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Chapter 5
Head and Neck
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter Objectives
• Overview of Head and Neck Region
• Posterior Cervical Muscles
• Anterior Cervical Muscles
• Head and Face Muscles
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Overview
• Muscle overview
• Trigger points (TP) and referral zones
• Trigger point activation
• Stressors and perpetuating factors
• Precautions and massage therapy (MT) considerations
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Suboccipitals: The Rock and Tilt Muscles
• Rectus Capitis Posterior Major and Minor
• Obliquus Capitis Superior and Inferior
• 4 pairs of short, small and posterior
muscles
• Indicated in severe headaches
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Attachment sites for
the suboccipitals
Suboccipitals cont’d
Suboccipitals TP:
• Located in muscle belly
– Difficult to distinguish from semispinalis trigger
points
Referral Zones:
• Refer behind, above, in front of ear
• Sensation extends forward unilaterally to occiput, and
eyes
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Subocciptals Trigger Point Map
Trigger points and referral zones
for the suboccipitals
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Stressors and Perpetuating Factors
Suboccipitals TP Activation:
• Develop when trying to control neck flexion
Stressors and Perpetuating Factors:
• Whiplash
• Any sustained awkward head position
• Uncorrected nearsightedness or maladjusted glasses
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Precautions and MT Considerations
Precautions:
• Avoid chin poking and jabbing movements
MT Considerations:
• Treat tissue between C1 and occiput
• Treat area between C1 and C2
• Use wave-like motion at base of skull
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Levator Scapulae: The Stiff Neck Muscle
• Inserts in two layers
• Bursa found between two layers
Attachment sites for
the levator scapula
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Precautions and Massage Considerations
Precautions:
• Observe the transverse process of C1
MT Considerations:
• Use muscle stripping and friction
• Tendonous attachment is fibrotic and easy to locate
• Pay special attention to C1 attachment site
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Trigger Points and Referral Zones
Levator Scapulae TP:
• Painful stiff neck often mimics torticollis
Referral Zones:
• Refer to the crook of neck
• Sensation extends to vertebral border of scapulae and
posterior shoulder
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Levator Scapulae Trigger Point Map
Trigger points and referral zones
for the levator scapulae
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Stressors and Perpetuating Factors
Levator Scapulae TP Activation:
• Postural stress, occupational stress or sleep position
Stressors and Perpetuating Factors:
• Overexertion in sports
• Using crutches or a cane
• Sleeping in a airplane seat
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Sternocleidomastoid: Amazingly Complex
SCM has both sternal and clavicular head
• Controls posterior head and neck movements
• Refer pain to face and head (not to neck)
• Mimics atypical facial neuralgia
• Mimics tension headaches
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SCM Sternal Head Trigger Points cont’d
Sternal head
• Referral felt at mastoid process, occipital ridge and eyes
Creates the following symptoms:
• Blurred vision and sinus congestion
• Unilateral deafness without tinnitus
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SCM Clavicular Head Trigger Points cont’d
Clavicular head:
• Refer to the front of head and behind ears
• Pain can extend to cheek and teeth on same side
Causes the following symptoms:
• Dizziness, vertigo, mimics tender lymph glands
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SCM Trigger Point Map
Trigger points and referral
zones for the sternal head
of the SCM
Trigger points and referral
zones for the clavicular head
of SCM
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Stressors and Perpetuating Factors
SCM TP Activation:
• Awkward head posture
• Mechanical overload
Stressors and Perpetuating Factors:
• Sleeping on back with too many pillows
• Drooping shoulders, slouched posture
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Precautions and Massage Considerations
Precautions:
• Avoid the carotid artery
• Avoid the styloid process
MT Considerations:
• Rotate head toward the working side
• Use a pincer compression
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Scalenes: Anterior, Medius and Posterior
• Associated with thoracic outlet entrapment syndrome
• Scalenes minimus exists in 50-75% of population
• Trigger points difficult to identify and treat
Trigger points and referral zones for the scalenes
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Scalenes Trigger Point Map
