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Fibromyalgia and Myofascial Pain Syndrome symptoms and treatment of the Sternocleidomastoid

This is an excerpt from Fibromyalgia and Myofascial Pain Syndrome by Devin Starlanyl.

This unusual two-part muscle is commonly called the SCM. The clavicular part in the back connects to the collarbone (clavicle), and the sternal part in the front connects to the top of the breastbone (sternum). The SCM TrPs don’t usually cause pain in the neck, but they can cause a lot of trouble. Along with characteristic referral patterns specific to each part of the muscle, SCM TrPs can cause many unusual symptoms. These symptoms are very real, and they can be life-disrupting. They are also treatable. Donnelly and colleagues (2018, p. 95) inform us that these symptoms may occur because of the close association of the SCM and the brain stem.

Proprioceptors are one type of sensory receptor that can be affected by myofascial TrPs. Their job is to inform the brain where they, the receptors, are located in relation to the world around them. The human body is hard-wired to keep the eyes level. If the eyes are not level, because of unequal leg length or some other reason, the SCM is the muscle that tries to compensate. The SCM is loaded with proprioceptors. If there are TrPs in the SCM, those proprioceptors will be spatially disoriented, and so will you. You’re no longer sure where you are in relation to objects around you. Vertigo isn’t unusual with these TrPs. You can even black out if you turn your head suddenly, although that is rare. Episodes of dizziness caused by these TrPs can last for seconds or hours. Unintentional veering with loss of motor coordination, called ataxia, can occur unexpectedly as you stumble though the world. You are no longer sure of your steps and may no longer trust your ability to walk straight. This can cause extreme clumsiness as well as close encounters of the painful kind with door jambs, walls, corners of tables, and any unfortunate object or person in your way. Postural responses are exaggerated. If you look down, you can feel as if you are falling forward. Picking up something from the floor can be fraught with peril. With these TrPs, when you drive around a corner it can feel as if you are banking in an airplane. You feel tilted. If you stop in a parking lot and the car next to you pulls out, you can get the sensation that you are moving again and slam on the brake. Driving through a car wash can be disorienting. Nausea is common, although vomiting is infrequent. It helps to understand what is going on. If it is safe, close your eyes until the feeling passes.

You can also lose the ability to accurately judge the weight of objects you are holding. Your brain may not know how much force you need to lift those objects. You try to put a cup on the counter only to have the cup and your hand smash against the side of that counter. Eating can be frustrating, and messy. It’s often wise to choose your food to match your clothes. When it comes to turning into traffic … You may not be able to drive safely when these TrPs are very active. SCM TrPs can also cause a variety of autonomic symptoms, such as skin redness, warmth, or sweating in the characteristic patterns. If you have active TrPs on one side only, this can seem very odd. In combination, these TrPs can confuse and disturb your care providers. Remind them that they are worse for you. Be aware that spatial disorientation, exaggerated postural responses, difficulty walking a straight line, and other symptoms from these TrPs can give the mistaken impression of alcohol or drug use.

Hunting Hints:

General SCM: It’s possible to have TrPs in one segment and not the other, although that is unlikely if FM coexists. Work on one segment on one side of the muscle at a time until you see how you respond to treatment. This will minimize the chance of massive disorientation. Some of these TrP referral patterns and other symptoms vary as to the location of the TrPs. These TrPs can contribute to neck stiffness if there are other initiating causes, such as TrPs in levator scapulae or upper trapezius. If there are TrPs only on one side of the SCM, you may have developed a habit of tilting your head to that side. This is probably because it hurts more holding your head upright. Of course, if you need to lie down during the day in order to rest your neck muscles, the SCMs are already sending a strong message.

Work the TrPs and look at figure 13.6. Start at one end of the muscle and go to the other end. Try positioning your head and neck in different ways, as head position significantly affects TrP accessibility. See how work on one SCM segment affects you before working on the other segment. You may need to wait until the next day to work on the other side, one segment at a time. Once you know how you are affected, you can change your self-treatment accordingly.

Sternal SCM TrPs (see figure 13.7a): Along with the characteristic referral pattern, these TrPs can cause visual disturbances including blurring of vision, an appearance of dimness in the surrounding area, tearing and redness of the eye, difficulty raising the upper eyelid, and/or light sensitivity. They can cause a pressure sensation behind the eye. Strong contrasting light and shadow patterns can cause dizziness. The pupils react normally despite the visual disturbances. Patterns that move increase the effect, such as conveyor belts. This dizziness can increase to a petit-mal-like absence seizure effect, as if you are staring into space until your brain can catch up to the visual messages. These TrPs can also cause sinus symptoms, including congestion and runny nose on the same side as the TrPs, with possible ringing of the ear, a stuffy sensation, or muted hearing in that side of the head. These symptoms may often be misinterpreted as psychological.

The TrPs close to the top of the sternal segment cause scalp pain. The scalp can be very pressure-sensitive, giving you the impression that your hair hurts. Bilateral TrPs close to the breastbone in the sternal segment can cause a persistent dry cough. Pressing this TrP area can often initiate the cough. TrPs in the middle of this segment cause pain in the back of the tongue, throat, and pharynx during swallowing.

