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Home , Scalene muscles, Serratus anterior muscle, Suboccipital muscles

3 - MM 2014.indd 73 Cervical Bones Cervical AROM Cervical Kinematics Vizniak &Richer Sternocleidomastoid (SCM) Splenius Capitis&Cervicis Levator Scapulae (upperfibers) Anterior &LateralNeck Posterior NeckMuscles Cervical Ligaments Palpation Checklist □ □ □ □ □ □ □ □

Surface anatomy Lymph nodes Thyroid gland & Hyoid bone Submental gland Submandibular gland Masseter/Parotids & TMJ Mandible

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...... Splenius cervicis Levator scapulae Upper trapezius Carotid pulse SCM &mastoid Scalenes/ Suprasternal notch /SC joint 90 88 86 84 82 80 79 78 77 76 75 74 Myofascial References Larynx Posterior Scalene Middle Scalene Anterior Scalene Scalenus Minimus Scalene MuscleGroup Longus Cervicis(colli) Longus Capitis Rectus Capitis Ant. &Lateralis Omohyoid Sternohyoid Thyrohyoid &Sternothyroid □ □ □ □ □ □ □ □ ......

. . . T1 SP &upper ribmotion Spinous processes(C2-C7) Facet joints/ Articular pillars Suboccipitals Semispinalis cerv./cap...... Neck Contents ...... Bony Landmarks ...... Video Demo Video prohealthsys.com 2014-01-04 2:02:10 AM Neck ......

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Neck 2014-01-04 2:02:10 AM Vizniak & Richer & Vizniak fingers between open teeth be able to place three knuckles or TMJ 3 Knuckle or 3-Finger Test: With normal TMJ ROM patient should With normal www.prohealthsys.com www.prohealthsys.com any region in the spine below C2 any region in the spine below Ipsilateral flexion & lateral flexion Left lateral flexion coupled with left rotation Right lateral flexion coupled with right rotation full extension C-spine: TMJ: teeth clenched = rotation, extension C-spine: lateral flexion opening TMJ: limitation of mouth Flexion: tissue stretch Extension: tissue stretch Lateral flexion: tissue stretch Rotation: tissue stretch Early myospasm → muscle/ligament tear Late myospasm → instability Empty → ligament rupture Hard → bone approximation (osteophyte) flexion do not occur at Pure rotation and pure lateral C2-T5 vertebral segments Close packed position Close of restriction Capsular pattern Normal end feel Abnormal end feel Coupled motions • • • on (superior concave (anterior facet of dens (articular facet for dens (mandibular condyle & disc) (mandibular condyle & disc) (mandibular fossa of temporal bone) (mandibular fossa of temporal Muscle Manual | (3 knuckle test) longus capitis, rectus capitis anterior capitis, suboccipitals levator , trapezius, longissimus capitis, scalenes, rectus capitis lateralis splenius, suboccipitals concave articular facets of atlas) on atlas) on convex on ) condyles of occiput) on Flexion ...... 60° Flexion ...... 60°Extension ...... 45°Lateral Flexion ...... 80° Rotation ...... 35-50TMJ mm opening Cervical Kinematics C-spine: slight extension TMJ: mouth closed with teeth not in contact Extension: trapezius, splenius cervicis & capitis, Lateral flexion: splenius capitis & cervicis, Rotation: SCM, longus capitis & coli, rotatores, Flexion: sternocleidomastoid (SCM), longus coli, Atlantoaxial: concave Zygapophyseal: facets are oriented 45° Intervertebral discs: horizontal plane TMJ: convex (occipital Atlanto-occipital joint: convex Gliding (zygapophyseal joints) (zygapophyseal Gliding joint) Pivot (atlantoaxial (intervertebral joints) Fibrocartilaginous (TMJ) Hinge & gliding Resting position Main muscle actions Active range of motion Articular surfaces Joint types: Joint types: 74

Neck 3 - MM Neck 2014.indd 74 3 - MM Neck 2014.indd 75 Tissue Compressed:ipsilateral: Tissue Stretched:contralateral:trapezius(upper), Muscles Activated: Lateral Flexion (45º-60º) Vizniak &Richer Tissue Compressed:anteriorneckmuscles,trachea, Tissue Stretched:trapezius,spleniuscervicis& Muscles Activated: Flexion (50º-70º) Muscles Activated: Rotation (80º-90º) Tissue Compressed: ipsilateral: Tissue Stretched: contralateral:spleniuscervicis& Tissue Compressed:posteriorneckmuscles, Tissue Stretched:anteriorneckmuscles, Muscles Activated: Extension (50º-70º) Introduction statement:“Try andmoveasfarpossible,ifanyoftheactionsormovements z-joints longissimus capitis,SCM,lateralIVD,carotidartery, z-joints longissimus capitis,SCM,lateralIVD,carotidartery, levator scapulae,suboccipitals splenius cervicis&capitis,longissimus esophagus, carotidarteries posterior facetjointcapsule ligament, interspinousposteriorIVD, capitis, longissimussuboccipitals,nuchal splenius, semispinalis,longissimuscapitis anterior; eccentric longus cervicis,capitis,rectuscapitis capitis, suboccipitals; capitis, suboccipitals capitis, suboccipitals; vertebral posterior intervertebraldiscs,facet(z-joints)joints, esophagus, carotidarteries longitudinal ligament,anteriorIVD,trachea, cervicis & capitis, longissimussuboccipitals are painfulpleaseletmeknow, donotanyactionyoufeelwillcausefurtherinjury.”

www.prohealthsys.com ipsilateral: sternocleidomastoid (SCM), ipsilateral: contractionofuppertrapezius, trapezius (upper),splenius ; contralateral: contralateral: ipsilateral: trapezius(upper), spleniuscervicis& trapezius(upper), splenius cervicis& SCM SCM SCM Cervical AROM Cervical Lateral Flexion Extension Rotation Flexion 2014-01-04 2:02:11 AM Neck

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Neck 2014-01-04 2:02:11 AM Vizniak & Richer & Vizniak (no spinous process) anterior view anterior (no vertebral body) Vertebral canal (spinal cord) Vertebral Superior articular facet Facet for anterior arch of C1 Lamina process Transverse foramen Transverse Body Pedicle Superior articular facet Inferior articular process Uncinate process (uncus) Spinous process (bifid) Posterior tubercle Posterior arch Anterior arch Anterior tubercle Lateral mass process Transverse foramen Transverse Articular facet for dens Articular process (superior & inferior) Dens (odontoid process) Spinous process (bifid) Lamina process Transverse Superior articular facet Body Pedicle foramen Transverse Inferior articular facet pillar 10. 1. 2. 3. 4. 5. 6. 7. 8. 9. Articular 6. 7. 8. 9. 10. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 3. 4. 5. www.prohealthsys.com www.prohealthsys.com 10 9 9 lateral view lateral 10 5 6 5 7 6 4 4 4 3 8 9 5 T1 C1 C2 C3 C4 C5 C6 C7 10 3 6 8 7 3 8 7 5 2 2 2 1 1 posterior view posterior Muscle Manual | Typical CervicalTypical C2 - Axis C1 - Atlas 1 10 Cervical Bones 76

