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Scalene Muscles: Location, Actions, Trigger Points, and Thoracic Outlet Syndrome
Ground Up Strength Categories Physiology and Anatomy Muscles Trigger Points Scalene Muscles: Location, Actions, Trigger Points, and Thoracic Outlet Syndrome
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Like 16 The scalene muscles are three paired muscles of the Tweet 1 1 neck, located in the front on either side of the throat, just lateral to the sternocleidomastoid. There is an anterior scalene (scalenus anterior), a medial scalene (scalenus medius), and a posterior scalene (scalenus posterior). They derive their name from the Greek word skalenos and the later Latin scalenus meaning "uneven", similar to the scalene triangle in mathematics, which has all sides of unequal length. These muscles not only have different lengths but also considerable variety in their attachments and fiber arrangements. As you will see from the descriptions below, these muscles are in a very crowded place and are related to many important structures such as nerves and arteries that run through the neck.
The scalenes run deep to the sternocleidomastoid. They all start at the cervical vertebra and run to the first to second ribs. The anterior scalene runs almost vertically and its upper part is concealed by the SCM and the lower part is concealed by the clavicle. Along its medial border runs the carotid artery. The internal jugular vein, the intermediate tendon of the omohyoid, the phrenic nerve; and the transverse cervical and scapular arteries all lie between the anterior scalene and the sternocleidomastoid (in front of scalene behind the SCM) Between the muscle and the clavicle runs the subclavian vein. The rear of the muscle, its posterior border, makes contact with the brachial plexus nerve roots, which run between it and the medial scalene. Together with the first rib these muscles form a triangle known as the scalene triangle or interscalene triangle1 through which the brachial plexus nerves and the subclavian artery pass. Also behind the anterior scalene are the pleura of the lungs and the superior intercostal artery. Just behind the anterior scalene is the scalenus medius, referring to the "middle" muscle. This muscle forms part of the floor of the posterior triangle of the neck2. The front of the muscle runs close the the brachial plexus and the upper two thoracic nerve roots run through it. It makes contact with the levator scapulae in the rear, and the dorsal scapular nerve and transverse cervical artery pass between the two. The upper two roots of the long thoracic nerve go through the muscle. Only the anterior and medial scalene can be palpated.
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The posterior scalene is much shorter than the other two, and only starts at the lower cervical vertebra, where it attaches via two three tendinous slips. Whereas the first two attach to the first rib, the medius attaches to the second rib. 1,2,3,4,5,6.7 Some texts refer to a fourth scalene muscle, the scalenus minor. This variant does not always occur on both sides of the neck, but may be present in up one-third of people. This normal variation may have implications in thoracic outlet syndromes as does the scalenus anterior, resulting in a syndrome known as Scalenus Anterior sydrome or Scalenus Anticus syndrome (another name for the anterior muscle). The brachial plexus and the subclavian artery, as mentioned above, pass between the anterior scalene and the middle scalene. When present, the minimus inserts between the scalenus anterior and medius, passing behind the subclavian artery while the scalene anterior passes over and in front of it.7,8 At the top of the lungs is the suprapleural membrane, which is a dense fascial layer also called Sibson's fascia. This fascia is attached to the inner border of the first rib and the costal cartilage. The pleura of the lungs attach to this fascia underneath. The fascia attaches to the transverse process of the C7 vertebra and when muscle fibers are found in it, it is called the pleuralis muscle, which is another name for the scalenus minimus. So this suprapleural membrane could be regarded as a flattened out tendon of the scalenus minimus, meaning that the scalenus minimus is attached to the pleura of the lungs, or the pleural dome and then beyond to the first rib, lying behind the anterior scalene and the groove of the subclavian artery. The scalenus muscle is a reinforcement of Sibson's fascia, which serves to stiffen the thoracic inlet and the neck structures above it so that they are not "puffed" up and down during forced respiration.8 The scalenes are clearly individual muscles but the all work together as a functional unit. They are usually considered accessory muscles of inspirations, as they work to elevate and fix the first and second ribs, while serving to fix them during quiet breathing, becoming guy-wires from the neck. It was thought that they were only active during labored or forceful breathing. However, measurement of their activity with concentric needles electrodes have demonstrated their activity even during quiet, normal breathing, even when the intake of breath is quite small. This has caused some researchers to drop the "accessory" label and consider them primary muscles of inspiration. During normal diaphragmatic breathing, the ribs are elevated by the intercostal muscles and the scalenes. The orientation of the ribs causes them, when elevated, to expand the chest to the sides and front which increases the thoracic volume available for the lungs to expand into, although a most of this expansion is into the abdominal space which is made available by the contraction of the diaphragm downward. Their exact role in breathing is difficult to resolve.
