Quick viewing(Text Mode)

Levator-Scapulae.Pdf

Levator-Scapulae.Pdf

THE DREADED

CORNER levator scapulae

rhomboids

FIG. 1 ANATOMIST’S

LEVATOR LEVATORSCAPULAE

80 MASSAGE & BODYWORK • OCTOBER/NOVEMBER 2001 o single muscle takes more blame for the problems of bodywork N clients (or the occupational strains of bodyworkers themselves) than the poor, benighted levator scapulae. rectus capitis lateralis Many clients will roll their heads and point or dig at the base of their , urging us to put our fingers into this longus capitis hard-to-reach place. If you are sitting down and a massage therapist comes up longus colli behind you, they are more than likely going to squeeze your traps a few times, and then start after the gold at the top of anterior scalenes the . And there’s nearly always gold to find when they get down to the anterior scalenes superior angle. Why is this such a univer- posterior scalenes sally sore area? The situation has become so serious Stone Phillips is preparing a Dateline seg- ment titled “Levator Scapulae: Threat? Or Menace? You decide!” And Anne Robinson has declared the levator “the weakest link – goodbye.” Okay, bad jokes. But what is the cause of the persistent ten- sion, annoying trigger points, and fibrotic in the levator scapulae? Most clients will say it’s stress. I suppose they are describing the daily stresses which pile up brachial plexis FIG. 2 into distress – a distress that involves feel- ings of fear or withdrawal. Lifting the to “turtle” the head is a protec- Fig. 2: (Above) tive response, ergo: lifted shoulders and from the constantly overworked levators. front. MOTOR CYLINDER MAKEUP In the spirit of the times, shouldn’t we The front of the try to understand the levator scapulae in he levator scapulae is one of the motor cylinder terms of its context? Go into its upbring- muscles of the “motor cylinder” of shows us the two ing, socio-economic background and pre- T the neck – that inner core of cer- longus muscles vious traumatic episodes? Surely, in these vical stabilizing muscles deep to the outer and the scalene days of relativism, we can’t actually sleeve of the trapezius, sternocleidomas- group. blame anybody, or even any muscle, can toid and platysma. The motor cylinder Fig. 1: (Facing) surrounds the entire , we? Of course not, so this article is a plea Levator scapulae for tolerance, an expansion of our under- creating movement through their contrac- from behind. standing of the stresses the levator itself tion, but also stabilizing the cervical spine is working under, and a call to build the like the guy wires on your local radio self-esteem of levators everywhere. So the tower or sailboat mast. Depending on following is my only slightly different the- how you count, there are about a dozen ory as to why the levator is so commonly major muscles in the motor cylinder, overloaded, but the theory leads to a dif- most with multiple slips to several of the ferent plan of treatment. Here goes. bones, including the occiput; that is ➝

By Thomas Myers • Illustrations by Andrew Mannie

OCTOBER/NOVEMBER 2001 • MASSAGE & BODYWORK 81 anatomist’s corner

FIG. 3

not counting the really small one- and two-joint muscles of the transversopinalis. An astonishing number of muscles manage to find attachments to the transverse pro- cesses (TPs), though some attach to the spinous process (SPs). Beginning from the front, we have the longus capitis and longus colli, which seem to lie in front of the bodies of the vertebrae, but which actually attach to the very rectis capitis lateralis front of the TPs. These muscles act to flex the neck vertebrae and pos- turally to prevent neck hyperexten- capitis sion. They are intrinsic to the longus capitis splenius cervicis spine in that they do not have longus colli attachments anywhere else, though the longus colli reaches down levator scapulae through the thoracic inlet to the anterior scalenes third or fourth thoracic . medial scalenes The next muscles back in the motor cylinder are the scalene posterior scalenes group. The scalenes form a skirt scapulae around the side of the neck, and are clearly felt as hard, wiry mus- cles when you push in from the side of the neck. All three attach to the TPs, but the anterior scalene attaches to the anterior tubercle of the TP, and passes down and for- ward (remember that, it’ll be on the quiz later) to the anterior surface of the first rib just under and behind the medial part of the collarbone. Fig. 3: Neck from the side, showing scalenes and levator. The middle and posterior scalene The levator scapulae is set right behind the scalenes, reaching down, back and (which I think of as one muscle in out from the transverse process to the apex of the scapula. terms of treatment) come from the posterior tubercle of the TP, pass- ing straight out to the side to the first and second ribs. These guy wires create lateral flexion in movement, but act posturally to stabilize the side-to-side move- ments of the neck vertebrae. The of the , by the way, go out through the trough See Levator, p84

