Trigger points (TrPs), or muscle “knots,” are a common cause of stubborn & strange aches & pains, and yet they are under-diagnosed. The 14 Perfect Spots (jump to list below) are trigger points that are common & yet fairly easy to self-treat with massage — the most satisfying & useful places to apply pressure to muscle. For tough cases, see the advanced trigger point therapy guide.
Deep within the Anatomical Bermuda Triangle, a region on the side of the neck, is the cantankerous scalene muscle group. Massage therapists have vanished while working in this mysterious area, never to be seen again. The region and its muscles are complex and peculiar, and many less-trained massage therapists have low confidence working with them. This article explains how the scalene muscles can be involved in several common pain problems in the neck, chest, arm, and upper back, and how to treat pain in these areas by massaging the scalenes. The scalenes are a difficult muscle group to work with, but rewarding!
“It’s my hand, doc. My hand hurts.”
The scalenes are a strange muscle group
The scalenes are often involved in common neck pain and headaches, but that's just the tip of the iceberg. Seriously, this is a weird area: the scalenes often harbour TrPs with more diverse and peculiar symptoms than any other muscle tissue in the body. The primary mechanism for this strangeness is the phenomenon of “referred pain.” Pain in the scalenes is often felt just about anywhere but the scalenes themselves. Instead of your scalenes, your arms or chest might hurt.1
Referred pain effects are par for the course with all muscle pain or any other internal pain — for instance, heart attacks are felt in the shoulder and arm — but the scalene muscles consistently produce unusually complex, variable, and extensive patterns of referred pain. The results can be a bit bizarre, causing symptoms that most people never guess are coming from the scalenes, even doctors and therapists.
Just like the pain of a heart attack spreads from the heart into the shoulder & arm, the pain of painful scalene muscles spreads throughout the chest, upper back & chest, the arm & hand & the side of the head. Pain referred to the back may feel like a penetrating pain stabbing through the torso.
And scalene TrPs can also have several other “interesting” (in the sense of the Chinese curse2) effects: on your voice, on swallowing, on emotions, on sensations that sweep through the entire head, the sinuses, hearing, and teeth. I have found scalene TrPs to be obviously clinically relevant to conditions as seemingly unrelated as:
- a professional singer with a mysterious degradation of quality in his voice (helped by releasing scalene and other throat trigger points)
- at least two patients with severe chronic sinus infections that they’d actually had surgery to try to correct (one of them virtually cured by scalene trigger point release alone, the other significantly helped)
- several people with severe cases of what I call “brick back,” where the space between the shoulder blades feels so stiff and stuck that it’s like there’s a cinder block there instead of bone and muscle
- cutting off blood and nerve supply to the arm, because tight scalenes can impinge the brachial artery and brachial nerve plexus in the neck
- the sensation of a lump in the throat in the absence of an actual mass (“globus sensation”)3
So scalene trigger points are “drama queens,” with symptoms and consequences that seem out of proportion to such small and obscure muscles. They often contribute to anything else that goes wrong in the whole region. Like a gang, scalene TrPs can be counted on to mess up the neighbourhood. The anterior scalene in particular is a trouble-maker, causing and complicating many other problems.
The cult of scalenes
Is the clinical importance of scalenes exaggerated? Some muscles in the human body are put on a weird pedestal by many massage therapists, made into the scapegoat for an unrealistic number of ailments. The canonical example of muscle mystique is the psoas muscle, a big muscle buried deep in the pelvis and abdomen … but the scalenes are probably the other main example, and they are directly analogous to each other anatomically.
Psoas hype is just silly — there’s almost nothing to it, and it’s deliberately missing from my “Perfect Spots” series. But the kernel of truth in scalenes hype is more substantive.4 Yes, the importance of scalenes is exaggerated by many professionals … but there’s a little more rational justification for it than there is with psoas.
The scalenes are part of a larger group of deep cervical flexors — all the deep anterior muscles of the cervical spine. It is quite trendy to try to exercise these muscles to treat neck pain. See Deep Cervical Flexor Training: “Core” strengthening for the neck.
The anatomy of the Anatomical Bermuda Triangle
The scalenes fan out from the sides of the neck bones to attach to the ribs, above the collarbone.5 The scalene group consists of three muscles: the anterior, middle, and posterior scalenes. They generally attach to the sides of the neck vertebrae at the top and to the uppermost ribs at the bottom. So the scalenes are mostly head pullers: they pull the head from side to side. And although they certainly do move the neck, they are also breathing muscles, because of the way they pull up on the ribs.