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The actions of the scalene muscles as movers of the neck and head are variously reported. They stabilize the cervical spine against lateral movement. The most common moving action attributed to them unilaterally is contralateral rotation of the cervical spine (rotation of head to the opposite side of working muscle). They have also been reported to be ipsilateral rotators (rotation to same side as working muscle). Bilaterally they are reported to be flexors of the neck. Their action in this regard depends on whether the thorax is fixed or the neck is fixed.1,2,3,4,5,6.7 Whether they are always active during breathing or not, the scalenes may become overactive in quiet breathing in upper chest breathing patterns. Prolonged coughing can overuse these muscles as well, and they may be especially problematic to asthma sufferers. Pain can come from myofascial trigger points in the scalenes or from thoracic outlet entrapment syndromes associated with the muscles.7
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syndrome: labored breathing and/or habitual upper chest breathing (paradoxical), or chronic coughing, possibly associated with: nervous hyperventilation asthma emphysema pneumonia bronchitis allergies playing wind instruments work habits and activities such as: working for long periods with arms in front and possible slouched forward (as at a desk) working long periods with arms overhead work the requires repeatedly raising and lowering the arms carrying heavy loads at the sides pulling or lifting (especially with arms as waist) rowing swimming pulling ropes as in sailing wearing a heavy backpack poor posture with head-forward, kyphotic slouching and other problems such as: one short leg when standing small hemipelvis when sitting idopathic scoliosis sleeping with the head and neck low trauma from a hard fall or auto accident, whiplash (also affects sternocleidomastoid)7
Scalene-Relief Test
Assuming that one of both of your arms are in pain from scalene trigger points, place the painful arm across the top of your forehead, so that the crook of your elbow is resting on the forehead. Lift your shoulder forward and up. This will lift the clavicle off the scalene muscles underneath, thus relieving some of the pressure on them if they are tight and tender. Hold the position for a few minutes to see if your pain abates. The action of lifting the clavicle up using the scalene-relief test can also lift it off of the underlying brachial plexus, if the nerves are being compressed by the clavicle. Therefore, this test can not verify one-hundred percent whether your pain is from myofascial trigger point origin or neurogenic origin (because the brachial plexus is being compressed). Therefore, you can also try the "Finger-Flexion test" to help establish whether the pain is of a primarily myofascial origin.
Finger-Flexion Test
The finger flexion test tests for both extensor digitorum trigger points and for scalene trigger points. To do this test properly you must flex your fingers without making a tight fist. This means that you will bend your fingers but not bend the first (proximal) joints of your fingers, as you would when making a fist. The proximal joints of your finger are called the metacarpophalangeal joints (MCP's). You must keep these joint absolutely straight (fully extended) when performing the test.
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So, straighten your fingers and then try to touch the volar pads of your hand with the tips of your fingers. The volar pads are the little pads just under the first joint of each finger. This means you will be bending only the second and third joints of your fingers but not the first joint. If all your fingers are able to touch the pads, the test is normal, meaning it does not indicate any trigger points in the scalenes OR the extensor digitorum. If only one or more of your fingers fails to touch the pads, this may indicate TP's in the part of the extensor digitorum that attaches to that finger. For instance, if your index finger will not touch the pad, it could mean that the part of the extensor digitorum that attaches to the index finger harbors a TP. However, if all of the fingers fail to touch, this could point to scalene trigger points, which can tend to set up satellite trigger points in the extensor digitorum. The TP's could be in any or all of the scalenes. Remember, if you actually make a fist, the test is invalid because there would be no problem flexing the MCP joint, even if you have trigger points in the scalenes or ED muscles. Trigger points in the sternocleidomastoids, which is also a muscle of inspiration, usually occur after the scalenes have been affected for a while and sternocleidomastoid TP's are commonly associated with scalene TP's. Also, associated are TP's of the trapezius and splenius capitis muscles.
