Levator Scapula Neck Pain

Levator Scapula Disfunction Can Cause Pain and Stiff Neck Syndrome

Next week I will be teaching a class at the Florida State Oriental Medical Association (FSOMA) Annual Conference. The class will discuss neck pain and stiffness and will specifically highlight acupuncture and manual therapy techniques to treat the levator scapula, a muscle which frequently causes neck pain and stiffness and pain in the shoulder blade region.

Fig. 1 A (left) and 1 B (right): Images from Myofascial Pain and Dysfunction: The Trigger Point Manual, by Drs. Janet Travell and David Simons,

The levator scapula, seen in Fig. 1 A, is a muscle which stretches from the upper neck to the upper part of the shoulder blade. Not surprisingly based on its name, the levator scapula elevates the scapula. But it also rotates bends it sideways. Both of these movements basically move the shoulder blade closer to the neck on the same side. When this muscle develops trigger points (painful nodules within the muscle), it can cause quite a lot of pain and neck stiffness. This pain pattern is illustrated in the Fig. 1B and as can be seen, the pain concentrates at the base of the neck and frequently spreads to the medial border of the scapula. Patients often state that they feel the pain between the shoulder blades. The neck frequently becomes stiff, and pain is worse when patients turn the head to the side of the pain, as in looking over the shoulder.

Fig. 2: Neck position which shortens the levator scapula and can lead to pain.

Fig. 3: The imbalance in the pelvis
and legs, causing an elevation on
of the right ilium which frequently
contributes to an elevation of the
left shoulder girdle. This can
cause pain and stiffness in the
left neck.

This can be a chronic condition, or it can come on suddenly. It is not uncommon for people to wake with this pain after a night's sleep in an awkward position. A cold draft on the neck while sleeping is also frequently reported by patients. This pain can be quite distressing as it interferes with activities such as driving and makes it difficult to find a comfortable position.

In chronic cases, it is found that patients often perform an activity that repetitively shortens this muscle. A common example is a busy office worker, student or parent holding a phone to their ear with their shoulder. Awkward computer workstations, poor sitting posture, poor breathing, and even imbalances affecting the leg length (more on this in a different post) can contribute to pain in the levator scapula (Fig. 3)

Local acupuncture techniques can be an excellent way to address the muscle directly to release muscle contraction. In addition, acupuncture along the related channels and to muscles that are part of the dysfunction, myofascial release (a deep tissue type of massage) to lengthen bound muscles and connective tissue, and corrective exercises to address posture are all tools that can greatly reduce pain and improve range of motion in the neck and treat this 'stiff neck syndrome.'

A self-help exercise is described below. This can be performed several times a day and should not cause pain or aggravation of symptoms. Use your judgment and consult your physician if you have any doubts.

This exercise is described as if there is pain at the base of the neck on the left side, which is worse when turning to the left. The directions can be reversed for pain occurring on the right side.

1) Lie face-up or sit upright in a chair with your feet on the floor.
2) Gently turn your neck towards the painful side (to the left) to the point just before it hurts (this may be only a small turn in severe cases).
3) Place the hand opposite the painful side on your cheek (right hand on the right cheek) and gently, with very little force, turn the head back into the palm (to the right). There should be no movement, and this is an isometric contraction. In other words, you are resisting the gentle turn with your palm and not allowing any movement. Hold this position for about 6 seconds.
4) Relax for about 1 second, and then see if you can turn more towards the painful side (to the left). Still stop before there is actual pain and do not attempt to turn more than your body will allow.
5) Repeat steps 3 and 4.

Note: This exercise is most useful in acute problems when there is severe pain and difficulty turning the neck. The goal is to GENTLY tease out movement. Many times, the body perceives that there is danger to the joints (maybe you fell asleep in a position that was stressing the joints of the neck, for instance) and there is a reflexive spasm to guard and prevent movement. Trying to stretch aggressively and forcefully will often aggravate the condition more in these situations, as the neck muscles such as the levator scapula will contract more to guard the area. In more chronic cases, stretching and range of motion exercises can be employed.

