Scalene Trigger Points and Referred Pain Patterns

The scalene muscles of the neck are quite complex and can be a huge source of pain from myofascial trigger points. You may want to find out more about the scalenes before you read on about scalene pain syndromes.

Scalene Trigger Point and Pain Causes

As stated in the article linked above, since the scalenes can become overly active in improper high-chest breathing habits or labored breathing due to lung or airway problems, this can cause the muscles to become overworked. Here is a list of possible causes of scalene trouble which can lead to trigger points in the muscles or to neurovascular entrapment syndrome:

  • labored breathing and/or habitual upper chest breathing (paradoxical), or chronic coughing, possibly associated with:
    • nervous hyperventilation
    • asthma
    • emphysema
    • COPD
    • 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 that requires repeatedly raising and lowering the arms
    • carrying heavy loads at the sides
    • pulling or lifting (especially with arms at 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) 1Simons, 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.

Travell, Simons & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual

Resistance Exercise and Scalene Strain

When you strain on a heavy lift, such as a barbell squat, you may find yourself holding your breath while tensing the muscles in your shoulder and chest area. This can strain the scalenes. Learn to take your breaths into the diaphragm (discussed more below) and don’t tense your neck, or crane if forward when lifting. Although it is a good idea to keep the shoulders pinned back during most lifting exercises, do not exaggerate this and do not excessively puff the chest out and up.

See The Trigger Point Therapy Workbook.

Scalene Trigger Point Symptoms

The scalenes, as should be obvious from the preceding description, are quite complicated muscles and so they can have many different trigger points. They refer pain to such a wide area of the chest, shoulders, arms, hands, and upper back that the symptoms can be mistaken for many different things or be blamed on trigger points in different muscles, which may be a problem as well but not the ultimate source of the pain. Since the scalenes are hidden and rarely mentioned or even thought about they are easily overlooked for more prominent (and popular) muscles. They may be the most likely muscle to harbor trigger points resulting in upper extremity pain, but unfortunately may also be the hardest to locate and treat.

Trigger points in the scalenes can be a source of interscapular pain (pain between the shoulder blades) and medial scapular border pain. This may be blamed on problems with the rhomboid muscles. They may also refer pain to the chest, which can be mistaken for angina. Shoulder pain from scalene TrP’s may pass for bursitis or tendonitis. Arm pain may be assumed to be a muscle strain, or, pain to the arms or hands may be diagnosed as a cervical nerve root compression caused by a ruptured or degenerated disc. Also, neurovascular compression of scalene associated thoracic outlet syndrome may cause ischemic pain mistaken for cervical nerve root origin, although the pain patterns are different. 2Davies, 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.

Travell and Simons' Trigger Point Flip Charts

According to Travell and Simons, the anterior scalene is most often affected by trigger points, followed in order of reducing frequency by the middle and then the posterior scalene. The anterior and medius are often involved together and when the minimus is affected, so are all three others.

Moving the head and neck around, trying to relieve your sore neck, may be an indication of scalene myofascial problems. This may cause you to be unable to bend your neck all the way to the opposite side (of the problem muscles). Scalene TP’s do not restrict neck rotation as levator scapulae trigger points can, but there may be pain on the same side when turning your head as far as you can, especially if you also dip your chin down to your chest while doing so. Doing this may activate the referred pain pattern of your scalene TP’s.

However, if you are in constant pain from scalene trigger points, which is quite possible, you may not be able to tell the difference between pain caused by turning your head and the general pain you already have. Travell and Simons describe a test called the “Scalene-relief test” that may be helpful to verify that your pain is coming from scalene TP’s.

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.

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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.

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.

Scalene Trigger Point Referred Pain Patterns

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 in the chest is referred in two finger-like projections to the pectoral region down to about the level of the nipple. This pain is more likely to be caused by trigger points in the lower part of the scalenus medius or posterior.

scalene muscle trigger points
Scalene Trigger Points and Referred Pain Patterns

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 rarer 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. 3Simons, 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.

How To Release Scalene Muscles

The first thing you need to do to get rid of your scalene trigger points is to eliminate the underlying causes. Simons and Travell recommend placing an 8 or 9cm block under the legs at the head of your bed so that the top of your body is elevated and gentle traction of the scalenes is created. This seems far-fetched to the author, as do their recommendations to place your pillow in a position that is “just so” so that the scalenes are not aggravated. Certainly a good pillow, one not too thick or too thin, is a great idea but the idea that you can stay in one perfect position on your pillow all night long seems more like wishful thinking than therapy.

However, they also recommend a moist heating pad to be used over the scalenes for about 10 to 15 minutes before going to sleep, which may certainly help to relax the muscles.

Use proper ergonomic desk habits when working at your desk. There are many good resources on the web. Avoid slouching forward when working and refer to any of the scalene aggravating factors above.