If you suspect these TrPs, hold this portion of the muscle in a pincer grasp as you swallow. If those symptoms disappear, these TrPs were the cause. Sternal TrP symptoms can be similar to those caused by trigeminal neuralgia (TN), although there is no facial grimace or jabs of pain that true TN causes. These TrPs can also be mistaken for swollen lymph glands. In some combinations, symptoms from these TrPs can be mistaken for an upper respiratory infection.

Clavicular SCM TrPs (see figure 13.7b): This segment of the muscle is the segment further back, attached to the collarbone. Start hunting for TrPs here close to the collarbone attachment. It can help access if you turn your head away from the side being treated. TrPs here can cause dizziness if you hyperextend your head or otherwise overstretch the SCM. Keep your head flat on the pillow when you roll over in bed. If you raise your head before you roll over and “lead with your head,” that will perpetuate TrPs. These TrPs can cause a bout of dizziness whenever you turn your head quickly. Dizziness can last for seconds, or for hours. This can be especially dangerous because you turn your head right and left just before you turn into traffic.

Sustained tilting of the head can cause these TrPs to activate, which can cause nausea, frontal headache, and earache. Dramamine can relieve the nausea, but not the dizziness and other symptoms. Spatial disorientation and similar symptoms can worsen significantly immediately after bodywork on the SCM area. You may be unable to drive safely. Loss of balance can also occur after sustained tilting of the head to one side. Disorientation and imbalance can occur separately from postural dizziness. Sudden falls can occur during bending or stooping. You can veer to one side as you walk; bouncing from one wall or door jamb to another. Postural responses are exaggerated. This can lead observers to suspect alcohol or drug-related problems. While lying down in bed or on a sofa, you can feel as if you are tilted and have to put your foot on the floor for an illusion of stability. Some of this can be due to proprioceptive neck mechanisms.

Active TrPs here can also contribute to seasickness or motion sickness. They can also cause anorexia, leading to poor diet.

Treatment Tips: Control perpetuating factors, so set an alarm to stretch every 20 minutes during prolonged computer sessions. Muscles can be more tolerant of static seating tasks if there are frequent stretch breaks. If only one side of the SCM has active TrPs, sleeping on the side of the TrPs with the pillow properly adjusted can help ease symptoms. Make sure your neck is supported and your face is not bearing any weight. Don’t sleep on your stomach. When the SCM muscles are hyperirritable, these muscles must be supported without immobilization. A pinned, folded kitchen towel or supporting scarf wrapped around your neck and secured with a safety pin can prevent the TrP-ridden tissues from being squeezed together. This can occur even from the weight of your head, especially if you have forward head posture.

After any therapy, take it easy; you may require a driver to take you home. If you use a heating pad, strap it to your body. Don’t hold a heating pad up to the front of your neck with your hand. That shortens the pectoral muscles, and they pull on the SCMs. Be mindful of muscles that are attached to the muscle that is hurting. The shape of the SCM segments lends itself to pincer palpation. Grip one segment of the muscle at a time between the thumb and forefinger of the other side hand. Start at one end and work to the other, gently pinching each segment to search for and treat TrP nodules. Press the TrPs under your fingers for 15 to 30 seconds.

Palpation of the SCMs can be most difficult close to the muscle attachments if tissues are very tight. SCM TrPs seem to be more reactive than other TrPs to manual therapies, dry needling, and TrP injections. Reactions can be immediate or delayed, and can be incapacitating. Approach each new area or new therapy with caution and limit your therapy time. Don’t overdo. Keep your neck draft-free and warm after therapy and support your head as much as possible.

Perpetuating Factors: These include anything that puts too much stress on these muscles. If they’re already stressed, even a tight collar, turtleneck, or tie can activate TrPs. Poorly designed or ill-fitting work areas, ill-fitting furniture, working when you are tired, or even a cold draft can activate TrPs.

Other perpetuating factors include paradoxical breathing, forward head posture, any chronic upper body infection or respiratory illness, uncorrected vision, poor lighting, body asymmetry, sustained side tilting or turning of the head, painting ceilings, head rolling exercises, or ill-fitting pillows.

With proper therapy and control of perpetuating factors, TrPs can resolve. As the curvature of the neck changes, the pillow support must change to fit it. Anything that produces a deviation of the normal pattern of gait, such as limping from shoes that are too tight, can perpetuate these TrPs, as can a tight pectoralis muscle pulling down and forward on the clavicular head of the SCM. Be attentive. Are you reading in bed with the light to one side? Do you have glare on your computer screen or on your glasses from light placement? Do you have one-sided ear or eye problems that cause you to tilt your head for extended amounts of time?

Stretch: When you shower, let the hot water fall on the sides of your neck as you stretch them. Be mindful of the ways such ordinary activities can treat your muscles. You can also stretch this muscle while you lie on your back. Keeping your head straight, slowly bring your left ear down to the left shoulder. Rest a moment. Then return to the center position. Then rest. Then bring the right ear down to the right shoulder. Rest again. Then return to the center. The resting portion of the stretch is as important as the stretch. It takes extra time for TrP-laden muscles to recover. Be mindful when you rise from the flat surface.

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