The levator scapulae extends from the superior angle of the scapulae to the transverse processes of C1-C4. Its fibers are deep to the trapezius, but reveal themselves for palpation at the lateral neck, bracketed between the splenius capitis and posterior scalene.
Origin: C1-C4 transverse processes Insertion: Superior angle of the scapulae
Action: Scapular elevation and abduc-tion, scapular downward rota-tion, cervical lateral flexion to the same side, cervical rotation to the same side, cervical extension
Innervation: C3-C4 (ventral rami); C5 (dorsal scapular nerve)
Palpation Procedure
• The patient can be prone or supine.
• Locate the lateral border of the trapezius fibers at the lateral neck.
• Slide two fingers forward onto the splenius capitis. Ask the patient to elevate the shoulder.
If the fingers are over the splenius capitis, the muscle will not contract with shoulder eleva-tion; if it does contract, the fingers are over the levator scapulae. The levator scapulae muscle is just anterior to the splenius capitis, which on some people is difficult to differentiate from the levator.
• Strum your fingers gently over the levator fibers (they often feel ropelike), which lead superiorly toward the ear and inferiorly toward the scapulae.
• Additionally, the head can be rotated away from the palpation side to accentuate tension at the levator scapulae.
• Determine the most dominant tender point or fasciculation (or both) and maintain light pres-sure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred.
PRT Clinician Procedure
• Place the patient supine.
• With your near hand, apply cervical lateral flexion and rotation towards the lesion, then apply slight cranial lateral flexion and rotation.
• With your far hand, grasp the patient’s elbow on the involved side. Translate the shoulder toward the head to apply shoulder elevation.
Also apply slight shoulder abduction and humeral rotation.
Levator scapulae
Supraspinatus Rhomboids
Infraspinatus Teres minor
Teres major
E6296/Speicher/Fig. 08.10/532205/JG/R1
• Corollary tissues treated: Trapezius, sternoclei-domastoid, splenius capitis, digastric
See video 8.5 for the levator scapulae PRT procedure.
Levator scapulae palpation procedure.
Levator scapulae PRT clinician procedure.
Suboccipitals
The suboccipital group is composed of eight individual muscles (rectus capitis posterior major and minor, obliquus capitis superior and inferior, longissimus capitis, splenius capitis, semispinalis capitis, spinalis capi-tis) at the base of the skull. The muscles course among the atlas, axis, skull, and upper cervical vertebrae.
They are primarily responsible for capital extension and rotation and lateral bending of the head. Although they are not discernible individually because of their deep location, the density of their muscle bellies can be felt under palpation.
Origin: Rectus capitis posterior major: Axis spinous process
Rectus capitis posterior minor: Atlas tubercle on the posterior arch Obliquus capitis superior: Atlas transverse process
Obliquus capitis inferior: Axis spinous process
Longissimus capitis: T1-T5 transverse processes, C4-C7 articular processes Splenius capitis: Ligamentum nuchae at C3-C7, C7-T4 spinous processes
Semispinalis capitis: C7 and T1-T6 transverse processes, C4-C6 articular processes Spinalis capitis: C5-C7 and T1-T3 spinous processes
Insertion: Rectus capitis posterior major: Occiput at the lateral portion of the inferior nuchal line Rectus capitis posterior minor: Occiput at the medial portion of the inferior nuchal line Obliquus capitis superior: Occiput between the superior and inferior nuchal lines Obliquus capitis inferior: Atlas
Longissimus capitis: Mastoid process
Splenius capitis: Mastoid process and occiput below the lateral third of the superior nuchal line
Semispinalis capitis: Occiput between the superior and inferior nuchal lines Spinalis capitis: Occiput between the superior and inferior nuchal lines
Action: Capital extension; head rotation and lateral bending to the same side (as a group) Innervation: Rectus capitis posterior major: C1 (suboccipital, dorsal rami)
Rectus capitis posterior minor: C1 (suboccipital, dorsal rami) Obliquus capitis superior: C1 (suboccipital, dorsal rami) Obliquus capitis inferior: C1 (suboccipital, dorsal rami) Longissimus capitis: C3-C8 (dorsal rami)
Splenius capitis: C3-C6 (dorsal rami); C1-C2 (suboccipital and greater occipital nerves) Semispinalis capitis: C2-T1 (dorsal rami and greater occipital nerve)
Spinalis capitis: C3-T1 (dorsal rami) Rectus capitis
posterior minor Superior oblique Rectus capitis posterior major Inferior oblique
E6296/Speicher/Fig. 08.09/532202/JG/R1
Palpation Procedure
• Place the patient supine with the neck in slight extension.
• Cup the base of the cranium with both hands.
• Feel the back of the cranium for two bony knobs and C2, the second bony protuberance at the center of the spine. The two knobs are the occiput. The suboccipitals span the region between these landmarks.
• Using your fingertips, apply firm pressure through the overlying tissue to feel the density of the suboccipital muscle bellies.
• Note the location of any tender points or fas-ciculatory response along the tissues and their attachment sites.
• Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred.
PRT Clinician Procedure
• Place the patient supine with the head resting on the table.
• With your far hand, move the neck into exten-sion either by moving the patients head off the table or dropping a section of the table.
• Cradle the posterior cranium with your far hand and apply a small upward translational force at the cervical spine with this hand to facilitate capital extension.
• With your far hand, laterally flex the head and neck toward the lesion.
• Rotate the far hand under the cranium to facilitate cranial lateral flexion and rotation for fine-tuning.
• Once the optimal treatment position is attained, place the fingers of your far hand below the lesion and apply a cephalad translational force upward of the tissue.
• Corollary tissues treated: Trapezius, splenius capitis, digastric, levator scapulae, sternoclei-domastoid, interspinalis, multifidi, rotatores
Suboccipitals palpation procedure.
Suboccipitals PRT clinician procedure.