82 MASSAGE & BODYWORK • OCTOBER/NOVEMBER 2001 anatomist’s corner

Levator, from p82 between the anterior and posterior FIG. 4 tubercle, and therefore between the anterior and middle scalenes, a subject we will return to when we talk about palpation. Right behind the scalenes comes the levator scapulae. This thin band of muscle actually starts as four slips from each of the first four cer- semispinalis capitis, lateral vical vertebrae, from the TPs like the rest, which blend into one mus- cle. The longus muscles attached to semispinalis the vertebrae themselves, the capitis, medial scalenes attached to the ribs. What next? The next logical place from splenius capitis which to stabilize the neck is the scalene, medial scapula, and there the levator goes, and posterior attaching right to the upper inner splenius cervicis corner known as the superior angle. supraspinatus Because we want to concentrate nuchal ligament on the levator, we will give short shrift to the rest of the motor cylin- levator scapulae der, which consists of the – reaching down from the head and the posterior part of the cervical TPs and into SPs of vertebrae way down the back. The first ones are the large bandages of the splenius muscles (these, too, will be on the quiz). Splenius passes back and down, angling in sharply and acting like the reins of a horse: shorten the splenius on the right side, and the head will turn to the right. Splenius capitis comes from the side of the occiput and temporal bone (the TP of the skull, if you will) and cervi- cis from the first two cervical verte- Fig. 2: Neck from back. brae, the and axis. The posterior part of the motor cylinder, behind the levator, is taken up with Inside the wrapping of the the spinal muscles – the longer erector spinae and the shorter transversospinalis splenii, we have the continuations muscles. of the erector spinae from the back: the most laterally, the longissimus in the middle, and the heavy band of the semispinalis closest to the SPs. Deep to these three are the smaller and shorter multifidus, and other little guys of the transversospinalis, but these muscles are intrinsic to the neck See Levator, p86

84 MASSAGE & BODYWORK • OCTOBER/NOVEMBER 2001 anatomist’s corner

FIG. 5

rectus capitis lateralis

levator scapulae

Fig. 2: Deep Back arm line. Consider the levator’s fascial supraspinatus connections, and we see it connected from the skull, via the tiny rectus capitis lateralis, to the little finger, via the supraspinatus. triceps and ulnar periosteum.

Levator, from p84 is that the ubiquity of levator scapu- At the top, the levator scapulae and have less to do with the guy- lae pain and dysfunction has more to connects to one more tiny muscle, wire action we are talking about. do with the neck than with the rectus capitis lateralis, which To summarize, we have guy-ropes use. But you’re right. To be fair we connects from the TP of the atlas to arrayed around the neck: the longus should detail the connections the the TP of the occiput, so that the muscles along the front, the scalene levator has to the shoulder before we levator is fascially connected to the muscles around the side, the levator spout off about neck balance. skull, even though it cannot directly to the shoulder blade, and the erec- The levator, as we have noted, goes act on it muscularly. At the bottom, tors down the back. Over these are from the TPs of the first four cervical the supraspinatus muscle, that the more superficial trapezius and vertebrae to the apex of the scapula. abducting member of the rotator sternocleidomastoid, which can also If we continue in either, via the con- cuff, is the continuation of the leva- act as stabilizers, but are more con- necting fascia, what other muscles is tor scapulae, and these connections cerned with moving the shoulder it connected to? (This is a favorite carry on out the back of the arm to and rotating the head respectively. game of mine called the Anatomy the little finger. Now why are you carrying on Trains, which was explained in Clearly problems in the arm, tri- about the neck when the levator Massage & Bodywork (April/May ceps or rotator cuff could show up scapulae is clearly a shoulder mus- 2001), and in a recently published in the levator scapulae, but I don’t cle? Because, dear reader, my theory book of the same name.) See Levator, p88

