Scalenes: The Great Impersonators
Where the pain is located, is not always where the problem originates. There is no better example of this than when we are dealing with the scalenes. These lateral neck muscles are located in such a critical location they could be considered the Bermuda Triangle of the body. Short, tight scalene muscles can activate a confusing and complex set of symptoms for both the client and the therapist. Clients have reported symptoms such as: “My arm falls asleep at night.” “I always have this deep ache between my shoulder blades.” “I thought I was having a heart attack.” “I’m having pain opening a jar and my grip is really weak.” “My cousin tells me I have carpal tunnel.” “My arm burns all the way down to the hand.” “If I put my arm up over my head the pain goes away.” Symptoms can consist of one or more of the following:
Sources of Scalene Trouble:
Muscle Origin Insertion Action Innervation scalene anterior anterior tubercles of the transverse processes of vertebrae C3-C6 scalene tubercle of the first rib elevates the first rib, assists respiration; flexes and laterally bends the neck C5-C7 scalene medius posterior tubercles of the transverse processes of vertebrae C2-C7 upper surface of the first rib behind the subclavian artery elevates the first rib, assists respiration; flexes and laterally bends the neck C3-C8 scalene posterior posterior tubercles of the transverse processes of vertebrae C5-C7 lateral surface of the second rib elevates the second rib, assists respiration; flexes and laterally bends the neck C7-C8 Relationship to surrounding tissues:
Intake interview: Interviewing techniques: The art of watching, listening and hearing An in-depth conversation with the client to ascertain the specific location of their discomfort will assist in determining which scalene muscle or muscles are involved in their discomfort. Any of the scalene muscles may refer pain to any of the associated areas but some are more likely to send pain to certain areas than others. Pain Patterns: Scalene anterior: Pain that is referred to the back upper half of the inner border of the scapula. Scalene anterior and medius: Superficial shoulder pain that extends down the front and/or back of the arm, skipping the elbow and occurring again in the radial forearm, thumb and index finger. Scalene medius/posterior: Pain in the chest like two finger-like projections to the pectoral region. Scalene minimus: Pain in the lateral part of the arm, from the top of the deltoid down to the elbow, again skipping the elbow itself and reappearing in the back of the forearm, wrist, hand and all five fingers with occasional numbness in the thumb. Functional Assessment: This is the procedure to assess the scalene muscles. Below, the use of the term ‘Apply pressure’ means: Place 2 fingers about 2 inches superior to the back of the wrist. Apply 2 pounds of pressure to move the arm 2 inches up for 2 seconds. It is easy to overpower any muscle by applying too much force. Doing so causes other muscles to be recruited and does not create the desired assessment. By using a slight pressure we achieve the optimal results needed in order to isolate the specific muscle. Ask to patient to use 10% of their strength. 1. Position the arm at about 45⁰ away from the body, elbow straight, palm up and head forward. 2. Place two fingers just above the wrist on the back side of the arm. Apply slight pressure to move the arm up 2 inches off the table. Have the client match your pressure with about 10% of their strength. 3. Have the client turn their head to the same side and tuck their chin to their clavicle. 4. Repeat steps 1 & 2. If there is a ‘weakness’ or an inability to keep the arm in the desired position when repeating steps 1 & 2, then there is an insufficient neurological flow between the brain and the arm. This gives both you and the client the information that the imbalance in the neural pathway is located in the neck. It is helpful to ask the client if they feel the inability to hold their arm in position. This has them more involved in the process. There can be tension in the scalenes on one side and not the other so it is important to do the assessment on both sides. If the scalenes are not involved, your client should be able hold their arm in position. The neurological information flow between the brain, the central nervous system, the brachial plexus and the arm is sufficient to maintain muscle contraction in opposition to the pressure applied. If there are no interruptions in the neural relays, the arm will ‘lock’ and maintain its ‘strength’. The omohyoid muscle, as stated above, bends underneath the scalenes and sternocleidomastoid. An assessment of this muscle can also confirm tension in the scalenes. The same process is used to assess the Omohyoid. 1. Position the arm at about 45⁰ away from the body, elbow straight, palm up and head straight. 2. Apply pressure. Have the client match your pressure with equal resistance. 3. Have the client swallow. 4. Repeat steps 1 & 2. If there is an inability to maintain the arm position upon swallowing this is most often surprising to the client. When the weakness occurs they often ask what that has to do with the pain. This gives us an opportunity to explain how the muscles in the neck are arranged and how they are involved in the areas of pain. Treating the scalenes with the client supine: You want to instill a level of knowledge, confidence and trust with the client. The first thing to remember is that giving pain does not change pain. Have your client be comfortable with your touch. The scalenes have been active since birth.