Neck 3 - MM Neck 2014.indd 76 3 - MM Neck 2014.indd 77 Vizniak &Richer posterior viewwithvertebral posterior view

lamina &SPsremoved www.prohealthsys.com 9 10 4 3 2 1 12 11 9 8 lateral view C1-C2 Articulation (lateralview) C1-C2 Articulation 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. Cervical Ligaments Cervical Posterior longitudinalligament Tectorial membrane Anterior longitudinalligament Anterior atlantoaxialmembrane Anterior atlanto-occipitalmembrane Nuchal ligament Capsular ligaments(zygapophyseal) Posterior atlantoaxialmembrane Posterior atlanto-occipitalmembrane 7 6 5 Apical ligament Cruciform/cruciateligament Alar ligaments anterior view 2014-01-04 2:02:11 AM Neck

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Neck 2014-01-04 2:02:12 AM 13 Vizniak & Richer & Vizniak 14 Deep 12 Superficial 11 10 6 5 4 3 Trapezius (upper fibers) Trapezius Splenius capitis Splenius cervicis Levator scapulae Rhomboid minor capitis Semispinalis capitis Longissimus capitis Occipitalis www.prohealthsys.com www.prohealthsys.com 2. 3. 4. 5. 6. 7. 8. 9. 1. 13 lateral view 12 10 11 9 8 7 2 Muscle Manual 1 | Rectus capitis posterior minor* Rectus capitis posterior major* Obliquus capitis inferior* Obliquus capitis superior* Interspinalis Suboccipital muscles* Posterior Neck Muscles Neck Posterior 12. 13. 14. 10. 11. 78

Neck 3 - MM Neck 2014.indd 78 3 - MM Neck 2014.indd 79 Vizniak &Richer Superficial How tochecktheintegrityofyourdeep neckflexors:lyingsupine,flexwithchintuckedto~45°, Deep hold for30seconds(nohands)-Canyou dothiswithoutshakingordroppingyourhead?

www.prohealthsys.com 4 13 14 1 2 15 16 5 6 7 Anterior &LateralMuscles 11 8 10 9 2 3 16. 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. Lines indicatemuscleattachments 12 Posterior scalene Middle scalene Thyrohyoid Sternothyroid Sternohyoid Omohyoid Trapezius Sternocleidomastoid Platysma Longus cervicis Longus capitis Rectus capitisanterior Rectus capitislateralis Levator scapulae Scalenus minimus Anterior scalene to thebaseofskull 2014-01-04 2:02:13 AM Neck 9 8 10 16

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Neck 2014-01-04 2:02:13 AM Vizniak & Richer & Vizniak where it can be compressed, trapezius lateral flexion of head www.prohealthsys.com www.prohealthsys.com of clavicle, acromion, spine of scapula of clavicle, 3 extension of head / 1 SPs of C7-T5 bilateral: arm movements stabilization of scapula for levator scapulae lateral of scapula retraction (adduction) elevation & upward rotation of scapula unilateral: C2-C4 spinal accessory (CN XI), ventral rami of scapular arteries transverse cervical & dorsal EOP, nuchal line & nuchal ligament line nuchal EOP, upper: middle: lower: SPs T5-T12 I S A B O N (upper fibers) (upper º of abduction is most active in the last 60º of shoulder flexion & abduction Muscle Manual | Clinical Notes Palpation occurs (requires both upper & lower fibers to activate) edge of SCM; attachments to thoracic vertebrae are sometimes reduced (up to as high as T7); often reduced (up to as high as edge of SCM; attachments to thoracic vertebrae are sometimes separations between the cervical & thoracic portions lower fibers is often clinically divided into: upper fibers, middle fibers & Trapezius and lower fibers contracting together Upward rotation of scapula is caused by upper fibers may contribute to postural fatigue syndrome fibers of The greater occipital passes through the upper (resistance may be applied with non- palpating hand) by asking patient to lift their head & neck potentially contributing to muscle tension headaches in the final 60 desk or working with a mouse (other contributing factors: anterior rotated , large a computer, one-sided sports activities, whiplash) breasts, cradling a phone on one shoulder, HA muscles, tension headache, occipital neuralgia & cervicogenic During shoulder abduction, upward rotation of the scapula Trapezius • blend with posterior Anatomical variation: clavicular insertion may extend to middle of clavicle, or • • • Trapezius • of the deltoid The insertion of trapezius is just superior to the exact origin • the trapezius may become fatigued which With an anterior head carriage & rounded shoulders posture, • 1. Patient prone or seated 2. Place palpating hand over upper trapezius 3. Ask patient to elevate their arm/shoulder 4. Upper trapezius can be further exposed • position & weakness carried in a ‘dropped’ Paralysis of trapezius will cause the ipsilateral shoulder to be • work/posture sitting at Common injuries: Postural Fatigue Syndrome (trapezius myalgia) - repetitive • TMJ disorders, MFTPs in other DDx: trapezius myalgia, articular dysfunction (cervical or thoracic), 80

Neck 3 - MM Neck 2014.indd 80 3 - MM Neck 2014.indd 81 Vizniak &Richer • To increasestretchconsidergrippingsideofchair • • Self Stretch: Paincanextendtoocciputandrarelylower • Intensepainmayreachtemples,backofeye, • Maycause“tensionneckache” • Referpainoverposterolateralneck&mastoid • PrimarylocationsforMFTP arejustabovethe • Middle/lower trapeziusmuscletestingarediscussedintrunk Note: Uppertrapeziusmayalsobetestedbilaterallybyresisting Ipsilateralshoulder • Stabilization • Examiner’s force Seated,headlaterallyflexedtoward, • Patient position in thetrunk&backchapter Stretching ofmiddleandlowerfibersarediscussed trapezius grabthechairwithyourighthand) with ipsilateralhand(ifyouarestretchingtheright with oppositehand Laterally flexheadtooneside&applymildtension molar teethcanbeaccompaniedbydizziness and angleofthejaw process the inferiorangleofscapula superior borderofthescapula&justinferiorto chapter ~75% towardoppositelateralflexion,25%downonshoulder extended fromsidebeingtested shoulder elevation(alsotestslevatorscapulae) Muscle Test Stretch&Strengthen Trigger Point Referral

www.prohealthsys.com rotated away&slightly ♦ Proneneckextension • Shrug • Resistedshoulderelevation • Strengthen Trapezius Stabilize ♦ (upperfibers) 2014-01-04 2:02:13 AM Neck ♦