And here’s some more weirdness that makes this muscle group quite interesting: in some people the scalene muscles even reach down between the ribs and attach directly to the top of the lungs, the only muscles that attach directly to the lungs other than the diaphragm. They pull up on the pleura, the membrane that shrink-wraps the lungs. A strange muscle group indeed! Such anatomical variability is actually fairly common throughout our bodies.6
The scalenes as a group are not hard to find, but they are intricate in their details. They fill the space between three obvious structures that form the triangle:
- the collarbone
- the trapezius muscle on top of your shoulder
- the long V-shaped throat muscles (sternocleidomastoid or, if that’s too much of a mouthful, just the SCM)
Where is Perfect Spot No. 4 and the scalene muscle group?
Perfect Spot 4 is somewhere in the triangle. There is one particular spot, in the belly of the middle scalene, that I think is the most common clinically significant trigger point — the spot most likely to feel important to patients — but I don’t want to send you on a wild goose chase trying to locate exactly that spot. Any location within the triangle could prove to be important, so you should definitely explore. Things change, too: Perfect Spot 4 might be in one corner of the triangle one day, and in another corner the next. Precise self-treatment isn’t necessary — a willingness to gently experiment is.
The best way to approach this area as a helper is from above the head, with the recipient face up. Without a massage table, it works well to place his or her head in the corner of a bed. Hold your fingers flat and place the pads of your fingertips in the hollow of the triangle: above the collarbone, in front of the massive trapezius muscle along the top of the shoulder, and on the outside of the prominent V-shaped sternocleidomastoid muscles of the throat.
In this position, your hands will be angled inward a bit, and roughly pointing at the sternum. Now press down and perhaps a little inwards with a fairly broad pressure — finger pads, not finger tips — on the ropy muscles that fill the triangle. By using a broad pressure, you can easily stimulate some TrPs and stiff muscle without having to worry about being too accurate.
Explore in the triangle with your fingertips, using small circles to find the ropy bands of muscles, gently strumming across them. The area is a rich minefield of trigger points, any of which might be worthwhile and interesting.
How should scalene massage feel?
Massage feels better on some muscles than others.7 The scalenes are not really pleasurable to massage, in general. The throat is a vulnerable body part, so many people feel threatened by pressure here — beware of underestimating it,8 and all the more so if you aren’t confident that massage is safe, or if you don’t understand the strange sensations that are so common in this area. That vulnerability seems to translate into sensitivity, so even a gentle approach may feel a bit hot, nasty, and dodgy at first — not really the kind of trigger point you want to mess around with for fun.
Wow, sign me up! Sounds great, doesn’t it? But it’s not all bad news.
Some people enjoy scalene massage right out of the box, and others can come to appreciate it after a period of “working through” and getting used to the uglier sensations. But the best case scenario is when you are actually solving a problem: if your scalenes are in distress and causing a chronic pain problem, then it’s going to feel more like you’re finding the right place to scratch an itch that you couldn’t reach before.
Maximize your chances of a positive experience by moving slowly and respectfully, and massaging the scalenes with broader, less “poky” pressure. Such pressure is more likely to produce the best case scenario: a peculiar deep ache spreading into the head, chest, back, and/or arm. At its best, scalene massage feels challenging but “profound.” The spectacular referral patterns make the scalenes feel important, the key to the region. No muscle produces more amazed comments. As an entire limb “lights up” with referred pain from a light pressure in the neck, many people will say something like, “Holy $%[email protected]$#$!, what the hell is that?” This is generally true of all referred pain, and it’s equally true of all the Perfect Spots, but “some trigger points are more equal than others.” The scalenes may be awkward and uncomfortable to massage at first, but this Perfect Spot can be very impressive in the end.
So be prepared for anything, and take it easy.
Although you might have to “work through” a little unpleasant sensation to get to the better sensations, this doesn’t mean “no pain, no gain” — do not be brutal in this area. Patients need a little time to adjust and “accept” the stimulation here. Persist respectfully, and there is a fair to middling chance that the sensation will change from hot to warm, from sharper to achier. It might make the transition in five minutes, or it might take a few days of sweet-talking the area. But there is a limit to how much you should try. If the effort doesn’t start to develop a bright side after a reasonable amount of time, then this Perfect Spot isn’t so perfect, and you should let it go.
