Human Movement Science & Functional Anatomy of the:

Levator Scapulae

by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Levator Scapulae - http://classconnection.s3.amazonaws.com/228/flashcards/504228/jpg/heaposmusmhnlevator_20scapulae_20m_1351523887828.jpg

What’s in a name:

  • levator (n.) from medical latin levator “a lifter,” from Latin levatus, past participle of levare “to raise” (see lever).(Etymology Online)
  • scapula (n.) “shoulder blade,” 1570s, Modern Latin, from Late Latin scapula “shoulder,” from Latin scapulae (plural) “shoulders, shoulder blades,” perhaps originally “spades, shovels,” on notion of similar shape, but animal shoulder blades might have been used as scraping tools in primitive times, from PIE *skap-, variant of *skep- “to cut, scrape” (see scabies).(Etymology Online)

    • A lifter of the scapulae

Levator Scapulae - http://classconnection.s3.amazonaws.com/443/flashcards/1157443/jpg/levator_scapulae1329438979051.jpg

Levator Scapulae:

Origin: Transverse process of the first four cervical vertebrae (posterior tubercles of C3 and C4 transverse processes) (8, 11).

Insertion: Medial border of the scapula from pointed edge close to origin of the spine of the superior angle of the scapula (11, 19)

Nerve: Primarily innervated by cervical nerves 3 and 4, via the cervical plexus, originating from cervical roots 3 and 4. Additional innervation from the dorsal scapular nerve and the C5 trunk of the brachial plexus (with communicating nerves from cervical nerve 4), which continues on to innervate the rhomboids (8, 11, 20).

Note the 3rd cervical nerve arising between the posterior and middle scalene to innervate the levator scapulae - http://upload.wikimedia.org/wikipedia/commons/e/ef/Gray794.png

Action:

  • Cervical Spine: Extension, lateral flexion and ipsilateral rotation (8, 11)
  • Scapula: Elevation and downward rotation (8, 11, 19, 21).

Dorsal Scapular Nerve innervating the Levator Scapulae and Rhomboids - https://classconnection.s3.amazonaws.com/37/flashcards/1700037/png/screen_shot_2012-08-25_at_21428_pm1345922320701.png

Relative Location:

  • The levator scapulae has a large cross sectional area relative to other cervical muscles. Rarely noted, this muscle is formed by 4 discrete bands, with the fibers originating from C1 attaching most medially on the scapula and having a nearly vertical fiber arrangement, and the fibers originating from C4 attaching most laterally on the scapula and having a more oblique fiber arrangement. The insertion of the the levator scapulae is adjacent and superior to the insertion of the rhomboid minor, and separated by the root of the spine of the scapula from the supraspinatus laterally. In some individuals the serratus anterior may actually overlap the insertion of the levator scapulae on the anterior side of the scapula (8). The inferior third of this muscle is deep to the upper and middle trapezius, and superficial to the splenii (as well as, semispinalis, multifidus, rotatores, interspinalis and intertransversarii muscles). The middle third of this muscle may be palpated as a superficial structure if approached from the lateral side of the neck (anterior to the upper trapezius) in the "posterior triangle. From the lateral side of the neck, the levator scapulae is bordered posteriorly by the splenii and anteriorly by the middle scalene. The superior third of this muscle is covered by the sternocleidomastoid. Just deep to the superior half of the levator scapulae is the longissimus cervicis muscle of the erector spinae muscle group, the posterior scalenes, and the deeper multifidus, rotatores, interspinalis and intertransversarii. Although some of the cervical nerves abut the anterior border of the levator scapulae as they course between the anterior and middle scalene, the levator scapulae does not seem to be directly related to nerve impingement.

Cross-section of cervical spine, notice the position and large cross-sectional area of the Levator Scapulae - http://d3j7fudf8o8iuo.cloudfront.net/var/ezwebin_site/storage/images/media/images/e-anatomy/rachis-anatomy-illustrations/cross-section-anatomy-neck-cervical-vertebra/2334804-1-fre-FR/cross-section-anatomy-neck-cervical-vertebra_medical512.jpg

Posterior Triangle of Neck - https://classconnection.s3.amazonaws.com/33/flashcards/602033/jpg/posterior_triangle_schematic_(black_triangle)1315803074585.jpg

Palpation:

  • There are two methods for palpating the levator scapulae.