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Neck 2014-01-04 2:02:14 AM Vizniak & Richer & Vizniak Scalene muscle nd or 2 st www.prohealthsys.com www.prohealthsys.com medial border of scapula (superior part) medial border scapula elevation of lateral flexion of neck extension & (C3, C4, C5) dorsal scapular trapezius (upper fibers) TPs of C1-C4 TPs of I S A B N O in not affected because of its C3-C4 nerve supply in not affected twist & result in increased tissue density in that region of the twist & result in increased tissue density in that region , the Serratus Anterior muscle or a muscle, the Serratus Trapezius levator scapulae to the Trapezius Muscle Manual | Occasionally, fibers may attach to occipital bone or mastoid process or 1 fibers Occasionally, Clinical Notes Palpation • Fibers may merge with the • differentiate fibers of levator scapulae) differentiate of the scapula Place place palpating fingers just above superior angle elevate and depress their scapula on the side you are palpating Levator Scapulae fibers superiorly as they extend to the lateral side of the neck sometimes leads to sensory disturbances (numbness or paresthesia) in dermatomes of this plexus sometimes leads to sensory disturbances (numbness (mainly posterior neck region) hiking), anterior rotated shoulders, whiplash possible neck & shoulder postural asymmetries (shoulder headache, torticollis muscle (do not confuse increased density with MFTP) Levator Scapulae Levator Most of the Levator Scapulae runs deep • Anatomical variation: number of the vertebral attachments may vary (C1-C3) 1. over their lumbar spine (position relaxes trapezius to help Patient seated or prone with their forearm 2. 3. Ask patient to alternately 4. Continue palpating the • spastic contracture of this muscle Due to close relation of levator scapulae with , • “I don’t know” one-sided sports activities, saying ADL: lifting objects, cradling a phone on one shoulder, • to “hold” stress, neck”, common area for many people Common injuries: patient complains of “stiff • MFTPs in other muscles, tension DDx: trapezius myalgia, articular dysfunction (cervical or thoracic), • stresses MFTPs develop secondary to postural stress &/or activity overload • In most brachial plexus lesions the • Fibers in the middle belly of 82

Neck 3 - MM Neck 2014.indd 82 3 - MM Neck 2014.indd 83 • Stabilization • Examiner’s force • Patient position Vizniak &Richer • • Self Stretch: • • • Ipsilateral shoulder 25% pressuredownonscapula 75% towardoppositelateralflexion& slightly extendedtowardsameside Seated, headlaterallyflexed,rotated& right hand) stretching therighttrapeziusgrabchairwithyou with ipsilateralhandtoanchorshoulder(ifyouare To increasestretchconsidergrippingsideofchair ☺) opposite armpit head &applymildtensionwithoppositehand(smell Contralaterally flex,contralaterallyrotate&flex the posteriorshoulder along themedialborderofscapulaandalsooutto refer paintotheangleofneck,withaspilloverzone Both primaryandthesecondarylocationtriggerpoints the scapularattachmentofmuscle Secondary locationfortriggerpointsisjustsuperiorto trapezius muscle) the neck(wheremuscleemergesfromdeepto Primary locationfortriggerpointsisattheangleof Muscle Test Trigger Point Referral Stretch&Strengthen

www.prohealthsys.com • • • Strengthen Prone neckextension Shrug Resisted shoulderelevation Levator Scapulae 75% 25% ♦ ♦ 2014-01-30 6:40:20 AM Neck

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Neck 2014-01-04 2:02:14 AM Vizniak & Richer & Vizniak insertion point splenius cervicis ipsilateral rotation & lateral ipsilateral rotation ipsilateral rotation & lateral extension of head & neck extension of head & neck extension of neck flexion of head & neck portion) www.prohealthsys.com www.prohealthsys.com flexion of neck bilateral: (lower (lower ligament C3-T4 & nuchal SPs of of temporal bone, mastoid process line) (superior nuchal occipital bone unilateral: cervical spinal (dorsal rami) occipital artery longus capitis upper trapezius, semispinalis, upper trapezius, semispinalis, longus cervicis SPs of T3-T6 TPs of C1-C3 (posterior tubercles) unilateral: bilateral: cervical spinal nerves (dorsal rami) occipital artery runs more vertically & is deeper I S A B O N Splenius CapitisSplenius I S A B O N Splenius cervicis semispinalis may only attach to T3 and above, T3 and may only attach to forms a “V” shape on the back of the neck runs obliquely whereas Muscle Manual | Clinical Notes may only be on C1 & C2 vertebrae in some people mouse; strain from cradling a phone on one shoulder, one-sided sports activities, excess stress causing one-sided sports activities, mouse; strain from cradling a phone on one shoulder, upper back tension, whiplash MFTPs in other muscles, tension headache, cervicogenic headache, costothoracic syndrome along fiber direction & have patient extend neck (realize that splenius muscles are deep to trapezius) Splenius CapitisSplenius Cervicis & • Splenius capitis • Splenius capitis • Anatomical variation: splenius capitis • ADL: shoulder check, looking up • a desk or working with Common injuries: repetitive trauma from work/posture sitting at a computer, • DDx: trapezius myalgia, cervical or thoracic subluxation, • Palpation: Patient prone or seated, place palpating fingers 84

Neck 3 - MM Neck 2014.indd 84 3 - MM Neck 2014.indd 85 Upperthoracicspine • Stabilization • Examiner’s force • Patient position Vizniak &Richer Keeptheshoulderloose&DoNOT anchorthe • • Self Stretch: MFTPsaregenerally • direction ofmuscle) toward oppositesidelateralflexion(infiber 75% towardflexion&25%pressure slightly extendedtowardsameside Prone, headlaterallyflexed,rotated& more stretchoflevatorscapulae) shoulder beingstretched(anchoringwillresultin to oneside&applymildtensionwithoppositehand Flex, contralaterallyflex&rotatehead supraorbital region even tothe & onrareoccasions at thetopofhead neck, abovetheear, over theposterior belly &referpain located inthemuscle Muscle Test Trigger Point Referral Stretch&Strengthen

www.prohealthsys.com ♦ ♦ Splenius Capitis &Cervicis Splenius Capitis stabilize Neckextensionwithhead • Proneneckextension • Strengthen ipsilaterally rotated ♦ ♦ 2014-01-04 2:02:15 AM Neck

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Neck (dorsal rami of C1) of rami (dorsal nerve Suboccipital 2014-01-04 2:02:15 AM Vizniak & Richer & Vizniak inferior superior Obliquus capitis Obliquus capitis Obliquus capitis Action Nerve flexion of head flexion of head rotation of head rotation & lateral rotation & lateral extension, ipsilateral extension, ipsilateral lateral flexion of head extension & ipsilateral extension & ipsilateral www.prohealthsys.com www.prohealthsys.com Insertion lateral portion of medial portion of inferior nuchal line inferior nuchal line line (occipital bone) below inferior nuchal Origin of atlas (C1) TP of atlas (C1) of atlas TP posterior tubercle spine of axis (C2) spine of axis (C2) of atlas (C1) TP not powerful contractions - no specific muscle test due to small muscle movement Note: The main function of the suboccipital muscles is postural stabilization of the head, The main function of the suboccipital muscles Note: Muscle Manual | Muscle Rectus capitis Rectus capitis posterior major Rectus capitis Suboccipital Muscles Suboccipital posterior minor superior posterior major inferior posterior minor Rectus capitis Obliquus capitis Rectus capitis Obliquus capitis 86