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Head Forward Posture

The Head Forward Posture and Health Ramifications

One of the most common postural disparities I see is a head-forward posture. In The Physiology of Joints, Volume III, French surgeon and anatomist Adalbert I. Kapandji states that for every inch the head goes forward it gains an additional ten pounds of weight in terms of strain on the posterior neck and upper back muscles. The average weight of the head is about 4.5-5 kg (10-11 pounds) and, in a balanced posture, it is supported evenly amid the muscles of the neck. With a head-forward posture, this balanced support is disrupted, and the posterior neck and upper back muscles then become increasingly more overloaded (and painful) with every additional degree of head-forward posture. With the head an inch forward (neutral is considered as consisting of the ear aligning over the acromion process which is the highest point of the shoulder) this means that the posterior neck and upper back muscles have to support about 20 pounds of weight all day. At 2 inches forward, this becomes about 30 pounds. With Americans spending more and more time behind the wheel, in front of computer screens, glued to cell phones and tablets, and performing other activities which lend themselves to this already common posture, it is not surprising that we frequently see so many problems attributed to this posture.

The following are common complaints that involve a head-forward posture:

Generalized neck pain and shoulder pain caused from muscle overuse: As stated above, for every inch the head moves forward, it gains an additional 10 pounds of weight in terms of strain on the posterior neck and upper back muscles. What this means is that the muscles of the posterior cervical spine are working overtime, day in and day out, and for a prolonged time. It is just a matter of time before they start to cry out for some attention and that usually comes in the form of aches and pain. Specifically, the upper trapezius, levator scapula, and splenius cervicis are frequent muscular contributors to neck discomfort; they not only produce pain, but reduce range of motion and can contribute to stiffness, including stiffness which makes it difficult to turn the neck. Generally, restriction in the upper trapezius manifests in reduced range of motion and discomfort towards the end of the range of motion when looking in the opposite direction, while restriction in the levator scapula often causes pain when looking to the same direction. However, sometimes all three of these muscles can become spasmed, making it very difficult to turn the neck in any direction without considerable pain.

And it is not just the muscles which are involved with neck pain from a head-forward posture. The strain in the posterior neck from the additional load signals fibroblasts to produce more extracellular matrix to support this area. Fibroblasts are specialized cells that produce the building blocks of fibrous connective tissue, such as collagen fibers and a sticky, syrupy substance called proteoglycans (a protein-carbohydrate based molecular structure). Prolonged strain (such as years of bracing against the extra weight of having the head forward) stimulates production of this extra material which can be easily felt as dense, ropy, fibrous bands in the upper back and neck region. It is the body’s attempt to add more support to a region that has additional demands placed on it. Local massage, acupuncture, or other treatments applied directly to the painful tissue may temporarily help make this dense, stagnant tissue feel better, but the posture as a whole needs to be addressed if there is to be any hope of long-lasting relief.

Cervical facet joint referral patterns.
Image from: Osteoarthritis of the Spine:
The Facet Joints, Gellhorn, A.C. et al
Nature Reviews Rheumatology 9, April 2013

Facet joint syndrome: This involves a degeneration of the vertebral facet joints, which is usually secondary to degeneration of the intervertebral discs. Cervical disc degeneration is usually exaggerated whenever there is long term hypomobility (limited movement) of cervical spine. While the outer part of the intervertebral disc has a blood supply, the inner part does not and requires nutrition and fluids via diffusion from the outside. So, with any limited movement patterns that persist for a long time, the discs suffer. As one of my tai chi instructor states, “Motion is Lotion,” and this is definitely true for the spine. In addition to the discs, the synovial, freely moveable (at least they should be) joints of the spine can become degenerative and lead to pain, which can affect the neck but can also refer to the head and, even more commonly, between the shoulder blades. This is a commonly overlooked source of pain and patients with a head-forward posture are much more predisposed to it.

Facets joints are the synovial joints between adjacent vertebrae. They can become degenerative and painful with osteoarthritis of the spine. In a head forward posture, the upper cervical facets are often in a closed position while the lower facets are in an open unstable position. Both situations can aggravate the joints and lead to referred pain. This image is from Kapandji's Physiology of Joints.

