Muscles of Head and Neck Pain

With active trigger points (TP), the muscles in this section lead to pain in the head and neck region, which could be misinterpreted as one of the following:

• Arthrosis of the temporomandibular joint

Origin

• Middle third of the superior nuchal line

• Nuchal ligaments

• Spinous processes and supraspinous ligament up to T12.

Insertion

• Outer third of the back border of the clavicle

• Medial section of the acromion

• Upper border of the spine of the scapula

Action

• Outward rotation in the shoulder joint

• Lifting the scapula

• Retracting the scapula to the spinal column

• In cases with fixed scapula: extension and lateral flexion of the thoracic spinal column (TSC)

• Pharyngitis

• Laryngitis

• Dental disease

• Trigeminal neuralgia etc.

Innervation

• Accessorius nerve

• Proprioceptive fibers from C3/C4

Trigger Point Location

Trigger points of the trapezius are found throughout the entire muscle:

TP1 In the free border of the descending part palpable as hypertonic bands TP2 Posterior of TP1 and above the scapular spine—

around the center of the spine TP3 In the region of the lateral rim of the descending part, near the medial border of the scapula TP4 In the ascending part directly below the scapular spine, near the medial border of the scapula TP5 In the horizontal part ca. 1 cm medial of the insertion of the levator scapula muscle on the scapula

TP6 In the supraspinatous fossa of the scapula, near the acromion

Levator Scapula Muscle

Trapezius, descending part Tendon of the trapezius Trapezius, transverse part

Ridge of the shoulder blade -Deltoid

TP of the latissimus dorsi

Trapezius, ascending part Thoracolumbar fascia

Trapezius, descending part Tendon of the trapezius Trapezius, transverse part

Ridge of the shoulder blade -Deltoid

TP of the latissimus dorsi

Rhomboid major Latissimus dorsi

Trapezius, ascending part Thoracolumbar fascia

Levator Scapulae Muscle Thoracolumbar Fascia Pain

Referred Pain

TP1 Posterolateral in the throat and neck region up to the mastoid process

Lateral at the head-especially in the temple region and eye socket, temporomandibular joint TP2 Mastoid process and upper cervical spinal column (CSC) (posterolateral) TP3 Mastoid process and upper CSC (posterolateral)

and in the area of the acromion TP4 Along the medial border of the scapula TP5 Paravertebral between C7 and TP5 TP6 Roof of the shoulders, acromion

Associated Internal Organs

• Gallbladder

Sternocleidomastoid Muscle (Figs. 19.5,19 Origin

Ventrocranial at the manubrium

Upper rim of the medial third of the clavicle

Insertion

Outside of the mastoid process Lateral half of the superior nuchal line

Action

■ Ipsilateral lateral flexion and contralateral rotation of the CSC

Double-sided contraction: extension of the CSC with ventral translation

Innervation

• Accessorius nerve

Trigger Point Location

Trigger points are found in the sternal and clavicular section throughout the entire length of the muscle.

6. 19.7) Referred Pain

Trigger points of the sternocleidomastoid muscle (SCM) lead to facial pain, which can easily be mistaken for trigeminal neuralgia.

Trigger Points in the Sternal Section

• Supraorbital and in the orbita

• Outer auditory canal

• Temporomandibular joint region

• Pharynx and tongue

• Occiput, posterior to the mastoid process

Trigger Points in the Clavicular Section

• Forehead, potentially also on both sides

■ Outer auditory canal

• Immediately behind the ear

Associated Internal Organs

• Gallbladder

Mylohyoid muscle

Digastric muscle (anterior belly) Mandible

Mandibular angle

Hyoid bone

Hyoid Bone Skull

Cricoid cartilage Thyroid gland

Omohyoid muscle - Clavicle clavi- "I of the cularhead sternoclei-

Sternal I domastoid head J muscle

Mylohyoid muscle

Mandibular angle

Hyoid bone

Thyroid cartilage

Cricoid cartilage Thyroid gland

Digastric muscle (anterior belly) Mandible

Stylohyoid muscle

Digastric muscle (posterior belly)

Thyrohyoid muscle

Omohyoid muscle

Sternocleidomastoid muscle Sternohyoid muscle Trapezius

Omohyoid muscle - Clavicle clavi- "I of the cularhead sternoclei-

Sternal I domastoid head J muscle

Stylohyoid Muscle
Fig. 19.7

• Frontal two-thirds of the zygomatic arch

• Zygomatic process of the maxilla

Insertion

• Outside of the mandibular joint

• Lower section of the mandibular branch

Action

• Lifting the lower jaw (closing the mouth) Innervation

Mandibular nerve (trigeminal nerve)

Zygomatic bone

Clavical Trigger Points

Temporalis

TPs of the masseter

Zygomatic bone

TPs of the masseter

Temporalis

Zygomatic arch

Articular capsule

- Lateral ligament Styloid process

Masseter (deep part) Masseter (superficial part)

Digastric Trigger Point

Fig. 19.9a-d Trigger Point Location

Trigger points are found distributed throughout the entire muscle.