Neck 3 - MM Neck 2014.indd 86 3 - MM Neck 2014.indd 87 Anatomicalvariation: • Vizniak &Richer NotethatMFTPsinthesuboccipitalmusclesare • • • Commoninjuries:cervicalhyperflexion&hyperextension(whiplash),verycommonlychronicpoor • Studieshaveshownthatthereisaveryhighspindledensityinthesuboccipitalmuscles;whichlinked • Myospasmofthesuboccipitalsmaybeassociatedwithmuscletensionheadaches • Obliquuscapitisinferiori • It maybedifficulttodistinguishindividualmusclebellies Askpatienttoslightlyextendhead¬emuscle 5. Palpategentlythroughthelayersoftrapezius,splenius 4. Locatesuperiornuchalline&spinousprocessofC2; 3. Cradlethepatient’s skullinboth hands 2. Patientsupine 1. • • • Self Stretch: Occasionally • sternocleidomastoid, andthespleniusmuscles often accompaniedbyMFTPsinthetrapezius, time or extensionoftheassociatedjointforextendedperiods MFTPs typicallyoccurwhenapersonismaintainingflexion forehead area is oftendescribedasbeingfromtheocciputtoeyeand MFTPs referheadpainthatmaybedifficulttolocalize; posture orstresscancausecontractureofthemuscletissue,resultinginmyospasm position [proprioception]andmovementsofcraneovertebraljoints”(Kulkarnietal.2001) to theabilityfacilitatefinemotormovement,indicatingthattheirprimaryfunctionisas“sensorsofjoint atlanto-occipital joint(theterm‘capitis’ ismisleading) Fibersofthe • Rectuscapitusposteriormajor • contraction capitis, andsemispinaliscapitis cradle skullwithpalms&palpatetwoflatfingertips suboccipital muscles flexion inordertoeffectively stretch the it mustbedistinguishedfromcervical upper cervicalspine&occipitalbone; Capital flexionisanactionbetweenthe head posteriorly Consider placingfingersonchintopush your chinin” Capital flexion-chinretractionor“tuck Palpation Trigger Point Referral ClinicalNotes Stretch&Strengthen cord &mayhelppullitoutofthewayduringanteriortranslationoccipitalboneonatlas

www.prohealthsys.com rectus capitisposteriorminor rectus capitusposteriorminor s theonlysuboccipitalmusclethatdoesnotattachtoheadorcross maysplitintotwomusclebellies may alsoattachtotheduramatersuroundingspinal may beabsent Neutral Suboccipital Muscles ♦ ♦ Stretch 2014-01-04 2:02:15 AM Neck

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Neck 2014-01-04 2:02:15 AM Vizniak & Richer & Vizniak trapezius capital extension) medial portion of clavicle portion of medial neck flexion & capital extension neck flexion & capital manubrium of sternum manubrium ventral rami of C2, C3 www.prohealthsys.com www.prohealthsys.com longus capitis, longus cervicis mastoid process of temporal bone of temporal bone mastoid process to contralateral side rotation of head to ipsilateral side lateral flexion bilateral action: (CN XI) motor: spinal accessory sensory: arteries occipital & superior thyroid sternal head: sternal head: clavicular blend with posterior lateral edge of I S A B N O = contracture or spasm of SCM Torticollis Muscle Manual | rotated to one side (‘look toward me & away’) Place palpating fingers along the muscle fiber direction & ask patient to flex or rotate their neck Clinical Notes Palpation 2. 3. Note contraction of the muscle tissue Realize that platysma is superficial to SCM 1. head Patient supine, seated or standing with The specific action of SCM is flexion of the cervical spine & head, and extension of the upper cervical The specific action of SCM is flexion of the cervical l flexion with spine (C1-C3) & at the atlanto-occipital joint (C0-C1) (cervica of respiration” , therefore SCM is considered an “ or even unconsciousness, therefore palpation & drop in blood pressure resulting in feeling light-headed treatment in the area should be performed with caution may be damaged during the hyperflexion muscles may be torn. In addition, the posterior neck muscles phase tennis, lifting head from pillow and severe injury; usually driver will contralaterally rotate their neck to look into their rear view mirror just prior to rear impact - suboccipitals, tension headache, torticollis Sternocleidomastoid (SCM) • Anatomical variation: upper medial fibers may • • also theoretically help elevate the anterior Because SCM attaches to the medial clavicle & sternum it may • over the carotid sinus may cause a Medial to the SCM lies the carotid sinus & carotid arteries; pressure • the SCM & other anterior neck During whiplash, where the head may be thrown into hyperextension, • ADL: turning head while doing a shoulder check, watching • Common injuries: hyperextension (whiplash): frequent • DDx: articular dysfunction (cervical or thoracic), MFTPs in 88

Neck 3 - MM Neck 2014.indd 88 3 - MM Neck 2014.indd 89 Sternum(havepatientcoverchestwith • Stabilization Withhandonlateralfrontalbone,force • Examiner’s force • Patient position Vizniak &Richer Referralpainfromtheupperpartof • Referredpainfromthesetriggerpointscan • Primaryreferralzonesareoverthemastoid • Trigger pointscanbelocatedthroughout • free hand) following anatomicalarcofmuscleaction is posteriorandslightlylateral,inacurve & rotatedtocontralateralside Patient seatedorsupinewithneckflexed problems) SCM cancausedisequillibrium(balance dysfunction syndrome cervicocephalalgia andmyofascialpain- be misdiagnosedastensionheadache, process &supraorbitalregionsoftheface the entiremusclebelly Muscle Test Trigger Point Referral Stretch&Strengthen

www.prohealthsys.com Sternocleidomastoid (SCM) Sternocleidomastoid Supine neckcurlswithchinout • Strengthen extend &rotatenecktocontralateralside Self Stretch2:extendlowerneck&flexupperneck, to contralateralside Self Stretch1:extend,contralaterallyflex&rotateneck 1 ♦ ♦ ♦ ♦ stabilize 2 2014-01-04 2:02:16 AM Neck ♦ ♦

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Neck 2014-01-04 2:02:16 AM Vizniak & Richer & Vizniak facial nerve (CN VII) mastoid notch of mastoid notch digastric fossa of internal digastric fossa trigeminal nerve (CN V) by a pulley tendon) temporal bone mandible greater horn) www.prohealthsys.com www.prohealthsys.com branches off external carotid artery branches off posterior belly: meet & attach (both bellies body of hyoid elevation of hyoid bone (open mouth) depression of mandible infrahyoid action stabilize hyoid bone for of mandible) lateral pterygoid (depression posterior belly: anterior belly: anterior belly: septum) mylohyoid) styloid process of temporal bone lateral margin of hyoid body (base of elevation of hyoid (during swallowing) stabilizes hyoid bone for infrahyoid action facial nerve (CN VII) facial & occipital artery lingual artery inner surface of mandible (mental spines) body of hyoid (paired muscles separated by elevation of hyoid bone depression of mandible (works with hypoglossal nerve (CN XII) I I S B A O N A B O N Digastric Stylohyoid I B A O N Manual | Suprahyoid Muscles Suprahyoid 90

