Palpations of Neck Muscles Painful sleeping Dr Hafiz Sheraz Arshad

SCM Lateral view of the right SCM.

SCM ATTACHMENTS: Manubrium of the sternum and the medial 1/3 of the clavicle to the mastoid process of the temporal bone and the lateral 1/2 of the superior nuchal line of the occiput ACTIONS: Flexes the lower neck and extends the head and upper neck at the spinal joints Laterally flexes and contralaterally rotates the head and neck at the spinal joints Elevates the sternum and clavicle

SCM Palpation Supine palpation of the right SCM as the client raises the head and neck from the table. A, Palpation of the clavicular head. B, Palpation of the sternal head.

SCM Palpation SCM can be easily palpated with the client seated. Ask the client to rotate the head and neck to the opposite side (contralaterally rotate) and slightly laterally flex to the same side; then resist any further lateral flexion to the same side. The sternal head will often become visible with contralateral rotation. Resistance to same side lateral flexion will usually bring out the clavicular head (indicated). If the clavicular head is not visible, try increasing the resistance to lateral flexion.

SCM Trigger points Anterolateral views illustrating common sterno­ cleidomastoid (SCM) TrPs and their corresponding referral zones. A, Sternal head. B, Clavicular head.

How and what ? Chronic postures of sitting with the head turned to one side or looking upward to paint a ceiling Chronic cough using the muscle for its respiratory function Having a protracted head posture, looking downward to read a book in the lap by flexing the lower cervical spine Sleeping with a pillow that is too thick Irritation from wearing a tie or a shirt with a tight collar, or trauma (e.g., whiplash, fall). Headaches, altered posture of ipsilateral lateral flexion of the head and neck, restricted range of motion of the neck and head, a sore throat. Autonomic symptoms: Sternal head: eye symptoms, such as ptosis of the upper eyelid, loss of visual acuity, and excessive tear formation. Clavicular head: localized vasoconstriction and increased sweating Proprioceptive symptoms Sternal head: dizziness, vertigo, nausea, and ataxia Clavicular head: hearing loss and even entrapment of cranial nerve XI (spinal accessory nerve).

SCM Stretch Figure : A stretch of the right SCM. The client left laterally flexes and right rotates the head and neck, and extends the lower neck but tucks the chin (flexes the head).

Scalenes Fig: Anterior view of the scalenes. All three scalenes are seen on the right; the posterior scalene and ghosted-in middle scalene are seen on the left.

Scalenes ATTACHMENTS: Anterior scalene: first rib to the transverse processes of C3-C6 Middle scalene: first rib to the transverse processes of C2-C7 Posterior scalene: second rib to the transverse processes of C5-C7 ACTIONS: Anterior scalene: flexes, laterally flexes, and contralaterally rotates the neck at the spinal joints; elevates the first rib at the sternocostal and costovertebral joints Middle scalene: flexes and laterally flexes the neck at the spinal joints; elevates the first rib at the sternocostal and costovertebral joints Posterior scalene: laterally flexes the neck at the spinal joints; elevates the second rib at the sternocostal and costovertebral joints

Scalenes Palpation Fig: Starting position for supine palpation of the right scalenes, lateral to the lateral border of the clavicular head of the SCM.

Scalenes Trigger points Figure A, Anterior view illustrating common scalene TrPs and their corresponding referral zone. B, Posterior view showing the remainder of the referral zone.

How and what  Acute or chronic overuse of the muscles  Coughing, labored breathing, especially due to chronic obstructive respiratory disease  Motor vehicle accidents. Thoracic outlet syndrome (especially anterior scalene syndrome but also may contribute to costoclavicular syndrome, causing neurologic or vascular symptoms in the upper extremity Restricted lateral flexion and/or ipsilateral rotation of the neck Entrapment of nerve roots that contribute to the long thoracic nerve (that innervates the serratus anterior muscle) Joint dysfunction of the first or second ribs Painful sleeping.