Tennis, meet elbow
Tennis is the traditional way to get a case of tennis elbow, but it’s not the only way.
The respiration connection (theoretical but plausible)
Many common aches and pains, particularly around the head, neck and shoulders, may be caused in part by inefficient breathing. It’s just a theory, but the connection between dysfunctional breathing and pain is straightforward in principle: if the diaphragm doesn’t do its job well, muscles in the upper chest (pectoralis minor) and throat (sternocleidomastoid and scalenes) try to take over. Unfortunately, these muscles just aren’t built for routine respiration, and they can exhaust themselves to the point of irritation and injury. A cascade of consequences may result, from garden variety stiffness to seemingly unlikely and severe consequences such as rotator cuff injuries, whiplash, and thoracic outlet syndrome — a constellation of painful upper body conditions.
And the strange, cranky scalenes are the most likely muscles to cause symptoms in this scenario. They are “uniquely structured in fiber composition to sustain prolonged contraction.”9
Anything that makes breathing more difficult could easily provoke over-use of the scalenes. There are many possibilities, but probably the most common and preventable is smoking — which is also a risk-factor for chronic pain independently,10 so it’s a double whammy. This is pure speculation, but smokers could not only have more trigger points in their accessory respiratory muscles, but also nastier ones, more painful and persistent.
For more information, see The Respiration Connection.
A surprising relationship between the scalenes and tennis elbow
This tennis elbow connection is a good example of how odd and clinically relevant the scalenes can be to conditions they don’t seem to have anything to do with at first.
The scalene muscle group has surprising importance to a condition called “tennis elbow” or lateral epicondylitis, which commonly afflicts typists as well as racquet sports players. It is generally characterized as an inflammatory condition, but it is rarely that simple.11 It is likely that myofascial TrPs, particularly Perfect Spot No. 5 in the muscles of the forearm, play a significant role in any case of tennis elbow.
And Perfect Spot No. 4 seems, in turn, to significantly affect Perfect Spot No. 5. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.” That is, trigger points on the back of the forearm.12 So an interesting benefit to treating Perfect Spot No. 4 is that it may be a key to treating Perfect Spot No. 5!
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter.
Appendix A: Is trigger point therapy too good to be true?
Trigger point therapy isn’t too good to be true: it’s just ordinary good. It can probably relieve some pain cheaply and safely in many cases. Good bang for buck, and little risk. In the world of pain treatments, that’s a good mix.
But pain is difficult and complex, no treatment is perfect, and there is legitimate controversy about the science of trigger points. Their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle tissue may well be wrong. What we do know is that people hurt, and it can often be helped.
The Perfect Spots are based on a decade of my own clinical experience as a massage therapist, and years of extensive science journalism on the topic. Want to know more? This is the tip of the iceberg. I’ve written a whole book about it …
Not too good to be true.
Just ordinary good. Trigger point therapy isn’t a miracle cure, but it is a valuable life skill. Practically anyone can benefit at least a little & many will experience significant relief from stubborn aches & pains. The first few sections are free.
Appendix B: All the perfect spots
There’s also a more detailed index of the spots and other trigger point resources.
- Massage Therapy for Tension Headaches — Perfect Spot No. 1, in the suboccipital muscles of the neck, under the back of the skull.
- Massage Therapy for Low Back Pain — Perfect Spot No. 2, in the erector spinae and quadratus lumborum muscles in the thoracolumbar corner
- Massage Therapy for Shin Splints — Perfect Spot No. 3, in the tibialis anterior muscle of the shin
- Spot No. 4 is this page.