Neck 3 - MM Neck 2014.indd 90 3 - MM Neck 2014.indd 91 Vizniak &Richer Keepjawclosed,extendhead&neck • Self Stretch: ADL:themainfunctionofallhyoidmusclesistoassistwithactionswallowing&speech • Thereare4suprahyoidmuscle( • Stylohyoid • • Digastricistheprimemoverfordepressionofmandible • Geniohyoid • Anatomicalvariation:fibersoftheright&left • . Notecontractionofthemuscletissue 4. Askpatienttoswalloworpushtongue againstroofofmouthor 3. 2. Patientsupine,seatedorstanding 1. difficult todistinguishfromothersuprahyoidmuscles;rememberthe attachment points&actionstohelpdifferentiate individualmuscles All suprahyoidmusclesarepalpatedinasimilarway, butmaybe When themouthisclosedsuprahyoid&infrahyoidmusclescanweaklyassistwithneckflexion perform primaryactionoftheindividualmuscle & superiortohyoidbone Place palpatingfingersalongthemusclefiberdirectionunderchin Palpation ClinicalNotes Stretch&Strengthen

sharesitspointoforiginwith mayalsodrawthehyoidboneanteriorly&thushelpprotrudetongue www.prohealthsys.com digastric, mylohyoid,stylohyoid&geniohyoid styloglossus geniohyoid Mylohyoid N O B A I & stylopharyngeus inferior alveolar&lingualarteries trigeminal nerve(CNV-mandibular depression ofmandiblewhenhyoidisfixed elevation ofhyoidbone(raisesfloor along midlineatmylohyoidraphe body ofhyoid(anteriorsurface) inner surfaceofmandible(mylohyoidline) division, V3) mouth forswallowing) mayblendtogether Suprahyoid Muscles ) 2014-01-04 2:02:16 AM Neck

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Neck 2014-01-04 2:02:17 AM Vizniak & Richer & Vizniak ) are important for the www.prohealthsys.com www.prohealthsys.com Patient supine, seated or standing Place palpating fingers along the muscle fiber direction just inferior to thyroid cartilage & superior to sternum; then ask patient to swallow May be difficult to distinguish from other Patient supine, seated or standing Patient supine, seated or along the muscle fiber Place palpating fingers bone & superior to direction just inferior to hyoid patient to swallow thyroid cartilage; then ask May be difficult to distinguish from other infrahyoid muscles May be difficult to distinguish from 1. 2. thyroid cartilage (oblique line) depression of thyroid cartilage acts eccentrically with suprahyoid muscles to provide them a stable base ansa cervicalis (C1, C2, C3) inferior & superior thyroid arteries manubrium of sternum (posterior aspect) 1. (oblique line) (oblique line) thyroid cartilage bone body of hyoid of hyoid bone depression thyroid cartilage (larynx) elevation of C1 (via CN XII) arteries inferior & superior thyroid 2. I I P A B P O N B A N O Sternothyroid Thyrohyoid sternohyoid, sternothyroid, thyrohyoid & omohyoid is transmitted by the thyrohyoid membrane & muscle to result in depression of is transmitted by the thyrohyoid membrane & muscle is innervated by fibers from C1 which have piggybacked onto the hypoglossal nerve (CN is innervated by fibers from C1 which have piggybacked Manual | Clinical Notes actions that occur during swallowing, chewing & speech or cheering) XII) and subsequently jump off that nerve twice: once to supply this muscle, and a second time in the XII) and subsequently jump off floor of the mouth to supply the geniohyoid the hyoid bone & larynx flexion The infrahyoid muscles also assist very weakly with neck Thyrohyoid Sternothyroid & • Common injuries: infra & suprahyoid muscles may be damaged with prolonged vocal straining (yelling • ADL: the infrahyoid muscles ( • to the hyoid bone Sternothyroid is the only “hyoid” muscle that does not directly attach • • The thyrohyoid • The action of 92

Neck 3 - MM Neck 2014.indd 92 3 - MM Neck 2014.indd 93 . Notecontractionofthemuscletissue 4. Askpatienttoswallow 3. 2. Patientsupine,seatedorstanding 1. Vizniak &Richer To stretchmuscleusesameactionassuprahyoidmuscles(neckextensionwithjawclosed-seepage91) • • ADL: The infrahyoidmuscles( • Thecarotidsinus(whichhelpscontrolbloodpressure)islocatedjustlateraltothesternohyoid,assuch • Anatomicalvariation:occasionallythe • attachment points&actionstohelpdifferentiate from otherinfrahyoidmuscles;rememberthe similar way, butmaybedifficulttodistinguish superior tothesternum fiber directionjustinferiortohyoidbone& Place palpatingfingersalongthemuscle The infrahyoidmusclesalsoassistveryweaklywithneckflexion actions thatoccurduringswallowing,chewing&speech patients) physical medicineproceduresperformedinthisareashouldbedonewithcaution(especiallyelderly clavicle Palpation All infrahyoidmusclesarepalpatedina ClinicalNotes

individual muscles www.prohealthsys.com sternohyoid, sternothyroid,thyrohyoid&omohyoid sternohyoid N O B A S I omohyoid, thyrohyoid,sternothyroid inferior &superiorthyroidarteries ansa cervicalis(C1,C2,C3) acts eccentricallywithsuprahyoidmusclesto depression ofhyoid&larynx body ofhyoid manubrium &sternoclavicularjoint may originatefromtheposterioraspectofmedial provide themastablebase (posterior aspectofboth) Sternohyoid ) areimportantforthe 2014-01-04 2:02:17 AM Neck

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Neck 2014-01-04 2:02:17 AM Vizniak & Richer & Vizniak ) are important for the (lateral to bone (lateral hyoid superior scapular border superior scapular www.prohealthsys.com www.prohealthsys.com to the clavicle by a pulley tendon) to the clavicle muscles to eccentrically with suprahyoid provide them a stable base) sternohyoid) sternohyoid) notch) (medial to suprascapular inferior & superior thyroid arteries inferior & superior thyroid (both bellies meet & are held loosely meet & are held loosely clavicle (both bellies & larynx (acts depression of hyoid bone ansa cervicalis (C1, C2, C3) superior belly: superior inferior belly: I B A O N sternohyoid, sternothyroid, thyrohyoid & omohyoid as such physical medicine procedures in this area should be performed with caution as such physical medicine procedures in this area should also lies over the middle cervical , superficial to the jugular vein, as such it can help also lies over the middle , superficial to Muscle Manual | Clinical Notes Palpation to hold open the internal jugular vein & may help increase the return of blood flow from the head to the to hold open the internal jugular vein & may help increase inferior vena cava and temporal regions mandibular, supraclavicular, neck, arm, and hand, and in the scapular, the shoulder, (especially with elderly patients) actions that occur during swallowing, chewing & speech the omohyoid, Superior belly Place palpating fingers along the muscle fiber direction just inferior to hyoid bone Ask patient to swallow Inferior Belly Place palpating fingers along the muscle fiber direction just lateral to SCM & superior to clavicle (note scalene fiber direction is more vertical) Omohyoid • There are also documented cases of a omohyoideus myofascial pain syndrome that may cause pain in • Omohyoid • the muscle so slide back & forth The pulley of attachment of the omohyoid at the clavicle allows • just lateral to the superior belly of The carotid sinus (which helps control blood pressure) is located • ADL: the infrahyoid muscles ( May be difficult to distinguish from other infrahyoid muscles 1. Patient supine, seated or standing 2. 3. 4. 5. Ask patient to swallow 6. Note contraction of the muscle tissue 94