Referred Pain

• Maxilla and upper molars

• Mandible and lower molars

• From the temple to above the eyebrows

Trigger Points Outer Ear

• Temporomandibular joint

• Outer auditory canal

Sometimes trigger points cause tinnitus in the mass-eter.

Associated Internal Organs

None

■ Temporalis Muscle (Fig. i9.ioa-d) Origin

Temporal bone between the inferior temporal line and the infratemporal crest

Insertion

Medial and ventral section of the coronoid process of the mandible

Trigger Point Temple Above Ear

Action

Raising and guiding back the lower jaw Innervation

Mandibular nerve (trigeminal nerve)

Trigger Point Location

TP1-3 Found above the zygomatic process. TP4 Above the ear (see also Fig. 19.8)

Referred Pain

• From the temple to parietal

• Above the eyebrow

Associated Internal Organs

None

■ Lateral Pterygoid Muscle (Figs. 19.11.19.12) Origin

• Underside of the greater wing of the sphenoid bone

• Outside of the lateral pterygoid plate

Insertion

• Pterygoid bone below the condyloid process of the mandible

• Articular disk of the temporomandibular joint Action

Opening the mouth (pulling the lower jaw forward, which also pulls the disk forward)

Innervation

Lateral pterygoid nerve from the mandibular nerve (trigeminal nerve)

Trigger Point Location

The trigger points of this short muscle are found by intraoral palpation roughly in the middle of the muscle belly.

Referred Pain

• Temporomandibular joint

Associated Internal Organs

None

Lateral Pterygoid Palpation

Fig. 19.12

Fig. 19.11

Fig. 19.12

TPs of the lateral pterygoid muscle

Lateral Pterygoid Palpation

Lateral pterygoid muscle

Temporalis

Medial pterygoid muscle

TP of the medial pterygoid muscle

Masseter

Lateral pterygoid muscle

TPs of the lateral pterygoid muscle

Temporalis

Medial pterygoid muscle

TP of the medial pterygoid muscle

Masseter

■ Medial Pterygoid Muscle (Fig. 19.13) Origin

• Inside the lateral pterygoid plate

• Pterygoid bone

• Maxillary tuberosity

• Pyramidal process of the palatine bone

Insertion

Inside the mandibular joint Action

Moving the lower jaw forward, upward, and lateral (chewing)

Innervation

Medial pterygoid nerve from the mandibular nerve (trigeminal nerve)

Trigger Point Location

The trigger points of this short muscle are found by intraoral palpation roughly in the middle of the muscle belly (see also Fig. 19.11, page 131).

Referred Pain

• Temporomandibular joint

■ Digastric Muscle (Figs. 19.14,19.15) Origin

• Ventral head: digastric fossa on the backside of the symphysis menti

• Dorsal head: mastoid notch on the mastoid process

Insertion

On the intermediate tendon that inserts laterally on the hyoid bone

Action

Associated Internal Organs

None

Digastric Trigger Point
Fig. 19.13

Innervation

• Ventral head: mandibular nerve (trigeminal nerve)

• Dorsal head: facial nerve

Trigger Point Location

The trigger points are palpated along the course of the muscle as hypersensitive points medial to the SCM muscle.

• Lifting the hyoid bone

• Pulling the mandible forward

• Supports the process of swallowing

Mylohyoid line

Manubrium Scapula

Muscles Chains

Anterior belly Posterior belly.

of the digastric muscle

Scapular notch

Raphe of the mylohyoid muscle

Anterior belly Posterior belly.

of the digastric muscle

Stylohyoid muscle Hyoid bone Thyrohyoid muscle Omohyoid muscle v. intermediate tendon

Clavicle Acromion

Scapular notch

Mylohyoid line

Geniohyoid muscle (transparent)

Mastoid process

Mylohyoid muscle Thyroid cartilage

Trachea Sternothyroid muscle Sternohyoid muscle

Manubrium Scapula

Muscles Chains
Fig. 19.15

■ Orbicularis Oculi, Zygomaticus Major, and Platysma Muscles (Fig. 19.16)

Orbicularis Oculi Insertion

Origin Palpebral ligament

Medial orbita rim. wall of the lacrimal sac . .

