Scalene Static Manual Release (Soft Tissue Mobilization)

Differentiation

1. The scalenes can be palpated in the posterior cervical triangle.
   • The anterior border is the SCM, which may be identified by asking the patient to contralaterally rotate the head, and then lift the head off the table (flexion).
   • The posterior border is the upper trapezius , which may be identified by asking the patient to shrug against resistance.
   • The inferior border is the skin overlying the space between the upper trapezius and clavicle.
2. The origin of the scalenes is on the transverse processes of C2 through C7, which can be palpated in the posterior cervical triangle, in-line with the mastoid process. The transverse processes feel pointy and are fairly sensitive; try not to press too hard.
3. The insertion of the scalenes is the first and second rib. The first rib can be palpated by finding the spinous process of C7 (vertebra prominens) and falling off laterally. Inching the fingers laterally will result in pressing into the hard, but springy 1st rib which continues into the space between the upper trapezius and clavicle. It is helpful to ipsilaterally flex the neck to soften the upper trapezius which must be palpated through.
4. The second rib is more challenging palpation and is likely best achieved by dropping inferiorly off the posterior aspect of the first rib. Additionally, the second rib may be palpated by falling off the most lateral aspect of the first rib, and pressing deeper into the tissues just medial the acromion shelf.
5. The scalenes can be palpated by running the fingers anterior to posterior over (not into) the transverse processes, in the posterior cervical triangle, feeling for fairly vertical fibers that run from the transverse processes to the first and second ribs.
   • The levator scapulae is also a vertical muscle with attachments on the transverse processes; however, the scalenes run vertically and inferoanterior and the levator scapulae runs from the transverse processes in an inferoposterior direction (toward the scapulae).
   • Tip: When trying to differentiate the scalenes from the splenii and levator scapulae ask the patient to actively flex and laterally flex the neck. This will inhibit the splenii and levator scapulae, and activate the scalenes and SCM. The active muscles you feel during active flexion to posterior to the SCM (in the posterior cervical triangle, over the transverse processes) will be the anterior and middle scalenes muscles.

Potentially Sensitive Tissues

• The carotid arteries are anterior to the scalenes. Although momentarily compressing or abutting these vessels while investigating the area is unlikely to pose any harm, obstructing or repeatedly abrading these tissues may be an issue. If you feel a pulse, change your hand position.
• It is possible that you will feel the "bead" like lymph nodes in the lateral neck. Compressing lymph nodes into the transverse processes could be problematic. Again, if these structures are felt, adjust your hand position and work around them.
• The brachial plexus passes between the anterior and middle scalene. Monitor your patient closely for signs associated with nerve irritation and radiculopathy. If nerve symptoms are noted, change your hand position.

Trigger Points

• The most common trigger points in the scalenes are closer to their insertion on the 1st and second ribs.

Release Technique:

1. This technique is most comfortable with the patient lying supine and the practitioner sitting at the head of the table.
2. The practitioner slides the hand opposite the side of the treatment under the patient's head. This hand will be used to control the head and cervical spine.
3. Using the directions for differentiation above, the practitioner uses the thumb to identify the vertical fibers of the scalenes in the posterior cervical triangle. (Note, flexion and lateral flexion can be used to differentiate the scalenes from the splenii and levator scapulae)
4. The practitioner then "strums" the fibers from posterior to anterior looking for taut bands, starting with the superior portion of the muscle and working inferiorly.
5. Once a taut band is located, the length of the band is explored for a dense nodule, and consistent pressure is applied.
   1. Generally, dense nodules in the scalene are found closer to the insertion, near the 1st and 2nd ribs.
6. The practitioner may move the head to control the amount of tension within the muscle and adjust the force to a superior to inferior direction, to aid in pinning and compressing the nodule and achieving a release.
7. Consistent pressure is held until the nodule softens under the practitioner's fingers, or tissue density/sensitivity is significantly reduced (generally 30 - 120 seconds).