Splenius capitis (close to GB-20) and splenius cervicis
(at extrapoint Bailao) TrP referral patterns.
Image from Travell and Simons' Myofascial Pain and
Dyfunction: A Trigger Point Manual.

Tension headaches: With cervical (neck) flexion and capital (head) extension, the posterior cervical muscles are in a shortened position, especially the muscles referred to as the suboccipitals. These four deep upper cervical muscles are very common causes of referred pain into the head, contributing to tension headaches. With the movement of the head forward, the eyes would be looking toward the ground if not for these muscles tightening to lift the head, placing the occiput into an extended position relative to the top of the cervical spine. Other muscles, such as the upper trapezius, splenius capitis, splenius cervicis, and sternocleidomastoid (SCM) are also negatively impacted and common contributors to tension headaches.

Nerve impingements and entrapments: Since disc health is affected by head-forward posture, it can play a role in spinal nerve impingement. In addition, thoracic outlet syndrome (another type of entrapment of neural structures) is often seen with a head-forward posture. Both of these can radiate pain into the upper extremities and be causes of pain in the arms, elbows, forearms or hands.

Thoracic outlet syndrome involves an entrapment of the brachial plexus, which is the bundle of nerves that exit from the neck and travel to the arms. The brachial plexus can be entrapped as it travels between the anterior and middle scalene muscles (two anterior neck muscles which are shortened in a forward-head posture), between the clavicle and ribcage, and between the pectoralis minor muscle and the ribcage. The head-forward posture is often a contributing factor to all of these, especially as the entire shoulder girdle is involved (more on this in the next post).

Jaw tension: a head-forward posture places the mandible (lower jaw bone) in a position which stresses and tightens the muscles of the jaw. The position of the head places anterior neck muscles such as the suprahyoids and infrahyoids in an overstretched position. These muscles attach to the mandible and pull down on the lower jaw bone. The muscles of mastication (chewing), such as the masseter, reflexively tighten to hold the jaw close. They then develop trigger points which put pressure on the temporomandibular joint (TMJ).

Shoulder and other problems: Part 2 of this post will discuss the relationship of the balance of the cervical spine to the shoulder girdle. Because these are so intimately tied to each other, shoulder dysfunction such as supraspinatus tendinopathy, bicipital tenosynovitis, infraspinatus and subscapularis myostrain, and other conditions are often made worse by the strain of a head-forward posture. As we explore the sinew channel relationship described in Chinese medicine, this neck-shoulder girdle relationship will become even more apparent.

Image from Startle as a Paradigm
for Malposture, by Pierce, F. et al
Perceptual and Motor Skills, 1964
A) Patient standing upright
B) Door closes loudly and startles patient. Notice the shortening along the front of the body

In addition to shoulder dysfunction, head-forward posture can contribute to other problems elsewhere in the body. This could become a very complex analysis, so I will not give a complete list. However, I will mention some interesting research that explored hamstring flexibility in relation to the suboccipital muscles (which extend the joint between the occiput and top of the cervical spine). This research measured hamstring flexibility and then split the subjects into two groups. Members of one group performed hamstring stretches; members of the other performed stretching to the suboccipital muscles. Surprisingly, the group that received stretching for the suboccipitals alone had a greater increase in hamstring flexibility (13%) than the group receiving hamstring stretches alone (9%). The reason likely has to do with the high concentration of muscle spindles present in the suboccipital muscles and, due to this, the fact that they have such a strong influence on tone throughout the musculature of the back, especially at the hip joint. Consider what happens when someone is startled, and the typical startle response observed. The firing of the suboccipitals might be reflexively tied to the firing of the hamstrings which assists in extending the hip joint. This, along with the shortening in the front of the body, would effectively protect the vulnerable organs.

For acupuncturists, it is worth reexamining the Urinary Bladder sinew channel and noting that it does bind to the occiput, and, therefore would include the suboccipital muscles. Looking for a head-forward posture and addressing shortened suboccipitals would be a worthwhile strategy, not only when treating local dysfunction, but with any strain pattern affecting the Urinary Bladder sinew channel. Addressing this pattern would help focus the selection of effective points to treat according to the principle of “selecting points above to treat below.”

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