86 MASSAGE & BODYWORK • OCTOBER/NOVEMBER 2001 anatomist’s corner

Considered as a Levator, from p86 The scapula starts to creep up the think that is what’s happening most ribs, the structural balance of the neck guy wire, the levator of the time. Let us return to the guy and shoulders is substantially dis- wires of the neck idea. turbed, and the levator scapulae – would prevent the doing its best to hold the head on for QUIZ TIME 16 hours a day – develops chronic ten- sion, retains painful metabolites, lays upper cervicals going irst quiz question: What is the down extra fibrotic fascia, takes on levator’s job if described from trigger points, you name it. forward by pulling F lower insertion to upper inser- Note that in performing this func- tion? I cleverly avoided answering this tion, the levator scapulae is tense- back on them like the in the above discussion so I could stretched, not tense-bunched. We use spring it on you now. The very name, “locked long” for this strained, eccen- reins on a horse. levator scapulae, implies the muscle tric/isometric contraction, as opposed works top to bottom, lifting the scapu- to the “locked short” concentric/iso- The longus muscles la. But what if it works from scapula metric chronic contraction. The mus- to neck? Since it goes up and forward cle is already being stretched by these from the scapular apex to the first forces into a “too long” state, and us prevent the neck from four cervical TPs, it would pull these coming around with our fingers to cervicals down and back. That’s right. stretch it and relax it and make it hyperextending, You could also say it would contract to longer is only going to make it feel bet- prevent these cervicals from going for- ter in the most temporary way. In fact, the scalenes prevent it ward. So if we considered the levator over the long term, continual stretch- scapulae working from its lower inser- ing of the already overstretched levator from falling or leaning tion to its upper, we could rename it will actually contribute to a greater “capitis-preventus-going-forwardus.” head-forward postural problem. to the side, the levator Considered as a guy wire, the levator I hate to say I told you so, but do would prevent the upper cervicals you see why it’s not the levator’s prevents the neck going forward by pulling back on them fault? The more practical point is that like the reins on a horse. The longus working on the levator is not going to muscles prevent the neck from hyper- help much, despite the temporary from falling forward, extending, the scalenes prevent it from good feeling. So how can we help in a falling or leaning to the side, the leva- more permanent way? Since the prob- and the erectors tor prevents the neck from falling for- lem is the ubiquitous head-forward ward, and the erectors prevent the posture, we can help by doing a few prevent the heavy face heavy face from falling into your soup. things which might lead to the head But now, second quiz question: sitting in a balanced way atop the from falling Which of these muscles has the least spine and body. stable base (meaning distal or lower • First and most important is to into your soup. insertion)? The vertebrae move with release those myofasciae that are con- neck and back motion, and the ribs tributing to a head-forward posture. move with breathing, but the scapulae This can be due to quite distant mus- is clearly the most movable bone of all cles, such as rectus abdominis or even of these lower insertions. the hip flexors, or any of the fascia THE REAL HERO running along the sternum and chest. e arrive now at my main Closer to home, both the sternocleido- point: If the head starts to mastoid or anterior scalene (because W move forward, carrying the they both run down and forward from neck vertebrae with it, what is in the cervical TPs) might need release. place to stop it? The levator scapulae, On a deeper level, the scalene fasciae or, as we now prefer, capitis-preven- are attached to the top of the lung fas- tus-going-forwardus. And where is cia, so that breathing restrictions this hero standing? On the highly might be involved in pulling the head movable scapula. So what happens? See Levator, p90

88 MASSAGE & BODYWORK • OCTOBER/NOVEMBER 2001 anatomist’s corner

FIG. 6 Access to palpate levator scapulae muscle

trapezius

motor cylinder fascia splenius muscles transversospinalis

Fig. 6: Superficial cylinder fascia containing trapezius and sternocleidomastoid. Finger position for supine movement palpation of the levator scapulae.

