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Massage Today
May, 2012, Vol. 12, Issue 05

Scalene Muscles: Playing Havoc with Your Clients

By Nicole Nelson

As a massage therapist, I am quite grateful to the scalene muscles as they have offered me a great deal of job security. Trigger points in the scalene muscles have been attributed a wide array of myofascial pain and motor disturbance, extending from head to toe.

Trigger points in the scalene muscles are known to refer pain anteriorly, laterally, and/or posteriorly.1 Pain in the scalene muscles is routinely felt just about everywhere but in the scalenes themselves. How can these three (occasionally four, but for the sake of this article three) muscles wreak so much havoc and what strategies are most effective for clients suffering from laminated, matted down scalene muscles? It is important to understand the basic anatomy of the scalene muscles so therapists can utilize some basic treatment strategies to perform on clients that have scalene trigger points and brachial plexus entrapment syndrome.

Anatomy and Function

The three scalene muscles are located between the sternocleidomastoid and the anterior portion of the trapezius. Without getting too specific (most anatomy books will do a far better job at illustrating precise attachments), the scalene muscles attach to transverse and costal processes of C2 and attach onto the superior surfaces of the first two ribs. The brachial plexus and subclavian artery share passage around and sometimes through anterior and middle scalenes. Therefore, it is not uncommon for clients with tight scalene muscles to complain of paresthesia, anesthesia, coldness, claudication and lymphedema in the involved extremity.2

Scalene Muscles - Copyright – Stock Photo / Register Mark The scalene muscles when contracting bilaterally elevate the ribs during inhalation and flex the neck. Unilateral contraction (with the ribs fixed) laterally flex the neck to the same side, and rotate the head and neck to the opposite side. The scalene muscles also serve in a stabilizing role for the cervical spine against lateral movement. Additionally, the scalene muscles have been credited with being essential auxiliary muscles of respiration.3 Evidence goes so far as to support the scalene muscles as having a more primary role in respiration rather than just an accessory muscle of inspiration.4

Treatment Implications

What is clinically significant is understanding the mechanical advantage these muscles have on the upper ribs and cervical spine. The anterior and medial scalene, when chronically shortened, has the ability to elevate, rotate and fixate the first rib.5 An elevated first rib will certainly limit the space of the thoracic outlet, creating a strong potential for neurovascular and subclavian artery entrapment.

Bilaterally, contraction of these muscles flex the neck and pull the head forward. Like it or not, forward head posture is here to stay; driving, typing, gaming and empathetic listening all involve subjecting our bodies to this postural pitfall. Unilateral tightness in the scalene muscles typically expresses itself with an elevated shoulder. This unilateral shortening can result from leg length asymmetry, whiplash injuries, poor sleeping habits, heavy bouts of coughing, carrying awkwardly large objects or even swimming.6 To sum up, if your clients have ever slept, taken a labored breath, stood at a bar with reckless disregard of gravity, done any work on a computer, sat with crossed legs or had a cold, scalene work is necessary.

Treatment Strategies

Any structural integrationist or alignment expert will tell you that a successful treatment plan addresses the entire body and that we as therapists must consider all deviations as relevant in coming up with our bodywork strategy. Some therapists start at the feet and credit them as the platform of all postural aberrations. Others would argue that the rotations and anomalous curvatures of the spine are the root of chronic pain. I believe they are all probably correct in some way. Regardless of your approach, consider the following strategies a piece of the puzzle in formulating a course of treatment for clients experiencing signs of brachial plexus entrapment or have pain patterns that correlate with the scalene muscles.

One of the first things that I establish with clients, regardless of their exercise history or yoga and pilates proficiency, is to assess how they breath. Paradoxical breathing is huge contributor to scalene trigger points. Clients should be able to breathe diaphragmatically in sitting, standing and supine positions. I strongly suggest evaluating their breathing in all positions. What you will find in practice is that a client might successfully diaphragmatically breath in a supine position, yet have difficulty doing so in a sitting or standing position. Depending on which position you have observed a breathing deficiency, you must have them retrain appropriate breathing in that position. The best technique I have found, courtesy of Travell, is to have the client place their right hand on their chest and left hand on their abdomen. With their eyes closed, instruct them to inhale through the nose to a four second count then exhale through the mouth (also to a four second count), allowing the abdomen to relax and retract to the starting position, extending their bellies into the left hand. Corrective exercise like this takes time for motor re-patterning to occur; therefore, the should be repeated for 30 to 60 seconds every hour throughout the day. Sixty seconds is adequate time to practice this without overly fatiguing the muscles. Diaphragmatic breathing certainly helps reduce the overworking of the scalene muscles and it is a very useful strategy in helping clients deal with scalene trigger points. But, those who have mastered good breathing practices are not out of the woods.