Paradoxical breathing is a big problem for the scalenes. Read the article Paradoxical vs. Diaphragmatic Breathing: Learn Proper Breathing to learn how to correct this faulty breathing pattern. Trying to treat your scalenes with self-release without correcting your upper chest breathing patterns is likely to yield only frustration. If you have a medical condition that produces chronic coughing, seek appropriate medical care to control the coughing.

There are also some passive stretches you can perform to help restore the scalenes to their normal length:

Side-Bending Scalene Stretch

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 shoulder.
  • 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 seconds. 4Simons, 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.

Scalene Trigger Point Self-Release

For more complete instructions see The Trigger Point Therapy Workbook.

Anterior Scalene: To find the anterior scalene you must find the clavicular branch of the sternocleidomastoid. Once you locate it, you want to find the posterior border of it, which is the rear part of the muscle toward the side of the neck. Using the opposite hand, just above your collar bone (clavicle) grasp the sternocleidomastoid with your fingers and thumbs and with your fingers, pull the SCM toward the front of your neck so that your fingers are brought further to the front of the neck underneath the SCM, where you can palpate the anterior scalene. Feel around this area, from the top part of the SCM under your ear down to the collar bone, and even a bit down underneath the bone, until you encounter a trigger point, which will cause a very weird pain and may create the referred pain patterns. Massage the area by pushing your fingers across the muscle toward the side of the neck, the skin moving with the fingers.

Middle Scalene: For the scalenus medius, massage the side of the neck, just behind the area you treated for the anterior muscle, using the same type of stroke.

Posterior Scalene: The posterior scalene is very difficult to directly palpate. It lies in the area where the upper trapezius attaches to the collar bone and is hidden behind the levator scapulae. Push your fingers into this area under the front of the trapezius where it attaches to the clavicle and exert downward pressure while pulling your finger toward your throat, running the stroke parallel to the collar bone. 5Simons, 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.,6Davies, 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.

Scalenes and Thoracic Outlet Syndrome

For a general overview of thoracic outlet syndrome refer to the link above. As described, the anterior and middle scalenes, together with the first rib at the bottom, form a small triangular space through which the brachial plexus and the subclavian artery pass to the costoclavicular space. This triangle can be from 0.4 to 3.5cm in width. The subclavian artery passes over the first rib and through the fissure formed by the scalenes. If the scalenes become shortened and tight, the artery can be compressed by the rib. The brachial plexus has nerve roots from C5 to c8 and T1 (and possibly from C4 and T2). Like the subclavian artery, these nerves have no bony protection and are stretched tightly between the neck and the shoulder. Neurovascular compression caused by narrowing of this area is known as anterior scalene syndromescalenus anticus syndrome, or Naffziger syndrome.

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 and nerves to be compressed by the clavicle as the scapular is retracted. 7Simons, 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.
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 rib, 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. 8Pecina, Marko, Jelena Krmpotic-Nemanic, and Andrew D. Markiewitz. Tunnel Syndrome: Peripheral Nerve Compression Syndromes. Boca Raton, FL: CRC, 2001. 39-42.,9Russell, Stephen M. Examination of Peripheral Nerve Injuries: An Anatomical Approach. New York: Thieme, 2006.

What is a cervical rib? 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. KIRGIS, Homer 10D., 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>.

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 and 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. 11Pecina, Marko, Jelena Krmpotic-Nemanic, and Andrew D. Markiewitz. Tunnel Syndrome: Peripheral Nerve Compression Syndromes. Boca Raton, FL: CRC, 2001. 39-42.,12Russell, Stephen M. Examination of Peripheral Nerve Injuries: An Anatomical Approach. New York: Thieme, 2006. 12. Medifocus Guidebook On: Thoracic Outlet

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. 13Pecina, Marko, Jelena Krmpotic-Nemanic, and Andrew D. Markiewitz. Tunnel Syndrome: Peripheral Nerve Compression Syndromes. Boca Raton, FL: CRC, 2001. 39-42.

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 your 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. 14Simons, 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. ,15Dubuisson, 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.

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.

Sources   [ + ]

1, 14. 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.
2, 6. 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.
3, 4, 5, 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, 11, 13. Pecina, Marko, Jelena Krmpotic-Nemanic, and Andrew D. Markiewitz. Tunnel Syndrome: Peripheral Nerve Compression Syndromes. Boca Raton, FL: CRC, 2001. 39-42.
9. Russell, Stephen M. Examination of Peripheral Nerve Injuries: An Anatomical Approach. New York: Thieme, 2006.
10. 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>.
12. Russell, Stephen M. Examination of Peripheral Nerve Injuries: An Anatomical Approach. New York: Thieme, 2006. 12. Medifocus Guidebook On: Thoracic Outlet
15. 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.