Shoulder pain from scalene TP's is not deep in the joint, but superficial and more to the deltoid muscle. This pain extends down the front and back of the arm, skipping the elbow and occurring again in the radial forearm, thumb, and index finger. This pain pattern of the upper extremity is more likely to be caused by TP's in the upper part of the scalenus anterior and medius. Pain is sometimes referred to the back, over the upper half of the inner border of the scapula and the interscapular region, caused by TP's in the anterior scalene. The scalenus minimus is associated with a more rare referred pain pattern in the lateral part of the arm, from the top of the deltoid down to the elbow, but again skipping the elbow itself. The pain reappears in the back of the forearm (dorsal area), wrist, hand, and all five fingers, becoming very concentrated in the thumb. There may be occasional numbness in the thumb. 7
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It may be helpful to apply a hot pack or heating pad across the neck for 10 to 15 minutes before performing this stretch. Between stretches, use proper diaphragmatic breathing, taking deep, slow, breaths, to relax the neck. Lie supine (face up) in your bed or on the floor Lower and anchor the shoulder of the side to be stretched by placing that side's hand under your buttock Bring the opposite hand over your head so that your fingers make contact with the top of the ear. Gently pull the head and neck so that it tilts to the opposite side of the side you want to stretch, relaxing your neck muscles as you do so. Try to pull your ear down to your shoudler. Now, you will rotate your head, and the degree of rotation will determine which scalene is targeted. To target the posterior scalene, turn your face toward the arm that is pulling To target the anterior scalene, turn your face away from the pulling arm. To target the middle scalene, look straight up at the ceiling, or just slightly toward the pulling arm. Concentrate your efforts on the muscle that feels the tightest when you rotate your head to target that muscle Hold the stretch for around six slow seconds7
The scalene triangle and associated structures. Notice the pectoralis minor . See how the axillary (subclavian) artery and brachial plexus run under the pec minor where it attaches to the scapula? A tight pec minor can lead to another entrapment syndrome which can cause pressure on the vessel and nerves when the arm is completely abducted and externally rotated because the tight pec minor pulls on and stretches these structures. Also, pulling the shoulders back in an extreme "military" posture, can cause the vessel
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When we evolved from a quadruped to an erect position, the nerves and artery became bent over the first rib under tension. Also, the change from a thorax that is wider front to back, to one that is wider side to side, placed the nerves and arteries under more tension. Normally, there is enough room in the scalene triangle for the brachial plexus and the subclavian artery. But sometimes anatomical variations or changes in the structures may cause narrowing, thus making compression more likely. The insertion of the scalene anterior and medius may be close together on the first rib, making the space narrower. There may be fibrous bands between the two muscles which act like a sling which elevates the artery and the brachial plexus. The presence of a scalenus minimus in the area can add to the problem. Also, a cervical rib4, or an elongated C7 transverse process can re-orient the borders of the scalenes, predisposing on to compression in the scalene triangle. It is even reported that shortening of the muscles can chronically elevate the firt rib so that the rib itself compresses the structures.10,11 When you have poor posture, with a forward head and rounded shoulders (slouching) the structures in the scalene triangle are put under more tension and the scalenes themselves may undergo changes due to the chronic strain, which can include fibrotic changes adn adhesions, further adding to the tension and compression of the brachial plexus and subclavian artery. Extended overhead work, wearing a knapsack for long periods, and simply getting older, can all cause your shoulders to slump forward and round, which makes the nerves and vessels have to travel and even further distance. This may be a bigger problem for women, who have shoulders lower to the thorax than men. Carrying heavy things at your sides for long periods, while becoming exerted and breathing heavily, can cause the scalenes to work overtime and this can possibly compress the structures. Anything that causes the muscles to tighten and shorten, or to hypertrophy, together with predisposing factors, can lead to the compression syndrome, as well as any repetitive strain or sudden injury that causes the associated tissues, ligaments, and muscles to shorten or swell. With forward-head posture, the sternocleidomastoid and pectoralis muscles, in addition to the scalenes, are likely to become shortened. 10,12 Some of these things can also cause narrowing of the costoclavicular space, which is the space between the first rib and the clavicle, causing neurovascular compression there and similar complaints as with anterior scalene syndrome. Another potential outcome of the first rib being pulled up by chronically shortened scalenes is double crush syndrome. Double crush is a theoretic condition in which compression of the brachial plexus in the scalene space by the first rib causes the nerves to be susceptible to further compression injury at distal sites such as the elbow and wrist. It is not clear as to whether this theory is true, but there does seem to be a high incidence of carpal tunnel syndrome and cubital tunnel syndrome (at the elbow) associated with thoracic outlet syndrome. The theory holds that the symptoms are the result of the cumulative effect of several minor compressions along the nerves path.10 Scalenus anterior syndrome produces symptoms similar but not identical to scalene trigger points. Brachial plexus compression causes pain on the ulnar side of the hand (the side where your pinkie finger is) as opposed to the radial side (where you thumb is), or to the medial part. Along with this pain can come tingling and numbness. There may be weakness in the arm and hand, especially with overhead work. Objects may be suddenly dropped from the hand. Pain may also occur in the cervical region. Arterial compression, which is much more rare, can result in hand pain and weakness, numbness and tingling in the fingers, cold and pale fingers, and chronic arm fatigue. Thoracic outlet syndrome caused by the scalene anterior syndrome is likely to be misdiagnosed as carpal tunnel syndrome.7,14 You may have noticed a few tests described above to help determine whether your pain was from scalene trigger points. There are also tests that professionals use to determine whether the pain is from neurovascular compression. These test will not be described here as, should you be experiencing the symptoms of thoracic outlet syndrome described above, you should consult a physician. This is not a time for do-it-yourself! And remember, while trigger points can sometimes be self-treated, there is no shame in seeking professional help for them as well. The scalenes are especially difficult to deal with and they are associated with many important and vulnerable nerves and vessels. Should you try to treat them, you do so at your own risk! This article is meant to provide you information to help you make informed medical choices, it is not meant to replace professional medical advice.