Action

Closing the eyelids, supporting tearing

Fig. 19.14

Referred Pain

— into the upper region of the SCM muscle

— neck region, near the mandible

• Ventral head: lower incisors and the mandibles underneath

Associated Internal Organs

None

Epicranial aponeurosis

Depressor supercilii

TPs of the platysma

Mentalis-

Zygomatics minor

Zygomatics major

Risorius

Depressor — labii inferioris

Depressor anguli oris

Mastoid Pain

Orbicularis oculi (labial part)

Masseter

Occipitofrontalis (frontal belly)

- TP of the occipitofrontalis

- Procerus

Corrugator supercilii

Orbicularis oculi (palpebral part)

Nasalis

Levator labii superioris alaeque nasi

Levator anguli oris

Parotid duct

Buccinator

Sternocleidomastoid muscle

Orbicularis oculi (labial part)

Masseter

Orbicularis oculi (marginal part)

Sternocleidomastoid muscle

Epicranial aponeurosis

Depressor supercilii

Orbicularis — oculi

(lacrimal part)

orbicularis oculi

Orbicularis — oculi

(orbital part)

TPs of the platysma

Occipitofrontalis (frontal belly)

- TP of the occipitofrontalis

- Procerus

Corrugator supercilii

Mentalis-

Orbicularis oculi (palpebral part)

Nasalis

Levator labii superioris alaeque nasi

Levator labii superioris

Levator anguli oris

Parotid duct

Buccinator

Zygomatics minor

Zygomatics major

TP of the zygomaticus

Risorius

Depressor — labii inferioris

Depressor anguli oris

Fig. 19.16

Zygomaticus Major Muscle Origin

Foreside of the zygomatic bone Insertion

Lateral to the corner of the mouth

Action

Pulling the corners of the mouth backward and upward

Platysma Muscle Origin

Skin in the lower neck region and upper exterior thorax region

Insertion

Lower edge of the mandible, skin in the lower facial region, corner of the mouth

Action

Pulling the skin of the lower face and mouth regions and the lower jaw downward

Innervation

Facial nerve

Trigger Point Location Orbicularis Oculi

Above the eyelid, immediately below the eyebrow

■ Occipitofrontal^ Muscle (Figs. 19.17,19.18) Origin

• Superior nuchal line, mastoid process

• Referring to the fibers of the upper facial muscles

Mastoid Process Pain

Fig. 19.17

Fig. 19.17

Zygomaticus Major in the area of the muscle near the insertion-craniolat-eral to the corner of the mouth

Platysma

Ca. 2 cm above the clavicle on the intersection with the SCM muscle

Referred Pain Orbicularis Oculi

Zygomaticus Major

Originating from the trigger point, lateral to the nose and medial to the eyes, to the forehead (center)

Platysma

Associated Internal Organs

None

Insertion

Epicranial aponeurosis

Epicranial Aponeurosis

Fig. 19.18

Action

• Stabilizing the epicranial aponeurosis

• Wrinkling the forehead

Innervation

Facial nerve

Trigger Point Location

• Frontal: above the medial end of the eyebrow

• Occipital: above the superior nuchal line and ca. 4 cm lateral to the center line (see also Fig. 19.16, p. 134)

Referred Pain

This originates from the orbita, across the ipsilateral half of the skull along the course of the muscle.

Associated Internal Organs

None

■ Splenius Capitis and Cervicis Muscles (Figs. 19.19,19.20)

Origin

• Splenius capitis: nuchal line and spinous processes • Splenius cervicis: spinous processes and supraspi-and supraspinous ligaments T1-T3 nous ligaments T3-T6

TP3 TP2 TP1

Semispinals capitis

Longissimus capitis

Intertrans-versarii

Thoracolumbar fascia

Multifidus lumborum

Semispinalis cervicis

Semispinalis thoracis

Muscles Chains

Iliocostals cervicis lliocostalis thoracis

— Spinalis thoracis Interspinales muscles lliocostalis lumborum

Tendon of origin of the longissimus

Iliac crest

Gluteus med i us

Guteus maximus

TP3 TP2 TP1

Semispinals capitis

Longissimus capitis

Intertrans-versarii

Thoracolumbar fascia

Multifidus lumborum

TP of the splenius capitis Splenius capitis TP of the splenius cervicis Splenius cervicis

