Therapy Notes – Scalenes


Structural anomalies are common in the scalenes. Developed palpation skills are needed to reach the proper belly for assessment and treatment. Be aware that the lateral tip of the cervical transverse process is blunt and puts significant space between the attachments of the anterior scalene on anterior tubercle and the attachment of the scalenes on the posterior tubercles.

The superior end of scalenus anterior can be found at the anterior tubercle of C3. It is usually prominent. Then, reaching under the SCM from the side, follow the belly down to its attachment on the first rib. Feeling the lateral edge of the tendon attachment on the first rib is important. Caution is needed to avoid the brachial plexus.

Often, the inferior attachment of scalenus medius is blends across the rib toward the attachment of the anterior scalene. Many times the two lower attachments will weave with one another supporting thoracic outlet syndrome. Finding the first rib is often confusing for the new student as it is a smaller loop than expected. Follow the blunt edge of the transverse processes down the lateral neck until the first rib stops your decent. Have the subject laterally flex the head while palpating the upper edge of the rib. The medial scalene will pop out and can be followed to its attachment on the posterior tubercles.

Scalenus posterior can be palpated by following the lamina groove, under the trapezius, down the back of the neck until a thick section is felt inserting at C4. The most posterior part of this clump of muscle is the attachment of serratus posterior superior on the nuchal ligament. The deepest portion is scalenus posterior and in between is iliocostalis lumborum. Scalenus posterior may blend anteriorly with scalenus medius but continues onto the second rib. Scalenus posterior will attach more medially where iliocostalis lumborum and serratus posterior superior will continue out to the lateral angle of the ribs.

Scalenes are often suspected when pain occurs in the arm and hand. This is both useful and confusing. Many referral patterns overlap the scalene referral patterns. It leads the novice therapist to treat scalenes too often.
Although the entire referral pattern is seldom presented, the trigger points of scalenes are numerous and usually only elicit part of the pattern. Further assessment of impaired functions, causes and perpetuating factors are needed. Serratus posterior superior, which is similar in attachments and similar in referral pattern, is easily mistaken for scalenes.

Fortunately, the treatment of scalenes usually restores motion in displaced cervical joints and the joints of the shoulder girdle. The function of many muscles in the arm and hand are restored from this alone. The therapist would be successful more consistently and work more efficiently if they would assess the pattern in more detail and apply more appropriate treatment.

Structural Issues

Scalenus anterior is a poor flexor of the neck but does become chronically shortened in forward head posture. This is complemented on the upper posterior neck by the short extensors of the head; sub-occipitals, splenius capitis and semispinalis capitis. After the more superficial phasic muscles are released, the deep tonic muscles must be addressed.

Scalenus posterior has very similar attachments to iliocostalis cervicis and serratus posterior superior. They pull on the same structures and synergize closely. They are an important part of resolving forward head posture and lateral flexion of the lower cervicals.

Breathing from the upper thoracic region is a more common issue as we become more sedentary and spend more time bent forward reading, watching television and driving. Although scalenes are a big contributor, other synergists need to be assessed for longer-lasting results. Sternocleidomastoid, serratus posterior superior and iliocostalis cervicis have similar attachments but the therapist must look further for lasting treatment. Electro-myographical studies show that serratus anterior and pectoralis minor are very active in assisted or labored breathing. They open the upper ribs from the pectoral girdle. They need the support of the muscles that lift the pectoral girdle; trapezius, levator scapula, and rhomboids.

When scalene muscles refer to both the front and back of the thorax as well as down the arm, it produces chest pain with sensations up and down the arm. It is similar to the sensations created by a heart attack. If these symptoms arise, it is imperative to see a doctor first to rule out a cardiac problem. I have seen clients that have these symptoms but have been cleared by their doctor beforehand. They received relief from symptoms when the scalenes were treated.

Take a good look at this post. The exercises are great for helping your client retrain their breathing and doing homework while you’re taking care of the therapy. It’s hard to get scalenes resolved when serratus anterior, levator scap[ula, clavicular pec, and others are contributing to the paradoxical breathing patterns.

Looking to sharpen your treatment protocol?

This post has detailed steps for treating scalenes in the supine position from The Workbook of Classical Neuromuscular Therapy PLUS pre-protocol steps to help you have more comfortable treatment with longer-lasting results.

This site is undergoing changes. Starting in early 2020, we began changing the format of the posts to include more extensive self-care, illustrations, therapist notes, anatomy, and protocols. We’d love your feedback. We are adding posts and converting the old posts as quickly as time permits.

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Tony Preston has a practice in Atlanta, Georgia where he sees clients. He has written and taught about anatomy, trigger points and cranial therapies since the mid-90s.

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