Postural strain patterns is next on our list. If a client is at their computer all day, or holding babies on a hiked hip or is attached to their cell phone, you can be assured body alignment will need addressing. Thomas Meyers suggests in his book, Anatomy Trains, to have your client observe their own posture in a mirror and ask them what they see. Take a picture of the client which is imposed on a postural grid and show it to them and get their impressions of their own alignment. I have found that when you take a more team approach in analyzing posture, the message is accepted fairly well and the client's awareness is heightened that much more. From here, postural alignment tips such as chin tucking exercises or discussing their workstation set up will not only be appreciated, but they will be far more compliant in applying these suggestions.

Now, as far as the actual act of bodywork. Basic compression and stripping of these muscles will do the trick. No muscle produces more amazed comments from clients. A useful tip when beginning this work is to communicate the possible referral patterns that can light up when working on these trigger points. Mentally, set your treatment pace at slow and then perform it even slower. I like to start with the scalene muscles in a slightly shortened position. The bit of slack will make the initial work far more tolerable and it better enables you to scoot under the SCM. With the client supine, laterally slightly flex (maybe 10 degrees) the neck to the side you are treating, and gently glide across the entire length of the tissue. Depending on the size of the neck, I either use my thumb or middle finger. Once you notice some softening to these structures, begin the same gently stripping process with the client's head in a more neutral cervical alignment, once softening occurs in this position, rotate the head away from the side you are treating and elevate it slightly off the table. In this position, place your thumb or index finger between the sternal and clavicular heads of the distal attachment of the SCM, have your client take a deep breath upon exhalation, and friction the scalene muscles underneath the clavicle. Finish with some pin and stretch anywhere you feel restriction.

Mobilizing the first rib is a key part in the success of scalene work. The scalene attachments can place the first rib in awkwardly fixated, elevated and/or rotated position.7 Take care of the rib if you want your scalene work to have lasting results. Don't let rib mobilization scare you, this is not a chiropractic adjustment, simply steady pressure. With your client supine, palpate the posterior aspect of the first rib in front of the upper trap with your thumb. It should feel like a flat surface; however, if rotated it will feel more like a sharp edge. Simply apply a steady downward pressure (in the direction of the client's heel) once you feel the surrounding tissue soften, have the client flex their shoulder, while you continue to pin the rib down. Additionally, flexing the clients head to the contra-lateral side while pinning the rib should also prove to be effective. Patience will prevail and remember to set your treatment pace at slow and then go slower.

Any client that breathes will benefit from scalene work. These entrappers are associated with a wide range of upper extremity issues ranging from carpal tunnel syndrome to tennis elbow. This article is hardly exhaustive in it's treatment suggestions, but will hopefully serve as a good starting point.


  1. Simons, David G., Janet G. Travell, and Lois L. Limons. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume I. Second Edition: Upper Half of Body. 1999 (p504-508)
  2. Simons DG. Undiagnosed pain complaints: trigger points? Clin. J Pain. 1997; 13:82-83
  3. Cambell, EJ. Accessory Muscles. In: The Respiratory Muscles: Mechanics and Neural Control. Ed 2 Edited by Capmbell EJ, Agostoni E, Davis JN. W.B. Saunders, Piladelphia, PA 1970 (p181-183)
  4. Basmajian JV, DeLuca CJ: Muscles Alive. ED. 5 Williams & Wilkins, Baltimore, 1985 (p409, 412, 426)
  5. Mackinnon SE, Patterson GA, Novak CB: Thoracic Outlet Syndrome: a current overview. Semin Thorac Cardiovasular Surger 8(2): 176-182. 1996
  6. Frankel SA, Hirata I Jr.: The Scalenus anticus syndrome and competitive swimming. JAMA 215: 1796-1798.
  7. Murphy, Donald R., DC, Scalene Trigger Points: The Great Imitators, Dynamic Chiropractic, November 1991.

Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.


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