Scalenes TP:
• Common source of back pain
Referral Zones:
• Refer to chest, scapula, arm, elbow and thumb
• Rarely refer to head
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Stressors and Perpetuating Factors
Scalenes TP Activation:
• Activation secondary to SCM trigger points
Stressors and Perpetuating Factors:
• Pulling, lifting or carrying heavy items
• Scoliosis
• Respiratory issues
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Precautions and Massage Considerations
Precautions:
• Avoid direct pressure on brachial plexus and clavicle
• Tight scalenes traps brachial plexus (TOS)
• May mimic carpal tunnel symptoms
MT Considerations:
• Use gliding thumb strokes and rotate head
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Anterior Suboccipitals
• Anterior suboccipitals: rectus capitis anterior and lateralis
Trigger points:
• Refer to larynx, neck and mouth
• Activated by controlled flexion
• Stressors include vision problems
• Avoid the styloid process
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Longus Capitis and Colli: Military Neck
• Deepest anterior neck muscles
Trigger points:
• Activated by flexion/extension injuries
• Causes difficulty with swallowing and sore throat
• Avoid poking movements during massage
• Use appropriate pressure
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Suprahyoids
• Suprahyoids: mylohyoid, geniohyoid and digastric
Trigger points:
• Refer to lateral side of tongue and side of jaw
• Activated by chronic mouth breathing
• Difficulty with swallowing or lump in throat sensation
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Suprahyoids cont’d
Attachment sites for the
suprahyoids
Trigger points and referral
zones for the diagastric
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Occipitalis: The Scalp Tensor
• Occipitalis and frontalis make the epicranius muscle
Trigger points:
• Refer deep in orbit of the eye and eyeball
• Activated and stressed by glaucoma/decreased vision
• Deactivate key trigger points in clavicular portion of SCM
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Frontalis
• Also considered a scalp tensor
Trigger points:
• Refer pain in forehead
• Activated by SCM and constant facial expression
• Could create entrapment of supraorbital nerve
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Epicranius Trigger Point Map
Trigger points and referral
zones for the occipitalis
Trigger points and referral
zones for the frontalis
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Corrugator Supercilii
• Tiny facial muscle associate with eye headaches
Trigger Points:
• Refer behind the eyes
• Activated by facial expressions of anger and surprise
• Use the pincer grasp
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Attachment sites for corrugator supercilii
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Temporalis
• Key player in TMJ
Trigger Points:
• Refer to teeth, maxilla, eyebrows
• Causes hypersensitivity in teeth
• Activated and stressed by bruxism and gum chewing
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Temporalis Trigger Point Map
Trigger points and referral zones
for the temporalis
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Masseter
• Strongest muscle of the body (for its size)
Trigger Points:
• Refer to teeth, inner ear and eyebrow
• Significantly restrict jaw opening
• Associated with unilateral tinnitus
• Activated by teeth clenching, nail biting, an uneven bite
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Masseter Trigger Point Map
Trigger points and referral zones
for the masseter
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Medial Pterygoid
• Only small portion of muscle can be palpated
Trigger points:
• Refer to TM joint area, ears, throat, cheek
• Activated by forward head posture
• Stressed by thumb sucking and anxiety
• Work very gently as muscle is extremely tender
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Medial Pterygoid Trigger Point Map
Attachement sites for the
medial pterygoid
Trigger points and referral zones
for the medial pterygoid
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Lateral Pterygoid
• The key muscle in managing TMJD
Trigger Points:
• Refer to the TM joint and maxilla
• Activated as satellite trigger points of SCM
• Stressed by bruxism, playing a wind instrument or violin
• Work very gently as muscle is extremely tender
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Lateral Pterygoid Trigger Point Map
Attachment sites for the
lateral pterygoid
Trigger points and referral
zones for the lateral pterygoid
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Review
The galea aponeurotica is associated with which of the
following muscles?
• A. SCM
• B. Epicranius
• C. Lateral pterygoid
• D. Scalenes
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Answer
• B. Epicranius
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