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Digastric Muscle:

Location, Actions

and Trigger Points

Temporalis

Muscle: Location,

Action and Trigger

Points

Scalene Muscles: Location, Actions, Trigger Points, and Thoracic

Outlet Syndrome Ground Up Strength Categories Physiology and Anatomy Muscles Trigger Points Scalene Muscles:

Location, Actions, Trigger Points, and Thoracic Outlet Syndrome

The scalene muscles are

three paired muscles of the

neck, located in the front

on either side of the

throat, just lateral to the sternocleidomastoid. There is an

anterior scalene (scalenus anterior), a medial scalene

(scalenus medius), and a posterior scalene (scalenus

posterior). They derive their name from the Greek word

skalenos and the later Latin scalenus meaning "uneven",

similar to the scalene triangle in mathematics, which has all

sides of unequal length. These muscles not only have

different lengths but also considerable variety in their

attachments and fiber arrangements. As you will see from

the descriptions below, these muscles are in a very crowded

place and are related to many important structures such as

nerves and arteries that run through the neck.

The scalenes run deep to the sternocleidomastoid. They all

start at the cervical vertebra and run to the first to second ribs. The anterior scalene runs almost vertically

and its upper part is concealed by the SCM and the lower part is concealed by the clavicle. Along its medial

border runs the carotid artery. The internal jugular vein, the intermediate tendon of the omohyoid, the

phrenic nerve; and the transverse cervical and scapular arteries all lie between the anterior scalene and the

sternocleidomastoid (in front of scalene behind the SCM) Between the muscle and the clavicle runs the

subclavian vein. The rear of the muscle, i ts posterior border, makes contact with the brachial plexus nerve

roots, which run between it and the medial scalene.

Together with the first rib these muscles form a triangle known as the scalene

triangle or interscalene triangle1 through which the brachial plexus nerves and

the subclavian artery pass. Also behind the anterior scalene are the pleura ofthe lungs and the superior intercostal artery.

Just behind the anterior scalene is the scalenus medius, referring to the

"middle" muscle. This muscle forms part of the floor of the posterior triangle of

the neck2. The front of the muscle runs close the the brachial plexus and the

upper two thoracic nerve roots run through it. It makes contact with the

levator scapulae in the rear, and the dorsal scapular nerve and transverse

cervical artery pass between the two. The upper two roots of the long thoracic

nerve go through the muscle. Only the anterior and medial scalene can be

palpated.

The Scalene Muscle Group

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ene Muscles: Location, Actions, Trigger Points, and Thoracic Outle... http://www.gustrength.com/muscles:scalene-muscles-location-actions-tr...

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Trigger Point StuffThe posterior scalene is much shorter than the other two, and only starts at

the lower cervical vertebra, where it attaches via two three tendinous slips.

Whereas the first two attach to the first r ib, the medius attaches to the second

rib. 1,2,3,4,5,6.7

Some texts refer to a fourth scalene muscle, the scalenus minor. This variant

does not always occur on both sides of the neck, but may be present in up

one-third of people. This normal variation may have implications in thoracic

outlet syndromes as does the scalenus anterior, resulting in a syndrome

known as Scalenus Anterior sydrome or Scalenus Anticus syndrome (another

name for the anterior muscle). The brachial plexus and the subclavian artery,

as mentioned above, pass between the anterior scalene and the middle

scalene. When present, the minimus inserts between the scalenus anterior

and medius, passing behind the subclavian artery while the scalene anteriorpasses over and in front of it.7,8

At the top of the lungs is the suprapleural membrane, which is a dense fascial

layer also called Sibson's fascia. This fascia is attached to the inner border of

the first rib and the costal cartilage. The pleura of the lungs attach to this

fascia underneath. The fascia attaches to the transverse process of the C7

vertebra and when muscle fibers are found in it, it is called the pleuralis

muscle, which is another name for the scalenus minimus. So this suprapleural

membrane could be regarded as a flattened out tendon of the scalenus

minimus, meaning that the scalenus minimus is attached to the pleura of the

lungs, or thepleural dome and then beyond to the first rib, lying behind the

anterior scalene and the groove of the subclavian artery. The scalenus muscle

is a reinforcement of Sibson's fascia, which serves to stiffen the thoracic inlet

and the neck structures above it so that they are not "puffed" up and down

during forced respiration.8

The scalenes are clearly individual muscles but the all work together as a

functional unit. They are usually considered accessory muscles of inspirations,

as they work to elevate and fix the first and second ribs, while serving to fix

them during quiet breathing, becoming guy-wires from the neck. It was

thought that they were only active during labored or forceful breathing.

