The fascial continuity that is part of the biotensegrity model prevents any muscle from acting alone. Every muscle action is the result of the cooperation of all the neighboring muscles. Every muscle knows the muscular tension of the neighboring districts.

The deep muscles such as the rectus capitis anterior and lateralis, the cervical and brachial plexus innervate the capitis and longus colli muscles. It is extremely difficult not to meet a scalene problem without a dysfunction of other deep muscles of the neck; the inability to extend the head is synonymous of a general dysfunction of these muscles and scalene muscles.

Scalene muscles, like any other anatomic district, possess various anatomical variables.

• The anterior scalene muscle could have its origin from C2 and/or not involve C6. Insertion of the muscle could involve not only the first rib but also the second or third thoracic rib. The anterior scalene muscle could pass behind the subclavian artery, either homolaterally or bilaterally (right and left). Furthermore, it could be found behind the first thoracic nerve. In some cases in the literature, the anterior scalene muscle is absent, both on one side and on both sides.

• The middle scalene muscle could involve in its insertion the transverse processes of the atlas cervical vertebra, leaning in its final path on the second thoracic rib. In some scientific articles, an accessory middle scalene muscle is identified, which builds a bridge with the anterior scalene muscle. This anatomical variant could cause a symptomatic picture that refers to the thoracic outlet syndrome.

• The posterior scalene muscle could involve the cervical vertebrae from C3 to C7; some of its fibers can create a single muscle structure with the middle scalene or the first intercostal muscle. Its final insertion could touch the third thoracic rib. In some subjects, this muscle may be absent. The middle scalene could be perforated by branches of the brachial plexus, such as C7 and C8, which will terminate on the posterior scalene muscle. Some authors have found that posterior scalene muscle could have a double layer, with a ventral area and a dorsal portion.

• The minimum scalene may arise flattened and involving a large area of the thoracic outlet. This muscle in its origin could involve C6 and C7 vertebrae.

Thoracic Outlet Syndrome [1]

Thoracic outlet syndrome (TOS) occurs secondary to direct or indirect mechanical compression of the subclavian vessels and/or the brachial plexus between the clavicle, scalene muscles, and the first rib. The most common presenting clinical symptoms include fatigue, pain, and paresthesias affecting the upper extremity. Dynamic, postural-based symptoms can often make the diagnosis somewhat challenging. The latter occur secondary to neurovascular compression and when the upper extremity is brought to increasing levels of overhead elevation. TOS can be suspected in patients reporting the aforementioned symptoms, and further suggestions of TOS as a diagnosis include the presence of a cervical rib (0.5% of the population).

There have been case reports of various forms of TOS occurring secondary to a hypertrophic anterior scalene muscle.[2] In some cases, it is necessary to eliminate the scalene, either the anterior or middle (i.e., a scalenectomy) muscles. In the presence of abnormal muscle bundles that can compress the vascular-nervous brachial package, identified with ultrasound ("wedge-sickle sign"), the patient must undergo muscular resection. In certain situations when the pathology is secondary to the scalene muscle itself, symptoms can be acutely managed with type A botulinum toxin (botox) injections. These are also helpful in older patients that may need to delay surgery.[3] In specific situations of spasmodic torticollis or cervical dystonia, botox injections can help mitigate symptoms as well.

Neck Mass Dissections

Tumor formation can form within the scalene muscle; one particular type is known as a myopericytoma. This tumor is very rare, and it is often necessary to remove it surgically. Surgical dissection for tumor/mass removal includes intramuscular dissection to either marginally or radically resect the tumor bed. Another example of a tumor is the myxoma, a rare mesenchymal tumor of the head and neck. More frequently, benign tumors are found, such as fibromatosis within the muscle, which also is often surgically removed. You can perform biopsies to the lymph nodes of the scalene muscles to check the type of tumor. In some cases, splenectomies can be performed to create space for extracting deeper tumors, such as a cervical schwannoma. Finally, mass effects can occur secondary to direct trauma with a resultant intramuscular hemangioma.