Scalenes Stretch Figure A stretch of the right scalene group. The client extends, left laterally flexes, and right (ipsilaterally) rotates the neck. An additional stretch can be obtained by using the left hand to passively move the head and neck further in this direction.

Longus colli & Longus capitis ATTACHMENTS: Longus colli: between T3 and CI, from transverse processes and anterior surfaces of vertebral bodies inferiorly to the transverse processes and anterior surfaces of vertebral bodies superiorly Longus capitis: transverse processes of C3 ACTIONS: Longus colli: flexes, laterally flexes, and contralaterally rotates the neck at the spinal joints Longus capitis: flexes and laterally flexes the head and neck at the spinal joints -C5 to the occiput

Longus colli & Longus capitis Anterior view of the longus colli and capitis. The longus colli is seen on the right; the longus capitis is seen on the left.

Longus colli & Longus capitis A:Starting position for supine palpation of the right longus colli and capitis. B:Palpation of the right longus colli and capitis as the client engages the muscles by lifting his head and neck into flexion.

Longus colli & Longus capitis In Sitting: Resist flexion of the client's head and neck with your support hand to make the longus musculature contract (because flexion of the head and neck is not against gravity when seated).

HOW and what? Trauma such as whiplash. TrPs in the longus muscles tend to produce a sore throat, difficulty swallowing, and tight posterior neck muscles (working harder to oppose the tension of tight longus muscles). TrPs in the longus muscles are often incorrectly assessed as a sore throat.

Longus colli & Longus capitis A stretch of the right longus colli and capitis muscles. The client's head and neck are extended and laterally flexed to the opposite side.

Upper Trapezius Attachments: External occipital protuberance and medial to the superior nuchal line of the occiput, entire nuchal ligament, and the spinous process of C7 to the lateral clavicle and the acromion process of the scapula ACTIONS: Elevates, retracts, and upwardly rotates the scapula at the scapulocostal joint Extends, laterally flexes, and contralaterally rotates the head and neck at the spinal joints

Upper Trapezius Posterior view of the right trapezius. The sternocleidomastoid, splenius capitis, and levator scapulae have been ghosted in.

Upper Trapezius Starting position for seated palpation of the right upper trapezius. Palpation of the right upper trapezius as the client extends the head and neck against resistance. The upper trapezius can be palpated with the client prone. Asking the client to lift her head up from the face cradle will engage the upper trapezius.

How and what? Chronic postures of elevation of the shoulder girdle Anteriorly held head, or any chronic posture due to poor ergonomics Computer use or with crimping the phone between the ear and shoulder When working, to resist depression of the shoulder girdle when the upper extremity is hanging Trauma (e.g., whiplash) Compression forces (e.g., carrying a heavy purse or backpack on the shoulder, having a tight bra strap) Irritation from wearing a tie or a shirt with a tight collar, having a cold draft on the neck, or chronic stress/ tension (holding the shoulder girdles uptight). TrPs in the upper trapezius tend to produce a classic stiff neck with restricted contralateral lateral flexion and ipsilateral rotation of the neck at the spinal joints A posture of elevated shoulder girdles, pain at the end of ipsilateral rotation of the neck, and tension headaches.

Upper Trapezius Common upper trapezius TrPs and their corresponding referral zones. A, Lateral view. B, Posterior view. A stretch of the right upper trapezius. The client's head and neck are flexed, left laterally flexed (to the opposite side), and (ipsilaterally) rotated to the right. To keep the shoulder girdle down, the right hand holds onto the bench.

Levator scapulae Posterior view of the right levator scapulae. The trapezius has been ghosted in.

Levator scapulae ATTACHMENTS: Transverse processes of C1-C4 to the medial border of the scapula from the root of the spine to the superior angle ACTIONS: Elevates and downwardly rotates the scapula at the scapulocostal joint Extends, laterally flexes, and ipsilaterally rotates the neck at the spinal joints

Levator scapulae Starting position for seated palpation of the right levator scapulae. A, Palpation of the levator scapulae deep to the trapezius as the client performs gentle, short ranges of motion of elevation of the scapula with the hand in the small of the back; no resistance is given. B, Palpation in the posterior triangle of the neck; resistance can now be added to elevation of the scapula to better engage the levator scapulae.