Neck 3 - MM Neck 2014.indd 94 3 - MM Neck 2014.indd 95 temporal bone Vizniak &Richer 5. 4. 3. PalpatethetransverseprocessofC1 (posteriortoramusof 2. Patientseatedorsupine 1. Note contractionofthemuscletissue(difficult) Ask patienttolaterallyflexheadthesame side above transverseprocessofC1) Gently moveyourpalpatingfingersuperior anddeep(just mandible &anteriortomastoidprocess) Palpation

www.prohealthsys.com occipital bone Rectus Anterior&Lateralis Capitis Rectus Lateralis Capitis Rectus Anterior Capitis N O N O A A B B P I I cervical spinalnerves lateral flexionofhead occipital bone(jugularprocess) atlas (C1)(superiorsurfaceof TP) to bepalpated Rectus capitisanteriormuscleistoodeep cervical spinalnerves flexion ofhead foramen magnum) occipital bone(basilarpartanteriorto atlas (C1)(anteriorbaseof TP) vertebral &occipitalarteries (ventral ramiC1-C2) (ventral ramiC1-C2) 2014-01-04 2:02:18 AM Neck

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Neck 2014-01-04 2:02:18 AM Vizniak & Richer & Vizniak anterior to foramen magnum) anterior to foramen C1-C3) ascending pharyngeal arteries SCM, rectus capitis anterior (basilar portion - (basilar portion occipital bone head & neck flexion of neck lateral flexion of head & rami cervical spinal nerves (ventral & inferior thyroid, vertebral (anterior tubercles) C3-C5 (anterior TPs of I S A B N O www.prohealthsys.com www.prohealthsys.com curls with chin tucked in Strengthen • Supine neck may also originate from C6 extend head & neck stretch on supra & infrahyoid muscles is reduced Self Stretch: • Open jaw open, • By opening jaw bone occipital may be injured or strained in whiplash injuries (cervical hyperextension) may be injured or strained in whiplash injuries (cervical Muscle Manual | Stretch & Strengthen Clinical Notes Palpation temporal bone temporal Place palpating fingers just medial to SCM (upper mid belly) & gently press into anterolateral cervical Place palpating fingers just medial to SCM (upper mid spine engage longus capitis Ask patient to patient to flex the neck as you resist to Longus CapitisLongus • on next page) Patient supine (same position as longus cervicis - see image • • • Note contraction of the muscle tissue palpation is contraindicated The carotid artery runs near the site of palpation, bilateral CAUTION: • Longus capitis • Anatomical variation: longus capitis 96

Neck 3 - MM Neck 2014.indd 96 3 - MM Neck 2014.indd 97 Vizniak &Richer Notecontractionofthemuscle 4. 3. 2. Patientsupine 1. Stretch&strengthen • Prevertebralmuscleinclude • Commoninjuries:Longuscervicis • ADL:longuscervicis • Somecliniciansdivide • CAUTION: The carotidarteryruns near thesiteofpalpation,bilateral tissue longus colli neck asyouresisttoengage Ask patienttoflexthe cervical spine gently pressintoanterolateral medial toSCM(midbelly)& Place palpatingfingersjust damage tothismusclemaypresentverysimilarasorethroat neck duringcoughing,sneezing,swallowing&talking fibers &medial palpation iscontraindicated Palpation ClinicalNotes

www.prohealthsys.com , alsoknownas arethesameas longus cervicis longus colli,capitis,rectuscapitisanterior&lateralis maybedamagedduringwhiplash(cervicalhyperextensioninjury), longuscolli into3anatomicalparts;superiorobliquefibers,inferioroblique longus capitis , isastrongflexoroftheneck&alsostabilization (seepage96) Longus Cervicis (colli) Longus Cervicis N O B A S I SCM, longuscapitis inferior thyroid,vertebral& cervical spinalnerves(ventralrami rotation ofneck(weakaction) flexion &lateralofneck TPs C1-C6 anterior vertebralbodies& lower anteriorvertebralbodies& ascending pharyngealarteries C2-C6) TPs ofC3-T3 2014-01-04 2:02:18 AM Neck

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Neck 2014-01-04 2:02:18 AM Vizniak & Richer & Vizniak 2→7 middle 3→6 anterior 5→7 posterior TPs of cervical vertebrae TPs of cervical Scalene Origination Points Scalene Origination The scalenes originate from the The scalenes measurements (36˝, 27˝, 57˝ ☺) measurements (36˝, 27˝, 57˝ Which corresponds to your “ideal” Which corresponds to your Differential Diagnosis • Articular dysfunctions (cervical or thoracic) • MFTPs in other cervical muscles • • Carpal tunnel syndrome www.prohealthsys.com www.prohealthsys.com stabilize 1 2 3 4 Muscle Manual | Posterior Scalene Scalenus minimus Anterior scalene Middle scalene Common Injuries/DDx Palpation flexed without tucking of the chin (moving patient into extension) breathing, instead of using abdomen and diaphragm; often associated with head forward posture & hunched shoulders; leading to chronic tension in the 2. 3. 4. 1. Scalene Muscles Introduction Muscles Scalene Patient position • Supine or seated with arms at their side, neck Examiner’s force • thumb & palm pushing down on forehead Finger, Stabilization • Over superior sternum or shoulder Consider resisted lateral flexion to test scalene muscles as well (all tests also recruit synergist muscles) Common Injuries Causes • Cradling a phone on one shoulder • Poor ergonomics at work station • Overuse syndrome, COPD • Brachial plexus compression • Whiplash • Thoracic outlet syndrome • Prolonged anxiety tends to cause upper chest 98

Neck 3 - MM Neck 2014.indd 98 3 - MM Neck 2014.indd 99 Whenscaleneminimusis • Posteriorreferralpattern • Lateralreferralpattern • Anteriorreferralpatternconsistsofpaininthepectoralregion(patternoftenspreadsouttwoinferior • MFTPscausereferralpatternsthattravelanteriorly, laterallyandposteriorly • Vizniak &Richer syndrome may alsobeassociatedwiththoracicoutlet & muscleweaknessintheupperextremity & resulting insymptomsofnumbness,tingling cause compressionofthebrachialplexus Tightness orcontractureofthescalenesmay Cervicalribs(~5-10%ofpopulation)may • Scalenusminimus,whenpresent,mayalso • ~1%ofthepopulationmayhavea • ~33%ofpopulationhavebrachialplexus • ~66%ofpopulationplexuspassesbetween • anatomical variationsthatcanoccur: & middlescalenes;howevertherearemany brachial plexuspassesbetweentheanterior that suppliestheupperextremity. Usuallythe The brachialplexusisanetworkofnerves tuberosity ofthehumerus occur aroundthedeltoid present, referralpaincan interscapular region border ofscapulaandthe towards themedial extends downback anterior &middlescalene 2 of theforearmto1 radiates downradialside projections); commonformiddle&posteriorscalene also influencescalenefunction symptoms play aroleinthedevelopmentofclinical pierces throughtheanteriorscalene subclavian arterythatpassesbehindor roots thatpenetratetheanteriorscalene anterior &middlescalene nd Trigger Point Referral Scalenes & Brachial PlexusScalenes &Brachial phalanges;commonfor

www.prohealthsys.com st & ♦ Scalene Muscles Introduction 2014-01-04 2:02:19 AM Neck ♦