Nerve Blocks and Catheter Considerations

Nerve blocks and nerve catheters are becoming increasingly important as the healthcare system continues to shift toward more outpatient-based procedures.[4] The indications for nerve blocks vary, some of which include improving neurological pain or depressive-type syndromes. The literature supports a continuous interscalene over single-injection block because of lower rates of toxicity as well as lower reported levels of symptomatic rebound once the anesthetic wears off.[5][6] Another invasive intervention is the pharmacological block of the stellate ganglion, in which a needle, passes through different tissues including the anterior and middle scalene.

Instrumental Evaluation

To evaluate the function of the scalene muscles, electromyography can be used, identifying contractile anomalies. You can use sonography or ultrasound, as well as other more expensive instruments, such as magnetic resonance and CT scan.

To assess whether vascular compromise exists, there are no valid manual tests to identify the compromised area or to determine if the cause is arterial or venous. Only an examination with an echo-color doppler can make a vascular diagnosis on a scalene level.

Electromyography can be used not only in cases of suspected thoracic outlet syndrome but also in other clinical settings. In patients with temporomandibular joint dysfunction, it has been shown that anterior scalene has a greater electrical activity than people without mandibular joint problems. This could be useful information for the physiotherapist or the osteopath. We know that a dysfunction of the scalene muscles reduces the ventilatory capacity of the patients, and a mandibular disorder could be a symptom, rather than the cause.

Manual Assessment of Scalene Muscles

Palpation is a valuable tool used to evaluate, classify, and make a diagnosis. The fingertip has a tactile sensitivity can be used to evaluate objects measured in micron. Clinicians can use palpation to determine the position of the joints and recognize abnormal joint movements, tissue abnormalities including temperature, tone, and hardness on the surface and deep in the various layers, and to identify painful areas. 

From an osteopathic point of view, tissue injury always creates a “mnemonic tattoo.” This immediately allows clinicians to understand, at the touch, the direction of the tissue toward the primary lesion. This lesional tattoo is the changed morphology of the cells, as well as their preferential vector, the altered behavior at the pressure of our touch.

According to literature, when palpating to verify the status of the scalene muscles, it is necessary to ask the patient to laterally flex the neck, with the direction opposite to our fingers; touch to the right with the neck flexion to the left. In this way, the scalene muscles are put in tension, and it is easier to palpate them.

The scalene musculature (including the posterior scalene) can fatigue during a repeated respiratory effort, in particular in patients suffering from chronic obstructive pulmonary disease, in whom these contractile districts are often over-stimulated and hypertonic in comparison with healthy subjects.

To evaluate tone and the tissutal quality of the scalene muscles, the examiner must position himself behind the patient, who is supine (better) or seated. With one hand he holds and controls the patient's nape, while with the other hand he tries to prevent the first thoracic rib to rise, supporting the eminence hypothenar in the anatomical area of the supraclavicular fossa. This last position is necessary to prevent the first rib moving, during the movement of the neck, and to prevent an incorrect tension of the muscles.

• For the anterior scalene, the patient's head tilts to the left and simultaneously turns to the right side. (See photo 1)

• For the middle scalene, the head bends to the left without rotations, respecting the functional anatomy (See photo 2). The hand placed on the rib is useful when the stretching of the muscle involves the insertion area, with an additional passive movement of the head. The abnormal tension in the muscle, and often, painful, induced movements, will result in a reduced excursion. Tension and pain in the anterior and middle scalene muscles can be frequent causes of thoracic outlet syndrome.

• For the posterior scalene, preventing the elevation of the first rib, slightly incline the neck, while trying to rotate the head to the left.

With the same positions for the assessment of any restrictions on each portion of the scalene muscles, stretching exercises can be performed. The exercise must be performed in the presence of an operator because the patient cannot understand the movement of the first rib during the small movements allowed by each scalene muscle.

To differentiate a problem of the scalene muscles from a dysfunction of the sternocleidomastoid muscle (SCM), an operator positions himself behind the patient (sitting or standing). The operator places his hands on the patient's shoulders and asks for a deep inhalation, preventing the movement of the shoulders. In this way, the intervention of the sternocleidomastoid muscle is excluded, and the elevation of the first ribs is allowed. If the scalene musculature is painful or has some restrictions, the problems of the scalene muscles will be highlighted. On the contrary, to focus attention on SCM, the elevation of the first ribs is prevented by resting the thumbs during a forced inhalation.