Begin by softening up the other layers of the neck.
By keeping your hands at this location for a period of time you will feel the tension ‘release/let go’. There is no set time period involved. The release of tension will govern this. Next, move up to the base of the skull.
Holding this position will release tension in the carotid sheath (fascia) and will delicately stimulate the vagus nerve causing a relaxing effect to the entire parasympathetic nervous system. How long to hold this position will depend on the clients’ response. Watch for rapid eye movement, a change in breathing and pulse rate. Now move on to the scalenes
Work the scalenes on both sides. The amount of time you spend on each side may be different. When this is completed, place your hands again to support the cervical vertebra and surrounding muscles. As the client breaths, apply a slight traction. Repeat this move several times. Finally, reassess the chin tuck scalene test as described above. Both you and the client will find it very easy to maintain the arm position. Encourage them to perform the stretch you’ve shown them and let them know that they will possibly be sore tomorrow but that they will like you the day after tomorrow. As an option you can incorporate a rock and roll cervical muscle stretch and/or a manual scalene stretch. Course description: A confusing and complex set of symptoms occur with scalene muscle tension. Due to their location, many therapists avoid this area. This class will improve your knowledge of the symptoms and anatomical structure of the neck. It will instill confidence to assess and effectively treat one of the most common locations of pain. Course Objectives: 1. Gain a deeper understanding of and ability to discuss common symptoms and complex pain patterns. 2. Improve intake interview skills and address contributing factors. 3. Expand your knowledge of specific anatomy of the cervical spine, muscular function and explain their relationship to surrounding tissue. 4. Become proficient in the practical application of manual muscle testing as a tool to determine muscular dysfunction. 5. Enhance the accuracy, confidence and thoroughness in your palpation and treatment. 6. Acquire and be able to demonstrate self-help strategies which will affect faster and longer lasting outcomes. Course outcomes: Will be able to recognize and discuss common symptoms and pain patterns. Improve intake interview skills and address contributing factors. Will demonstrate knowledge, palpation and treatment of specific anatomy of the cervical muscular spine, function and explain their relationship to surrounding tissue. Become proficient in the practical application of manual muscle testing as a tool to determine muscular dysfunction. Be able to explain and show self-help strategies and techniques. 055625-00 Welcoming Opening statements House keeping Guidelines and expectations: Questions and Answers Restroom use Breaks – Lunch Participation Introduction Self Students Syllabus (class description) Intake process Interviewing techniques: The art of watching, listening and hearing Interactive suggestions and tips (class participation) Description of symptoms Sources of contributing factors Common misinterpretations of pain Break Muscle specific anatomy of the scalenes Relationship to surrounding tissues Muscular Nerves Fascia Description of pain patterns Functional assessment Introduction Explanation Demonstration Application Lunch Regroup Recap of first half Demonstration Assessment Self- help home stretches Treatment process Break Class participation Exchange interaction Closing Recap of class Question & Answers Certificates I understand that it is required that my policies clearly state how participants register for my courses I understand that it is required that my policies clearly state registration deadlines I understand that it is required that my policies clearly state cancellation policies I understand that it is required that my policies clearly state my refund policy Intake interview: injury surgery accident Notice also the fingerlike projections of pain extending down the chest. This is easily confused with angina. If you think you are having heart problems, see a doctor immediately! If, however, no cardiac problems are found, consider other muscles, especially if the chest pain was accompanied by a tingly thumb or index finger. The electrical supply for arm and fingers comes from the brachial plexus. This network of nerves supplies the arm and fingers but it originates in the neck. One of these, the median nerve, supplies the thumb, index, and half the middle finger. It also passes under the carpal tunnel of the wrist. If pain and tingling in thumb and index fingers is diagnosed as entrapment of the median nerve, the patient may be referred for carpal tunnel surgery. (Note that pain in the ring and pinkie fingers has nothing to do with the median nerve.) If the problem is identified as scalene entrapment of the brachial plexus, the current treatment is surgical removal (“scalenectomy”) of the anterior scalene and the first rib. Unfortunately, this barbaric surgery usually often causes more problems than it cures. Scalene problems are better treated by relaxing the involved muscles and their trigger points, and by restoring the first rib to its proper position. |