However, measurement of their activity with concentric needles electrodes

have demonstrated their activity even during quiet, normal breathing, even

when the intake of breath is quite small. This has caused some researchers to

drop the "accessory" label and consider them primary muscles of inspiration.

During normal diaphragmatic breathing, the ribs are elevated by the

intercostal muscles and the scalenes. The orientation of the ribs causes them,

when elevated, to expand the chest to the sides and front which increases the

thoracic volume available for the lungs to expand into, although a most of this

expansion is into the abdominal space which is made available by the

contraction of the diaphragm downward. Their exact role in breathing is

difficult to resolve.

The actions of the scalene muscles as movers of the neck and head are variously reported. They stabilize thecervical spine against lateral movement. The most common moving action attributed to them unilaterally is

contralateral rotation of the cervical spine (rotation of head to the opposite side of working muscle). They

have also been reported to be ipsilateral rotators (rotation to same side as working muscle). Bilaterally they

are reported to be flexors of the neck. Their action in this regard depends on whether the thorax is fixed or

the neck is fixed.1,2,3,4,5,6.7

Whether they are always active during breathing or not, the scalenes may become overactive in quiet

breathing in upper chest breathing patterns. Prolonged coughing can overuse these muscles as well, and

they may be especially problematic to asthma sufferers. Pain can come from myofascial trigger points in the

scalenes or from thoracic outlet entrapment syndromes associated with the muscles.7

Origins, Insertions, and Actions

Origins: TheAnterior Scalene (front scalene) originates on the anterior tubercles of the transverse

processes of the third or fourth to the sixth cervical vertebrae.

The Scalenus Medius (middle scalene) originates on the posterior tubercles of the transverse processes of

the first or second to seventh cervical vertebrae.

The Scalenus Posterior(rear scalene) attaches by two or three tendons from the posterior tubercles of the

transverse processes of the the fifth or sixth to the seventh cervical vertebra (the last two or three).

Insertions: The scalenus anteriorinserts onto the scalene tubercle and cranial crest of the firt rib, in front

of the subclavian groove. The middle scalene inserts onto the cranial surface of the first rib, between the

scalene tubercle and the subclavian groove. Theposterior scalene inserts onto the outer surface of the

second rib.

Actions: As above, the scalenes function as fixers and elevators of the first and second ribs during

inspiration. The anterior and medial scalenes elevate the first rib and the posterior scalene elevates the

second rib.

It is generally accepted that, acting unilaterally, they flex the head to the same side and acting bilaterally

the flex the head forward (cervical flexion). Their roles as rotators of the neck given differently by different

texts. Some report that all three scalenes rotate the head to the same side and some report that they all

rotate it to the opposite side. Some report different functions for each scalene. According to Buford, et al., a

multiple single-subject study on anesthetized macaques and human cadaver follow up revealed all threemuscles as contralateral rotators of the cervical spine (rotating the head to the opposite side).4 The scalenes

also help to laterally stabilize the neck, which is especially suited to the scalenus posterior.7

Sources of Scalene Trouble and Trigger Points

As stated above, breathing habits can be a cause of the scalenes being overworked. Here is a li st of possible

causes of scalene trouble which can lead to trigger points in the muscles or the neurovascular entrapment

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Muscle Trigger Points


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syndrome:

labored breathing and/or habitual upper chest breathing (paradoxical), or chronic coughing, possibly

associated with:

nervous hyperventilation

asthma

emphysema

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 overheadwork the requires repeatedly raising and lowering the arms

carrying heavy loads at the sides

pulling or lifting (especially with arms as 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)7

Strength Training and Scalene Strain

When you strain on a heavy lift, such as a barbell squat, you may find yourself holding your breath whiletensing 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 shoulder pinned back during most lifting exercises, do not

exaggerate this and do not excessively puff the chest out and up.

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, shoudlers,

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 the 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 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 ortendonitis. 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, neuruovascular

compression of scalene associated thoracic outlet syndrome may cause ischemic pain mistaken for cervical

nerve root origin, although the pain patterns are different.9

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 i f 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

forwardand 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.

Finger-Flexion TestThe 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 f inger are called the metacarpophalangeal joints (MCP's). You must keep these joint

absolutely straight (fully extended) when performing the test.


