The Scalenes: Small Muscles That Cause Big Problems

November 20, 2023

Pop quiz: do you know what pain between the shoulder blades, shoulder pain, chest pain, forearm and hand pain all have in common?

They are all very likely caused by the scalene muscles!

In today's newsletter, I'm going to give you a mini-course on the scalenes, what symptoms to look for and how to treat them using my Coaching The Body® approach.

The scalene muscles are  one of the most prevalent and least understood sources of pain in the body. As is typical in trigger point pain referral, the scalenes send their pain elsewhere and don't betray themselves as origin muscles unless you know what to look for.

While the scalenes live in the neck, they don't cause neck pain or headaches. Their referrals are all distal, causing pain in the mid-back, shoulder, chest, forearm and hand.

These symptoms are rarely traced to the scalenes by practitioners, but they are a huge key that you should not overlook.

The medical system is biased toward injury, and it is very tempting to explain these types of symptoms via typical diagnoses like cervical radiculopathy.

However, trigger points in muscles are very capable of producing scary symptoms - and the scalenes are tiny muscles that punch above their weight, producing a very profound array of effects.

Hidden Culprits

Most therapists attempt to treat pain between the shoulder blades with vigorous cross-fiber work in the rhomboids, but working in this area is generally a painful and exhausting waste of everyone's time. Most often this type of pain is caused by the scalenes, possibly with co-involvement of levator scapulae.

You probably don't make a connection between shoulder and mid-back pain when you see it in your clients, but this co-occurrence is a strong tipoff that the scalenes are involved.

Whenever you see multiple aspects of a particular muscle's referral patterns showing up in a client report, consider that a strong clue.

In addition to causing shoulder pain via direct referral, the scalenes can silently perpetuate shoulder pain by throwing a constant stream of subliminal nociception in the form of satellite referral across the anterior shoulder.

Entrapment Effects

Another, completely independent path for the scalenes to cause trouble is their position in the neurological and vascular anatomy of the neck.

Muscles with trigger points tend to become shortened and bunched up as a result of contractures in taut fibers. The scalenes attach from the cervical column to the first and second ribs, and can potentially lift the ribs closer to the clavicle, resulting in an effective clamp around the nerves and blood vessels of the thoracic outlet.

In this manner, trigger points in the scalenes can cause true thoracic outlet syndrome, producing a variety of disturbing symptoms in the forearm and hand.

Taut fibers due to trigger points in the scalenes can cause entrapment of brachial plexus nerves and/or thoracic outlet blood vessels

Other Neurological Impacts

The potential neurological effects of shortened scalenes are even more obscure and confusing. The nerves of the brachial plexus, which innervate the muscles of the shoulder and arm, pass between (and sometimes through) the different branches of the scalenes, variable with each individual.

Nerves that are being squeezed in a taut, shortened muscle are likely to cause dysfunction, including trigger point formation, in muscles they innervate downstream.

A compromised suprascapular nerve due to scalene entrapment can cause ongoing issues in supraspinatus and infraspinatus. Unless you address this hidden cause, you will make little progress in these muscles.  

This is why we include the scalenes within our Core Upper Body Protocol in the Coaching The Body® Membership. Our protocols are extremely valuable, because they guide you through muscles that you might not have otherwise known to treat, and they do so in an optimal order.

Why Scalenes Become Troubled

By far, the most common perpetuator of scalene issues is breathing dysfunction.

The ancillary muscles of breathing, including the scalenes along with high trapezius, pectoralis minor and others, are useful for increasing lung volume by pulling the ribs up during more forceful inhalation.

This is a far less efficient way of expanding lung volume than the action of the diaphragm, which pulls the soft membrane surrounding the lungs down - but the extra effort is necessary during times of high-demand breathing.

When people develop a habit of involving the high chest during normal breathing, the ancillary muscles can become stressed. The diaphragm is the prime mover during waking breathing, and should ideally be the initiator of normal inhalation.

Interestingly, the scalenes are actually primary during sleep - the body uses small movements of the scalenes to handle the lower metabolic needs when asleep.

This makes the scalenes doubly vulnerable, since they never get a break. In my clinical experience, chest breathing is extremely common - particularly during times of stress.

Treating The Scalenes

The lead video in this article shows some effective techniques we have developed at Coaching The Body® for treating the scalenes.

You should find these helpful in your practice, but I would also caution you to look at scalene treatment as part of the solution, not an isolated silver bullet.

Particularly in the muscles of the shoulder, head and neck, it's important to view treatment as calming and downregulating a highly orchestrated network of muscles rather than treating single rogue actors.

This is a complex task, but there's no need to figure it all out by yourself.

Our CTB Membership practitioner trainings empower you with highly successful protocols refined over 20 years of clinical practice and teaching - targeting the complaints you see every day in your treatment room.

I would love for you to join us.

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