Clinical Implications

An increase in tone or thickness of the anterior scalene muscle may result in distant symptoms. Vascular compression of the subclavian artery would give pallor and cold sensation to the extremities, cyanosis, and difficulty using the arm. If C5-C6 crosses the muscle in non-physiological conditions (hypertrophy, shortening), it could cause paresthesia, anesthesia, or weakness of the muscles innervated by these roots. If the root of C8 runs back to the two attacks the anterior scalene and there is a squeeze, there may be symptoms such as tingling, pain, and weakness of the hand and the interosseous muscles. If the anterior scalene tendon mixes with the longus capitis muscle, headaches may occur.

• If the suprascapular nerve passes through the middle scalene (hypertonic and hypertrophic, shortened), symptoms such as weakness of the supraspinatus and infraspinatus muscle may occur, with paresthesia and pain in the shoulder and scapular area and subsequent alteration of the arthrokinematics of the scapulohumeral joint. If the deep branch of transverse cervical artery passes through the muscle, it could cause a nuanced symptomatology or difficult to identify the problem.

• An increase in thickness of the posterior scalene muscle could alter the course of the long thoracic nerve and the scapular dorsal nerve, with pain or weakness in the anterior serratus muscle, the scapula elevator, and the rhomboid muscles.

• The presence of minimum scalene may reduce the brachial plexus passage space, as well as the passage of the subclavian artery and the subclavian vein, causing symptoms related to thoracic outlet syndrome.

Chronic Obstructive Pulmonary Disease (COPD)

In patients with COPD, the diaphragm muscle is weakened, flattened, and during the inhalation position, forces the accessory muscles for breathing to intervene with greater emphasis. What happens to the scalene muscles? An inverse relationship between the thickness of the diaphragm muscle and the thickness of the scalene muscles has been demonstrated: decreased thickness of the diaphragm and increased hypertrophy of the scalene muscles. Generally, the latter is rich in red or aerobic fibers, but if subjected to constant work, bearing a greater load, the red fibers increase their mass, both as proteins and as quantities of mitochondria and enzymes, capillaries. COPD is an aggravating disease, and the scalene muscles increase the tone and volume not only for hypertrophy but the chronic shortening of the muscles themselves. The first ribs are in an inspiratory attitude, with the pulmonary dome in constant tension. During inspiration, the dome will have difficulty to move downward, further complicating the respiratory act, by decreasing the pulmonary vital capacity.

It has been shown that a postural attitude of the neck, where the head is held forward, reduces lung vital capacity for the same mechanisms described above of the scalene muscles: shortening and increased tone. This happens independently from the presence of respiratory diseases.

A valid approach to reducing non-physiological adaptation of the lung due to scalene muscles in shortening is stretching, as shown by clinical research.

Myofascial Pain

Scalene muscles can be a source of pain. On the one side, muscle mass can present trigger points and painful differences. On the other side, the same connective tissue that covers and connects the muscle, the fascia that connects the muscle with other muscles, viscera, and joints can present anomalies that provide pain. The scalene muscles can cause a sore cervical tract. Pain can easily be located, or cause more distant symptoms, such as migraines.

These fascial anomalies or alterations of the contractile tissue can occur in the absence of traumas, such as erroneous daily attitudes, or traumas such as whiplash; or, due to the presence of diseases that alter the thoracic conformation such as scoliosis, which can cause a non-physiological cervical biomechanical environment.

This constant pain can reduce lung vital capacity. Studies show that an approach with breathing exercises that re-educate the scalene muscles helps to decrease or eliminate the pain experienced by the patient.

Another approach to reducing myofascial pain is osteopathy, with techniques defined as indirect or fascial techniques. Several studies show how these gentle techniques can reduce local pain with systemic involvement. The blood values of the inflammatory indices are lowered, and the activity of the sympathetic system is lowered.

Other more recent approaches demonstrated in the literature are the use of dry needle by physiotherapists or the use of taping. The mechanisms of action of these last two therapeutic approaches are not well understood, despite the positive results. 

Anti-inflammatory drugs do not solve the structural abnormalities but only treat the symptoms. Once the analgesic effect ends, there is a high chance that the pain will return.