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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 tr igger 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 thescalenes 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 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 Trigger Points and Referred Pain Pat terns

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 more

rare 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.

7

Scalene Trigger Point Self-Treatment

The first thing you need to do to get rid of your scalene trigger points is to eliminate the underlying causes.

Simons and Travell recommends to place 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 farfetched 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 and Diaphragmatic

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 youhave a medical condition that produces chronic coughing, seek appropriate medical care to control the

coughing.7

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

Side-Bending Scalene Stretch


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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 shoudler.

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 seconds7

Scalene Trigger Point Self-Release

For more complete instructions see The Trigger Point Therapy Workbook

Anterior Scalene: To find the anterior scalene your must find the clavicular branch of the

sternocleidomastoid. Once you locate it, you want to find the posterior border of it, which is the rearpart 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, whereyou 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 sclenus 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 adn exert downward pressure

while pulling your finger toward your throat, running the stroke parallel to the collar bone.((bicite simons)),

9

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 thebrachial plexus and the subclavian artery pass to the costoclavicular space. This triangle can be from 0.4 to

3.5cm in width. The suclavian 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 T13. 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 syndrome, scalenus anticus syndrome, or Naffziger

syndrome.

The scalene triangle and associated structures. Notice the pectoralis minor. See how the axilla ry (subclavian) artery and brachialplexus 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 pecminor pulls on and stretches these structures. Also, pulling the shoulders back in an extreme "military" posture, can cause the vessel


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and nerves to be compressed by the clavicle as the scapular is retracted.7

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 rib4, 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. 10,11

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 adn 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. 10,12

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.10

Scalenus anterior syndrome produces symptoms similar but not identical to scalene trigger points. Brachial

plexus compression causes pain on the ulnarside of the hand (the side where your pinkie finger is) as

opposed to the radial side (where you 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 thefingers, 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.7,14

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.

References

1. Rockwood, Charles A. The Shoulder, Volume 1. Philadelphia, PA: Saunders/Elsevier, 2009. 66.

2. Hamid, Qutayba, Joanne Shannon, and James Martin. Physiologic Basis of Respiratory Disease. Hamilton:

BC Decker, 2005. 271.

3. Schuenke, Michael, Lawrence M. Ross, Edward D. Lamperti, Erik Schulte, and Udo Schumacher. Atlas of

Anatomy: Neck and Internal Organs. Stuttgart, NY: Thieme, 2006. 8, 92.

4. Buford, John A., Stephanie M. Yoder, Deborah G. Heiss, and John V. Childley. "Actions of the Scalene

Muscles for Rotation of the Cervical Spine in Macaque and Human." Journal of Orthopaedic & Sports Physical

Therapy Volume 32.10 (2002) 488-496.

5. Gray, Henry, and Edward, ROBERT HOWDEN, Anatomy Descriptive and Applied with the Ordinary

Terminology. Philadelphia: Lea & Febiger, 1913. Google eBook

6. Cunningham, D. J. Cunningham's Manual of Practical Anatomy. Oxford: Oxford UP, 1921.

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. McMinn, Robert M. H., and Raymond Jack Last. Last's Anatomy Regional and Applied. Edinburgh [u.a.:

Churchill Livingstone, 1993.

9. 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.

10. Pecina, Marko, Jelena Krmpotic-Nemanic, and Andrew D. Markiewitz. Tunnel Syndrome: Peripheral Nerve

MSK Ultrasound

Buy Quality Ultrasound for Musculoskeletal Applications

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Compression Syndromes. Boca Raton, FL: CRC, 2001. 39-42.

11. Russell, Stephen M. Examination of Peripheral Nerve Injuries: An Anatomical Approach. New York:

Thieme, 2006.

12. Medifocus Guidebook On: Thoracic Outlet

13. KIRGIS,, Homer 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.

.

14. Dubuisson, Annie S. "The Thoracic Outlet Syndrome." LSU School of Medicine. Web. 02 Mar. 2012.

.Syndrome]. Medifocus.com. March

2, 2012.

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Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved. Images not for reuse.

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This page created March 03 2012

Last updated 31 Jul 2012, 22:52 GMT+02

Footnotes

1. Also called the posterior scalene foramen, the scalene hiatus or the scalene fissure

2. The posterior triangle of the neck is an area of the neck defined by the rear border of the

sternocleidomastoid, the anterior border of the trapezius, and the middle portion of the clavicle.

3. And possibly from C4 or T2.

4. 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 undereven 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.13

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