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Neck 2014-01-04 2:02:19 AM Vizniak & Richer & Vizniak (weak action) rib & superior pleura of st (named after its insertion on the pleural lung (if neck is stabilized) lung and/or supraplural membrane of rib and/or supraplural st anterior & middle scalene 1 flexion of neck flexion & lateral rotation of neck contralateral elevation of 1 plexus) variable (cervical & brachial (anterior tubercles) (anterior TPs C6-C7 www.prohealthsys.com www.prohealthsys.com I S A B N O is present bilaterally in ~28%-46% of the population & is present bilaterally in ~28%-46% of the population & scalenus pleuralis muscle may be quite strong & well developed is also known as great care Muscle Manual | Clinical Notes carotid artery (superiorly) & Palpation Place palpating fingers along fiber direction between SCM & trapezius just superior to clavicle further expose muscle belly tissue brachial plexus (mid belly), as unilaterally in ~45%-75% of people membrane at the apex of the lung) very close to both the common CAUTION: scalene muscles are Scalenus Minimus Scalenus such palpation must be done with 1. Patient supine or seated 2. 3. Have patient inhale deeply to 4. Note contraction of muscle • When present, scalenus minimus • Scalenus minimus • Anatomical variation: scalenus minimus 100

Neck 3 - MM Neck 2014.indd 100 3 - MM Neck 2014.indd 101 Vizniak &Richer Considerbreathingouttodepresschest& • Applymildpressurewithoppositehand • • Self Stretch: Commoninjuries:whiplash(hyperextension&hyperflexioninjuryoftheneck) • Compressiononthebrachialplexusbyscalenesoftencontributestothoracicoutletsyndrome(TOS) • Thebrachialplexus&subclavianarteryusuallypassbetweenthe • Anteriorscalene • . Justlateraltoanteriorscaleneismiddle scalene 6. Anteriorscalenecanalsobepalpated inferiorlybehindtheclavicle 5. Askpatienttoinhaledeeplyfurther exposethemusclebelly 4. 3. Rotatethepatient’s headslightly tocontralateralsidebeingpalpated 2. Patientsupineorseated 1. CAUTION: scalenemusclesareveryclosetoboththecommoncarotidartery(superiorly) &brachialplexus increase stretch Contralaterally flex&ipsilaterallyrotate neck (~1%) thesubclavianarterywillalsopassthrough in ~30%ofcasesbranchesthebrachialplexusmaypassdirectlythrough Place palpatingfingerjustlateraltoSCM&superiorclavicle (moves SCMoutoftheway) Palpation ClinicalNotes Stretch&Strengthen

www.prohealthsys.com isconsideredanaccessorymuscleofrespiration (mid belly),palpationmustbedonewithgreatcare anterior scalene O N A B S I middle scalene&scalenusminimus ) inferior thyroidartery(branchof cervical spinalnerves elevation of1 flexion &ipsilateralofneck 1 TPs ofC3-C6(anteriortubercles) contralateral rotationofneck st rib(scalenetubercle) middle Anterior Scalene and anteriorscalenes st rib(ifneckisstabilized) anterior scalene (ventral ramiC3-C6) Neck 2014-01-04 2:02:20 AM (weak action)

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Neck 2014-01-04 2:02:20 AM Vizniak & Richer & Vizniak rib (if neck is fixed) and anterior scalene st middle (behind anterior scalene) rib (behind anterior st www.prohealthsys.com www.prohealthsys.com 1 flexion of neck flexion & ipsilateral 1 elevation of cervical spinal nerves (ventral rami C3-C8) inferior thyroid artery minimus anterior scalene & scalenus (posterior tubercle) (posterior TPs C2-C7 I S A B N O is considered an accessory muscle of respiration is considered an accessory Muscle Manual | (mid belly), palpation must be done with great care common carotid artery (superiorly) & brachial plexus CAUTION: scalene muscles are very close to both the muscles are scalene CAUTION: Stretch & Strengthen Clinical Notes Palpation Contralaterally flex neck increase stretch being palpated (moves SCM out of the way) clavicle Place palpating finger just lateral to SCM & superior to Middle Scalene Self Stretch: • • Apply mild pressure with opposite hand • Consider breathing out to depress chest & • Middle scalene • usually pass between the The brachial plexus & 1. Patient supine or seated 2. slightly to opposite side Contralaterally rotate the patients head 3. 4. expose the muscle belly Ask patient to inhale deeply to further 5. behind the clavicle inferiorly, Middle scalene can also be palpated 6. scalene Just medial to middle scalene is anterior • to thoracic outlet syndrome (TOS) Compression on the brachial plexus by the scalenes often contributes • neck) Common injuries: whiplash (hyperextension & hyperflexion injury of the 102

Neck 3 - MM Neck 2014.indd 102 3 - MM Neck 2014.indd 103 Vizniak &Richer Anatomicalvariation:occasionallytheposteriorscalenemayattachtolateralborderof3 • . Posteriorscalenemaybedifferentiated from 4. Havepatientinhaledeeplytofurtherexpose 3. Locatemiddlescalene&levatorscapulae 2. Patientsupineorseated 1. Commoninjuries:whiplash(hyperextension&hyperflexioninjuryoftheneck) • Posteriorscaleneisconsideredanaccessorymuscleofrespiration • Considerbreathingouttodepresschest& • Applymildpressurewithoppositehand • • Self Stretch: common carotidartery(superiorly)&brachialplexus(mid to alternatelyelevate&depressthescapula levator scapulae/trapeziusbyaskingthepatient muscle belly palpating fingerpadbetweentomuscles increase stretch Laterally flex&contralaterallyrotateneck CAUTION: scalenemusclesareveryclosetoboththe belly), assuchpalpationmustbedonewithgreatcare Palpation ClinicalNotes Stretch&Strengthen

www.prohealthsys.com , place N O B A S I anterior &middlescalene inferior thyroidartery(branchof cervical spinalnerves elevation of2 ipsilateral lateralflexionofneck 2 TPs ofC5-C7(posteriortubercles) nd thyrocervical trunk) rib Posterior Scalene nd rib(ifneckisfixed) (ventralramiC6-C8) Neck 2014-01-04 2:02:20 AM

| 103 rd rib

Neck 2014-01-04 2:02:21 AM Vizniak & Richer & Vizniak 5 6 View Posterior View Superior 6 3 www.prohealthsys.com www.prohealthsys.com Arytenoideus Cricrothyroid Thyrohyoid Sternothyroid 5 4 6. 7. 8. 9. 2 7 3 9 1 4 View 7 8 Thyroepidglotticus Thyroarytenoid Lateral cricoarytenoid Posterior cricoarytenoid Aryepiglotticus Right Lateral Right Lateral 1. 2. 3. 4. 5. 5 6 View Anterior Muscle Manual | Larynx 104