  1. You may palpate the insertion of the levator scapulae through the upper trapezius. With your partner in prone, place two fingers on the superior/medial border of the scapula (superior angle). Run your fingers up toward the head until you fall off the superior angle of the scapula. Press down into the tissue, through the upper trapezius, and feel for "ropy strands" of muscle about two fingers width across.
  2. The levator scapulae may also be palpated on the lateral side of the neck, on the floor of the posterior triangle (image above). With your partner in supine, place your fingers on the lateral side of the neck just anterior to the upper trapezius. On the floor of the posterior triangle, the levator scapulae lies between the splenius capitis and middle scalene. As neither of these muscles attaches to the scapula, we should be able to use scapular motion to differentiate the fibers of the levator scapulae. Cue your partner to keep their neck relaxed while elevating their scapula. You should notice a thick band of muscle become dense under your fingers. Providing your partner was able to maintain a relaxed neck you should also notice softer fibers on either side of the dense band. If you were successful, you have differentiated the levator scapulae from its neighbors.
  3. Once you have mastered the palpation techniques above, try using them in conjunction to follow the levator scapulae along its entire length from insertion to origin.

Superficial and Deep muscles of the Posterior Thorax - https://classconnection.s3.amazonaws.com/1211/flashcards/716464/jpg/posteriorthoracic.jpg

Integrated Function:

  • Stabilization: Stabilization of the cervical spine and scapula.
  • Eccentrically Decelerates: Upward rotation and depression of the scapulae, and flexion, contralateral flexion and contralateral rotation of the cervical spine.
  • Synergists:

    • The levator scapulae, upper trapezius, and rhomboids work synergistically during elevation of the scapula.
    • The levator scapulae, pectoralis minor and rhomboids work synergistically during downward rotation of the scapula
    • The levator scapulae may aid the pectoralis minor and upper trapezius in anterior tipping of the scapula (this synergy plays a major role in Upper Body Dysfunction (UBD)).
    • The levator scapulae may assist in cervical extension along with the upper trapezius, splenii, semispinalis, longissimus cervicis muscle of the erector spinae muscle group, the posterior scalenes, and the multifidus, rotatores, interspinalis and intertransversarii.
    • The levator scapulae may assist in cervical lateral flexion, along with all of the ipsilateral muscles of the cervical spine.
    • Rotation of the cervical spine is the result of a complex synergy of muscles including the ipsilateral levator scapulae, contralateral upper trapezius, ipsilateral sternocleidomastoid, ipsilateral scalenes, and contralateral extensors (listed above)

http://www.eorthopod.com/sites/default/files/images/shoulder_distal_clav_osteolysis_anatomy04.jpg

Arthrokinematics:

      • All of the muscles that move the scapula have an affect on acromioclavicular (AC) and sternoclavicular (SC) arthrokinematics, but the relationships are indirect and may vary depending on the intended motion, synergies recruited, compensation patterns present, and potentially individual differences in the shape of joint surfaces (16).

        • The AC Joint: The AC joint is primarily responsible for rotational movements (upward and downward rotation), and those movements that fine tune how the scapula lies on the rib cage (internal/external rotation and anterior/posterior tipping) (3).

