Following is an exercept from Save Yourself and helps us to look at the scalenes and the pain that can be associated with a trigger point in that group of muscles. As the author mentions, using your finger pads is a nice way to find and treat trigger points in this area, but if you do have a difficult one, and your thumbs are tired, consider the TheraCane.
Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain
Perfect Spot No. 4, an area of common trigger points in the peculiar scalene muscle group of the throat
by Paul Ingraham, Vancouver, Canada
illustrations by Paul Ingraham, Gary Lyons, Jim Smith, Elizabeth Boylan
Trigger points (TrPs), or muscle knots, are a common cause of stubborn and strange aches and pains, and yet they are under-diagnosed. The 13 Perfect Spots are trigger points that are common and yet fairly easy to massage yourself — the most satisfying and useful places to apply pressure to muscle. For tough cases, see the advanced treatment guide.
Deep within the Anatomical Bermuda Triangle, a region on the side of the neck, is the cantankerous scalene muscle group. Massage therapists have vanished while working in this mysterious area, never to be seen again. The region and its muscles are complex and peculiar, and many less-trained massage therapists have low confidence working with them. This article explains how the scalene muscles are involved in several common pain problems in the neck, chest, arm, and upper back, and how to treat pain in these areas by massaging the scalenes. The scalenes are a difficult muscle group to work with, but rewarding!
The scalenes are a strange muscle group
Seriously, this is a weird area: the scalenes often harbour TrPs with more diverse and peculiar symptoms than any other muscle tissue in the body. The primary mechanism for this strangeness is the phenomenon of “referred pain.” Pain in the scalenes is often felt just about anywhere but the scalenes themselves. Instead of your scalenes, your arm or chest might hurt instead.1Referred pain effects are par for the course with all muscle pain or any other internal pain — for instance, heart attacks are felt in the shoulder and arm — but the scalene muscles consistently produce unusually complex, variable, and extensive patterns of referred pain. The results can be a bit bizarre, causing symptoms that most people never guess are coming from the scalenes — even doctors and therapists.
And scalene TrPs can also have several other “interesting” (in the sense of the Chinese curse2) effects: on your voice, on swallowing, on emotions, on sensations that sweep through the entire head, the sinuses, hearing, and teeth. I have found scalene TrPs to be obviously clinically relevant to conditions as seemingly unrelated as:
- a professional singer with a mysterious degradation of quality in his voice (helped by releasing scalene and other throat trigger points)
- at least two patients with severe chronic sinus infections that they’d actually had surgery to try to correct (one of them virtually cured by scalene trigger point release alone, the other significantly helped)
- several people with severe cases of what I call “brick back,” where the space between the shoulder blades feels so stiff and stuck that it’s like there’s a cinder block there instead of bone and muscle
- cutting off blood and nerve supply to the arm, because tight scalenes can impinge the brachial artery and brachial nerve plexus in the neck
So scalene trigger points are “drama queens,” with symptoms and consequences that seem out of proportion to such small and obscure muscles. They are usually making at least some contribution to anything else that goes wrong in the whole region. Like a gang, scalene TrPs can be counted on to mess up the neighborhood. The anterior scalene in particular is a trouble-maker, causing and complicating many other problems.
The anatomy of the Anatomical Bermuda Triangle
The scalenes fan out from the sides of the neck bones to attach to the ribs.3 The scalene group consists of three muscles: the anterior, middle, and posterior scalenes. They generally attach to the sides of the neck vertebrae at the top and to the uppermost ribs at the bottom. So the scalenes are mostly head pullers: they pull the head from side to side. And although they certainly do move the neck, they are also breathing muscles, because of the way they pull up on the ribs.
And here’s some more weirdness that makes this muscle group quite interesting: in some people the scalene muscles even reach down between the ribs and attach directly to the top of the lungs. The only muscles that attach directly to the lungs other than the diaphragm. They pull up on the membrane that surrounds the lungs. A strange muscle group indeed! Such anatomical variability is actually fairly common throughout our bodies.4
The scalenes as a group are not hard to find, but they are intricate in their details. The scalenes fill the space between three obvious structures: your collarbone, your trapezius muscle on top of your shoulder, and the long V-shaped throat muscles (sternocleidomastoid or, if that’s too much of a mouthful, just the SCM). These three structures form the (Bermuda!) triangle in which the scalenes live.
Where is Perfect Spot No. 4 and the scalene muscle group?
Perfect Spot 4 is “somewhere in the triangle.” There is indeed one particular spot, in the belly of the middle scalene, that I believe to be the most common clinically significant trigger point — the spot most likely to feel important to the patient — but I don’t want to throw you off with that and send you on a wild goose chase trying to locate exactly that spot. Virtually any location within the triangle could prove to be a nemesis, so you should definitely explore. Things change, too: Perfect Spot 4 might be in one corner of the triangle one day, and in another corner the next. Precise self-treatment isn’t necessary — a willingness to gently experiment is.