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References
1. Rockwood, Charles A. The Shoulder, Volume 1. Philadelphia, PA: Saunders/Elsevier, 2009. 66. 2. Hamid, Qutayba, Joanne Shannon, and James Martin. Physiologic Basis of Respiratory Disease. Hamilton: BC Decker, 2005. 271. 3. Schuenke, Michael, Lawrence M. Ross, Edward D. Lamperti, Erik Schulte, and Udo Schumacher. Atlas of Anatomy: Neck and Internal Organs. Stuttgart, NY: Thieme, 2006. 8, 92. 4. Buford, John A., Stephanie M. Yoder, Deborah G. Heiss, and John V. Childley. "Actions of the Scalene Muscles for Rotation of the Cervical Spine in Macaque and Human." Journal of Orthopaedic & Sports Physical Therapy Volume 32.10 (2002) 488-496. 5. Gray, Henry, and Edward, ROBERT HOWDEN, Anatomy Descriptive and Applied with the Ordinary Terminology. Philadelphia: Lea & Febiger, 1913. Google eBook 6. Cunningham, D. J. Cunningham's Manual of Practical Anatomy. Oxford: Oxford UP, 1921. 7. Simons, David G., Janet G. Travell, Lois S. Simons, and Janet G. Travell. Travell & Simons' Myofascial Pain and Dysfunction: the Trigger Point Manual. Chp. 20: Scalene Muscles. Baltimore: Williams & Wilkins, 1999. 425-430. 8. McMinn, Robert M. H., and Raymond Jack Last. Last's Anatomy Regional and Applied. Edinburgh [u.a.: Churchill Livingstone, 1993. 9. Davies, Clair. "Chp. 5: Shoulder, Upper Back, and Upper Arm." The Trigger Point Therapy Workbook: Your Self-treatment Guide for Pain Relief. Oakland, CA: New Harbinger Publications, 2004. 78-82. 10. Pecina, Marko, Jelena Krmpotic-Nemanic, and Andrew D. Markiewitz. Tunnel Syndrome: Peripheral Nerve
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Compression Syndromes. Boca Raton, FL: CRC, 2001. 39-42. 11. Russell, Stephen M. Examination of Peripheral Nerve Injuries: An Anatomical Approach. New York: Thieme, 2006. 12. Medifocus Guidebook On: Thoracic Outlet 13. KIRGIS,, Homer D., and Adrian F. Reed. "SIGNIFICANT ANATOMIC RELATIONS IN THE SYNDROME OF THE SCALENE MUSCLES." Annals of Surgery 127.6 (1948): 1182. Web. 2 Mar. 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513694/pdf/annsurg01363-0080.pdf>. 14. Dubuisson, Annie S. "The Thoracic Outlet Syndrome." LSU School of Medicine. Web. 02 Mar. 2012. <http://www.medschool.lsuhsc.edu/neurosurgery/nervecenter/TOS.html>.Syndrome]. Medifocus.com. March 2, 2012. All images on this page used under license. Images by LifeART (and/or) MediClip image copyright 2010. Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved. Images not for reuse.
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This page is provided by Ground Up Strength for information purposes only and should not take the place of professional medical advice. Although we have done our utmost to provide accurate and safe information, we are not medical professionals and the information on this page should not be taken as professional medical advice, or any other kind of medical advice. This page contains affiliate links to Amazon.com. We have not been compelled in any way to place links to particular products and have received no compensation for doing so. We receive a very small commission only if you buy a product after clicking on one of these affiliate links.
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Footnotes
1. Also called the posterior scalene foramen, the scalene hiatus or the scalene fissure 2. The posterior triangle of the neck is an area of the neck defined by the rear border of the sternocleidomastoid, the anterior border of the trapezius, and the middle portion of the clavicle. 3. And possibly from C4 or T2. 4. A cervical rib is an extra rib arising from the seventh cervical vertebra. This extra rib, a congenital abnormality, is above the first rib and so serves to place the brachial plexus and subclavian artery under even more tension and compression, predisposing one to thoracic outlet syndrome. Originally, the cervical rib was focused on as the sole cause of the syndrome but later other contributing factors were discovered.13
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