          • I could not find a single reference regarding the affect the levator scapulae muscle may have on arthrokinematic motion of the acromioclavicular (AC) joint. However, based on common dysfunction, clinically effective mobilization techniques, and EMG studies we may be able to presume that optimal motion of the acromion on the clavicle follows convex on concave rules in the sagittal plane (slide opposite roll), concave on convex in the frontal plane (slide follows roll), and deduce that relative over-activity of the levator scapulae muscle contributes to alterations in these arthrokinematics and dyskinesis. That is, excessive downward rotation, anterior tipping and external rotation of the scapula are common in those individuals with Upper Body Dysfunction (UBD), and to aid in correcting impairment at the AC joint, many clinician's use posterior to anterior mobilizations and superior to inferior mobilizations applied on the distal clavicle. This could imply that the acromion has a propensity toward, inferior glide, and increased compressive forces relative to the distal clavicle, and that pushing inferior and anterior on the clavicle relative to a stable scapula results in better congruence. Further, a study by Lawrence et. al, demonstrated less relative posterior rotation of the clavicle (and upward rotation of the scapula) in those individuals with shoulder impingement (16), which may imply an increase in anterior roll of the acromion on the clavicle (relative motion). In summary, a model of arthrokinematic dyskinesis for the AC joint may include excessive inferior and lateral glide, anterior roll and an increase in compressive forces of the acromion on the clavicle. As the levator scapulae anteriorly tips and downwardly rotates the scapula, it may be implied that movement impairment results in, or is the result of, an over-active levator scapulae contributing to excessive inferior glide and anterior roll of the acromion on the clavicle. Further, movement impairment of the shoulder girdle results in relative inhibition of the upper trapezius (prime mover of upward rotation) and synergistic dominance of the rhomboids and levator scapulae. This leads to upward rotation being replaced by elevation accompanied by downward rotation and anterior tipping (21). The resulting arthrokinematic dyskinesis would be as described above (excessive inferior glide, anterior roll, lateral glide and increase in compressive forces of the acromion on the clavicle).

Rotation at the Acromioclavicular (AC) Joint - Note that illustration "A" depicts internal rotation. - http://iranjradiol.com/?page=image&file_id=27291&t=png&w=600&h=800&o=max&dpi=150

  • The Sternoclavicular Joint (SC): The SC joint allows motion in all three planes contributing to protraction/retraction in the transverse plane, elevation/depression in the frontal plane, and rotation along the clavicles longitudinal axis (3). As the SC joint is a saddle joint, convex on concave rules apply in the frontal plane (slide opposite roll), while concave on convex rules applied in the transverse plane (slide follows role) (3). Longitudinal rotation of the clavicle follows the direction of scapular tipping and would incorporate spin in the same direction at the proximal clavicle.

      • Although all scapular muscles must have a role in SC joint arthrokinematics, the role of the levator scapulae would be indirect at best. It is difficult to even conceptualize whether the force and amplitude of scapular motion caused by the levator scapulae, is large enough to take the AC joint past an end range and force further compensations by the SC joint. It may be that any change in muscle activity of the levator scapulae resulting in dyskinesis of the SC joint is more closely related to synergistic dominance and relative inhibition of the upper trapezius - a muscle which has a direct impact on the SC joint arthrokinematics via its attachment to the clavicle. More research is needed.

The articular surfaces of the sternoclavicular (SC) joint - Convex-on-Concave (slide opposite roll) in the frontal plane & Concave-on-Convex (slide follows roll) in the transverse plane - https://classconnection.s3.amazonaws.com/184/flashcards/1904184/png/11353978907868.png

  • The Cervical and Thoracic Spine: The spine is comprised of gliding joints (facet joints) whose motion could be described as arthrokinematic motion (superior, inferior, lateral and medial glide) at each facet that results in osteokinematic motion (flexion, extension, lateral flexion and rotation) when the movement at each joint is summated. For example, extension is nothing more than the combined inferior glide of all facets at several segments of the spine. "Closing" and "opening" of facets is often described relative to manual therapy in which extension, ipsilateral flexion and ipsilateral rotation results in maximal congruence of facet joint surfaces and flexion, contralateral flexion and contralateral rotation results in minimal congruence of joint surfaces.

A depiction of a face joint "locked open".

