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updated 5/26/10

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Trigger points in this area cause an astonishing array of problems in the neck, head, chest, back, and arms!

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 MORE

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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

illustrations by Paul Ingraham, Elizabeth Boylan

Trigger points (TrPs), or muscle knots, are the world’s most common cause of aches and pains, and yet they are rarely diagnosed correctly. Having too many stubborn trigger points is called “myofascial pain syndrome” (MPS). The Perfect Spots series of articles highlights trigger points that are unusually common and yet relatively easy to treat yourself — the most satisfying and therapeutically significant places to apply pressure on the human body. For a complete, advanced tutorial that walks you through every possible self-treatment option for muscle pain, see Save Yourself from Trigger Points & Myofascial Pain Syndrome!

Deep within the Anatomical Bermuda Triangle, a triangular 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 lesser-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. It also explains how to attempt treatment of 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 strange area: the scalenes often harbour TrPs with more diverse and peculiar consequences 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 routinely felt just about everywhere but the scalenes themselves. This is because our nervous systems struggle to isolate where pain is coming from when it’s deeper than the skin. A pinprick on the skin we can locate precisely, but the location of muscle pain often feels vague — we just don’t have the neurological “wiring” to get a clear signal. The net effect is sensory confusion.

And the confusion seems to be greater with the scalenes than with other muscles.

Pain in the scalenes is routinely felt just about everywhere but the scalenes themselves.

Referred 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 seem to produce unusually complex and large patterns of referred pain. These are patterns that vary more between people than the patterns produced by other muscles, and patterns that can even vary dramatically from day to day in the same person. The results can be somewhat spectacular, causing symptoms that most people — and many doctors and therapists — never guess are coming from the scalenes!

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Spreading pain

Just like the pain of a heart attack spreads from the heart into the shoulder and arm, the pain of painful scalene muscles spreads throughout the chest, upper back and chest, the arm and hand, and the side of the head. Pain referred to the back may feel like a penetrating pain stabbing through the torso.

But scalene TrPs can also have several other “interesting” (in the sense of the Chinese curse1) 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 different 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

Massage therapists have vanished while working in the Anatomical Bermuda Triangle, never to be seen again.

Scalene trigger point effects are so elaborate and seemingly out of proportion to these small, obscure muscles that they are almost always making at least some contribution to do with anything else that goes wrong in the whole region — like organized criminals, scalene TrPs can be counted on to mess up the area. The anterior scalene in particular is a trouble-maker, I find, 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. The scalene group consists of three muscles, the anterior, middle and posterior scalenes. They generally attach to the sides of the neck vertebrae at one end and to the uppermost ribs at the other end. Thus, 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 (see You Might Just Be Weird).

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 it. 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. Precision 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.

In this position, your hands will be angled inward a bit, and roughly pointing at the sternum. Now press down and perhaps a little bit 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 (see An Open and Closed Case). The scalenes are not pleasurable to massage, in general. The throat is a vulnerable area, and many people may feel threatened by pressure here: 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 vulnerable 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 nastier sensations. But the best case scenario is actually solving a problem. If your scalenes are in distress and causing a chronic pain problem, then finding the TrP that’s responsible is going to feel like scratching an itch 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 them seem important, the key to the region. No muscle produces more amazed comments from patients. As an entire limb “lights up” with referred pain from a light pressure in the neck, most patients 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.”

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 start to 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’s a reasonable limit to how much you should try. If it doesn’t develop a bright side after a reasonable amount of effort, then this Perfect Spot isn’t so perfect and you should let it go.

Tennis, meet elbow

Tennis is the traditional way to get a case of tennis elbow, but it’s not the only way.

A surprising relationship between the scalenes and tennis elbow

This 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.2 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.”3 This is a great example of an odd benefit to treating Perfect Spot No. 4. For more information, see Perfect Spot No. 5.

Further Reading

• SY Save Yourself from Neck Pain! — Many chronic neck pain treatment options explained and discussed in detail, supported by clearly explained scientific research
• SY Save Yourself from Tension Headaches! — Simple advice on healing from chronic tension headaches, also known as fibrositic headaches
• SY Singing, Breath and Scalenes — Connections between singing, breathing and a strange group of muscles

Appendix A: Is trigger point therapy too good to be true?

Trigger point therapy isn’t too good to be true: it’s just ordinary good. It can relieve some pain cheaply and safely in many cases. The existence of trigger points is not controversial. You can measure their electrical activity, take samples of their highly acidic tissue chemistry, and now a new MRI-like technology can now show them as well.

The Perfect Spots are based on a decade of my own clinical experience, and on the research and writing of Drs. Janet Travell and David Simons, pioneers of myofascial pain syndrome research. They produced “the Big Red Books” (a massive pair of texts).

Trigger points are clinically significant, but unfortunately obscure. As Dr. Simons wrote, “Muscle is an orphan organ. No medical speciality claims it.”

Want to know more? This is the tip of the iceberg. There’s a whole book …

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Not too good to be true.

Just ordinary good. Trigger point therapy isn’t a miracle cure, but it is a valuable life skill. Practically anyone can benefit at least a little, and many will experience significant relief from stubborn aches and pains. The first several sections are free.

Appendix C: Quick Reference Guide to the Perfect Spots

Notes

1. "May you live in interesting times" is one part of a three-part curse that is supposedly “ancient Chinese,” but is probably actually English or American in origin. According to Wikipedia, “The Chinese language origin of the phrase, if it exists, has not been found, making its authenticity doubtful.” The other two parts of the curse are the less famous “may you come to the attention of those in authority” and “may you find what you are looking for.” Return to text.
2. Boyer et al. Journal of Shoulder And Elbow Surgery. 1999. “The term epicondylitis suggests an inflammatory cause; however, in all but 1 publication examining pathologic specimens of patients operated on for this condition, no evidence of acute or chronic inflammation is found.” The scientific situation may have changed since, but I am not aware of any significantly clarifying research. Return to text.
3. Travell et al. Myofascial Pain and Dysfunction. 1999. Volume 1, p513. Return to text.

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