- Massage Therapy for Tennis Elbow and Wrist Pain — Perfect Spot No. 5, in the common extensor tendon of the forearm
- Massage Therapy for Back Pain, Hip Pain, and Sciatica — Perfect Spot No. 6, an area of common trigger points in the gluteus medius and minimus muscles of the hip
- Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome — Perfect Spot No. 7, the masseter muscle of the jaw
- Massage Therapy for Your Quads — Perfect Spot No. 8, another one for runners, the distal vastus lateralis of the quadriceps group
- Massage Therapy for Your Pectorals — Perfect Spot No. 9, in the pectoralis major muscle of the chest
- Massage Therapy for Tired Feet (and Plantar Fasciitis!) — Perfect Spot No. 10, in the arch muscles of the foot
- Massage Therapy for Upper Back Pain — Perfect Area No. 11, the erector spinae muscle group of the upper back
- Massage Therapy for Low Back Pain (So Low That It’s Not In the Back) — Perfect Spot No. 12, a common (almost universal) trigger point in the superolateral origin of the gluteus maximus muscle
- Massage Therapy for Low Back Pain (Again) — Perfect Spot No. 13, The Most Classic Low Back Pain Trigger Point
- Massage Therapy for Shoulder Pain — Perfect Spot No. 14, The Most Predictable Unsuspected Cause of Shoulder Pain
What’s new in this article?
2018 — New small section, “The cult of scalenes.” Is the clinical importance of scalenes exaggerated?
2016 — Edited for clarity.
2015 — Miscellaneous improvements.
2005 — Publication.
- This is because our nervous systems generally struggle to isolate where pain is coming from when it’s deeper than the skin. A pinprick on the skin we can locate precisely, but the location of muscle pain often feels out of focus — we just don’t have the neurological “wiring” to get a clear signal. The net effect is sensory confusion. And the confusion seems to be greater with the scalenes than with other muscles.
- “May you live in interesting times” is one part of a three-part curse that is supposedly “ancient Chinese,” but is probably actually English or American in origin. According to Wikipedia, “The Chinese language origin of the phrase, if it exists, has not been found, making its authenticity doubtful.” The other two parts of the curse are the less famous “may you come to the attention of those in authority” and “may you find what you are looking for.”
- Globus is the unexplained sensation of a lump in the throat, which is common and often alarming. Although many cases are “all in your head,” many cases probably have subtle physical causes, basically anything that irritates the throat (tonsil stones, acid reflux, Eagle syndrome, cysts, etc). For more information, see A Lump in My Throat: A globus hystericus story, with a side of science.
- Their involvement in some common pain problems is much more plausible and they are much more accessible for (cautious) self-treatment experimentation. In my career as a massage therapist, I routinely judged scalene massage to be worth trying, but almost never psoas work, and many years later (and much more cynical and educated) I still think my reasoning was sound.
- Yes, you heard me right: ribs! We actually have ribs above our collarbones. The rib cage and lungs are quite “tall,” and this area is the very top of your rib cage. In rare cases, people even have a small extra rib at the top, one vertebrae higher than normal.
- Ingraham. You Might Just Be Weird: The clinical significance of normal — and not so normal — anatomical variations. ❐ PainScience.com. 4327 words.
- There’s a broad pattern I observed as an Registered Massage Therapist, back in the day: sensitivity to pressure in the flexor muscles tends to be sharper and nastier than the extensor muscles, where “good pain” is more commonly reported. I have no explanation for this — it’s just an interesting correlation I noticed.
- The fear of throat touch can be severe, even phobic, with or without any obvious cause. But an obvious cause is that some victims of assault are choked, which may make massage in this area completely off-limits. An old friend and massage colleague of mine was extremely uncomfortable with throat massage. Despite making this clear, an instructor in our massage therapy college publicly attempted to “joke” about this during a massage demonstration, and touched my friend’s throat. She actually smacked his hands away and yelled at him, which he richly deserved. This was an extreme breach of ethics and professionalism on the part of the instructor, and a sad example of the poor quality of some massage training — we spent far too many hours learning massage therapy from that guy.
- Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression syndrome. Histochemical and morphometric studies. Arch Surg. 1986 Oct;121(10):1141–4. PubMed #3767646 ❐
- Ingraham. Smoking and Chronic Pain: We often underestimate the power of (tobacco) smoking to make things hurt more and longer. ❐ PainScience.com. 1307 words.
- Boyer MI, Hastings H2. Lateral tennis elbow: "Is there any science out there?". Journal of Shoulder And Elbow Surgery. 1999;8(5):481–491. “The term epicondylitis suggests an inflammatory cause; however, in all but 1 publication examining pathologic specimens of patients operated on for this condition, no evidence of acute or chronic inflammation is found.” This surprising lack of inflammation is actually typical of supposedly inflamed tendinitises. For much more information about that, see Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.
- Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. Volume 1, p513.