      • The levator scapulae may contribute to cervical spine extension, ipsilateral flexion and ipsilateral rotation, which results in maximal closure of the facet, but does not result in maximal reduction of the neural foramen. Significant closure of the neural foramen does occur with this combination of joint actions; however, contralateral rotation would close the foramen further. Although it is not uncommon for the levator scapulae to be over-active in those individuals presenting with nerve root impingement and/or radiculopathy, the levator scapulae is likely more implicated in facet joint pain and dyskinesis. Many clinicians have noted a relationship between cervical syndromes and active trigger point development and altered activity of the levator scapulae (7-9, 12, 18). Resolution and normalization of levator scapulae activity is dependent on not only release techniques, but mobilization of stiff facets, optimization of cervical arthrokinematics, and postural re-education.
      • Interestingly, this commonly over-active muscle is thought by some to resist the anterior shear force caused by forward head posture (8). This may imply that this muscle becomes long/overactive, and irritation is related to pattern overload as the levator scapulae attempts to unsuccessfully "pull" the neck into optimal alignment. This would be analogous to the long/over-active biceps femoris in an anterior pelvic tilt. Although I think this theory disregards the function of the levator scapulae at the shoulder, I have found myself stretching the levator scapulae less and less (relying on release techniques along).

Levator Scapulae - note the line of pull and he ability to create a posterior shear force on the cervical vertebrae. http://upload.wikimedia.org/wikipedia/commons/a/a1/Levator_scapulae_muscle_animation_small2.gif

Fascial Integration:

My Fascial Hypothesis: Large fascial sheaths not only play a role in the transmission of mechanical force, but may also play a role in dictating the function of muscular synergies. This is likely caused by reducing or increasing tone of invested musculature via reflex arcs formed between mechanoreceptors embedded in the connective tissue and the attached musculature. In this way my view of fascia differs slightly from noted expert on the subject Tom Myers. I think of these large fascial sheaths (specifically the thoracolumbar fascia, iliotibial band, and abdominal fascial sheath) as natures “mother board.” A place for mechanical information to be communicated to the nervous system for more efficient recruitment of the muscular system. Despite having a slightly different philosophy it does not change the fact that fascia plays an important communicative role in the human body and we have Tom Myers to thank for his work.

The fascial network between fascicles of a muscle - http://www.selfcare4rsi.com/images/fascia.jpg

  • Origin: The levator scapulae shares an attachment on the posterior tubercles of transverse process with intertransversarii posteriores at C1 - C4, the splenius cervicis at C1 - C3, the longissimus cervicis at C2 - C4, and the middles scalenes at C3 and C4. All of these muscles have a propensity to become short/over-active and are separated from the upper trapezius by the prevertebral (deep) layer of the cervical fascia. (Further evidence, that the levator scapulae and upper trapezius may adopt contrary changes in muscle activity in Upper Body Dysfunction (UDB).) Practically, this may imply that via fascial relationships in the cervical spine, the levator scapulae acts synergistically with a group of muscles known as the "lateral cervical muscles". In essence, the motor behavior and recruitment patterns of the levator scapulae may be more similar to the scalenes then the trapezius muscles at the cervical spine. Clinically, this would seem to be the case, as lateral flexion is often the first range of motion lost, the last range of motion to return, and levator scapulae trigger points and over-activity are very common, and often occur in conjunction with scalene trigger points and over-activity.
  • Insertion: The superficial layer of fascia of the levator scapulae runs nearly continuously over the root of the spine of the scapula to invest in the fascia of the supraspinatus. This is noted by Tom Myers, and is included in the Deep Back Arm Line (6). Both muscles have a propensity toward over-activity and the treatment of both is often necessary for long-term resolution of trigger points, over-activity, and length changes in either structure. Further, the nearly adjacent insertions of the rhomboid minor and levator scapulae may also imply a fascial relationship. Both muscles are generally over-active in Upper Body Dysfunction (UBD), as both muscles will contribute to elevation of the superior/medial angle and downward rotation of the scapula. Interestingly, both of these muscles are also innervated by the dorsal scapular nerve.

The Deep Back Arm Line - Notice the continuity between the levator scapulae and supraspinatus. http://api.ning.com/files/omkt7cwbhXICNyvLoGl93*LlNJWZtjoMpX*mws1oEW9P1*Q4d4MAEXeGQa2BqT-OLbIT22AQQ8ksHAwcH5STUWLJOovk3gJ2/ScreenShot20140310at12.45.56PM.png

Behavior in Postural Dysfunction:

The levator scapulae have been noted as short and over-active by many clinicians, texts and studies (1, 2, 4, 7, 8, 11, 18, 21).