Levator scapulae The superior attachment of the levator scapulae is accessed by reaching under the SCM and pressing anteriorly and superiorly toward the TP of the atlas (CI). This is best accomplished by first passively slackening the SCM by moving the client's head and neck into flexion and ipsilateral (same side) lateral flexion (not shown). Note the location of the TP of CI.

How and what Carrying a bag or purse on the shoulder Crimping a phone between the ear shoulder Excessive exercise such as playing tennis, holding the shoulders uptight Chronic shortening or stretching of the muscle due to poor work or leisure postures e.g., having a poorly placed computer monitor Reading with the head inclined forward Motor vehicle accidents Having a cold draft on the neck Being overly stressed psychologically. TrPs in the levator scapulae tend to produce a classic stiff neck (often called torticollis or wry neck) with re­ stricted contralateral rotation of the neck.

Levator scapulae Posterior view illustrating common levator scapulae TrPs and their corresponding referral zone. A stretch of the right levator scapulae. The client's neck is flexed, left laterally flexed, and (ipsilaterally) rotated to the left. To keep the shoulder girdle down, the right hand holds onto the bench.

The suboccipital group The suboccipital group is composed of the following Rectus capitis posterior major (RCPMaj) Rectus capitis posterior minor (RCPMin) Obliquus capitis inferior (OCI) Obliquus capitis superior (OCS)

Suboccipital group Views of the right suboccipital group. A, Posterior view. B, Lateral view. Note the anterior to posterior horizontal direction of the rectus capitis posterior minor (RCPMin) and the obliquus capitis superior (OCS). This fiber direction is ideal for anterior translation of the head at the atlanto-occipital joint.

Suboccipital group  RCPMaj: spinous process of C2 to the lateral 1/2 of the inferior nuchal line of the occiput  RCPMin: posterior tubercle of C1 to the medial 1/2 of the inferior nuchal line of the occiput  OCI: spinous process of C2 to the transverse process of C1  OCS: transverse process of C1 to the lateral occiput between the superior and inferior nuchal lines As a group, the suboccipital muscles extend and anteriorly translate the head at the atlanto-occipital joint. The obliquus capitis inferior ipsilaterally rotates the atlas at the atlantoaxial joint. ACTIONS:ATTACHMENTS:

Suboccipital group Starting position for supine palpation of the right suboccipital muscles. Palpation of the suboccipital muscles. A, Palpation of the right RCPMaj between the spinous process of the axis (C2) and the occiput. B, Palpation of the right RCPMin between the posterior tubercle of the atlas (CI) and the occiput.

How and what  Sustained extension of the head at the atlanto-occipital joint  while painting a ceiling or bird- watching  Sustained posture with the head rotated to one side [for the OCI]  Chronic forward (anterior translation) head posture  Trauma such as whiplash  Having a cold draft on the neck, or joint dysfunction of the atlantooccipital or atlantoaxial joints. TrPs in the suboccipitals tend to produce headache pain that is diffuse and difficult to localize. Restrict flexion or contralateral lateral flexion of the head at the atlanto- occipital joint. Restrict contralateral rotation of the axis at the atlantoaxial joint (OCI) Cause joint dysfunction of the atlanto-occipital or atlantoaxial joints.

Suboccipital group Lateral view illustrating common suboccipital TrPs and their corresponding referral zone Stretches of the suboccipital muscles. A, Stretch of the bilateral rectus capitis posterior major and minor muscles as well as the bilateral obliquus capitis superior muscles. The client both flexes the head (by tucking the chin toward the chest) and posteriorly translates the head at the atlanto-occipital joint. To focus this stretch to the right suboccipitals, add left lateral flexion (not shown). B, Stretch of the right obliquus capitis inferior. The client rotates as far as possible to the (contralateral) left side.