updated 2/25/10

Myofascial trigger points (muscle knots) in this area cause an astonishing array of problems through the neck, chest, upper back, arms and hands.

Massage Therapy for Neck Pain (and Much More)

Perfect Spot No. 4, in the scalene muscle group of the throat

by Paul Ingraham, Vancouver, Canada MORE

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 (muscle knots) are the world’s most common cause of aches and pains. The Perfect Spots series of articles teaches you how to self massage the most satisfying and therapeutically significant places on the human body to apply pressure. Each Perfect Spot article focuses on a specific location. 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!

Perfect Spot No. 4 is in what I call the Anatomical Bermuda Triangle, a triangular region on the side of the neck filled with the mysterious scalene muscle group. Massage therapists have vanished while working in the Anatomical Bermuda Triangle, never to be seen again. The region and its muscles are complex and peculiar, and many lesser-trained therapists have low confidence working with them. This article explains how the scalene muscles are involved in several common pain problems, and how to attempt treatment by massaging them. The scalenes are a difficult muscle group to work with, but rewarding!

(If you have a particularly stubborn and/or severe neck crick, you may prefer to look at my advanced tutorial instead: Save Yourself from Neck Pain!)

The scalenes are a strange muscle group

Seriously, this is a strange area: the scalenes often harbour trigger points 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 having 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!

But scalene trigger points can also have several other “interesting” (in the sense of the Chinese curse) 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 trigger points 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

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 trigger points 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 in the area.

The anatomy of the Anatomical Bermuda Triangle

The scalenes fan out from the sides of the neck bones to attach to the ribs — that’s right, ribs! You have ribs above and behind the collarbones. This is the very top of your rib cage.

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 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 — quite a few, actually — 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!

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). These three structures form the triangle in which the scalenes live.

Where is Perfect Spot No. 4?

Perfect Spot 4 is “somewhere in the triangle.” There is indeed one spot, in the belly of the middle scalene, that I believe to be the most common clinically significant trigger point, but I don’t want to throw you off with that: virtually any location within the triangle could turn out to be important. You should always explore. Perfect Spot 4 might be in one corner of the triangle one day, and in another corner the next. And precision isn’t necessary, either — it would be ideal, but not required.

Place your partner lying face up on a bed, with his or her head in the corner of the 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 fairly easily stimulate some trigger points without having to worry about being too accurate.

Is there any danger, massaging in this seemingly vulnerable area?

Many people are concerned about the possibility of impinging blood vessels or nerves. Don’t worry about it: if you touch the carotid artery or the jugular vein, there’s no missing the intensity of the pulse, and you simply back off. Smaller vessels are simply not a concern, and nerves — even nerve roots — are remarkably robust, and generally tolerate far more pressure than most people realize.

Are there “other things” in the throat? Well, the trachea and voice box are certainly more brittle and delicate structures — but they are also quite obviously too central to be pushing on them when doing scalene massage. No one will tolerate careless pressure on these parts! And there really just isn’t anything else you need to worry about.

Feel free to explore in this anatomical 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?

You may well encounter trigger points that feel hot, burning and nasty — not really the kind of trigger point you want to mess around with for fun. By massaging the scalenes with broader, less “poky” pressure, you are more likely to produce sensation and stimulation which is both interesting and useful.

As I’ve already suggested, sensation produced by massage in this area can be unpredictable or strange. Using broad pressure is likely to produce the most straightforward possibility: a peculiar but more or less pleasant deep ache spreading into the head, chest, back, and/or arm.

But be prepared for anything!

Even a gentle approach may feel a bit hot, nasty and vulnerable at first. 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 — but it does mean that your patient may need a little time to adjust and “accept” the stimulation. 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. Spreading ache is a good sign that it’s going well, and it will start to feel like scratching an itch you didn’t even know you had.

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 (by its name!) as an inflammatory condition, but it is rarely that simple.1 It is likely that myofascial trigger points, 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.”2 This is a great example of an odd benefit to treating Perfect Spot No. 4. For more information, see Massage Therapy for Tennis Elbow and Wrist Pain.

All The Perfect Spots for Trigger Point Massage

Choose your
perfect spot!

Or, for general information and advanced tips about trigger point therapy, see Save Yourself from Trigger Points!

and …

All the Spots — An extremely detailed tutorial filled with advanced troubleshooting tips, perfect for any Perfect Spot!

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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.”

Notes

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.
Travell et al. Myofascial Pain and Dysfunction. 1999. Volume 1, p513. Return to text.