In Upper Body Dysfunction (UBD)

The levator scapulae is most often short and over-active contributing to excessive anterior tipping and downward rotation of the scapula in those with UBD. Trigger points in the levator scapulae are among the most commonly noted trigger points in the human body (8, 22), and it is my opinion that much of the "tightness" and trigger point pain credited to the upper trapezius by patients, is actually due to activity, length changes, and trigger points in the levator scapulae and supraspinatus (see "Fascial Integration" above). It is my hypothesis that the levator scapulae becomes synergistically dominant for an inhibited upper trapezius, and that pain and soreness in the upper trap may often be attributed to an inability to effectively upwardly rotate the scapula due to less than optimal length/tension relationship and overload from over-coming the increased activity of the levator scapulae during arm elevation. Clinically, I have found release and lengthening of the levator scapulae is often sufficient to reduce soreness in both muscles.

It may be that the upper trapezius is over-active in those with the extremes of shoulder girdle and cervical dysfunction, contributing to both extension of the upper cervical spine and anterior tipping of the scapula. However, it is more common to find the upper trapezius long and under-active, leading to a decrease in scapular upward rotation and clavicular posterior rotation during arm elevation. See the article on the Trapezius for more detailed analysis.

In Lumbo Pelvic Hip Complex Dysfunction (LPHCD) and Sacroiliac Joint Dysfunction (SIJD) the levator scapulae play no significant role.

In Lower Leg Dysfunction (LLD) the plays no significant role.

In Cervical Dysfunction -

The levator scapulae plays a significant role in cervical dysfunction, contributing to closure of the facet joints, a reduction in both passive and active rotation (often in both directions), a reduction in passive contralateral flexion, and often causing pain when active flexion is attempted to the same side (8). Many clinicians have noted facet joint dysfunction often results in active trigger point development and altered activity of the levator scapulae (7-9, 12, 18). As mentioned above (in "Arthrokinematics") the levator scapulae seems to "act" as a lateral cervical muscle relative to cervical spine and is often paired with over-activity of the scalenes. Resolution and normalization of levator scapulae activity is dependent on not only release of the levator scapulae, but release of all associated structures, mobilization of stiff facets, optimization of cervical arthrokinematics, and postural re-education.

Note: The levator scapulae may be viewed as the bridge between UBD and Cervical dysfunction, having a role in both scapular mechanics and cervical mechanics with resulting changes in length and activity affecting both.

In Short, the levator scapulae has a propensity toward over-activity and an adaptive decrease in length. This implies that release and lengthening for the levator scapulae should be part of a human movement professional's repertoire. Further, cervical mobilization techniques may aid in optimizing length and activity of the levator scapulae and should be part of the repertoire of any licensed professional (PT, ATC, DC, DO) treating upper body and cervical pathologies.

Clinical Implications:

      • Levator Scapulae trigger points
      • Cervical Pain
      • AC Joint Pain
      • SC Joint Pain
      • Cervicogenic Headache
      • Cervical Radiculopathy
      • Shoulder impingement
      • Bursitis
      • Thoracic Outlet Syndrome
      • Scapular winging
      • Anterior shoulder laxity
      • Osteoarthritis

        • Thoracic Spine
        • AC Joint
        • SC Joint
        • Glenohumeral Joint

Signs of Altered Length/Tension and Tone:

  • Special Tests:

    • Apley's Scratch Test (Inability of the top arm to reach contralateral superior angle of the scapula)
    • Pain with resisted scapular elevation.

Levator Scapulae Trigger Points:

  • Palpation results in tenderness and may result in radiating symptoms along the angle of the neck and the vertebral border of the scapula (8).
  • Levator Scapulae is the second most common trigger point location after the upper trapezius in those with mechanical neck pain (22). In a study by Lluch et al. the occurrence was up to 65% in those with spinal pain and levator scapulae trigger points were the most common trigger point found in whiplash patients (23).

http://integrativeworks.com/wp-content/uploads/referral-levator-scapula1.jpg

Comparison of Upper Trapezius, Levator Scapulae and Rhomboid trigger points (listed from superior to inferior) with posterior deltoid trigger point marked on male subject:

