve made yourself an expert with your scalenes and
sternocleidomastoids, you’ll be encouraged to go on and explore trigger
point therapy on the rest of your body. It’s possible to self-treat all
the approximately 120 pairs of muscles discussed in Travell and Simons’
Trigger Point Manual, except the intrapelvic. Imagine what it would be
like to have mastered them all. Imagine the sense of empowerment it
would bring you—and potentially to your clients.
A large segment of the public is capable of learning how to treat their
own trigger-point-induced symptoms. No one is better suited to help them
do so than massage therapists who have been in touch with the intimate
realities of pain through self-treatment.
•••
Clair Davies, NCTMB, is a graduate of the
Utah College of Massage Therapy and the author of The Trigger Point
Therapy Workbook: Your Self-Treatment Guide For Pain Relief, 2001,
New Harbinger Publications. His book has been endorsed by practitioners
in the fields of massage therapy, chiropractic, osteopathy, dentistry,
and nursing, and by nine eminent physicians, including Dr. David Simons,
co-author of Myofascial Pain and Dysfunction: The Trigger Point
Manual. Davies is based in Lexington, Kentucky, and can be reached
at: clairdavies@aol.com, or via
this Web site: [www.TriggerPointBook.com].
References
Simons, David G.,
Janet G. Travell and Lois S. Simons. Myofascial Pain and
Dysfunction: The Trigger Point Manual, Upper Half of the Body.
Vol. 1, 2d ed. Baltimore: Lippincott Williams and Wilkins, 1999. Simons, David G.
Foreword to The Trigger Point Therapy Workbook: Your Self-Treatment
Guide For Pain Relief, by Clair Davies. Oakland, California: New
Harbinger Publications, 2001.
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