Iliocostals cervicis lliocostalis thoracis

— Spinalis thoracis Interspinales muscles lliocostalis lumborum

Tendon of origin of the longissimus

Internal oblique muscle of the abdomen

Iliac crest

Gluteus med i us

Guteus maximus

Semispinalis cervicis

Thorax with intercostal muscles

Semispinalis thoracis

Trigger Points

Insertion

• Splenius capitis: between the superior and inferior nuchal ligaments (lateral to the occiput)

• Splenius cervicis: posterior tubercle C1-C3

Action

Innervation

• Splenius capitis: spinal nerves C3/C4 (dorsal branches)

• Splenius cervicis: spinal nerves C5/C6 (dorsal branches)

Extension and ipsilateral rotation of the CSC

Trigger Point Location

• Splenius capitis: in the muscle belly roughly at the height of the spinous process of the axis

• Splenius cervicis: at the height of the transition from the shoulder to the neck and a little further up from there a second trigger point near the muscle insertion at the level of C2/C3

For palpation, slide the palpating finger between the trapezius and levator scapulae.

Referred Pain

• Splenius capitis: into the vertex of the skull—ipsilat-eral

• Splenius cervicis: through the skull to behind the eye, sometimes also to the occiput, shoulder-neck transition, and ascending ipsilateral up the neck

Associated Internal Organs

• Gallbladder

■ Semispinalis Capitis and Cervicis Muscl (Transversospinalis) (Figs. 19.21.19.22)

Origin

• Semispinalis: transverse processes

• Multifidus: lamina

Insertion

• Semispinalis: spinous processes (ca. six vertebrae cranial to the origin)

• Multifidus: spinous processes (ca. two to three vertebrae cranial to the origin)

These muscles run approximately between the T6 and the superior/inferior nuchal line.

, Multifidus Muscles

Action

Extension and lateral flexion ipsilateral to the spinal column

Innervation

Dorsal branches of the segmental spinal nerve Trigger Point Location

TP1 At the base of the neck at the level of C4/C5 TP2 2-4 cm below the occiput TP3 Immediately below the superior nuchal line (see also Fig. 19.19)

Semispinalis Trigger Points

Fig. 19.21

Fig. 19.21

Referred Pain Associated Internal Organs

TP1 Along the neck up into the suboccipital region • Heart and also caudally up to the medial border of • Lung/bronchial tubes the scapula TP2 From the occiput towards the vertex TP3 Painful band sideways across the skull up to the temple region

■ Rectus Capitis Posterior Major and Min Superior Muscles (Figs. 19.23,19.24)

Origin

• Rectus capitis posterior major: spinous process C2

• Rectus capitis posterior minor: posterior tubercle of the atlas

• Obliquus capitis inferior: spinous process C2

• Obliquus capitis superior: lateral mass of the atlas

Insertion

• Rectus capitis posterior major: outer half of the inferior nuchal line

• Rectus capitis posterior minor: medial half of the inferior nuchal line

• Obliquus capitis inferior: lateral mass of the atlas

• Obliquus capitis superior: lateral half of the inferior nuchal line

Muscles, Obliquus Capitis Inferior and

Action

• Rectus capitis posterior major: extension of the head and ipsilateral rotation in the atlantooccipital joint

• Rectus capitis posterior minor: extension of the head

• Obliquus capitis inferior: ipsilateral rotation in the atlantoaxial joint

• Obliquus capitis superior: sideways inclination of the head

Innervation

• Suboccipital nerve (dorsal branch of C1)

Trigger Point Location

In the muscle belly, only general tension is palpable, but not a definable trigger point.

Fig. 19.23

Semispinalis Rectus capitis capitis posterior minor

Rectus capitis Obliquus capitis posterior major superior

Obliquus capitis superior

Ligamentum flavum

Posterior tubercle of the atlas

Intertransversarii Muscle Only

Posterior atlantooccipital membrane

Mastoid process

Vertebral arch

Obliquus capitis inferior

Spinous process of the axis

Cervical intertransversarii

Cervical interspinales

Semispinalis Rectus capitis capitis posterior minor

Splenius capitis

Obliquus capitis superior

Third cervical vertebra

Rectus capitis Obliquus capitis posterior major superior

Longis-simus capitis Passage of the vertebral artery

Mastoid process

Posterior atlantooccipital membrane

Vertebral arch

Obliquus capitis inferior

Spinous process of the axis

Cervical intertransversarii

Cervical interspinales

Ligamentum flavum

Posterior tubercle of the atlas

Obliquus capitis inferior

Muscles Chains

Referred Pain

From the occiput through the temple region up to the orbita and forehead (ipsilateral). The pain is not exactly and clearly localizable.

Associated Internal Organs

None

Fig. 19.24

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Peripheral Neuropathy Natural Treatment Options

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