Upper Body Trigger points: Posterior Deltoid, Upper Trapezius and Levator Scapulae Upper Body Trigger points: Posterior Deltoid, Upper Trapezius and Levator Scapulae

Techniques for optimizing levator scapulae length and activity:

Levator Scapulae Self-administered Static Release:

Levator Scapulae Self-administered Active Release

Levator Scapulae Static Stretch:

Levator Scapulae Active Stretch:

Levator Scapulae, Trapezius and Splenii Vibration Release

Static Manual Release Technique:

Bibliography:

  1. Phillip Page, Clare Frank, Robert Lardner, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
  2. Dr. Mike Clark & Scott Lucette, “NASM Essentials of Corrective Exercise Training” © 2011 Lippincott Williams & Wilkins
  3. Donald A. Neumann, “Kinesiology of the Musculoskeletal System: Foundations of Rehabilitation – 2nd Edition” © 2012 Mosby, Inc.
  4. Michael A. Clark, Scott C. Lucett, NASM Essentials of Personal Training: 4th Edition, © 2011 Lippincott Williams and Wilkins
  5. Leon Chaitow, Muscle Energy Techniques: Third Edition, © Elsevier 2007
  6. Tom Myers, Anatomy Trains: Second Edition. © Elsevier Limited 2009
  7. Shirley A Sahrmann, Diagnoses and Treatment of Movement Impairment Syndromes, © 2002 Mosby Inc.
  8. David G. Simons, Janet Travell, Lois S. Simons, Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens
  9. Cynthia C. Norkin, D. Joyce White, Measurement of Joint Motion: A Guide to Goniometry – Third Edition. © 2003 by F.A. Davis Company
  10. Cynthia C. Norkin, Pamela K. Levangie, Joint Structure and Function: A Comprehensive Analysis: Fifth Edition © 2011 F.A. Davis Company
  11. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins
  12. Karel Lewit. Manipulative Therapy: Musuloskeletal Medicine © 2007 Elsevier
  13. Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004
  14. Andrew Biel, Trail Guide to the Human Body: 4th Edition, © 2010
  15. Scovazzo ML, Browne A, Pink M, et. al.: The Painful shoulder during freestyle swimming. Am J Sports Med 19(6):577-582, 1991
  16. Lawrence, R. L., Braman, J. P., Laprade, R. F., & Ludewig, P. M. (2014). Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 1: sternoclavicular, acromioclavicular, and scapulothoracic joints. journal of orthopaedic & sports physical therapy, 44(9), 636-A8.
  17. Dean, N.A. and B.S. Mitchell 2002. Anatomic relation between the nuchal ligament (ligamentum nuchae) and the spinal dura mater in the craniocervical region. Clin. Anat. 15:182-185.
  18. Craig Leibenson, Rehabilitation of the Spine: A Practitioner's Manual. © 2007 Lippencott Williams & Wilkens
  19. Oladipo GS, Aigbogun Jr EO, Akani GL. (2015). Angle at the medial border: the spinovertebral angle and its significance. Anatomy Research International. 1-5.
  20. Nasu H, Yamaguchi K, Nimura A, Akita K. (2012). An anatomic study of structure and innervation of the serratus anterior muscle. Surg Radiol Anat. 34:921-928.
  21. Choi W, Cynn H, Lee C, et al. (2014). Shrug exercises combined with shoulder abduction improve scapular upward rotator activity and scapular alignment in subjects with scapular downward rotation impairment. Journal of Electromyography and Kinesiology. 25: 363-370.
  22. Munoz-Munoz S, Munoz-Garcia MT, Alburquerque-Sendin, et al. (2012). Myofascial trigger points, pain, disability, and sleep quality in individuals with mechanical neck pain. Journal of Manipulative and Physiological Therapeutics. 35(8): 608-613.
  23. Lluch E, Nijs J, De Kooking M, et al. (2015). Prevalence, incidence, localization, and pathophysiology of myofascial trigger points in patients with spinal pain: a systematic literature review. J Manipulative Physiol Ther.38:587-600.

© 2015 Brent Brookbush

Questions, comments, and criticisms are welcome and encouraged.