Neck 3 - MM Neck 2014.indd 104 3 - MM Neck 2014.indd 105 Vizniak &Richer thyroepidglotticus larynx -oblique aryepiglotticus thyroarytenoid cricoarytenoid cricoarytenoid arytenoideus arytenoideus cricrothyroid posterior Muscle lateral

www.prohealthsys.com posterior surface& posterior aspectof laminae ofthyroid muscular process muscular process apex ofarytenoid surface ofthyroid surface between aspect ofcricoid lateral aspectof cricoid cartilage lower posterior lower posterior arch ofcricoid anterolateral of arytenoid of arytenoid cartilage cartilage cartilage cartilage cartilage cartilage rgnInsertion Origin muscular processof muscular processof opposite arytenoid arytenoid cartilage arytenoid cartilage arytenoid cartilage vocal processof thyroid cartilage lower laminarof lateral borderof lateral borderof superior poleof Inferior cornu& opposite side surfaces of epiglottis epiglottis cartilage cartilage aids closureofadditus aids closureofadditus cartilages (closesrima vocal cordsbymedial cartilage (closesrima cartilage (closesrima of arytenoidcartilage rotation &protraction (opens rimaglottidis) abducts &latrotates vocal cordsbytilting lengthens &tenses adducts &medially shortens &relaxes arytenoid cartilage adducts arytenoid adducts arytenoid rotates arytenoid thyroid cartilage glottidis ) forwards of larynx to larynx glottidis) glottidis) cinNerve Action Neck Larynx 2014-01-04 2:02:21 AM

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vagus nerve (CN X) - recurrent laryngeal branch

Neck 2014-01-04 2:02:22 AM Vizniak & Richer & Vizniak www.prohealthsys.com www.prohealthsys.com Physiol 102: 601-609, 2007. Physiol 102: Australia, Adelaide, of The University Safety Research, Automotive Centre for 2006 http://casr.adelaide.edu.au/reports/CASR016.pdf Publishers Inc. 1992. Aspen Application, Ebury House, 2000. Therapy, Physical Medicine, Sports and Livingston, 1996. lesions. 1996. ed., Butterworth-Heinemann, Williams & Wilkins. Livingstone. 1979. 1995. Appleton-Century-Crofts, 1976. Livingstone, 1970. Baltimore, 2003, Williams & Wilkins. Davis. Philadelphia, 1990, FA Louis, 1997, Mosby. Lange. Saunders Co., 1984. Livingstone, 1992. Williams & Wilkins, 1993. Baltimore, 1 Upper Body. Manual. 2nd ed. Volume Williams & Wilkins, 1993. Baltimore, 2 Lower Body. Manual. 2nd ed. Volume Clinical Theory and A. 1992: Myofascial manipulation - Cantu, RL,& Grodin, 10 review.” a comprehensive “Whiplash associated disorders: Anderson, RWG. 11 12 Biology, All Students of Human of the Moving Body : For Atlas Cash, M. Pocket 13 Churchill- Touch, Through Assessment and Diagnosis Palpation Skills L. Chaitow, 14 of soft tissue 1. Diagnosis Vol. of orthopaedic medicine. Textbook Cyriax J. 15 Medicine, 3rd Illustrated Manual of Orthopedic Cyriax, JH. & Cyriax, PJ. Cyriax’s 16 2008, 5 minute clinical consult, Baltimore, Dambro MR, Griffith JA: Griffith’s 17 DJ: Essential orthopaedics and trauma, Edinburgh, 1989, Churchill Dandy 18 Saunders Co., I.I.: Fundamentals of Orthopaedics. Philadelphia, W.B. Gartland, 19 PE. Principles of Manual Medicine, 2nd ed., Williams & Willkins, Greenman, 20 York, S.: Physical Examination of the Spine and Extremities. New Hoppenfeld, 21 Churchill York, The Physiology of Joints, vol. 1: . New I.A.: Kapandji, 22 and function, ed 4, GE: Muscles testing Wadsworth HO, Kendall FP, Kendall 23 2, Therapeutic exercise; foundations and techniques, ed C, Colby LA: Kisner 24 ed 3, St and sports physical therapy, AJ: Orthopedic TG, Nitz TR, MePoil Malone 25 Appleton & JH: Neuroanatomy text and atlas, ed 2, Stamford, Conn, 1996, Martin 26 LH, et al: Clinical anatomy principles, St Louis, 1996, Mosby. Mathers 27 MB: Sports medicine secrets, Philadelphia, 1994, Hanley & Belfus. Mellion 28 Athletes, 4th ed. Philadelphia. W.B. of Injuries to Treatment O’Donoghue, D.H.: 29 Churchill York, Assessment and Rehabilitation. New Reid, D.C.: Sports Injury 30 Point Trigger The TG., & Simons, LS. Myofascial Pain and Dysfunction: Travell, 31 Point Trigger The TG., & Simons, LS. Myofascial Pain and Dysfunction: Travell, Muscle Manual | Vizniak, NA. Gross Anatomy: Human Cadaver Dissections. 1999-2015 Anatomy: Human Cadaver Gross NA. Vizniak, J Orthop Sports Phys in macaque and human.” of the cervical spine for rotation reply 146-8. 33(3): 144-6; author 2003 Mar; Ther. Clin. Anatomical variations and their clinical significance.” the brachial plexus: Anat. 10:250-252, 1997. practice. J adult human subjects: implications for clinical of scalenus anterior in August; 183(Pt 1): 165–167. Anat. 1993 Sternocleidomastoids.” 2002, American Massage Therapy Association muscles and Forward Head points in the Suboccipital Pareja JA. “Trigger The Journal of Head and Face Headache”. Headache: Tension-type Posture in Pain. 2000; 46 (3): 456-460. India. 2001; 49: 355-9. Suboccipital Muscles of Human Fetuses. Neurol 18, issue 08. Apr.3, Chiropractic: 2000; Rectus Capitis Posterior Muscles”. Aspects of Supernumerary and Clinical Anatomy: 2005 Jul; 18(5): 373-5. Clinical Appl agonist/antagonist activity” J induces task-dependent changes in cervical References 1 2. of the scalene muscles “Actions JV. SM, Heiss DG, Chidley Yoder Buford JA, 2 and C.; Guha, Somes C. “Scalene muscles G.; Bennett, John D. Walter Harry, 3 insertion Anatomical variation of the D. S; and Shanahan, J; Miller, Wayman, 4 Scalenes & The Points In Trigger Of Davis, Clair (DC). “Self-Treatment 5 RD, Alonso-Blanco C, Cuadrado ML, Gerwin C, Fernandez-de-las-Penas 6 Chandy MJ, Babu KS. “Quantitative Study of Muscle Spindles in V, Kulkarni 7 S. “The Forward Head Posture”. Dynamic Troyanovich, D. and Seaman, 8 Anatomical into Understanding the SM, Ozcakar L, Bozkurt MC. “Insight Tagil 9 Graven-Nielsen. “Muscle pain T. Falla, D. Farina, M. Kanstrup Dahl, and D. 106

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