Levator, from p88 and head, and since they are anchored to the forward. Assessing which of these tissues far-more-stable spinous process of the upper might be restricted and then releasing them thoracic vertebrae, it’s better to urge them into may lead to letting the head lift up and back, the job of holding the head and neck back. and thus releasing the locked long tension of • Third, we need to educate these clients the levator scapulae. about letting the head float up and back to be • Second, strengthen those muscles which on top of the body. Putting a pillow under are better placed to be capitis-preventus-going- your client’s head while they are on the table forwardus, namely, the splenii muscles. Since may be temporarily comforting, but it rein- these muscles also act like reins to the neck forces the pattern of having the back of the

90 MASSAGE & BODYWORK • OCTOBER/NOVEMBER 2001 head more forward than the thoracic spine. Or, levator scapulae will tighten while the poste- when the client is finished with the session, rior scalene will not. If you do not feel the spend a little time reinforcing the “helium muscle tightening under your fingers, you bubble in the top of the head” image. Invent are not quite in the right place. Move your other client homework to let the head float up. fingers a bit and have your client do it again; Also, encouraging your client to drop their you will be able to distinguish the levator scapulae down the rib cage can be helpful in scapulae when you are correctly placed. Do this context – I have my clients clasp their fin- the complementary move on the other side to find the other one for certain. Then have gers in front of them, and then use the idea of your client clasp her fingers in front of her pulling their fingers apart to induce the down- and slide her scapulae down the table toward ward movement of the scapulae. her feet, and you will feel the muscle stretch. The splenii muscles are just behind the WHAT DOES IT MEAN? levator, and these can be found fairly easily rying to use the levator scapulae to by putting your hands under the occiput and hold the upper neck vertebrae from a bit to the side such that your fingertips are T going forward is a mistake which leads under the lateral part of the occipital ridge to all kinds of misuse patterns for the head, and the mastoid process, with your thumbs neck, upper back and shoulders. Reversing the extended up the side of the skull above the head-forward posture is the surest way to ear. Have your client rotate her head one reduce all the negative manifestations – such way and the other against the resistance of as pain and trigger points – in the levator your thumbs. You will feel the splenii con- scapulae. Working on the muscle itself is a tract on the same side to which she is turn- quick fix, but results are surely temporary, and ing. These are the muscles you need to in the long run may exacerbate the problem. strengthen if the levators are working too In rounding out the discussion, let’s quickly hard to try to keep the head on. identify the levator palpatorily, and distinguish In conclusion, it is always important to it from its surrounding muscles. It is easy to know if a tense muscle is tense because it is find down by the scapula, but impossible to too short, or, as is often the case with levator, distinguish where it attaches to the transverse tense because it is too long, or strained. processes. Yet, with a little guidance, we can Muscles that are strained like this benefit more find it in the middle of the muscle belly. from release work in complementary muscles Sit at the head of your table, with a client than they do from work directly on the affect- or model lying supine. Put your hands to the ed muscle. So, the quiz is over and you passed. side of her neck with your fingertips fairly Next time we are going to turn the atten- near the bottom of the neck in the triangle tion of the “Anatomist’s Corner” away from between the front edge of the trapezius and the discussions of individual muscles we the back edge of the clavicular head of the have been exploring, toward some of the his- sternocleidomastoid. The most prominent torical issues in the odd, interesting and cable you feel beneath your fingers is the occasionally gruesome details in the develop- middle scalene. pain or tingling in the ment of our anatomical knowledge. M&B fingers means you are on the brachial Thomas Myers, Certified Advanced Rolfer®, LMT, plexus. Move posterior a little to find the NCTMB, studied directly with Drs. Ida Rolf and Moshe muscular element of the middle scalene. Feldenkrais, and has practiced integrative bodywork for more Just behind and slightly more medial than than 25 years in a variety of cultural and clinical settings. this lies the posterior scalene and the leva- Myers directs Kinesis, Inc. which develops and runs training tor scapulae. Since these muscles are both courses internationally for manual and movement therapists. He served as a founding member of the NCBTMB, and as small and hard to distinguish at this point, chair of the Rolf Institute’s Anatomy faculty. His articles we need a movement to parse them out. have appeared in a number of magazines and journals, and a With your four fingertips laid in behind the book is now underway on his “Anatomy Trains” Myofascial middle scalene, reach across the body with Meridians approach. Myers retains a strong interest in peri- your other hand and hold the shoulder natal and developmental issues around movement. His prac- tice in Boston combines structural integration, physiological down against the rib cage. Ask your client rhythmic sensitivity and movement. He lives, writes and sails to raise her shoulder toward her ear – the on the coast of Maine.

OCTOBER/NOVEMBER 2001 • MASSAGE & BODYWORK 91

Top View