Palpating The Scalene Muscles: A Step-By-Step Guide

The scalene muscles are a group of three pairs of muscles in the lateral neck: scalenus anterior, scalenus medius, and scalenus posterior. Sometimes, a fourth muscle, the scalenus minimus, is present. These muscles contribute to the stabilization of the vertebral column, head movements, and deep inhalation. When tense, they can trigger pain in many body regions, including the front and back of the arms, chest, and upper back. To palpate the scalene muscles, a patient may be asked to flex and extend their neck or shrug their shoulders against resistance. This allows the examiner to feel the muscles contracting and relaxing, and any strength difference between the sides could indicate damage.

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Patient positioning: sitting, standing, or lying supine

The patient can be positioned in a few different ways—sitting, standing, or lying supine—while palpating the scalene muscles. The scalene muscles are a group of three pairs of muscles in the lateral neck: scalenus anterior, scalenus medius, and scalenus posterior. Sometimes, a fourth muscle, the scalenus minimus, is present behind the lower portion of the scalenus anterior.

If the patient is sitting or standing, the practitioner should stand in front of the patient. The practitioner should place their fingers on the sternocleidomastoid (SCM) muscle for orientation. With the patient relaxed, the practitioner should place their fingers on the scalene muscles, just posterior to the SCM. The practitioner should then ask the patient to resist ipsilateral lateral flexion by pushing on the side of the skull.

If the patient is lying supine, the practitioner should stand behind the patient's head. The practitioner should position the anterior scalene under the distal lateral margin of the SCM, with the middle scalene just behind the SCM. The patient should then be asked to slightly flex and rotate their head to the opposite side, tucking under the SCM to gain access to the muscular belly of the anterior scalene. The practitioner should then gently strum over the anterior scalene, following it inferiorly as it disappears under the clavicle. The patient should be asked to inspire during palpation to feel its contraction. The practitioner should then move laterally off the anterior scalene onto the middle scalene, which will be broader. They should strum across the middle scalene, following it as far as possible up and down its fibres, being careful not to compress this juncture to avoid causing sharp radiating nerve pain.

It is important to note that the supine position can be associated with risks such as effects on respiratory function, skin integrity, and circulation. For example, when in the supine position, heart rate and peripheral vascular resistance are lower compared to sitting. Additionally, the supine position can increase the risk for impaired respiratory function, including a reduction in lung volume.

Palpation technique: using fingers to feel muscle contractions and relaxations

To palpate the scalene muscles, the patient should be allowed to sit, stand, or lie supine. The patient should then be asked to flex and extend their neck or shrug their shoulders against resistance. This allows you to feel the muscles contracting and relaxing under the skin, helping you to identify them. Any strength difference between the two sides could suggest damage on the weaker side.

To palpate the anterior scalene, place your fingers on the sternocleidomastoid muscle for orientation. With the patient relaxed, place your fingers on the scalene muscles, just posterior to the sternocleidomastoid muscle. Ask the patient to hold while you push on the side of the skull to resist ipsilateral lateral flexion. Ask the patient to flex and rotate their head to the opposite side. Gently strum over the anterior scalene following it inferiorly as it disappears under the clavicle.

To palpate the middle scalene, place the patient in a supine position and stand behind their head. Position the anterior scalene under the distal lateral margin of the SCM with the middle scalene just behind the SCM. Ask the patient to slightly flex and rotate their head to the opposite side, tucking under the SCM to gain access to the muscular belly of the anterior scalene.

To palpate the posterior scalene, turn the patient's face toward the arm that is pulling. Push with your fingers into the spot where your collarbone meets your trapezius.

Identifying trigger points: locating tender areas and fasciculations

To identify trigger points in the scalene muscles, it is important to first understand their location and function. The scalene muscles are a group of three pairs of muscles in the lateral neck: scalenus anterior, scalenus medius, and scalenus posterior. Sometimes, a fourth muscle, the scalenus minimus, is present behind the lower portion of the scalenus anterior. These muscles contribute to the stabilization of the vertebral column and aid in head movements and deep inhalation.

To locate the tender areas and fasciculations, the patient can be asked to flex and extend their neck or shrug their shoulders against resistance. This allows you to feel the muscles contracting and relaxing, and any strength difference between the sides could indicate damage. Lateral flexion of the neck allows you to test both sides simultaneously.

To target specific muscles, the patient can rotate their head accordingly. To target the posterior scalene, turn the face toward the arm that is pulling. To target the anterior scalene, turn the face away from the pulling arm. To target the middle scalene, look straight up at the ceiling or slightly toward the pulling arm.

Additionally, the patient can be positioned supine, with their head elevated and rotated to the contralateral side being assessed, and their hands raised above their head. The practitioner can then stand at the head of the table with their fingers on the patient's forehead. To palpate the posterior scalene, push with your fingers into the spot where the collarbone meets the trapezius muscle. Be cautious to avoid the nerve running between the front and middle parts of the muscles.

Anterior scalene palpation: flexing and rotating the head to access the muscle

To palpate the anterior scalene muscle, the patient should be placed in a supine position, with their head elevated and rotated to the side that is to be assessed. The practitioner should stand behind the patient's head. The anterior scalene muscle is then positioned under the distal lateral margin of the SCM, with the middle scalene just behind the SCM.

The patient should then be asked to flex and rotate their head to the opposite side, allowing access to the muscular belly of the anterior scalene. The patient should tuck their chin towards their chest and rotate their head to the side, which will stretch the anterior scalene muscle. The patient's head should be tilted to the left and turned to the right to target the anterior scalene. This movement will also help the practitioner identify any tender points or fasciculatory responses along the muscle.

During palpation, the practitioner should gently strum over the anterior scalene, following it inferiorly as it disappears under the clavicle. The patient may be asked to flex and extend their neck or shrug their shoulders against resistance to contract and relax the muscle, allowing the practitioner to feel the muscle in action.

Palpation is a valuable tool to evaluate, classify, and make a diagnosis. The anterior scalene muscle is particularly important when thoracic outlet syndrome (TOS) is suspected. The muscle's hypertonicity can impinge on the neurovascular bundle, leading to TOS.

Posterior scalene palpation: pushing fingers into the spot where the collarbone meets the trapezius

To palpate the scalene muscles, the patient may be asked to flex and extend their neck or shrug their shoulders against resistance. This allows you to feel the muscles contracting and relaxing, and any strength difference between sides could indicate damage.

The scalene muscles consist of three parts: the anterior (front), medial (middle), and posterior (back). All three parts originate at the side of the neck vertebrae and run to the first or second rib. The scalenes are mostly head pullers, meaning they pull the head from side to side and aid in the flexion, lateral flexion, and rotation of the head.

To palpate the posterior scalene, push your middle finger under the front edge of the trapezius muscle near where it attaches to the collarbone. The trapezius muscle is the bulkier muscle that helps you shrug your shoulders. The posterior scalene is located just above the collarbone (clavicle) and below the front edge of the upper trapezius. Push downward and drag your finger an inch or so toward your neck in a short, straight line parallel to your collarbone.

When palpating the scalenes, it is important to move methodically and perform strokes at multiple points throughout each muscle, instead of focusing on just one point. Use short strokes in either a straight line or small circular motions, both performed with 1-2 fingers.

Frequently asked questions