The best way to approach this area as a therapist is from above the head, with your partner face up. Without a massage table, it works well to place his or her head in the corner of a bed. Sitting at the corner, hold your fingers flat and place the pads of your fingertips in the hollow of the triangle: above the collarbone, in front of the massive trapezius muscle along the top of the shoulder, and to the outsides of the prominent V-shaped sternocleidomastoid muscles of the throat.
Is there any danger when massaging in this seemingly vulnerable area? Some, yes. Many people are concerned about the possibility of impinging blood vessels or nerves, and that is not an unreasonable concern. Do not massage this area vigorously, and do not use tools. However, you should never be massaging yourself so hard in the first place that you could damage anything. And if you do touch the vital carotid artery or the jugular vein, the intensity of the pulse is obvious — simply back off. It’s not an appealing place to rub. You’re no more likely to “massage” your own carotid artery than your eyeball. Smaller vessels are not a concern, and nerves are remarkably robust, and generally tolerate far more pressure than most people realize. No reasonable intensity of massage is a threat. Are there other things in the throat you should worry about? The trachea and voice box are delicate — but they are also too central to get in the way of scalene massage, and no one would tolerate any careless pressure on these parts.
In this position, your hands will be angled inward a bit, and roughly pointing at the sternum. Now press down and perhaps a little inwards with a fairly broad pressure — finger pads, not finger tips — on the ropy muscles that fill the triangle. By using a broad pressure, you can easily stimulate some TrPs and stiff muscle without having to worry about being too accurate.
Explore in the triangle with your fingertips, using small circles to find the ropy bands of muscles, gently strumming across them. The area is a rich minefield of trigger points, any of which might be worthwhile and interesting.
How should scalene massage feel?
Massage feels better on some muscles than others.5 The scalenes are not really pleasurable to massage, in general. The throat is a vulnerable body part, so many people feel threatened by pressure here — beware of underestimating it.6 and all the more so if you aren’t confident that massage is safe, or if you don’t understand the strange sensations that are so common in this area. That vulnerability seems to translate into sensitivity, so even a gentle approach may feel a bit hot, nasty, and dodgy at first — not really the kind of trigger point you want to mess around with for fun.
Wow, sign me up! Sounds great, doesn’t it? But it’s not all bad news.
Some people enjoy scalene massage right out of the box, and others can come to appreciate it after a period of “working through” and getting used to the uglier sensations. But the best case scenario is when you are actually solving a problem: if your scalenes are in distress and causing a chronic pain problem, then it’s going to feel more like you’re finding the right place to scratch an itch that you couldn’t reach before.
Maximize your chances of a positive experience by moving slowly and respectfully, and massaging the scalenes with broader, less “poky” pressure. Such pressure is more likely to produce the best case scenario: a peculiar deep ache spreading into the head, chest, back, and/or arm. At its best, scalene massage feels challenging but “profound.” The spectacular referral patterns make the scalenes feel important, the key to the region. No muscle produces more amazed comments. As an entire limb “lights up” with referred pain from a light pressure in the neck, many people will say something like, “Holy $%!@$#$!, what the hell is that?” This is generally true of all referred pain, and it’s equally true of all the Perfect Spots, but “some trigger points are more equal than others.” The scalenes may be awkward and uncomfortable to massage at first, but this Perfect Spot can be very impressive in the end.
So be prepared for anything, and take it easy.
Although you might have to “work through” a little unpleasant sensation to get to the better sensations, this doesn’t mean “no pain, no gain” — do not be brutal in this area. Patients need a little time to adjust and “accept” the stimulation in this area. Persist respectfully, and there is a fair to middling chance that the sensation will change from hot to warm, from sharper to achier. It might make the transition in five minutes, or it might take a few days of sweet-talking the area. But there is a reasonable limit to how much you should try. If the effort doesn’t start to develop a bright side after a reasonable amount of time, then this Perfect Spot isn’t so perfect, and you should let it go.
A surprising relationship between the scalenes and tennis elbow
This tennis elbow connection is a good example of how odd and clinically relevant the scalenes can be to conditions they don’t seem to have anything to do with at first.
The scalene muscle group has surprising importance to a condition called “tennis elbow” or lateral epicondylitis, which commonly afflicts typists as well as racquet sports players. It is generally characterized as an inflammatory condition, but it is rarely that simple.7 It is likely that myofascial TrPs, particularly Perfect Spot No. 5 in the muscles of the forearm, play a significant role in any case of tennis elbow.
And Perfect Spot No. 4 seems, in turn, to significantly affect Perfect Spot No. 5. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.” That is, trigger points on the back of the forearm.8 So an interesting benefit to treating Perfect Spot No. 4 is that it may be a key to treating Perfect Spot No. 5!